Publications by authors named "Huong Q Nguyen"

94 Publications

Spiritual distress: symptoms, quality of life and hospital utilisation in home-based palliative care.

BMJ Support Palliat Care 2021 Jun 4. Epub 2021 Jun 4.

Department of Research and Evaluation, Kaiser Permanente Southern California Research and Evaluation, Pasadena, California, USA

Objectives: The purpose of this study was to use a spiritual screening question to quantify the prevalence of spiritual distress (SD) in a large cohort of seriously ill patients at admission to home-based palliative care (HBPC) and to examine the associations between SD with symptom burden, quality of life and hospital-based utilisation up to 6 months after admission to HBPC.

Methods: Data for this cohort study (n=658) were drawn from a pragmatic comparative-effectiveness trial testing two models of HBPC. At admission to HBPC, SD was measured using a global question (0-10-point scale: none=0; mild=1-4; moderate-to-severe=5+); symptoms and quality of life were measured with the Edmonton Symptom Assessment Scale (ESAS) and PROMIS-10. Hospital utilisation was captured using electronic records and claims. Median regression and proportional hazard competing risk models assessed the association between SD with symptoms and quality of life, and hospital utilisation, respectively.

Results: Nearly half of the patients/proxies reported some level of SD. Increasing SD was significantly associated with higher symptom burden (increase of 7-14 points on ESAS) and worse mental well-being (decrease of 2.7 to 4.6 points on PROMIS-10-mental) in adjusted models. Compared with patients/proxies who reported no SD, those with at least some level of SD were not at increased risk for hospital-based utilisation over a median follow-up period of 2 months.

Conclusion: While SD is cross-sectionally associated with worse symptoms and mental well-being, it did not predict downstream hospital-based utilisation. Our results highlight the importance of assessing for and managing SD in patients with serious illness.
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http://dx.doi.org/10.1136/bmjspcare-2021-003090DOI Listing
June 2021

Development and psychometric properties of surveys to assess provider perspectives on the barriers and facilitators of effective care transitions.

BMC Health Serv Res 2021 May 20;21(1):478. Epub 2021 May 20.

Center for Health Services Research, University of Kentucky, Lexington, KY, USA.

Background: The quality of the discharge process and effective care transitions between settings of care are critical to minimize gaps in patient care and reduce hospital readmissions. Few studies have explored which care transition components and strategies are most valuable to patients and providers. This study describes the development, pilot testing, and psychometric analysis of surveys designed to gain providers' perspectives on current practices in delivering transitional care services.

Methods: We underwent a comprehensive process to develop items measuring unique aspects of care transitions from the perspectives of the three types of providers (downstream, ambulatory, and hospital providers). The process involved 1) an environmental scan, 2) provider interviews, 3) survey cognitive testing, 4) pilot testing, 5) a Stakeholder Advisory Group, 6) a Scientific Advisory Council, and 7) a collaborative Project ACHIEVE (Achieving Patient-Centered Care and Optimized Health in Care Transitions by Evaluating the Value of Evidence) research team. Three surveys were developed and fielded to providers affiliated with 43 hospitals participating in Project ACHIEVE. Web-based survey administration resulted in 948 provider respondents. We assessed response variability and response missingness. To evaluate the composites' psychometric properties, we examined intercorrelations of survey items, item factor loadings, model fit indices, internal consistency reliability, and intercorrelations between the composite measures and overall rating items.

Results: Results from psychometric analyses of the three surveys provided support for five composite measures: 1) Effort in Coordinating Patient Care, 2) Quality of Patient Information Received, 3) Organizational Support for Transitional Care, 4) Access to Community Resources, and 5) Strength of Relationships Among Community Providers. All factor loadings and reliability estimates were acceptable (loadings ≥ 0.40, α ≥ 0.70), and the fit indices showed a good model fit. All composite measures positively and significantly correlated with the overall ratings (0.13 ≤ r ≤ 0.71).

Conclusions: We determined that the items and composite measures assessing the barriers and facilitators to care transitions within this survey are reliable and demonstrate satisfactory psychometric properties. The instruments may be useful to healthcare organizations and researchers to assess the quality of care transitions and target areas of improvement across different provider settings.
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http://dx.doi.org/10.1186/s12913-021-06369-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8136156PMC
May 2021

Sociodemographic Characteristics and Physical Activity in Patients with COPD: A 3-Month Cohort Study.

COPD 2021 May 10:1-13. Epub 2021 May 10.

Department of Medicine, University of Washington, Seattle, WA, USA.

Decreased physical activity (PA) is associated with morbidity and mortality in COPD patients. In this secondary analysis of data from a 12-week longitudinal study, we describe factors associated with PA in COPD. Participants completed the Physical Activity Checklist (PAC) daily for a 7- to 8-day period. PA was measured monthly using the Physical Activity Scale for the Elderly (PASE). At three different time points, daily step count was measured for one week with an Omron HJ-720ITC pedometer. The 35 participants were primarily male (94%) and White (91%), with an average age of 66.5 years and FEV 44.9% predicted. Common activities reported on the PAC were walking (93%), preparing a meal (89%), and traveling by vehicle (96%). PA measured by both PASE score ( = 0.01) and average daily step count ( = 0.04) decreased during follow-up. In repeated measures multivariable modeling, participants living with others had a higher daily step count (ß = 942 steps, = 0.01) and better PASE scores (ß = 46.4, < 0.001). Older age was associated with decreased step count (ß = -77 steps, < 0.001) whereas White race was associated with lower PASE scores (ß = -55.4, < 0.001) compared to non-White race. Other demographic factors, quality of life, and medications were not associated with PA. A better understanding of the role of social networks and social support may help develop interventions to improve PA in COPD.
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http://dx.doi.org/10.1080/15412555.2021.1920902DOI Listing
May 2021

Characteristics of patients discharged and readmitted after COVID-19 hospitalisation within a large integrated health system in the United States.

Infect Dis (Lond) 2021 May 8:1-5. Epub 2021 May 8.

Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA.

Background: Limited studies have explored post-discharge outcomes following Coronavirus Disease 2019 (COVID-19) hospitalisation. We sought to characterise patients discharged following a COVID-19 hospitalisation within a large integrated health system in the United States.

Methods: We performed a retrospective study of 2180 COVID-19 patients discharged between 1 April 2020 and 31 July 2020. The primary endpoint was all-cause observation stay or inpatient readmission within 30 days from discharge. Bivariate and multivariable logistic regression analyses were performed to estimate the association between key socio-demographic and clinical characteristics with risk of 30-day readmission.

Results: The 30-day readmission rate was 7.6% ( = 166); 30-day mortality rate was 1% ( = 19). Most readmissions were respiratory-related (58%) and occurred at a median time of 5 days post discharge. Adjusted models showed that prior hospitalisations (Odds Ratio = 2.36, [95% Confidence Interval: 1.59-3.50]), chronic pulmonary disease (1.57 [1.09-2.28]), and discharge to home health (1.46 [1.01-2.11]) were significantly associated with 30-day readmission. Longer duration from diagnosis to index admission was borderline associated with lower odds of readmission (0.95 [0.91-1.00]).

