Publications by authors named "Daniel J Tancredi"

214 Publications

Promoting Teen-to-Teen Contraceptive Communication with the SpeakOut Intervention, a Cluster Randomized Trial.

Contraception 2021 Sep 11. Epub 2021 Sep 11.

Center for Healthcare Policy and Research, University of California, Davis 2103 Stockton Blvd., Sacramento, CA 95817. Electronic address:

Background: To improve teen contraceptive use, the SpeakOut intervention combines structured counseling, online resources, and text reminders to encourage teens to share their experiences using intrauterine contraception (IUC) or an implant with peers.

Methods: To evaluate the effectiveness of remote delivery of the SpeakOut intervention in increasing teen contraceptive use, we conducted a cluster randomized trial involving female adolescents who were recruited online. Primary participants (n=520) were randomly assigned to receive SpeakOut or an attention control; each primary participant recruited a cluster of up to five female peers as secondary participants (n=581). We assessed contraceptive communication, knowledge, and use, at baseline, three and nine months after participants enrolled. We examined differences between study groups, controlling for clustering by primary participant and baseline characteristics.

Results: The trial's primary outcome, contraceptive use by secondary participants, was similar between groups at both three and nine months post-intervention. Compared to controls, primary participants receiving SpeakOut tended to be less likely to discontinue contraception within nine months (4.8% vs 7.8%, p=0.11 for IUC; 7.8% vs 9.8%, p=0.45 for implants), but this did not reach statistical significance. SpeakOut failed to increase contraceptive communication; regardless of study group, most secondary participants reported peer communication about contraception (86% vs 88%, p=0.57). Most secondary participants were aware of the hormonal IUC (91.4% vs 90.4%, p=0.72), copper IUC (92.9% vs 88.6%, p=0.13), and implant (96.5% vs 96.1%, p=0.83) three months after enrolling, regardless of the intervention their primary participant received. However, contraceptive knowledge remained incomplete in all study groups.

Conclusion: Remote delivery of the SpeakOut Intervention did not improve contraceptive communication, knowledge or use among participating teens or their peers.

Implications: Efforts to support teen-to-teen contraceptive communication and ensure that teens have accurate information about the full range of contraceptive methods, including highly effective reversible contraceptives, require refinement.
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http://dx.doi.org/10.1016/j.contraception.2021.08.018DOI Listing
September 2021

Parent experience and cost savings associated with a novel tele-physiatry program for children living in rural and underserved communities: Tele-physiatry for underserved communities.

Arch Phys Med Rehabil 2021 Aug 20. Epub 2021 Aug 20.

Department of Pediatrics, University of California Davis, Sacramento, California.

Objective: The aim of this study was to investigate parent and therapist experience and cost savings from the payer perspective associated with a novel tele-physiatry program for children living in rural and underserved communities.

Design: We designed a non-inferiority, cluster-randomized crossover study at four school-based clinics to evaluate parent experience and perceived quality of care between a telemedicine-based approach in which the physiatrist conducts the visit remotely with an in-person therapist and a traditional in-person physiatrist clinic.

Results: A total of 268 encounters (124 telemedicine and 144 in-person) were completed by 200 unique patients. For parents and therapists, experience and perceived quality of care were high with no significant differences between telemedicine and in-person encounters. For parents whose children received a telemedicine encounter, 54.8% reported no preference for their child's subsequent encounter, 28.8% preferred a physiatrist telemedicine visit, and 16.4% preferred a physiatrist in-person visit. From the payer perspective, costs were $100 higher for in-person clinics owing to physician mileage reimbursement.

Conclusions: We found that school-based tele-physiatry for children with special healthcare needs is not inferior to in-person encounters with regard to parent and provider experience and perceived quality of care. Tele-physiatry was also associated with an average cost savings of $100 per clinic to the payer.
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http://dx.doi.org/10.1016/j.apmr.2021.07.807DOI Listing
August 2021

Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids.

JAMA 2021 08;326(5):411-419

Department of Family and Community Medicine, University of California, Davis, Sacramento.

Importance: Opioid-related mortality and national prescribing guidelines have led to tapering of doses among patients prescribed long-term opioid therapy for chronic pain. There is limited information about risks related to tapering, including overdose and mental health crisis.

Objective: To assess whether there are associations between opioid dose tapering and rates of overdose and mental health crisis among patients prescribed stable, long-term, higher-dose opioids.

Design, Setting, And Participants: Retrospective cohort study using deidentified medical and pharmacy claims and enrollment data from the OptumLabs Data Warehouse from 2008 to 2019. Adults in the US prescribed stable higher doses (mean ≥50 morphine milligram equivalents/d) of opioids for a 12-month baseline period with at least 2 months of follow-up were eligible for inclusion.

Exposures: Opioid tapering, defined as at least 15% relative reduction in mean daily dose during any of 6 overlapping 60-day windows within a 7-month follow-up period. Maximum monthly dose reduction velocity was computed during the same period.

Main Outcomes And Measures: Emergency or hospital encounters for (1) drug overdose or withdrawal and (2) mental health crisis (depression, anxiety, suicide attempt) during up to 12 months of follow-up. Discrete time negative binomial regression models estimated adjusted incidence rate ratios (aIRRs) of outcomes as a function of tapering (vs no tapering) and dose reduction velocity.

Results: The final cohort included 113 618 patients after 203 920 stable baseline periods. Among the patients who underwent dose tapering, 54.3% were women (vs 53.2% among those who did not undergo dose tapering), the mean age was 57.7 years (vs 58.3 years), and 38.8% were commercially insured (vs 41.9%). Posttapering patient periods were associated with an adjusted incidence rate of 9.3 overdose events per 100 person-years compared with 5.5 events per 100 person-years in nontapered periods (adjusted incidence rate difference, 3.8 per 100 person-years [95% CI, 3.0-4.6]; aIRR, 1.68 [95% CI, 1.53-1.85]). Tapering was associated with an adjusted incidence rate of 7.6 mental health crisis events per 100 person-years compared with 3.3 events per 100 person-years among nontapered periods (adjusted incidence rate difference, 4.3 per 100 person-years [95% CI, 3.2-5.3]; aIRR, 2.28 [95% CI, 1.96-2.65]). Increasing maximum monthly dose reduction velocity by 10% was associated with an aIRR of 1.09 for overdose (95% CI, 1.07-1.11) and of 1.18 for mental health crisis (95% CI, 1.14-1.21).

Conclusions And Relevance: Among patients prescribed stable, long-term, higher-dose opioid therapy, tapering events were significantly associated with increased risk of overdose and mental health crisis. Although these findings raise questions about potential harms of tapering, interpretation is limited by the observational study design.
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http://dx.doi.org/10.1001/jama.2021.11013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8335575PMC
August 2021

Risk of Traumatic Brain Injuries in Infants Younger than 3 Months With Minor Blunt Head Trauma.

Ann Emerg Med 2021 09 17;78(3):321-330.e1. Epub 2021 Jun 17.

Department of Emergency Medicine, Columbia University Irving Medical Center, New York, NY.

