Publications by authors named "Jessica Keim-Malpass"

89 Publications

Association of Age at Cancer Diagnosis and Clinical Trial Participation.

JAMA Netw Open 2021 Feb 1;4(2):e2037573. Epub 2021 Feb 1.

Program in Public Health, Department of Family, Population, and Preventive Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York.

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http://dx.doi.org/10.1001/jamanetworkopen.2020.37573DOI Listing
February 2021

Accuracy and Monitoring of Pediatric Early Warning Score (PEWS) Scores Prior to Emergent Pediatric Intensive Care Unit (ICU) Transfer: Retrospective Analysis.

JMIR Pediatr Parent 2021 Feb 22;4(1):e25991. Epub 2021 Feb 22.

School of Nursing, University of Virginia, Charlottesville, VA, United States.

Background: Current approaches to early detection of clinical deterioration in children have relied on intermittent track-and-trigger warning scores such as the Pediatric Early Warning Score (PEWS) that rely on periodic assessment and vital sign entry. There are limited data on the utility of these scores prior to events of decompensation leading to pediatric intensive care unit (PICU) transfer.

Objective: The purpose of our study was to determine the accuracy of recorded PEWS scores, assess clinical reasons for transfer, and describe the monitoring practices prior to PICU transfer involving acute decompensation.

Methods: We conducted a retrospective cohort study of patients ≤21 years of age transferred emergently from the acute care pediatric floor to the PICU due to clinical deterioration over an 8-year period. Clinical charts were abstracted to (1) determine the clinical reason for transfer, (2) quantify the frequency of physiological monitoring prior to transfer, and (3) assess the timing and accuracy of the PEWS scores 24 hours prior to transfer.

Results: During the 8-year period, 72 children and adolescents had an emergent PICU transfer due to clinical deterioration, most often due to acute respiratory distress. Only 35% (25/72) of the sample was on continuous telemetry or pulse oximetry monitoring prior to the transfer event, and 47% (34/72) had at least one incorrectly documented PEWS score in the 24 hours prior to the event, with a score underreporting the actual severity of illness.

Conclusions: This analysis provides support for the routine assessment of clinical deterioration and advocates for more research focused on the use and utility of continuous cardiorespiratory monitoring for patients at risk for emergent transfer.
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http://dx.doi.org/10.2196/25991DOI Listing
February 2021

Congenital Melanocytic Nevus: Considerations for Neonatal Clinicians and a Parent Perspective.

Neonatal Netw 2021 Jan;40(1):40-45

Congenital melanocytic nevus (CMN) or nevi, also known as dark moles, are present at birth. While small CMN are quite common, large and giant nevi are rare and can be associated with significant psychological distress and the potential for further clinical sequelae. Neonatal clinicians can offer anticipatory guidance to families through distribution of resources and navigation to additional consultants.
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http://dx.doi.org/10.1891/0730-0832/11-T-660DOI Listing
January 2021

Nursing and precision predictive analytics monitoring in the acute and intensive care setting: An emerging role for responding to COVID-19 and beyond.

Int J Nurs Stud Adv 2021 Nov 5;3:100019. Epub 2021 Jan 5.

AMP3D: Advanced Medical Predictive Devices, Diagnostics and Displays, Inc., Charlottesville, VA, USA.

As the global response to COVID-19 continues, nurses will be tasked with appropriately triaging patients, responding to events of clinical deterioration, and developing family-centered plans of care within a healthcare system exceeding capacity. Predictive analytics monitoring, an artificial intelligence (AI)-based tool that translates streaming clinical data into a real-time visual estimation of patient risks, allows for evolving acuity assessments and detection of clinical deterioration while the patient is in pre-symptomatic states. While nurses are on the frontline for the COVID-19 pandemic, the use of AI-based predictive analytics monitoring may help cognitively complex clinical decision-making tasks and pave a pathway for early detection of patients at risk for decompensation. We must develop strategies and techniques to study the impact of AI-based technologies on patient care outcomes and the clinical workflow. This paper outlines key concepts for the intersection of nursing and precision predictive analytics monitoring.
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http://dx.doi.org/10.1016/j.ijnsa.2021.100019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7781904PMC
November 2021

A View from the past into our collective future: the oncofertility consortium vision statement.