Conclusion: Readmission and mortality rates for COVID-19 following discharge are low. Most readmissions occur early and are due to respiratory causes and may reflect the prolonged acute disease course.
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http://dx.doi.org/10.1080/23744235.2021.1924398DOI Listing
May 2021

COPD Comorbidity Profiles and 2-Year Trajectory of Acute and Postacute Care Use.

Chest 2021 Jun 19;159(6):2233-2243. Epub 2021 Jan 19.

Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA. Electronic address:

Background: Multiple morbidity is the norm in advanced COPD and contributes to high symptom burden and worse outcomes.

Research Question: Can distinct comorbidity profiles be identified and validated in a community-based sample of patients with COPD from a large integrated health care system using a standard, commonly used diagnostic code-based comorbidity index and downstream 2-year health care use data?

Study Design And Methods: In this retrospective cohort study, we used latent class analysis (LCA) to identify comorbidity profiles in a population-based sample of 91,453 patients with a COPD diagnosis between 2011 and 2015. We included specific comorbid conditions from the Charlson Comorbidity Index (CCI) and accounted for variation in underlying prevalence of different comorbidities across the three study sites. Sociodemographic, clinical, and health-care use data were obtained from electronic health records (EHRs). Multivariate logistic regression analysis was used to compare rates of acute and postacute care use by class.

Results: The mean age was 71 ± 11 years, 55% of patients were women, 23% of patients were people of color, and 80% of patients were former or current smokers. LCA identified four distinct comorbidity profiles with progressively higher CCI scores: low morbidity (61%; 1.9 ± 1.4), metabolic renal (21%; 4.7 ± 1.8), cardiovascular (12%; 4.6 ± 1.9), and multimorbidity (7%; 7.5 ± 1.7). In multivariate models, during 2 years of follow-up, a significant, nonoverlapping increase was found in the odds of having any all-cause acute (hospitalizations, observation stays, and ED visits) and postacute care use across the comorbidity profiles.

Interpretation: Distinct comorbidity profiles can be identified in patients with COPD using standard EHR-based diagnostic codes, and these profiles are associated with subsequent acute and postacute care use. Population-based risk stratification schemes for end-to-end, comprehensive COPD management should consider integrating comorbidity profiles such as those found in this study.
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http://dx.doi.org/10.1016/j.chest.2021.01.020DOI Listing
June 2021

Improving evidence-based grouping of transitional care strategies in hospital implementation using statistical tools and expert review.

BMC Health Serv Res 2021 Jan 7;21(1):35. Epub 2021 Jan 7.

Center for Health Services Research, University of Kentucky, Lexington, USA.

Background: As health systems transition to value-based care, improving transitional care (TC) remains a priority. Hospitals implementing evidence-based TC models often adapt them to local contexts. However, limited research has evaluated which groups of TC strategies, or transitional care activities, commonly implemented by hospitals correspond with improved patient outcomes. In order to identify TC strategy groups for evaluation, we applied a data-driven approach informed by literature review and expert opinion.

Methods: Based on a review of evidence-based TC models and the literature, focus groups with patients and family caregivers identifying what matters most to them during care transitions, and expert review, the Project ACHIEVE team identified 22 TC strategies to evaluate. Patient exposure to TC strategies was measured through a hospital survey (N = 42) and prospective survey of patients discharged from those hospitals (N = 8080). To define groups of TC strategies for evaluation, we performed a multistep process including: using ACHIEVE'S prior retrospective analysis; performing exploratory factor analysis, latent class analysis, and finite mixture model analysis on hospital and patient survey data; and confirming results through expert review. Machine learning (e.g., random forest) was performed using patient claims data to explore the predictive influence of individual strategies, strategy groups, and key covariates on 30-day hospital readmissions.

Results: The methodological approach identified five groups of TC strategies that were commonly delivered as a bundle by hospitals: 1) Patient Communication and Care Management, 2) Hospital-Based Trust, Plain Language, and Coordination, 3) Home-Based Trust, Plain language, and Coordination, 4) Patient/Family Caregiver Assessment and Information Exchange Among Providers, and 5) Assessment and Teach Back. Each TC strategy group comprises three to six, non-mutually exclusive TC strategies (i.e., some strategies are in multiple TC strategy groups). Results from random forest analyses revealed that TC strategies patients reported receiving were more important in predicting readmissions than TC strategies that hospitals reported delivering, and that other key co-variates, such as patient comorbidities, were the most important variables.

Conclusion: Sophisticated statistical tools can help identify underlying patterns of hospitals' TC efforts. Using such tools, this study identified five groups of TC strategies that have potential to improve patient outcomes.
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http://dx.doi.org/10.1186/s12913-020-06020-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7791839PMC
January 2021

Serotonin transporter gene polymorphisms and depressive symptoms in patients with chronic obstructive pulmonary disease.

Expert Rev Respir Med 2021 May 29;15(5):681-687. Epub 2020 Dec 29.

VA Puget Sound, University of Washington, Seattle, WA, USA.

: We examined the relationship between polymorphisms in the promoter region of the serotonin transport (SERT) gene (5-HTTLPR, short 'S' and long 'L' alleles) and in intron 2 variable number tandem repeat (STin2VNTR, 9, 10, or 12-repeat alleles) with depression or anxiety in patients with COPD.: 302 patients with moderate to severe COPD participated in SERT study. History and number of prior depressive episodes were measured using the Structured Clinical Interview for Depression; Hospital Anxiety Depression Scale (HAD) depression ≥8 or a Patient Health Questionnaire-9 (PHQ-9) >,10.: 240 (80%) male sample had a mean age of 68.0 years. Current depression was 22% (HAD) or 21% (PHQ-9), anxiety was 25% (HAD), and suicidal ideation (6%). 5-HTTLPR or STin2 VNTR genotypes were not associated with current depressive or anxiety symptoms. The mean number of prior depressive episodes was higher for patients with the 5-HTTLPR genotype S/S or S/L compared with L/L (4.4 ± 6.1; 5.3 ± 6.8; 4.0 ± 6.1, p < 0.001) and with STin2VNTR high-risk genotype (9/12 or 12/12), medium risk (9/10 or 10/12) compared to low risk (10/10) genotypes (5.1 ± 6.8; 4.9 ± 6.7; 2.7 ± 4.5, p < 0.001).: SERT 5-HTTLPR and STin2-VNTR polymorphisms were not associated with current depressive and anxiety symptoms, but the high-risk STin2-VNTR genotypes and S/L were associated with the number of prior depressive episodes.
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http://dx.doi.org/10.1080/17476348.2021.1865159DOI Listing
May 2021

Evaluation of a Transitional Care Program After Hospitalization for Heart Failure in an Integrated Health Care System.

JAMA Netw Open 2020 12 1;3(12):e2027410. Epub 2020 Dec 1.

Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena.

Importance: Prompted by null findings from several care transition trials and practice changes for heart failure in recent years, leaders from a large integrated health care system aimed to reassess the outcomes of its 10-year multicomponent transitional care program for heart failure (HF-TCP).