Study Objective: Infants with head trauma often have subtle findings suggestive of traumatic brain injury. Prediction rules for traumatic brain injury among children with minor head trauma have not been specifically evaluated in infants younger than 3 months old. We aimed to determine the risk of clinically important traumatic brain injuries, traumatic brain injuries on computed tomography (CT) images, and skull fractures in infants younger than 3 months of age who did and did not meet the age-specific Pediatric Emergency Care Applied Research Network (PECARN) low-risk criteria for children with minor blunt head trauma.

Methods: We conducted a secondary analysis of infants <3 months old in the public use data set from PECARN's prospective observational study of children with minor blunt head trauma. Main outcomes included (1) clinically important traumatic brain injury, (2) traumatic brain injury on CT, and (3) skull fracture on CT.

Results: Of 10,904 patients <2 years old, 1,081 (9.9%) with complete data were <3 months old; most (750/1081, 69.6%) sustained falls, and 633/1081 (58.6%) underwent CT scans. Of the 514/1081 (47.5%) infants who met the PECARN low-risk criteria, 1/514 (0.2%, 95% confidence interval [CI] 0.005% to 1.1%), 10/197 (5.1%, 2.5% to 9.1%), and 9/197 (4.6%, 2.1% to 8.5%) had clinically important traumatic brain injuries, traumatic brain injuries on CT, and skull fractures, respectively. Of 567 infants who did not meet the low-risk PECARN criteria, 24/567 (4.2%, 95% CI 2.7% to 6.2%), 94/436 (21.3%, 95% CI 17.6% to 25.5%), and 122/436 (28.0%, 95% CI 23.8% to 32.5%) had clinically important traumatic brain injuries, traumatic brain injuries, and skull fractures, respectively.

Conclusion: The PECARN traumatic brain injury low-risk criteria accurately identified infants <3 months old at low risk of clinically important traumatic brain injuries. However, infants at low risk for clinically important traumatic brain injuries remained at risk for traumatic brain injuries on CT, suggesting the need for a cautious approach in these infants.
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http://dx.doi.org/10.1016/j.annemergmed.2021.04.015DOI Listing
September 2021

Emergency Department Pediatric Readiness and Potentially Avoidable Transfers.

J Pediatr 2021 Sep 14;236:229-237.e5. Epub 2021 May 14.

Department of Pediatrics, University of California, Davis Health, Sacramento, CA.

Objective: To determine the association between potentially avoidable transfers (PATs) and emergency department (ED) pediatric readiness scores and the score's associated components.

Study Design: This cross-sectional study linked the 2012 National Pediatric Readiness Project assessment with individual encounter data from California's statewide ED and inpatient databases during the years 2011-2013. A probabilistic linkage, followed by deterministic heuristics, linked pretransfer, and post-transfer encounters. Applying previously published definitions, a transferred child was considered a PAT if they were discharged within 1 day from the ED or inpatient care and had no specialized procedures. Analyses were stratified by injured and noninjured children. We compared PATs with necessary transfers using mixed-effects logistic regression models with random intercepts for hospital and adjustment for patient and hospital covariates.

Results: After linkage, there were 6765 injured children (27% PATs) and 18 836 noninjured children (14% PATs) who presented to 283 hospitals. In unadjusted analyses, a 10-point increase in pediatric readiness was associated with lower odds of PATs in both injured (OR 0.93, 95% CI 0.90-0.96) and noninjured children (OR 0.90, 95% CI 0.88-0.93). In adjusted analyses, a similar association was detected in injured patients (aOR 0.92, 95% CI 0.86-0.98) and was not detected in noninjured patients (aOR 0.94, 95% CI 0.88-1.00). Components associated with decreased PATs included having a nurse pediatric emergency care coordinator and a quality improvement plan.

Conclusions: Hospital ED pediatric readiness is associated with lower odds of a PAT. Certain pediatric readiness components are modifiable risk factors that EDs could target to reduce PATs.
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http://dx.doi.org/10.1016/j.jpeds.2021.05.021DOI Listing
September 2021

Virtual Family-Centered Rounds in the Neonatal Intensive Care Unit: A Randomized Controlled Pilot Trial.

Acad Pediatr 2021 Sep-Oct;21(7):1244-1252. Epub 2021 Mar 18.

Department of Pediatrics, University of California Davis, Sacramento, Calif.

Objectives: To measure the feasibility, reach, and potential impact of a virtual family-centered rounds (FCR) intervention in the neonatal intensive care unit.

Methods: We conducted a randomized controlled pilot trial with a 2:1 intervention-to-control arm allocation ratio. Caregivers of intervention arm neonates were invited to participate in virtual FCR plus standard of care. We specified 5 feasibility objectives. We profiled intervention usage by neonatal and maternal characteristics. Exploratory outcomes included FCR caregiver attendance, length of stay, breast milk feeding at discharge, caregiver experience, and medical errors. We performed descriptive analyses to calculate proportions, means, and rates with 95% confidence intervals (CI).

Results: We included 74 intervention and 36 control subjects. Three of the five feasibility objectives were met based on the point estimates. The recruitment and intervention uptake objectives were not achieved. Among intervention arm subjects, recruitment of a caregiver occurred for 47 (63.5%, 95% CI 51.5%-74.4%) neonates. Caregiver use of the intervention occurred for 36 (48.6%, 95% CI 36.8%-60.6%) neonates in the intervention arm. Feasibility objectives assessing technical issues, burden, and data collection were achieved. Among the attempted virtual encounters, 95.0% (95% CI 91.5%-97.3%) had no technical issues. The survey response rate was 87.5% (95% CI 78.2%-93.8%). Intervention arm neonates had 3.36 (95% CI 2.66%-4.23) times the FCR caregiver attendance rate of subjects in the control arm.

Conclusions: A randomized trial to compare virtual FCR to standard of care in neonatal subjects is feasible and has potential to improve patient and caregiver outcomes.
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http://dx.doi.org/10.1016/j.acap.2021.03.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8429071PMC
September 2021

Using Prescription Drug Monitoring Program Data to Assess Likelihood of Incident Long-Term Opioid Use: a Statewide Cohort Study.

J Gen Intern Med 2021 Mar 19. Epub 2021 Mar 19.

Violence Prevention Research Program, University of California, Davis, Sacramento, CA, USA.

Background: Limiting the incidence of opioid-naïve patients who transition to long-term opioid use (i.e., continual use for > 90 days) is a key strategy for reducing opioid-related harms.

Objective: To identify variables constructed from data routinely collected by prescription drug monitoring programs that are associated with opioid-naïve patients' likelihood of transitioning to long-term use after an initial opioid prescription.

Design: Statewide cohort study using prescription drug monitoring program data PARTICIPANTS: All opioid-naïve patients in California (no opioid prescriptions within the prior 2 years) age ≥ 12 years prescribed an initial oral opioid analgesic from 2010 to 2017.

Methods And Main Measures: Multiple logistic regression models using variables constructed from prescription drug monitoring program data through the day of each patient's initial opioid prescription, and, alternatively, data available up to 30 and 60 days after the initial prescription were constructed to identify probability of transition to long-term use. Model fit was determined by the area under the receiver operating characteristic curve (C-statistic).