Authors:
Teresa K Woodruff Lauren Ataman-Millhouse Kelly S Acharya Teresa Almeida-Santos Antoinette Anazodo Richard A Anderson Leslie Appiah Joy Bader Kerri Becktell Robert E Brannigan Lesley Breech Maria T Bourlon Žana Bumbuliene Karen Burns Lisa Campo-Engelstein Jacira R Campos Grace M Centola Mauricio Barbour Chehin Diane Chen Michel De Vos Francesca E Duncan Ahmed El-Damen Douglas Fair Yemi Famuyiwa Patricia Y Fechner Paula Fontoura Olivia Frias Sabrina A Gerkowicz Jill Ginsberg Clarisa R Gracia Kara Goldman Veronica Gomez-Lobo Brent Hazelrigg Michael H Hsieh Luis R Hoyos Alfonso Hoyos-Martinez Robert Jach Jacek Jassem Murid Javed Yasmin Jayasinghe Roohi Jeelani Jacqueline S Jeruss Nalini Kaul-Mahajan Jessica Keim-Malpass Tyler G Ketterl Mohamed Khrouf Dana Kimelman Atsuko Kusuhara William H Kutteh Monica M Laronda Jung Ryeol Lee Vicky Lehmann Joseph M Letourneau Lynda K McGinnis Eileen McMahon Lillian R Meacham Monserrat Fabiola Velez Mijangos Molly Moravek Leena Nahata George Moses Ogweno Kyle E Orwig Mary Ellen Pavone Fedro Alessandro Peccatori Romina Ileana Pesce Hanna Pulaski Gwendolyn Quinn Ramiro Quintana Tomas Quintana Bruno Ramalho de Carvalho Rosalind Ramsey-Goldman Joyce Reinecke Fernando M Reis Julie Rios Alice S Rhoton-Vlasak Kenny A Rodriguez-Wallberg Cassandra Roeca Seth J Rotz Erin Rowell Mahmoud Salama Amanda J Saraf Anibal Scarella Tara Schafer-Kalkhoff Deb Schmidt Suneeta Senapati Divya Shah Ariella Shikanov Margarett Shnorhavorian Jodi L Skiles James F Smith Kristin Smith Fabio Sobral Kyle Stimpert H Irene Su Kouhei Sugimoto Nao Suzuki Mili Thakur David Victorson Luz Viale Wendy Vitek W Hamish Wallace Ellen A Wartella Lynn M Westphal Stacy Whiteside Lea H Wilcox Christine Wyns Shuo Xiao Jing Xu Mary Zelinski

J Assist Reprod Genet 2021 Jan 6;38(1):3-15. Epub 2021 Jan 6.

Division of Reproductive & Developmental Sciences, Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, OR, USA.

Purpose: Today, male and female adult and pediatric cancer patients, individuals transitioning between gender identities, and other individuals facing health extending but fertility limiting treatments can look forward to a fertile future. This is, in part, due to the work of members associated with the Oncofertility Consortium.

Methods: The Oncofertility Consortium is an international, interdisciplinary initiative originally designed to explore the urgent unmet need associated with the reproductive future of cancer survivors. As the strategies for fertility management were invented, developed or applied, the individuals for who the program offered hope, similarly expanded. As a community of practice, Consortium participants share information in an open and rapid manner to addresses the complex health care and quality-of-life issues of cancer, transgender and other patients. To ensure that the organization remains contemporary to the needs of the community, the field designed a fully inclusive mechanism for strategic planning and here present the findings of this process.

Results: This interprofessional network of medical specialists, scientists, and scholars in the law, medical ethics, religious studies and other disciplines associated with human interventions, explore the relationships between health, disease, survivorship, treatment, gender and reproductive longevity.

Conclusion: The goals are to continually integrate the best science in the service of the needs of patients and build a community of care that is ready for the challenges of the field in the future.
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http://dx.doi.org/10.1007/s10815-020-01983-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786868PMC
January 2021

Rural disparities in early childhood well child visit attendance.

J Pediatr Nurs 2020 Dec 25;58:76-81. Epub 2020 Dec 25.

University of Virginia School of Nursing, Charlottesville, VA, United States of America.

Purpose: Children should attend well child visits (WCVs) during early childhood so that developmental disorders may be identified as early as possible, so treatment can begin. The aim of this research was to determine if rurality impacts access to WCV during early childhood, and if altering rurality measurement methods impacts outcomes.

Design And Methods: We utilized a longitudinal correlational design with early childhood data gathered from the Virginia All Payer Claims Database, which contains claims data from Medicaid and the majority of Virginia commercial insurance payers (n = 6349). WCV attendance was evaluated against three rurality metrics: a traditional metric using Rural-Urban Commuting Area codes, a developed land variable, and a distance to care variable, at a zip code level.