Objective: To examine the association of the individual HF-TCP components and their bundle with the primary outcome of all-cause 30-day inpatient or observation stay readmissions.

Design, Setting, And Participants: This retrospective cohort study included patients enrolled in the HF-TCP during an inpatient encounter for heart failure at 13 Kaiser Permanente Southern California hospitals from January 1, 2013, to October 31, 2018, who were followed up from discharge until 30 days, readmission, or death. Data were analyzed from May 7, 2019, to May 1, 2020, with additional review from September 2 to October 1, 2020.

Exposures: Patients received 1 home health visit or telecare (telephone) visit from a registered nurse within 2 days of hospital discharge, a heart failure care manager call within 7 days, and a clinic visit with a physician or a nurse practitioner within 7 days.

Main Outcomes And Measures: Multivariable proportional hazards regression models were used to estimate the probability of 30-day readmission for those who received the individual or bundled HF-TCP components compared with those who did not.

Results: A total of 26 128 patients were included; 57.0% were male, and the mean (SD) age was 73 (13) years. The 30-day readmission rate was 18.1%. Both exposure to a home health visit within 2 days of discharge (hazard ratio [HR], 1.03; 95% CI, 0.96-1.10) and a 7-day heart failure case manager call (HR, 1.08; 95% CI, 0.99-1.18) compared with no visit or call were not associated with a lower rate of readmission. Completion of a 7-day clinic visit was associated with a lower readmission rate (HR, 0.88; 95% CI, 0.81-0.94) compared with no clinic visit. There were no synergistic effects of all 3 components compared with clinic visit alone (HR, 1.05; 95% CI, 0.87-1.28).

Conclusions And Relevance: This study found that HF-TCP as a whole was not associated with a reduction in 30-day readmission rates, although a follow-up clinic visit within 7 days of discharge may be helpful. These findings highlight the importance of continuous quality improvement and refinement of existing clinical programs.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.27410DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7716192PMC
December 2020

Findings and lessons learnt from early termination of a pragmatic comparative effectiveness trial of video consultations in home-based palliative care.

BMJ Support Palliat Care 2020 Oct 13. Epub 2020 Oct 13.

Center for Health Research, Kaiser Permanente Northwest Region, Portland, Oregon, USA.

Background: Health systems need evidence about how best to deliver home-based palliative care (HBPC) to meet the growing needs of seriously ill patients. We hypothesised that a tech-supported model that aimed to promote timely inter-professional team coordination using video consultation with a remote physician while a nurse is in the patient's home would be non-inferior compared with a standard model that includes routine home visits by nurses and physicians.

Methods: We conducted a pragmatic, cluster randomised non-inferiority trial across 14 sites (HomePal Study). Registered nurses (n=111) were randomised to the two models so that approximately half of the patients with any serious illness admitted to HBPC and their caregivers were enrolled in each study arm. Process measures (video and home visits and satisfaction) were tracked. The primary outcomes for patients and caregivers were symptom burden and caregiving preparedness at 1-2 months.

Results: The study was stopped early after 12 months of enrolment (patients=3533; caregivers=463) due to a combination of low video visit uptake (31%), limited substitution of video for home visits, and the health system's decision to expand telehealth use in response to changes in telehealth payment policies, the latter of which was incompatible with the randomised design. Implementation barriers included persistent workforce shortages and inadequate systems that contributed to scheduling and coordination challenges and unreliable technology and connectivity.

Conclusions: We encountered multiple challenges to feasibility, relevance and value of conducting large, multiyear pragmatic randomised trials with seriously ill patients in the real-world settings where care delivery, regulatory and payment policies are constantly shifting.
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http://dx.doi.org/10.1136/bmjspcare-2020-002553DOI Listing
October 2020

Frailty in Chronic Obstructive Pulmonary Disease and Risk of Exacerbations and Hospitalizations.

Int J Chron Obstruct Pulmon Dis 2020 11;15:1967-1976. Epub 2020 Aug 11.

Department of Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.

Background: Frailty is a complex clinical syndrome associated with vulnerability to adverse health outcomes. While frailty is thought to be common in chronic obstructive pulmonary disease (COPD), the relationship between frailty and COPD-related outcomes such as risk of acute exacerbations of COPD (AE-COPD) and hospitalizations is unclear.

Purpose: To examine the association between physical frailty and risk of acute exacerbations, hospitalizations, and mortality in patients with COPD.

Methods: A longitudinal analysis of data from a cohort of 280 participants was performed. Baseline frailty measures included exhaustion, weakness, low activity, slowness, and undernutrition. Outcome measures included AE-COPD, hospitalizations, and mortality over 2 years. Negative binomial regression and Cox proportional hazard modeling were used.

Results: Sixty-two percent of the study population met criteria for pre-frail and 23% were frail. In adjusted analyses, the frailty syndrome was not associated with COPD exacerbations. However, among the individual components of the frailty syndrome, weakness measured by handgrip strength was associated with increased risk of COPD exacerbations (IRR 1.46, 95% CI 1.09-1.97). The frailty phenotype was not associated with all-cause hospitalizations but was associated with increased risk of non-COPD-related hospitalizations.

Conclusion: This longitudinal cohort study shows that a high proportion of patients with COPD are pre-frail or frail. The frailty phenotype was associated with an increased risk of non-COPD hospitalizations but not with all-cause hospitalizations or COPD exacerbations. Among the individual frailty components, low handgrip strength was associated with increased risk of COPD exacerbations over a 2-year period. Measuring handgrip strength may identify COPD patients who could benefit from programs to reduce COPD exacerbations.
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http://dx.doi.org/10.2147/COPD.S245505DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7429100PMC
August 2020

Embedded Research in the Learning Healthcare System: Ongoing Challenges and Recommendations for Researchers, Clinicians, and Health System Leaders.

J Gen Intern Med 2020 12 29;35(12):3675-3680. Epub 2020 May 29.

Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA.

Embedded research is an innovative means to improve performance in the learning healthcare system (LHS). However, few descriptions of successful embedded research programs have been published. In this perspective, we describe the Care Improvement Research Team, a mature partnership between researchers and clinicians at Kaiser Permanente Southern California. The program supports a core team of researchers and staff with dedicated resources to partner with health system leaders and practicing clinicians, using diverse methods to identify and rectify gaps in clinical practice. For example, recent projects helped clinicians to provide better care by reducing prescribing of unnecessary antibiotics for acute sinusitis and by preventing readmissions among the elderly. Embedded in operational workgroups, the team helps formulate research questions and enhances the rigor and relevance of data collection and analysis. A recent business-case analysis cited savings to the organization of over $10 million. We conclude that embedded research programs can play a key role in fulfilling the promise of the LHS. Program success depends on dedicated funding, robust data systems, and strong relationships between researchers and clinical stakeholders. Embedded researchers must be responsive to health system priorities and timelines, while clinicians should embrace researchers as partners in problem solving.
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http://dx.doi.org/10.1007/s11606-020-05865-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7728937PMC
December 2020

Association between self-reported moderate to vigorous physical activity and the rate of outpatient treated COPD exacerbations: retrospective cohort study.