Key Results: Among 30,569,125 episodes of patients receiving new opioid prescriptions, 1,809,750 (5.9%) resulted in long-term use. Variables with the highest adjusted odds ratios included concurrent benzodiazepine use, ≥ 2 unique prescribers, and receipt of non-pill, non-liquid formulations. C-statistics for the day 0, day 30, and day 60 models were 0.81, 0.88, and 0.94, respectively. Models assessing opioid dose using the number of pills prescribed had greater discriminative capacity than those using milligram morphine equivalents.

Conclusions: Data routinely collected by prescription drug monitoring programs can be used to identify patients who are likely to develop long-term use. Guidelines for new opioid prescriptions based on pill counts may be simpler and more clinically useful than guidelines based on days' supply or milligram morphine equivalents.
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http://dx.doi.org/10.1007/s11606-020-06555-xDOI Listing
March 2021

Are Cal/OSHA Regulations Protecting Farmworkers in California From Heat-Related Illness?

J Occup Environ Med 2021 Jun;63(6):532-539

Center for Health and the Environment, University of California, Davis, Davis, California, USA (Dr Langer, Castro); Department of Public Health Sciences, School of Medicine, University of California, Davis, Davis, California, USA (Dr Mitchell, Armitage, Dr Vega-Arroyo, Dr Bennett, Dr Schenker); Betty Irene Moore School of Nursing, University of California, Davis, Davis, California, USA (Dr Moyce); College of Nursing, Montana State University, Bozeman, Montana, USA (Dr Moyce); Department of Pediatrics , Center for Healthcare Policy and Research, School of Medicine, University of California, Davis, Sacramento, California, USA (Dr Tancredi).

Objective: Determine compliance with and effectiveness of California regulations in reducing farmworkers' heat-related illness (HRI) risk and identify main factors contributing to HRI.

Methods: In a cross-sectional study of Latino farmworkers, core body temperature (CBT), work rate, and environmental temperature (WBGT) were monitored over a work shift by individual ingestible thermistors, accelerometers, and weather stations, respectively. Multiple logistic modeling was used to identify risk factors for elevated CBT.

Results: Although farms complied with Cal/OSHA regulations, worker training of HRI prevention and hydration replacement rates were insufficient. In modeling (AOR [95% CI]) male sex (3.74 [1.22 - 11.54]), WBGT (1.22 [1.08 - 1.38]), work rate (1.004 [1.002 - 1.006]), and increased BMI (1.11 [1.10 - 1.29]) were all independently associated with elevated CBT.

Conclusion: Risk of HRI was exacerbated by work rate and environmental temperature despite farms following Cal/OSHA regulations.
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http://dx.doi.org/10.1097/JOM.0000000000002189DOI Listing
June 2021

Longitudinal Dose Trajectory Among Patients Tapering Long-Term Opioids.

Pain Med 2021 07;22(7):1660-1668

the Center for Healthcare Policy and Research, Davis, Sacramento, California, USA.

Objective: To evaluate the dose trajectory of new opioid tapers and estimate the percentage of patients with sustained tapers at long-term follow-up.

Design: Retrospective cohort study.

Setting: Data from the OptumLabs Data Warehouse® which includes de-identified medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees, representing a diverse mixture of ages, ethnicities, and geographical regions across the United States.

Subjects: Patients prescribed stable, higher-dose opioids for ≥12 months from 2008 to 2018.

Methods: Tapering was defined as ≥15% relative reduction in average MME/day during any of six overlapping 60-day periods in the initial 7 months of follow-up after the period of stable baseline dosing. Average monthly dose was ascertained during consecutive 60-day periods up to 16 months of follow-up. Linear regression estimated the geometric mean relative dose by tapering status and follow-up duration. Poisson regression estimated the percentage of tapered patients with sustained dose reductions at follow-up and patient-level predictors of failing to sustain tapers.

Results: The sample included 113,618 patients with 203,920 periods of stable baseline dosing (mean follow-up = 13.7 months). Tapering was initiated during 37,170 follow-up periods (18.2%). After taper initiation, patients had a substantial initial mean dose reduction (geometric mean relative dose .73 [95% CI: .72-.74]) that was sustained through 16 months of follow-up; at which point, 69.8% (95% CI: 69.1%-70.4%) of patients who initiated tapers had a relative dose reduction ≥15%, and 14.2% (95% CI: 13.7%-14.7%) had discontinued opioids. Failure to sustain tapers was significantly less likely among patients with overdose events during follow-up (adjusted incidence rate ratio [aIRR]: .56 [95% CI: .48-.67]) and during more recent years (aIRR: .93 per year after 2008 [95% CI: .92-.94]).

Conclusions: In an insured and Medicare Advantage population, over two-thirds of patients who initiated opioid dose tapering sustained long-term dose reductions, and the likelihood of sustaining tapers increased substantially from 2008 to 2018.
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http://dx.doi.org/10.1093/pm/pnaa470DOI Listing
July 2021

Association between emergency department pediatric readiness and transfer of noninjured children in small rural hospitals.

J Rural Health 2021 Mar 18. Epub 2021 Mar 18.

Department of Pediatrics, Center for Health and Technology, University of California Davis, Sacramento, California, USA.

Purpose: Pediatric readiness scores may be a useful measure of a hospital's preparedness to care for children. However, there is limited evidence linking these scores with patient outcomes or other metrics, including the need for interfacility transfer. This study aims to determine the association of pediatric readiness scores with the odds of interfacility transfer among a cohort of noninjured children (< 18 years old) presenting to emergency departments (EDs) in small rural hospitals in the state of California.

Methods: Data from the National Pediatric Readiness Project assessment were linked with the California Office of Statewide Health Planning and Development's ED and inpatient databases to conduct a cross-sectional study of pediatric interfacility transfers. Hospitals were manually matched between these data sets. Logistic regression was performed with random intercepts for hospital and adjustment for patient-level confounders.

Findings: A total of 54 hospitals and 135,388 encounters met the inclusion criteria. EDs with a high pediatric readiness score (>70) had lower adjusted odds of transfer (aOR: 0.55, 95% CI: 0.33-0.93) than EDs with a low pediatric readiness score (≤ 70). The pediatric readiness section with strongest association with transfer was the "policies, procedures, and protocols" section; EDs in the highest quartile had lower odds of transfer than EDs in the lowest quartile (aOR: 0.54, 95% CI: 0.31-0.91).

Conclusions: Pediatric patients presenting to EDs at small rural hospitals with high pediatric readiness scores may be less likely to be transferred. Additional studies are recommended to investigate other pediatric outcomes in relation to hospital ED pediatric readiness.
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http://dx.doi.org/10.1111/jrh.12566DOI Listing
March 2021

Randomised trial of epinephrine dose and flush volume in term newborn lambs.

Arch Dis Child Fetal Neonatal Ed 2021 Mar 9. Epub 2021 Mar 9.

Department of Pediatrics, University of California Davis, Sacramento, California, USA.