BMJ Open Respir Res 2020 05;7(1)

Research and Evaluation, Kaiser Permanente Southern California Research and Evaluation, Pasadena, California, USA.

Introduction: Little has been published regarding the relationship between physical activity (PA) and outpatient treated, mild to moderate acute exacerbation of chronic obstructive pulmonary disease exacerbations (AECOPD). The purpose of this study was to determine the association between self-reported PA and outpatient treated AECOPD over 2 years using real-world data obtained from existing electronic medical records (EMRs).

Methods: We included 44 896 patients with a chronic obstructive pulmonary disease diagnosis from the EMR in this retrospective cohort study. Moderate to vigorous PA was measured via patient self-report, obtained during routine clinical care; patients were classified as inactive (0 min/week), insufficiently active (1-149 min/week) or active (≥150 min/week). AECOPDs were measured using both encounter and prescription fill (antibiotics and/or oral steroids) data. We used Poisson regression models to compare the unadjusted and adjusted rates of outpatient treated AECOPD over 2 years across the PA categories.

Results: In adjusted models, the 2-year AECOPD incidence rate ratio (IRR) was not different between the inactive and insufficiently inactive groups (IRR 0.98, 95% CI 0.96 to 1.01) and only marginally meaningful lower for the active group (IRR 0.97, 95% CI 0.95 to 0.98). Sensitivity analyses of patients meeting or not meeting obstructive criteria produced similar results with generally weak or non-significant associations.

Conclusion: The lack of an association between PA and AECOPD contrasts with previous published findings of a strong relationship between moderate to vigorous PA and hospitalisations for severe AECOPD. This difference could partially be attributed to the imprecision of our measurements for both the exposure and outcome.
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http://dx.doi.org/10.1136/bmjresp-2020-000590DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7264694PMC
May 2020

Telomere length in COPD: Relationships with physical activity, exercise capacity, and acute exacerbations.

PLoS One 2019 17;14(10):e0223891. Epub 2019 Oct 17.

VA Boston Healthcare System, Boston, MA, United States of America.

Rationale: Shorter leukocyte telomere length (LTL) is associated with reduced health-related quality of life and increased risk for acute exacerbations (AEs) and mortality in chronic obstructive pulmonary disease (COPD). Increased physical activity and exercise capacity are associated with reduced risk for AEs and death. However, the relationships between LTL and physical activity, exercise capacity, and AEs in COPD are unknown.

Methods: Data from 3 COPD cohorts were examined: Cohort 1 (n = 112, physical activity intervention trial), Cohorts 2 and 3 (n = 182 and 294, respectively, separate observational studies). Subjects completed a 6-minute walk test (6MWT) and provided blood for LTL assessment using real-time PCR. Physical activity was measured as average daily step count using an accelerometer or pedometer. Number of self-reported AEs was available for 1) the year prior to enrollment (Cohorts 1 and 3) and 2) prospectively after enrollment (all cohorts). Multivariate models examined associations between LTL and average daily step count, 6MWT distance, and AEs.

Results: A significant association between longer LTL and increased 6MWT distance was observed in the three combined cohorts (β = 3x10-5, p = 0.045). No association between LTL and average daily step count was observed. Shorter LTL was associated with an increased number of AEs in the year prior to enrollment (Cohorts 1 and 3 combined, β = -1.93, p = 0.04) and with prospective AEs (Cohort 3, β = -1.3388, p = 0.0003).

Conclusions: Among COPD patients, increased LTL is associated with higher exercise capacity, but not physical activity. Shorter LTL was associated with AEs in a subgroup of cohorts.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0223891PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6797105PMC
March 2020

Protocol for a Noninferiority Comparative Effectiveness Trial of Home-Based Palliative Care (HomePal).

J Palliat Med 2019 09;22(S1):20-33

Stakeholder Advisory Committee Member, Kaiser Permanente Northwest, Portland, Oregon.

As health care systems strive to meet the growing needs of seriously ill patients with high symptom burden and functional limitations, they need evidence about how best to deliver home-based palliative care (HBPC). We compare a standard HBPC model that includes routine home visits by nurses and prescribing clinicians with a tech-supported model that aims to promote timely interprofessional team coordination using video consultation with the prescribing clinician while the nurse is in the patient's home. We hypothesize that tech-supported HBPC will be no worse compared with standard HBPC. This study is a pragmatic, cluster randomized noninferiority trial conducted across 14 Kaiser Permanente sites in Southern California and the Pacific Northwest. Registered nurses ( = 102) were randomized to the two models so that approximately half of the participating patient-caregiver dyads will be in each study arm. Adult English or Spanish-speaking patients (estimate 10,000) with any serious illness and a survival prognosis of 1-2 years and their caregivers (estimate 4800) are being recruited to the HomePal study over ∼2.5 years. The primary patient outcomes are symptom improvement at one month and days spent at home. The primary caregiver outcome is perception of preparedness for caregiving. During implementation we had to balance the rigors of conducting a clinical trial with pragmatic realities to ensure responsiveness to culture, structures, workforce, workflows of existing programs across multiple sites, and emerging policy and regulatory changes. We built close partnerships with stakeholders across multiple representative groups to define the comparators, prioritize and refine measures and study conduct, and optimize rigor in our analytical approaches. We have also incorporated extensive fidelity monitoring, mixed-method implementation evaluations, and early planning for dissemination to anticipate and address challenges longitudinally. Trial Registration: ClinicalTrials.gov: NCT#03694431.
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http://dx.doi.org/10.1089/jpm.2019.0116DOI Listing
September 2019

Effect of Physical Activity Coaching on Acute Care and Survival Among Patients With Chronic Obstructive Pulmonary Disease: A Pragmatic Randomized Clinical Trial.

JAMA Netw Open 2019 08 2;2(8):e199657. Epub 2019 Aug 2.

Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena.

Importance: While observational studies show that physical inactivity is associated with worse outcomes in chronic obstructive pulmonary disease (COPD), there are no population-based trials to date testing the effectiveness of physical activity (PA) interventions to reduce acute care use or improve survival.

Objective: To evaluate the long-term effectiveness of a community-based PA coaching intervention in patients with COPD.

Design, Setting, And Participants: Pragmatic randomized clinical trial with preconsent randomization to the 12-month Walk On! (WO) intervention or standard care (SC). Enrollment occurred from July 1, 2015, to July 31, 2017; follow-up ended in July 2018. The setting was Kaiser Permanente Southern California sites. Participants were patients 40 years or older who had any COPD-related acute care use in the previous 12 months; only patients assigned to WO were approached for consent to participate in intervention activities.

Interventions: The WO intervention included collaborative monitoring of PA step counts, semiautomated step goal recommendations, individualized reinforcement, and peer/family support. Standard COPD care could include referrals to pulmonary rehabilitation.

Main Outcomes And Measures: The primary outcome was a composite binary measure of all-cause hospitalizations, observation stays, emergency department visits, and death using adjusted logistic regression in the 12 months after randomization. Secondary outcomes included self-reported PA, COPD-related acute care use, symptoms, quality of life, and cardiometabolic markers.

Results: All 2707 eligible patients (baseline mean [SD] age, 72 [10] years; 53.7% female; 74.3% of white race/ethnicity; and baseline mean [SD] percent forced expiratory volume in the first second of expiration predicted, 61.0 [22.5]) were randomly assigned to WO (n = 1358) or SC (n = 1349). The intent-to-treat analysis showed no differences between WO and SC on the primary all-cause composite outcome (odds ratio [OR], 1.09; 95% CI, 0.92-1.28; P = .33) or in the individual outcomes. Prespecified, as-treated analyses compared outcomes between all SC and 321 WO patients who participated in any intervention activities (23.6% [321 of 1358] uptake). The as-treated, propensity score-weighted model showed nonsignificant positive estimates in favor of WO participants compared with SC on all-cause hospitalizations (OR, 0.84; 95% CI, 0.65-1.10; P = .21) and death (OR, 0.62; 95% CI, 0.35-1.11; P = .11). More WO participants reported engaging in PA compared with SC (47.4% [152 of 321] vs 30.7% [414 of 1349]; P < .001) and had improvements in the Patient-Reported Outcomes Measurement Information System 10 physical health domain at 6 months. There were no group differences in other secondary outcomes.

Conclusions And Relevance: Participation in a PA coaching program by patients with a history of COPD exacerbations was insufficient to effect improvements in acute care use or survival in the primary analysis.

Trial Registration: ClinicalTrials.gov identifier: NCT02478359.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.9657DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6704745PMC
August 2019

Positive Charge Patterning and Hydrophobicity of Membrane-Active Antimicrobial Peptides as Determinants of Activity, Toxicity, and Pharmacokinetic Stability.

J Med Chem 2019 07 1;62(13):6276-6286. Epub 2019 Jul 1.

Division of Molecular Medicine , Research Institute, Hospital for Sick Children , Toronto M5G 0A4 Ontario , Canada.

Natural α-helical cationic antimicrobial peptide (CAP) sequences are predominantly amphipathic, with only ca. 2% containing four or more consecutive positively charged amino acids (Lys/Arg). We have designed synthetic CAPs that deviate from these natural sequences, as typified by the charge-clustered peptide KKKKKKAAFAAWAAFAA-NH (termed 6K-F17), which displays high antimicrobial activity with no toxicity to mammalian cells. We created a series of peptides varying in charge patterning, increasing the amphipathic character of 6K-F17 to mimic the design of natural CAPs (e.g., KAAKKFAKAWAKAFAA-NH). Amphipathic sequences displayed increased antimicrobial activity against bacteria but were significantly more toxic to mammalian cells and more susceptible to protease degradation than their corresponding charge-clustered variants, suggesting that amphipathic sequences may be desirable in nature to allow for more versatile functions (i.e., antibacterial, antifungal, antipredator) and rapid clearance from vulnerable host cells. Our approach to clustering of charges may therefore allow for specialization against bacteria, in concert with prolonged peptide half-life.
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http://dx.doi.org/10.1021/acs.jmedchem.9b00657DOI Listing
July 2019

End-of-Life Care in Patients Exposed to Home-Based Palliative Care vs Hospice Only.

J Am Geriatr Soc 2019 06 4;67(6):1226-1233. Epub 2019 Mar 4.

Pasadena Regional Office, Kaiser Permanente Southern California, Pasadena, CA.

Objectives: The current evidence base regarding the effectiveness of home-based palliative care (HomePal) on outcomes of importance to multiple stakeholders remains limited. The purpose of this study was to compare end-of-life care in decedents who received HomePal with two cohorts that either received hospice only (HO) or did not receive HomePal or hospice (No HomePal-HO).

Design: Retrospective cohorts from an ongoing study of care transition from hospital to home. Data were collected from 2011 to 2016.

Setting: Kaiser Permanente Southern California.

Participants: Decedents 65 and older who received HomePal (n = 7177) after a hospitalization and two comparison cohorts (HO only = 25 102; No HomePal-HO = 22 472).

Measurements: Utilization data were extracted from administrative, clinical, and claims databases, and death data were obtained from state and national indices. Days at home was calculated as days not spent in the hospital or in a skilled nursing facility (SNF).

Results: Patients who received HomePal were enrolled for a median of 43 days and had comparable length of stay on hospice as patients who enrolled only in hospice (median days = 13 vs 12). Deaths at home were comparable between HomePal and HO (59% vs 60%) and were higher compared with No HomePal-HO (16%). For patients who survived at least 6 months after HomePal admission (n = 2289), the mean number of days at home in the last 6 months of life was 163 ± 30 vs 161 ± 30 (HO) vs 149 ± 40 (No HomePal-HO). Similar trends were also noted for the last 30 days of life, 25 ± 8 (HomePal, n = 5516), 24 ± 8 (HO), and 18 ± 11 (No HomePal-HO); HomePal patients had a significantly lower risk of hospitalizations (relative risk [RR] = .58-.87) and SNF stays (RR = .32-.77) compared with both HO and No HomePal-HO patients.

Conclusion: Earlier comprehensive palliative care in patients' home in place of or preceding hospice is associated with fewer hospitalizations and SNF stays and more time at home in the final 6 months of life. J Am Geriatr Soc, 2019.
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http://dx.doi.org/10.1111/jgs.15844DOI Listing
June 2019

Applying the pragmatic-explanatory continuum indicator summary to the implementation of a physical activity coaching trial in chronic obstructive pulmonary disease.

Nurs Outlook 2018 09 12;66(5):455-463. Epub 2018 Jul 12.

Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA.

Background: Observational studies show that physical inactivity is associated with worse outcomes in chronic obstructive pulmonary disease (COPD). Despite practice guidelines recommending regular physical activity (PA), there are no large-scale experimental studies to confirm that patients at high risk for COPD exacerbations can increase their PA and consequently, have improved outcomes.

Purpose: The purpose of this case study is to describe the use of a widely accepted pragmatic trials framework for the design and implementation of a pragmatic clinical trial (PCT) of PA coaching for COPD in a real-world setting.

Method: The aim of the trial was to determine the effectiveness of a 12-month PA coaching intervention (Walk On!) compared to standard care for 2,707 patients at high risk for COPD exacerbations from a large integrated health care system. The descriptions of our implementation experiences are anchored within the pragmatic-explanatory continuum indicator summary (PRECIS-2) framework.

Discussion: Facilitators of PCT implementation include early and ongoing engagement and support of multiple stakeholders including patients, health system leaders, administrators, physician champions, and frontline clinicians, an organizational/setting that prioritizes positive lifestyle behaviors, and a flexible intervention that allows for individualization. Pragmatic challenges include reliance on electronic data that are not complete or available in real-time for patient identification, timing of outreach may not synchronize with patients' readiness for change, and high turnover of clinical staff drawn from the existing workforce.