Objectives: Neonatal resuscitation guidelines recommend 0.5-1 mL saline flush following 0.01-0.03 mg/kg of epinephrine via low umbilical venous catheter for persistent bradycardia despite effective positive pressure ventilation (PPV) and chest compressions (CC). We evaluated the effects of 1 mL vs 3 mL/kg flush volumes and 0.01 vs 0.03 mg/kg doses on return of spontaneous circulation (ROSC) and epinephrine pharmacokinetics in lambs with cardiac arrest.

Design: Forty term lambs in cardiac arrest were randomised to receive 0.01 or 0.03 mg/kg epinephrine followed by 1 mL or 3 mL/kg flush after effective PPV and CC. Epinephrine (with 1 mL flush) was repeated every 3 min until ROSC or until 20 min. Haemodynamics, blood gases and plasma epinephrine concentrations were monitored.

Results: Ten lambs had ROSC before epinephrine administration and 2 died during instrumentation. Among 28 lambs that received epinephrine, 2/6 in 0.01 mg/kg-1 mL flush, 3/6 in 0.01 mg/kg-3 mL/kg flush, 5/7 in 0.03 mg/kg-1 mL flush and 9/9 in 0.03 mg/kg-3 mL/kg flush achieved ROSC (p=0.02). ROSC was five times faster with 0.03 mg/kg epinephrine compared with 0.01 mg/kg (adjusted HR (95% CI) 5.08 (1.7 to 15.25)) and three times faster with 3 mL/kg flush compared with 1 mL flush (3.5 (1.27 to 9.71)). Plasma epinephrine concentrations were higher with 0.01 mg/kg-3 mL/kg flush (adjusted geometric mean ratio 6.0 (1.4 to 25.7)), 0.03 mg/kg-1 mL flush (11.3 (2.1 to 60.3)) and 0.03 mg/kg-3 mL/kg flush (11.0 (2.2 to 55.3)) compared with 0.01 mg/kg-1 mL flush.

Conclusions: 0.03 mg/kg epinephrine dose with 3 mL/kg flush volume is associated with the highest ROSC rate, increases peak plasma epinephrine concentrations and hastens time to ROSC. Clinical trials evaluating optimal epinephrine dose and flush volume are warranted.
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http://dx.doi.org/10.1136/archdischild-2020-321034DOI Listing
March 2021

Impact of high-sensitivity cardiac troponin implementation on emergency department length of stay, testing, admissions, and diagnoses.

Am J Emerg Med 2021 07 19;45:54-60. Epub 2021 Feb 19.

Department of Emergency Medicine, University of California, Davis, USA. Electronic address:

Objective: While high-sensitivity (hs) troponin (cTn) has been associated with shorter emergency department (ED) length of stay (LOS) and decreased hospital admissions outside the United States (US), concerns have been raised that it will have opposite effects in the US. In this study, we aimed to compare ED LOS, admissions, and acute coronary syndrome (ACS) diagnoses before and after the implementation of hs-cTn.

Methods: We conducted a single-institution, retrospective study of two temporally matched six-month study periods before and after the implementation of hs-cTn. We included consecutive adults presenting with chest pain. The primary outcome was ED LOS, which was log transformed and analyzed using multiple linear regression. Binary secondary outcomes of admissions, cardiac testing, cardiology consultation, and ACS diagnoses were analyzed using multiple logistic regression.

Results: We studied 1589 visits before and 1616 visits after implementation of hs-cTn. Median age and sex ratios were similar between study periods. Median ED LOS was longer in the post-implementation period [post: 384 (interquartile range, IQR 260-577) minutes; pre: 374 (IQR 250-564) minutes; adjusted geometric mean ratio 1.05; 95% confidence interval, CI 1.01-1.10)]. Admissions were lower in the post-implementation period [post: 24% (385/1616) vs. pre: 28% (447/1589); adjusted odds ratio, aOR 0.75 (95% CI 0.64-0.88)]. Cardiac risk stratification testing [pre: 9% (142/1589) vs post: 9% (144/1616); aOR 0.95 (95% CI 0.74-1.22)], cardiology consultation [pre: 13% (208/1589) vs post: 13% (207/1616); aOR 0.91 (95% CI 0.73-1.12)], and ACS diagnoses [pre: 7% (116/1589) vs post: 7% (120/1616); aOR 0.94 (95% CI 0.72-1.24)] were similar between the two study periods.

Conclusion: In this single-center study, transition to hs-cTn was associated with an increased ED LOS, decreased admissions, and no substantial change in cardiac risk stratification testing, cardiology consultation, or ACS diagnoses.
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http://dx.doi.org/10.1016/j.ajem.2021.02.021DOI Listing
July 2021

Watchful waiting as a strategy to reduce low-value spinal imaging: study protocol for a randomized trial.

Trials 2021 Feb 27;22(1):167. Epub 2021 Feb 27.

Center for Healthcare Policy and Research, University of California, Davis, Davis, USA.

Background: Patients with acute low back pain frequently request diagnostic imaging, and clinicians feel pressure to acquiesce to such requests to sustain patient trust and satisfaction. Spinal imaging in patients with acute low back pain poses risks from diagnostic evaluation of false-positive findings, patient labeling and anxiety, and unnecessary treatment (including spinal surgery). Watchful waiting advice has been an effective strategy to reduce some low-value treatments, and some evidence suggests a watchful waiting approach would be acceptable to many patients requesting diagnostic tests.

Methods: We will use key informant interviews of clinicians and focus groups with primary care patients to refine a theory-informed standardized patient-based intervention designed to teach clinicians how to advise watchful waiting when patients request low-value spinal imaging for low back pain. We will test the effectiveness of the intervention in a randomized clinical trial. We will recruit 8-10 primary care and urgent care clinics (~ 55 clinicians) in Sacramento, CA; clinicians will be randomized 1:1 to intervention and control groups. Over a 3- to 6-month period, clinicians in the intervention group will receive 3 visits with standardized patient instructors (SPIs) portraying patients with acute back pain; SPIs will instruct clinicians in a three-step model emphasizing establishing trust, empathic communication, and negotiation of a watchful waiting approach. Control physicians will receive no intervention. The primary outcome is the post-intervention rate of spinal imaging among actual patients with acute back pain seen by the clinicians adjusted for rate of imaging during a baseline period. Secondary outcomes are use of targeted communication techniques during a follow-up visit with an SP, clinician self-reported use of watchful waiting with actual low back pain patients, post-intervention rates of diagnostic imaging for other musculoskeletal pain syndromes (to test for generalization of intervention effects beyond back pain), and patient trust and satisfaction with physicians.

Discussion: This trial will determine whether standardized patient instructors can help clinicians develop skill in negotiating a watchful waiting approach with patients with acute low back pain, thereby reducing rates of low-value spinal imaging. The trial will also examine the possibility that intervention effects generalize to other diagnostic tests.

Trial Registration: ClinicalTrials.gov NCT04255199 . Registered on January 20, 2020.
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http://dx.doi.org/10.1186/s13063-021-05106-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7910785PMC
February 2021

Frailty, Race/Ethnicity, Functional Status, and Adverse Outcomes After Total Hip/Knee Arthroplasty: A Moderation Analysis.

J Arthroplasty 2021 06 21;36(6):1895-1903. Epub 2021 Jan 21.

Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, CA.