Discussion: PRECIS-2 is a useful guide for organizing decisions about study designs and implementation approaches to help diverse stakeholders recognize the compromises between internal and external validity with those decisions.
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http://dx.doi.org/10.1016/j.outlook.2018.05.005DOI Listing
September 2018

Translation and Evaluation of a Lung Cancer, Palliative Care Intervention for Community Practice.

J Pain Symptom Manage 2018 11 2;56(5):709-718. Epub 2018 Aug 2.

Nursing Research & Education, City of Hope Medical Center, Duarte, California.

Context: A notable gap in the evidence base for palliative care (PC) for cancer is that most trials were conducted in specialized centers with limited translation and further evaluation in "real-world" settings. Health systems are desperate for guidance on effective, scalable models.

Objectives: The objective of this study was to determine the effects of a nurse-led PC intervention for patients with non-small-cell lung cancer and their family caregivers (FCGs) in a community-based setting.

Methods: Two-group, sequential, quasi-experimental design with Phase 1 (usual care [UC]) followed by Phase 2 (intervention) was conducted at three Kaiser Permanente Southern California sites. Participants included patients with Stage 2-4 non-small-cell lung cancer and their FCG. Standard measures of quality of life (QOL) included Functional Assessment of Cancer Therapy-Lung, Functional Assessment of Chronic Illness Therapy-Spirituality Subscale, City of Hope Family QOL; other outcomes were distress, health care utilization, caregiver preparedness, and burden.

Results: Patients in the intervention cohort had significant improvements in three (physical, emotional, and functional well-being) of the five QOL domains at one month that were sustained through three month compared to UC (P < 0.01). Caregivers in the intervention cohort had improvements in physical (P = 0.04) and spiritual well-being (P = 0.03) and preparedness (P = 0.04) compared to UC. There were no differences in distress or health care utilization between cohorts.

Conclusion: Our findings suggest that a research-based PC intervention can be successfully adapted to community settings to achieve similar, if not better, QOL outcomes for patients and FCGs compared to UC. Nonetheless, additional modifications to ensure consistent referrals to PC and streamlining routine assessments and patient/FCG education are needed to sustain and disseminate the PC intervention.
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http://dx.doi.org/10.1016/j.jpainsymman.2018.07.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6248339PMC
November 2018

Care Transitions From Patient and Caregiver Perspectives.

Ann Fam Med 2018 05;16(3):225-231

Department of Family Medicine, Boston Medical Center/Boston University School of Medicine, Boston, Massachusetts (Mitchell, Laurens, Weigel, Howard, Jack); School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania (Hirschman, Shaid); Department of Communication, University of Kentucky, Lexington, Kentucky (Scott); Department of Research and Evaluation, Kaiser Permanente Southern California, Los Angeles, California (Nguyen); Medical Anthropology, Boston University School of Medicine, Boston, Massachusetts (Laird); Families and Health Care Project, United Hospital Fund, New York, New York (Levine); Department of Medicine and Pediatrics, Louisiana State University Health Sciences, New Orleans, Louisiana (Davis); Telligen, Quality Improvement, Des Moines, Iowa (Gass); Center for Health Services Research, University of Kentucky, Lexington, Kentucky (Li, Williams).

Purpose: Despite concerted actions to streamline care transitions, the journey from hospital to home remains hazardous for patients and caregivers. Remarkably little is known about the patient and caregiver experience during care transitions, the services they need, or the outcomes they value. The aims of this study were to (1) describe patient and caregiver experiences during care transitions and (2) characterize patient and caregiver desired outcomes of care transitions and the health services associated with them.

Methods: We interviewed 138 patients and 110 family caregivers recruited from 6 health networks across the United States. We conducted 34 homogenous focus groups (103 patients, 65 caregivers) and 80 key informant interviews (35 patients, 45 caregivers). Audio recordings were transcribed and analyzed using principles of grounded theory to identify themes and the relationship between them.

Results: Patients and caregivers identified 3 desired outcomes of care transition services: (1) to feel cared for and cared about by medical providers, (2) to have unambiguous accountability from the health care system, and (3) to feel prepared and capable of implementing care plans. Five care transition services or provider behaviors were linked to achieving these outcomes: (1) using empathic language and gestures, (2) anticipating the patient's needs to support self-care at home, (3) collaborative discharge planning, (4) providing actionable information, and (5) providing uninterrupted care with minimal handoffs.

Conclusions: Clear accountability, care continuity, and caring attitudes across the care continuum are important outcomes for patients and caregivers. When these outcomes are achieved, care is perceived as excellent and trustworthy. Otherwise, the care transition is experienced as transactional and unsafe, and leaves patients and caregivers feeling abandoned by the health care system.
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http://dx.doi.org/10.1370/afm.2222DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5951251PMC
May 2018

Impact of Inpatient Palliative Care on Quality of End-of-Life Care and Downstream Acute and Postacute Care Utilization.

J Palliat Med 2018 07 13;21(7):913-923. Epub 2018 Mar 13.

3 Department of Research and Evaluation, Kaiser Permanente Southern California , Pasadena, California.

Background: Additional evidence is needed regarding the impact of inpatient palliative care (IPC) on the quality of end-of-life care and downstream utilization.

Aim: Examine the effects of IPC on quality of end-of-life care and acute and postacute care use in a large integrated system.

Design: Retrospective cohort design.

Setting/participants: Adult decedents from January 1, 2012, to December 31, 2014, who had at least one hospitalization at 11 Kaiser Permanente Southern California medical centers in the 12 months before death and not hospitalized for a trauma-related condition or receiving home-based PC or hospice were included in the cohort.

Materials And Methods: Inverse probability of treatment weighting of propensity scores was used to compare outcomes between patients exposed to IPC (n = 3742) and controls (n = 12,755) who never received IPC before death.

Results: Patients who received IPC were more likely to enroll in home-based PC or hospice (69% vs. 43%) and were less likely to die in a hospital (15% vs. 29%) or intensive care (2% vs. 9%) compared with controls (all, p < 0.001). IPC exposure was associated with higher risk for rehospitalization (HR: 1.18, 95% CI 1.11-1.25) and more frequent emergency department visits (RR: 1.16, 95% CI 1.07-1.26) with no increase in postacute care use compared with controls. Stratified analyses showed that IPC effects on acute care utilization were dependent on code status.

Conclusion: IPC exposure was associated with higher enrollment in home-based PC/hospice and more deaths at home. The increased acute care utilization by the IPC group may reflect persistent confounding by indication.
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http://dx.doi.org/10.1089/jpm.2017.0275DOI Listing
July 2018

Effect of symptoms on physical performance in COPD.

Heart Lung 2018 Mar - Apr;47(2):149-156. Epub 2018 Feb 1.

VA Puget Sound Health Care Center, Seattle, WA, USA.

Background: Chronic obstructive pulmonary disease (COPD) patients experience multiple symptoms including dyspnea, anxiety, depression, and fatigue, which are highly correlated with each other. Together, those symptoms may contribute to impaired physical performance.