Background: Although frailty has been shown to be associated with adverse outcomes in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), prior studies have not examined how race/ethnicity might moderate these associations. We aimed to assess race/ethnicity as a potential moderator of the associations of frailty and functional status with arthroplasty outcomes.

Methods: The National Surgical Quality Improvement Program was queried for patients who underwent THA or TKA from 2011 to 2017. Frailty was assessed using the modified frailty index. Regression analyses were conducted to examine associations connecting frailty/functional status with 30-day readmission, adverse discharge, and length of stay (LOS). Further analyses were conducted to investigate race/ethnicity as a potential moderator of these relationships.

Results: We identified 219,143 TKA and 130,022 THA patients. Frailty and nonindependent functional status were positively associated with all outcomes (P < .001). Compared to White non-Hispanic patients, Black non-Hispanic patients had higher odds for all outcomes after TKA (P < .001) and for adverse discharge/longer LOS after THA (P < .001). Similar associations were observed for Hispanics for the adverse discharge/LOS outcomes. Race/ethnicity moderated the effects of frailty in TKA for all outcomes and in THA for adverse discharge/LOS. Race/ethnicity moderated the effects of nonindependent function in TKA for adverse discharge/LOS and on LOS alone for THA.

Conclusion: Disparities for Black non-Hispanic and Hispanic patients persist for readmission, adverse discharge, and LOS. However, the effects of increasing frailty and nonindependent functional status on these outcomes were the most pronounced among White non-Hispanic patients.
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http://dx.doi.org/10.1016/j.arth.2021.01.033DOI Listing
June 2021

Evaluation of Seasonal Respiratory Virus Activity Before and After the Statewide COVID-19 Shelter-in-Place Order in Northern California.

JAMA Netw Open 2021 01 4;4(1):e2035281. Epub 2021 Jan 4.

Department of Pediatrics, University of California at Davis School of Medicine, Sacramento.

Importance: Public health initiatives that include shelter-in-place orders are expensive and unpopular. Demonstrating the success of these initiatives is essential to justify their systemic or individual cost.

Objective: To examine the association of a shelter-in-place order with lower rates of seasonal respiratory viral activity.

Design, Setting, And Participants: This cohort study with interrupted time series analysis obtained monthly counts of respiratory virus testing results at UC Davis Health from August 1, 2014, to July 31, 2020. Patients of all ages underwent testing conducted by the laboratory at UC Davis Health, a referral center for a 65 000-square-mile area that includes 33 counties and more than 6 million Northern California residents.

Exposures: A statewide shelter-in-place order was instituted on March 19, 2020, restricting residents to their homes except for traveling for essential activities. Large social gatherings were prohibited, schools were closed, and nonessential personnel worked remotely. Those who had to leave their homes were mandated to wear face masks, engage in frequent handwashing, and maintain physical distancing.

Main Outcomes And Measures: Positivity rates of common respiratory viruses within the community served by UC Davis Health.

Results: A total of 46 128 tests for viral respiratory pathogens over a 6-year period were included in the analysis. For the postexposure period (March 25-July 31), approximately 168 positive test results occurred for the studied organisms in the 2020 virus year, a positivity rate of 9.88 positive results per 100 tests that was much lower than the positivity rate of 29.90 positive results per 100 tests observed for this date range in the previous 5 virus years. In contrast, the positivity rates were similar for the preexposure time frame (August 1-March 24) in the 2020 virus year and for the same time periods in the 5 previous years (30.40 vs 33.68 positive results per 100 tests). In the regression analyses, statistically significant decreases in viral activity were observed in the postexposure period for influenza (93% decrease; incidence rate ratio [IRR], 0.07; 95% CI, 0.02-0.33) and for rhinovirus or enterovirus (81% decrease; IRR, 0.19; 95% CI, 0.09-0.39) infections. Lower rates of postexposure viral activity were seen for respiratory syncytial virus, parainfluenzavirus, coronaviruses, and adenoviruses; however, these associations were not statistically significant.

Conclusions And Relevance: Using interrupted time series analysis of testing for viral respiratory pathogens, this study found that statistically significant lower rates of common community respiratory viruses appeared to be associated with a shelter-in-place order during the coronavirus disease 2019 pandemic.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.35281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7835714PMC
January 2021

Cases of Sexual Assault Prevented in an Athletic Coach-Delivered Gender Violence Prevention Program.

Prev Sci 2021 05 22;22(4):504-508. Epub 2021 Jan 22.

Division of Adolescent and Young Adult Medicine, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, 120 Lytton Avenue, Suite 302, Pittsburgh, PA, 15213, USA.

Sexual violence (SV) is pervasive and economically burdensome in the USA. According to the CDC, SV prevention could avert $122,461 in costs per victim of rape, totaling an estimated $3.1 trillion. Coaching Boys into Men (CBIM) is an evidence-based dating abuse and SV prevention program found to reduce dating abuse and SV perpetration among male high school athletes and dating abuse among middle school athletes. This secondary data analysis of CBIM's high school (N = 1520) and middle school (N = 973) RCTs estimated the incidence of dating abuse, sexual harassment, and sexual assault that CBIM could prevent as well as the potential cost savings. Ten items measured dating abuse, with a subset measuring sexual assault and sexual harassment, among participants who had ever dated a female. Perpetration measures were dichotomized as present or absent. Maximum likelihood estimates of Poisson-distributed event rates allowed for possible multiple incidents of perpetration per athlete. Among high school athletes, CBIM was associated with a relative reduction of 85 incidents of dating abuse (95%CI 24, 146), 48 incidents of sexual harassment (95%CI 3.8, 92), and 20 incidents of sexual assault (95%CI 1.7, 38) per 1,000 athletes. Results among middle school athletes demonstrated similar, albeit non-significant, trends. Based on the reduction of sexual assaults among high school athletes alone, CBIM may have resulted in $2.4 million reduction in costs per 1000 athletes exposed. CBIM may be associated with significant sexual assault-related cost reductions. Given the low costs and time needed to implement the program, sexual and dating violence prevention programs like CBIM may result in substantial economic benefits.
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http://dx.doi.org/10.1007/s11121-021-01210-1DOI Listing
May 2021

Should There Be a Recommended Daily Intake of Microbes?

J Nutr 2020 12;150(12):3061-3067

International Scientific Association for Probiotics and Prebiotics, Centennial, CO, USA.

The collective findings from human microbiome research, randomized controlled trials on specific microbes (i.e., probiotics), and associative studies of fermented dairy consumption provide evidence for the beneficial effects of the regular consumption of safe live microbes. To test the hypothesis that the inclusion of safe, live microbes in the diet supports and improves health, we propose assessment of the types and evidentiary quality of the data available on microbe intake, including the assembly and evaluation of evidence available from dietary databases. Such an analysis would help to identify gaps in the evidence needed to test this hypothesis, which can then be used to formulate and direct initiatives focused on prospective and randomized controlled trials on live microbe consumption. Outcomes will establish whether or not the evidence exists, or can be generated, to support the establishment of dietary recommendations for live microbes.
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http://dx.doi.org/10.1093/jn/nxaa323DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7726123PMC
December 2020

Impact of telemedicine on visit attendance for paediatric patients receiving endocrinology specialty care.

J Telemed Telecare 2020 Nov 23:1357633X20972911. Epub 2020 Nov 23.

Department of Pediatrics, University of California Davis, USA.

Background: Children in rural communities often lack access to subspecialty medical care. Telemedicine has the potential to improve access to these services but its effectiveness has not been rigorously evaluated for paediatric patients with endocrine conditions besides diabetes.

Introduction: The purpose of this study was to assess the association between telemedicine and visit attendance among patients who received care from paediatric endocrinologists at an academic medical centre in northern California between 2009-2017.

Methods: We abstracted demographic data, encounter information and medical diagnoses from the electronic health record for patients ≤18 years of age who attended at least one in-person or telemedicine encounter with a paediatric endocrinologist during the study period. We used a mixed effects logistic regression model - adjusted for age, diagnosis and distance from subspecialty care - to explore the association between telemedicine and visit attendance.

Results: A total of 40,941 encounters from 5083 unique patients were included in the analysis. Patients who scheduled telemedicine visits were predominantly publicly insured (97%) and lived a mean distance of 161 miles from the children's hospital. Telemedicine was associated with a significantly higher odds of visit attendance (odds ratio 2.55, 95% confidence interval 2.15-3.02,  < 0.001) compared to in-person care.

Conclusions: This study demonstrates that telemedicine is associated with higher odds of visit attendance for paediatric endocrinology patients and supports the conclusion that use of telemedicine may improve access to subspecialty care for rural and publicly insured paediatric populations.
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http://dx.doi.org/10.1177/1357633X20972911DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141067PMC
November 2020

Impact of a Parent Video Viewing Program in the Neonatal Intensive Care Unit.

Telemed J E Health 2021 06 25;27(6):679-685. Epub 2020 Sep 25.

Department of Pediatrics, UC Davis Health, Sacramento, California, USA.

Video visits, or televisits, have become increasingly popular across various medical subspecialties. Within the University of California, Davis, Neonatal Intensive Care Unit, a video visitation program known as FamilyLink allows families to remotely view their babies when they are otherwise unable to visit. This study aimed to explore parents' perceived effects of video camera use as well as the relationship of video visit use with rates of breast milk feedings at hospital discharge. Families enrolled in this study completed a series of two identical surveys that gathered self-reported data on their experiences during their infant's hospitalization. Comparisons were made considering whether the FamilyLink program was utilized during the admission as well as changes in self-reported experiences over the time course of the hospital admission. The type of enteral feeding at discharge was recorded and reviewed for each baby. Of 100 families enrolled in the study, 30 were found to have used FamilyLink to visit with their baby. The use of FamilyLink was associated with survey findings of sustained intention to breastfeed or provide breast milk to the baby, as well as increased perceived parental involvement in the baby's care. Improved rates of breast milk feedings at the time of discharge were also found among babies whose families conducted televisits using FamilyLink. Video viewing in the NICU has effected a positive impact on breast milk feedings and parents' feelings of involvement during the admission, with the potential to further improve on families' experiences with a hospitalized baby.
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http://dx.doi.org/10.1089/tmj.2020.0251DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8215426PMC
June 2021

Allopregnanolone and perampanel as adjuncts to midazolam for treating diisopropylfluorophosphate-induced status epilepticus in rats.

Ann N Y Acad Sci 2020 11 11;1480(1):183-206. Epub 2020 Sep 11.

Department of Neurology, School of Medicine, University of California, Davis, Sacramento, California.

Combinations of midazolam, allopregnanolone, and perampanel were assessed for antiseizure activity in a rat diisopropylfluorophosphate (DFP) status epilepticus model. Animals receiving DFP followed by atropine and pralidoxime exhibited continuous high-amplitude rhythmical electroencephalography (EEG) spike activity and behavioral seizures for more than 5 hours. Treatments were administered intramuscularly 40 min after DFP. Seizures persisted following midazolam (1.8 mg/kg). The combination of midazolam with either allopregnanolone (6 mg/kg) or perampanel (2 mg/kg) terminated EEG and behavioral status epilepticus, but the onset of the perampanel effect was slow. The combination of midazolam, allopregnanolone, and perampanel caused rapid and complete suppression of EEG and behavioral seizures. In the absence of DFP, animals treated with the three-drug combination were sedated but not anesthetized. Animals that received midazolam alone exhibited spontaneous recurrent EEG seizures, whereas those that received the three-drug combination did not, demonstrating antiepileptogenic activity. All combination treatments reduced neurodegeneration as assessed with Fluoro-Jade C staining to a greater extent than midazolam alone, and most reduced astrogliosis as assessed by GFAP immunoreactivity but had mixed effects on markers of microglial activation. We conclude that allopregnanolone, a positive modulator of the GABA receptor, and perampanel, an AMPA receptor antagonist, are potential adjuncts to midazolam in the treatment of benzodiazepine-refractory organophosphate nerve agent-induced status epilepticus.
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http://dx.doi.org/10.1111/nyas.14479DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7756871PMC
November 2020

Diagnostic Reclassification by a High-Sensitivity Cardiac Troponin Assay.

Ann Emerg Med 2020 11 15;76(5):566-579. Epub 2020 Aug 15.

Department of Pathology and Laboratory Medicine, University of California, Davis, Sacramento, CA.

Study Objective: Our objective is to describe the rates of diagnostic reclassification between conventional cardiac troponin I (cTnI) and high-sensitivity cardiac troponin T (hs-cTnT) and between combined and sex-specific hs-cTnT thresholds in adult emergency department (ED) patients in the United States.

Methods: We conducted a prospective, single-center, before-and-after, observational study of ED patients aged 18 years or older undergoing single or serial cardiac troponin testing in the ED for any reason before and after hs-cTnT implementation. Conventional cTnI and hs-cTnT results were obtained from a laboratory quality assurance database. Combined and sex-specific thresholds were the published 99th percentile upper reference limits for each assay. Cases underwent physician adjudication using the Fourth Universal Definition of Myocardial Infarction. Diagnostic reclassification occurred when a patient received a diagnosis of myocardial infarction or myocardial injury with one assay but not the other assay. Our primary outcome was diagnostic reclassification between the conventional cTnI and hs-cTnT assays. Diagnostic reclassification probabilities were assessed with sample proportions and 95% confidence intervals for binomial data.

Results: We studied 1,016 patients (506 men [50%]; median age 60 years [25th, 75th percentiles 49, 71]). Between the conventional cTnI and hs-cTnT assays, 6 patients (0.6%; 95% confidence interval 0.2% to 1.3%) underwent diagnostic reclassification regarding myocardial infarction (5/6 reclassified as no myocardial infarction) and 166 patients (16%; 95% confidence interval 14% to 19%) underwent diagnostic reclassification regarding myocardial injury (154/166 reclassified as having myocardial injury) by hs-cTnT.

Conclusion: Compared with conventional cTnI, the hs-cTnT assay resulted in no clinically relevant change in myocardial infarction diagnoses but substantially more myocardial injury diagnoses.
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http://dx.doi.org/10.1016/j.annemergmed.2020.06.047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7606506PMC
November 2020

Midlife vulnerability and food insecurity: Findings from low-income adults in the US National Health Interview Survey.