Objectives: The purpose of this study was to examine interrelationships among dyspnea, anxiety, depressive symptoms, and fatigue as contributing factors to physical performance in COPD.

Methods: This study used baseline data of 282 COPD patients from a longitudinal observational study to explore the relationship between depression, inflammation, and functional status. Data analyses included confirmatory factor analyses and structural equation modeling.

Results: Dyspnea, anxiety and depression had direct effects on fatigue, and both dyspnea and anxiety had direct effects on physical performance. Higher levels of dyspnea were significantly associated with impaired physical performance whereas higher levels of anxiety were significantly associated with enhanced physical performance.

Conclusion: Dyspnea was the strongest predictor of impaired physical performance in patients with COPD.
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http://dx.doi.org/10.1016/j.hrtlng.2017.12.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5857230PMC
December 2018

Influence of hydrocarbon-stapling on membrane interactions of synthetic antimicrobial peptides.

Bioorg Med Chem 2018 03 21;26(6):1189-1196. Epub 2017 Oct 21.

Division of Molecular Medicine, Research Institute, Hospital for Sick Children, 686 Bay Street, Toronto, ON M5G 0A4, Canada; Department of Biochemistry, University of Toronto, 1 King's College Circle, Toronto, ON M5S 1A8, Canada. Electronic address:

Cyclization has been recognized as a valuable technique for increasing the efficacy of small molecule and peptide therapeutics. Here we report the application of a hydrocarbon staple to a rationally-designed cationic antimicrobial peptide (CAP) that acquires increased membrane targeting and interaction vs. its linear counterpart. The previously-described CAP, 6K-F17 (KKKKKK-AAFAAWAAFAA-NH) was used as the backbone for incorporation of an i to i + 4 helical hydrocarbon staple through olefin ring closing metathesis. Stapled versions of 6K-F17 showed an increase in non-selective membrane interaction, where the staple itself enhances the degree of membrane interaction and rate of cell death while maintaining high potency against bacterial membranes. However, the higher averaged hydrophobicity imparted by the staple also significantly increases toxicity to mammalian cells. This deleterious effect is countered through stepwise reduction of the stapled 6K-F17's backbone hydrophobicity through polar amino acid substitutions. Circular dichroism assessment of secondary structure in various bacterial membrane mimetics reveals that a helical structure may improve - but is not an absolute requirement for - antimicrobial activity of 6K-F17. Further, phosphorus-31 static solid state NMR spectra revealed that both non-toxic stapled and linear peptides bind bacterial membranes in a similar manner that does not involve a detergent-like mechanism of lipid removal. The overall results suggest that the technique of hydrocarbon stapling can be readily applied to membrane-interactive CAPs to modulate how they interact and target biological membranes.
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http://dx.doi.org/10.1016/j.bmc.2017.10.020DOI Listing
March 2018

Use of a Remote Inhaler Monitoring Device to Measure Change in Inhaler Use with Chronic Obstructive Pulmonary Disease Exacerbations.

J Aerosol Med Pulm Drug Deliv 2018 06 16;31(3):191-198. Epub 2017 Oct 16.

3 Department of Health Services Research and Development, VA Puget Sound Health Care System , Seattle, Washington.

Background: Remote inhaler monitoring is an emerging technology that enables the healthcare team to monitor the time and location of a patient's inhaler use. We assessed the feasibility of remote inhaler monitoring for chronic obstructive pulmonary disease (COPD) patients and the pattern of albuterol inhaler use associated with COPD exacerbations.

Methods: Thirty-five participants with COPD used an electronic inhaler sensor for 12 weeks which recorded the date and time of each albuterol actuation. Self-reported COPD exacerbations and healthcare utilization were assessed monthly. We used generalized estimating equations with a logit link to compare the odds of an exacerbation day to a nonexacerbation day by the frequency of daily albuterol use.

Results: Average daily albuterol use on nonexacerbation days varied greatly between patients, ranging from 1.5 to 17.5 puffs. There were 48 exacerbation events observed in 29 participants during the study period, of which 16 were moderate-to-severe exacerbations. During the moderate-to-severe exacerbation days, the median value in average daily albuterol use increased by 14.1% (interquartile range: 2.7%-56.9%) compared to average nonexacerbation days. A 100% increase in inhaler use was associated with increased odds of a moderate-to severe exacerbation (odds ratio 1.54; 95% CI: 1.21-1.97). Approximately 74% of participants reported satisfaction with the sensor.

Conclusions: The electronic inhaler sensor was well received in older patients with COPD over a 12-week period. Increased albuterol use captured by the device was associated with self-reported episodes of moderate-to-severe exacerbations.
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http://dx.doi.org/10.1089/jamp.2017.1383DOI Listing
June 2018

Understanding Facilitators and Barriers to Care Transitions: Insights from Project ACHIEVE Site Visits.

Jt Comm J Qual Patient Saf 2017 09 10;43(9):433-447. Epub 2017 Jul 10.

Background: Care transitions between clinicians or settings are often fragmented and marked by adverse events. To increase patient safety and deliver more efficient and effective health care, new ways to optimize these transitions need to be identified. A study was conducted to delineate facilitators and barriers to implementation of transitional care services at health systems that may have been adopted or adapted from published evidence-based models.

Methods: From March 2015 through December 2015, site visits were conducted across the United States at 22 health care organizations-community hospitals, academic medical centers, integrated health systems, and broader community partnerships. At each site, direct observation and document review were conducted, as were semistructured interviews with a total of 810 participants (5 to 57 participants per site) representing various stakeholder groups, including management and leadership, transitional care team members, internal stakeholders, community partners, patients, and family caregivers.

Results: Facilitators of effective care transitions included collaborating within and beyond the organization, tailoring care to patients and caregivers, and generating buy-in among staff. Commonly reported barriers included poor integration of transitional care services, unmet patient or caregiver needs, underutilized services, and lack of physician buy-in.

Conclusion: True community partnership, high-quality communication, patient and family engagement, and ongoing evaluation and adaptation of transitional care strategies are ultimately needed to facilitate effective care transitions. Health care organizations can strategically prioritize transitional care service delivery through staffing decisions, by making transitional care part of the organization's formal board agenda, and by incentivizing excellence in providing transitional care services.
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http://dx.doi.org/10.1016/j.jcjq.2017.02.012DOI Listing
September 2017

Association between Social Support and Self-Care Behaviors in Adults with Chronic Obstructive Pulmonary Disease.

Ann Am Thorac Soc 2017 Sep;14(9):1419-1427

1 School of Nursing and.

Rationale: Higher social support is associated with a better quality of life and functioning in adults with chronic obstructive pulmonary disease (COPD).

Objectives: To determine the association between structural and functional social support and self-care behaviors in adults with COPD.

Methods: This was a longitudinal study using data from the CASCADE (COPD Activity: Serotonin Transporter, Cytokines, and Depression) study, which was focused on depression and functioning in COPD. Physical activity was measured with a validated accelerometer at baseline, year 1, and year 2. Additional self-care behaviors included pulmonary rehabilitation attendance, smoking status, receipt of influenza and/or pneumococcal vaccinations, and medication adherence. Structural social support indicators included living status, being partnered, number of close friends/relatives, and presence of a family caregiver. Functional social support was measured with the Medical Outcomes Social Support Survey (MOSSS). Mixed-effects and logistic regression models were used.