PLoS One 2020 13;15(7):e0233029. Epub 2020 Jul 13.

Communication Department, University of California, Davis, CA, United States of America.

Background: Food insecurity, limited access to adequate food, in adulthood is associated with poor health outcomes that suggest a pattern of accelerated aging. However, little is known about factors that impact food insecurity in midlife which in turn could help to identify potential pathways of accelerated aging.

Methods: Low-income adults (n = 17,866; 2014 National Health Interview Survey), ages 18 to 84, completed a 10-item food security module and answered questions regarding health challenges (chronic conditions and functional limitations) and financial worry. We used multinomial logistic regression for complex samples to assess the association of health challenges and financial worry with food insecurity status and determine whether these associations differed by age group, while adjusting for poverty, sex, race/ethnicity, education, family structure, social security, and food assistance.

Results: Food insecurity rates were highest in late- (37.5%) and early- (36.0%) midlife, relative to younger (33.7%) and older (20.2%) age groups and, furthermore, age moderated the relationship between food insecurity and both risk factors (interaction p-values < .05, for both). The effects of poor health were stronger in midlife relative to younger and older ages. Unlike younger and older adults, however, adults in midlife showed high levels of food insecurity regardless of financial worry.

Conclusions: Findings suggest that food insecurity in midlife may be more severe than previously thought. Greater efforts are needed to identify those at greatest risk and intervene early to slow premature aging.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0233029PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7357765PMC
September 2020

Association of Adherence to Weight Telemonitoring With Health Care Use and Death: A Secondary Analysis of a Randomized Clinical Trial.

JAMA Netw Open 2020 07 1;3(7):e2010174. Epub 2020 Jul 1.

Center for Healthcare Policy and Research, Division of General Medicine, University of California, Davis, Sacramento.

Importance: Adherence to telemonitoring may be associated with heart failure exacerbation but is not included in telemonitoring algorithms.

Objective: To assess whether telemonitoring adherence is associated with a patient's risk of hospitalization, emergency department visit, or death.

Design, Setting, And Participants: This post hoc secondary analysis of the Better Effectiveness After Transition-Heart Failure randomized clinical trial included patients from 6 academic medical centers in California who were eligible if they were hospitalized for decompensated heart failure and excluded if they were discharged to a skilled nursing facility, were expected to improve because of a medical procedure, or did not have the cognitive or physical ability to participate. The trial compared a telemonitoring intervention with usual care for patients with heart failure after hospital discharge from October 12, 2011, to September 30, 2013. Data analysis was performed from November 8, 2016, to May 10, 2019.

Interventions: The intervention group (n = 722) received heart failure education, telephone check-ins, and a wireless telemonitoring system that allowed the patient to transmit weight, blood pressure, heart rate, and selected symptoms. The control group (n = 715) received usual care. Patients were followed up for 180 days after discharge.

Main Outcomes And Measures: The main outcome was within-person risk of hospitalization, emergency department visit, or death by week during the study period. Poisson regression was used to determine the within-person association of adherence to daily weighing with the risk of experiencing these events in the following week.

Results: Among the 538 participants (mean [SD] age, 70.9 [14.1] years; 287 [53.8%] male; 269 [50.7%] white) in the present analysis, adherence was lowest during the first week after enrollment but steadily increased, peaking between days 26 and 60 at 69%, or 371 transmissions. Adherence to weight telemonitoring was associated with events in the following week; an increase in adherence by 1 day was associated with a 19% decrease in the rate of death in the following week (incidence rate ratio, 0.81; 95% CI, 0.73-0.90) and an 11% decrease in the rate of hospitalization (incidence rate ratio, 0.89; 95% CI, 0.86-0.91). Adherence in the previous week was not associated with reduced rates of emergency department visits (incidence rate ratio, 0.95; 95% CI, 0.90-1.02).

Conclusions And Relevance: In this study, lower adherence to weight telemonitoring in a given week was associated with an increased risk of subsequent hospitalization or death in the following week. It is unlikely that this is a result of the telemonitoring intervention; rather, adherence may be an important factor associated with a patient's health status.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.10174DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7352152PMC
July 2020

Pediatric Program Director Minimum Milestone Expectations Before Allowing Supervision of Others and Unsupervised Practice.

Acad Pediatr 2020 Nov - Dec;20(8):1063-1065. Epub 2020 May 22.

Departments of Pediatrics and the Center for Healthcare Policy and Research, University of California Davis (DJ Tancredi), Sacramento, Calif.

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http://dx.doi.org/10.1016/j.acap.2020.05.011DOI Listing
July 2021

The Effect of Rehospitalization and Emergency Department Visits on Subsequent Adherence to Weight Telemonitoring.

J Cardiovasc Nurs 2021 Sep-Oct 01;36(5):482-488

Background: Weight telemonitoring may be an effective way to improve patients' ability to manage heart failure and prevent unnecessary utilization of health services. However, the effectiveness of such interventions is dependent upon patient adherence.

Objective: The purpose of this study was to determine how adherence to weight telemonitoring changes in response to 2 types of events: hospital readmissions and emergency department visits.

Methods: The Better Effectiveness After Transition-Heart Failure trial examined the effectiveness of a remote telemonitoring intervention compared with usual care for patients discharged to home after hospitalization for decompensated heart failure. Participants were followed for 180 days and were instructed to transmit weight readings daily. We used Poisson regression to determine the within-person effects of events on subsequent adherence.

Results: A total of 625 events took place during the study period. Most of these events were rehospitalizations (78.7%). After controlling for the number of previous events and discharge to a skilled nursing facility, the rate for adherence decreased by nearly 20% in the 2 weeks after a hospitalization compared with the 2 weeks before (adjusted rate ratio, 0.81; 95% confidence interval: 0.77-0.86; P < .001).

Conclusions: Experiencing a rehospitalization had the effect of diminishing adherence to daily weighing. Providers using telemonitoring to monitor decompensation and manage medications should take advantage of the potential "teachable moment" during hospitalization to reinforce the importance of adherence.
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http://dx.doi.org/10.1097/JCN.0000000000000689DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8091911PMC
May 2020

Probiotics as a Tx resource in primary care.

J Fam Pract 2020 04;69(3):E1-E10

University of California Davis School of Medicine and Center for Healthcare Policy and Research, Sacramento, USA.

While probiotics have not been marketed as drugs, clinicians can still recommend them in an evidence-based manner.
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April 2020

Assessment of primary outcome measures for a clinical trial of pediatric hemorrhagic injuries.

Am J Emerg Med 2021 05 9;43:210-216. Epub 2020 Mar 9.

Departments of Emergency Medicine and Pediatrics, UC Davis School of Medicine, 4150 V. Street, PSSB 2100, Sacramento, CA 95817, United States of America. Electronic address:

Objective: We evaluated the acceptability of the Pediatric Quality of Life Inventory (PedsQL) and other outcomes as the primary outcomes for a pediatric hemorrhagic trauma trial (TIC-TOC) among clinicians.

Methods: We conducted a mixed-methods study that included an electronic questionnaire followed by teleconference discussions. Participants confirmed or rejected the PedsQL as the primary outcome for the TIC-TOC trial and evaluated and proposed alternative primary outcomes. Responses were compiled and a list of themes and representative quotes was generated.

Results: 73 of 91 (80%) participants completed the questionnaire. 61 (84%) participants agreed that the PedsQL is an appropriate primary outcome for children with hemorrhagic brain injuries. 32 (44%) participants agreed that the PedsQL is an acceptable primary outcome for children with hemorrhagic torso injuries, 27 (38%) participants were neutral, and 13 (18%) participants disagreed. Several themes were identified from responses, including that the PedsQL is an important and patient-centered outcome but may be affected by other factors, and that intracranial hemorrhage progression assessed by brain imaging (among patients with brain injuries) or blood product transfusion requirements (among patients with torso injuries) may be more objective outcomes than the PedsQL.

Conclusions: The PedsQL was a well-accepted proposed primary outcome for children with hemorrhagic brain injuries. Traumatic intracranial hemorrhage progression was favored by a subset of clinicians. A plurality of participants also considered the PedsQL an acceptable outcome for children with hemorrhagic torso injuries. Blood product transfusion requirement was favored by fewer participants.
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http://dx.doi.org/10.1016/j.ajem.2020.03.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7483869PMC
May 2021

The Impact of Telemedicine on Transfer Rates of Newborns at Rural Community Hospitals.

Acad Pediatr 2020 07 17;20(5):636-641. Epub 2020 Feb 17.

Department of Pediatrics, UC Davis Health (SC Haynes, M Dharmar, KR Hoffman, LT Donohue, KM Kuhn-Riordon, CA Rottkamp, P Vali, DJ Tancredi, and JP Marcin), Sacramento, Calif.

Background And Objective: Telemedicine may have the ability to reduce avoidable transfers by allowing remote specialists the opportunity to more effectively assess patients during consultations. In this study, we examined whether telemedicine consultations were associated with reduced transfer rates compared to telephone consultations among a cohort of term and late preterm newborns. We hypothesized that neonatologist consultations conducted over telemedicine would result in fewer interfacility transfers than consultations conducted over telephone.

Methods: We collected data on all newborns who received a neonatal telemedicine or telephone consultation at 6 rural hospitals in northern and central California between August 2014 and June 2018. We used adjusted analyses to compare transfer rates between telemedicine and telephone cohorts.

Results: A total of 317 patients were included in the analysis; 89 (28.1%) of these patients received a telemedicine consultation and 228 (71.9%) received a telephone consultation only. The overall transfer rate was 77.0%. Patient consultations conducted using telemedicine were significantly less likely to result in a transfer than patient consultations conducted using the telephone (64.0% vs 82.0%, P = .001). After controlling for 5-minute Apgar score, birthweight, gestational age, site of consultation, and Transport Risk Index of Physiologic Stability score, the odds of transfer for telemedicine consultations was 0.48 (95% confidence interval: 0.26, 0.90, P = .02).

Conclusions: Our findings suggest that telemedicine may have the potential to reduce potentially avoidable transfers of term and late preterm newborns. Future research on potentially avoidable transfers and patient outcomes is needed to better understand the ways in which telemedicine affects clinical decision-making.
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http://dx.doi.org/10.1016/j.acap.2020.02.013DOI Listing
July 2020

Establishing a case definition of thiamine responsive disorders among infants and young children in Lao PDR: protocol for a prospective cohort study.

BMJ Open 2020 02 13;10(2):e036539. Epub 2020 Feb 13.

Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic.

Introduction: Diagnosis of infantile thiamine deficiency disorders (TDD) is challenging due to the non-specific, highly variable clinical presentation, often leading to misdiagnosis. Our primary objective is to develop a case definition for thiamine responsive disorders (TRD) to determine among hospitalised infants and young children, which clinical features and risk factors identify those who respond positively to thiamine administration.

Methods And Analysis: This prospective study will enrol 662 children (aged 21 days to <18 months) seeking treatment for TDD symptoms. Children will be treated with intravenous or intramuscular thiamine (100 mg daily for a minimum of 3 days) alongside other interventions deemed appropriate. Baseline assessments, prior to thiamine administration, include a physical examination, echocardiogram and venous blood draw for the determination of thiamine biomarkers. Follow-up assessments include physical examinations (after 4, 8, 12, 24, 36, 48 and 72 hours), echocardiogram (after 24 and 48 hours) and one cranial ultrasound. During the hospital stay, maternal blood and breast-milk samples and diet, health, anthropometric and socio-demographic information will be collected for mother-child pairs. Using these data, a panel of expert paediatricians will determine TRD status for use as the dependent variable in logistic regression models. Models identifying predictors of TRD will be developed and validated for various scenarios. Clinical prediction model performance will be quantified by empirical area under the receiver operating characteristic curve, using resampling cross validation. A frequency-matched community-based cohort of mother-child pairs (n=265) will serve as comparison group for evaluation of potential risk factors for TRD.

Ethics And Dissemination: Ethical approval has been obtained from The National Ethics Committee for Health Research, Ministry of Health, Lao PDR and the Institutional Review Board of the University of California Davis. The results will be disseminated via scientific articles, presentations and workshops with representatives of the Ministry of Health.

Trial Registration Number: NCT03626337.
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http://dx.doi.org/10.1136/bmjopen-2019-036539DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7044841PMC
February 2020

An Iterative Quality Improvement Process Improves Pediatric Ward Discharge Efficiency.

Hosp Pediatr 2020 03 12;10(3):214-221. Epub 2020 Feb 12.

Department of Pediatrics, University of California, Davis, Sacramento, California.

Objectives: Discharge of hospitalized pediatric patients may be delayed for various "nonmedical" reasons. Such delays impact hospital flow and contribute to hospital crowding. We aimed to improve discharge efficiency for our hospitalized pediatric patients by using an iterative quality improvement (QI) process.

Methods: Opportunities for improved efficiency were identified using value stream mapping, root cause, and benefit-effort analyses. QI interventions were focused on altered physician workflow, standardized discharge checklists, and physician workshops by using multiple plan-do-study-act cycles. The primary outcome of percentage of discharges before noon, process measure of percentage of discharges with orders before 10 am, and balancing measures of readmission rate, emergency department revisit rate, and parent experience survey scores were analyzed by using statistical process control. The secondary outcome of mean length of stay was analyzed using tests and linear regression.

Results: Implementation of our interventions was associated with special cause variation, with an upward shift in mean percentage of discharges before noon from 13.2% to 18.5%. Mean percentage of patients with discharge orders before 10 am also increased from 13.6% to 23.6% and met rules for special cause. No change was detected in a control group. Adjusted mean length of stay index, 30-day readmissions, and parent experience survey scores remained unchanged. Special cause variation indicated a decreased 48-hour emergency department revisit rate associated with our interventions.

Conclusions: An iterative QI process improved discharge efficiency without negatively affecting subsequent hospital use or parent experience. With this study, we support investment of resources into improving pediatric discharge efficiency through value stream mapping and rapid cycle QI.
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http://dx.doi.org/10.1542/hpeds.2019-0158DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7041555PMC
March 2020
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