Results: A total of 282 participants with Global Initiative for Chronic Obstructive Lung Disease stage II to IV COPD were included (age, 68 ± 9 yr; 80% men; FEV% predicted, 45 ± 16). For physical activity, participants who lived with others accrued 903 more steps per day than those who lived alone (95% confidence interval [CI], 373-1,433; P = 0.001); increases in the MOSSS total score were associated with more steps per day (β = 10; 95% CI, 2-18; P = 0.02). The odds of pulmonary rehabilitation participation were more than 11 times higher if an individual had a spouse or partner caregiver compared with not having a caregiver (odds ratio [OR], 11.03; 95% CI, 1.93-62.97; P < 0.01). Higher functional social support (MOSSS total score) was associated with marginally lower odds of smoking (OR, 0.99; 95% CI, 0.98-1.00; P = 0.03) and higher odds of pneumococcal vaccination (OR, 1.02; 95% CI, 1.00-1.03; P = 0.02). Social support was not associated with influenza vaccination or medication adherence.

Conclusions: Structural social support, which was measured by reports of living with others and having a caregiver, was respectively associated with higher levels of physical activity and greater participation in pulmonary rehabilitation in adults with COPD. Our findings reinforce the critical importance of the social environment in shaping patients' success with self-care. Clinical Trial registered with clinicaltrials.gov (NCT01074515).
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http://dx.doi.org/10.1513/AnnalsATS.201701-026OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5711401PMC
September 2017

Completion of an Outpatient Visit After Skilled Nursing Facility Discharge and Readmission Risk.

J Am Med Dir Assoc 2017 Sep 1;18(9):797-798. Epub 2017 Jul 1.

Kaiser Permanente Southern California, Pasadena, CA. Electronic address:

Objectives: Examine the association between completion of an outpatient visit with a physician or advanced practice provider (PCP) within 7 days of discharge from a short skilled nursing facility (SNF) stay and 30-day readmission and determine if functional status at discharge moderates visit effectiveness.

Design: Retrospective cohort study.

Setting: Large integrated health care system.

Participants: Adults 65 years and older, discharged home from a short SNF stay (n = 4073).

Intervention: None.

Measurements: Exposure is completion of an outpatient visit with a PCP within 7 days of discharge from an SNF. Primary outcome is readmission within 30 days of SNF discharge. Covariates included gender, risk score for readmission or early death, medical or surgical hospitalization, SNF facility, SNF length of stay, SNF stay in the previous 12 months, discharge to home or home health, and discharge functional independence measures (FIM).

Results: A total of 476 (11.6%) patients were readmitted within 30 days of SNF discharge. Patients who completed an outpatient visit with a PCP within 7 days of SNF discharge had a 23% higher risk of being readmitted compared to patients who did not complete any visit (hazard ratio [HR] 1.23, 95% confidence interval [CI] 1.01-1.50). Patients who had FIM scores ≥80 and completed a visit had an increased readmission risk (HR 1.37, 95% CI 1.04-1.79); the increased risk was not seen for those with worse functional impairment, FIM <80 (HR 1.11, 95% CI 0.85-1.46).

Conclusion: The finding of increased risk of readmission post SNF discharge with completion of an outpatient visit likely reflects inadequate adjustment for selection bias in this observational study, which strongly argues for the need to design prospective studies to test transitional care services post SNF discharge.
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http://dx.doi.org/10.1016/j.jamda.2017.05.023DOI Listing
September 2017

Integration of a Palliative Care Intervention into Community Practice for Lung Cancer: A Study Protocol and Lessons Learned with Implementation.

J Palliat Med 2017 12 9;20(12):1327-1337. Epub 2017 Jun 9.

5 City of Hope Medical Center , Duarte, California.

Background: A notable gap in the evidence base for outpatient palliative care (PC) for cancer is that most trials were conducted in specialized oncology or academic centers with limited translation and further evaluation in "real-world" settings. Health systems are desperate for guidance regarding the most effective and sustainable PC service models.

Objective: Describe the study protocol to evaluate the dissemination of a previously tested nurse-led PC intervention (PCI) for patients with lung cancer and their family caregiver in community-based settings, lessons learned in adapting and implementing the PCI, and implications for future dissemination-translational efforts Design: Two-group, prospective sequential, quasi-experimental design with Phase 1 (Usual care) followed by Phase 2 (Intervention) setting/subjects. Three Kaiser Permanente Southern California sites. Patients with stage 2-4 nonsmall cell lung cancer and their caregiver.

Measurements: Standard measures of quality of life (QOL; FACT-L, FACIT- SP12, City of Hope Family QOL), symptom burden, distress, and caregiver preparedness and perceived burden.

Results: Adaptations were made to the PCI (comprehensive patient/caregiver assessment, interdisciplinary care planning, and patient/caregiver education) to harmonize with existing workflows, minimize burden to patients, caregivers, and the PC team, and maximize chances of sustainability. Implementation facilitators include external competitive pressures, internal readiness, and adaptability of the PCI. Barriers include the changing lung cancer therapeutic landscape and perceived need for PC support by patients and providers, insufficient staffing, and people-dependent processes.

Conclusions: Efforts to disseminate and implement previously tested PC models into real-world community practices need to be more realistic and consider the local context.
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http://dx.doi.org/10.1089/jpm.2017.0143DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5706626PMC
December 2017

Components of Comprehensive and Effective Transitional Care.

J Am Geriatr Soc 2017 Jun 3;65(6):1119-1125. Epub 2017 Apr 3.

Center for Health Services Research, University of Kentucky, Lexington, Kentucky.

Transitional care (TC) has received widespread attention from researchers, health system leaders, clinicians, and policy makers as they attempt to improve health outcomes and reduce preventable hospital readmissions, yet little is known about the critical elements of effective TC and how they relate to patients' and caregivers' needs and experiences. To address this gap, the Patient-Centered Outcomes Research Institute (PCORI) funded a national study, Achieving patient-centered Care and optimized Health In care transitions by Evaluating the Value of Evidence (Project ACHIEVE). A primary aim of the study is the identification of TC components that yield desired patient and caregiver outcomes. Project ACHIEVE established a multistakeholder workgroup to recommend essential TC components for vulnerable Medicare beneficiaries. Guided by a review of published evidence, the workgroup identified and defined a preliminary set of components and then analyzed how well the set aligned with real-world patients' and caregivers' experiences. Through this process, the workgroup identified eight TC components: patient engagement, caregiver engagement, complexity and medication management, patient education, caregiver education, patients' and caregivers' well-being, care continuity, and accountability. Although the degree of attention given to each component will vary based on the specific needs of patients and caregivers, workgroup members agree that health systems need to address all components to ensure optimal TC for all Medicare beneficiaries.
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http://dx.doi.org/10.1111/jgs.14782DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5497308PMC
June 2017