Results: Two of the rurality methods revealed that rural children attend fewer WCVs than their urban counterparts, (67% vs. 50% respectively, using a traditional metric; and a 0.035 increase in WCV attendance for every percent increase in developed land). Differences were attenuated by insurance payer; children with Medicaid attend fewer WCVs than those with private insurance.

Conclusions: Young children in rural Virginia attend fewer WCVs than their non-rural counterparts, placing them at higher risk for missing timely developmental disorder screenings. The coronavirus disease pandemic has been associated with an abrupt and significant reduction in vaccination rates, which likely indicates fewer WCVs and concomitant developmental screenings. Pediatric nurses should encourage families of young children to develop a plan for continued WCVs, so that early identification of developmental disorders can be achieved.
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http://dx.doi.org/10.1016/j.pedn.2020.12.005DOI Listing
December 2020

Continuous Pulse Oximetry Monitoring in Bronchiolitis Patients Not Receiving Oxygen.

JAMA 2020 10;324(13):1349-1350

Department of Medicine, University of Virginia School of Medicine, Charlottesville.

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http://dx.doi.org/10.1001/jama.2020.12740DOI Listing
October 2020

Variation In State Medicaid Implementation Of The ACA: The Case Of Concurrent Care For Children.

Health Aff (Millwood) 2020 Oct;39(10):1770-1775

Lisa C. Lindley is an associate professor and Nightingale Endowed Faculty Fellow in the College of Nursing at the University of Tennessee, Knoxville.

More than 55,000 children die each year in the United States, and hospice is used for very few of them at the end of their lives. Nearly one-third of pediatric deaths are a result of chronic, complex conditions, and the majority of these children are enrolled in Medicaid because of disability status or the severity of their disease. Changes in Medicaid/Children's Health Insurance Program regulations under Section 2302 of the Affordable Care Act require all state Medicaid plans to finance curative and hospice services for children. The section enables the option for pediatric patients to continue curative care while enrolled in hospice. We examined state-level implementation of concurrent care for Medicaid beneficiaries and found significant variability in guidelines across the US. The implementation of concurrent care has fostered innovation yet has added barriers to how pediatric concurrent care has been implemented.
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http://dx.doi.org/10.1377/hlthaff.2020.01192DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7874853PMC
October 2020

Predicting adjuvant endocrine therapy initiation and adherence among older women with early-stage breast cancer.

Breast Cancer Res Treat 2020 Dec 12;184(3):805-816. Epub 2020 Sep 12.

Division of Surgical Oncology, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA.

Purpose: The CALGB 9343 trial demonstrated that women age 70 or older with early-stage, estrogen receptor positive (ER +) breast cancer (BC) may safely forgo radiation therapy (RT) and be treated with breast conserving surgery followed by adjuvant endocrine therapy (AET) alone. However, most patients in this population still undergo RT in part because AET adherence is low. We sought to develop a predictive model for AET initiation and adherence in order to improve decision-making with respect to RT omission.

Methods: Women ages 70 and older with early-stage, ER + BC were identified using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Comorbidities, socioeconomic measures, prescription medications, and demographics were collected as potential predictors. Bivariate analysis was performed to identify factors associated with AET initiation and adherence. Stepwise selection of significant predictors was used to develop logistic regression classifiers for initiation and adherence. Model performance was evaluated using the c-statistic and other measures.

Results: 11,037 patients met inclusion criteria. Within the cohort, 8703 (78.9%) patients initiated AET and 6685 (60.6%) were adherent to AET over 1 year. Bivariate predictors of AET initiation were similar to predictors of adherence. The best AET initiation and adherence classifiers were poorly predictive with c-statistics of 0.65 and 0.60, respectively.

Conclusions: The best models in the present study were poorly predictive, demonstrating that the reasons for initiation and adherence to AET are complex and individual to the patient, and therefore difficult to predict. Initiation and adherence to AET are important factors in decision-making regarding whether or not to forgo adjuvant RT. In order to better formulate treatment plans for this population, future work should focus on improving individual prediction of AET initiation and adherence.
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http://dx.doi.org/10.1007/s10549-020-05908-8DOI Listing
December 2020

Exploring Perceptions of Shift Length: A State-Based Survey of Registered Nurses.

J Nurs Adm 2020 Sep;50(9):449-455

Author Affiliations: Nursing Administrator (Ms Haller), Research Coordinator (Ms Miller-Davis), Coordinator (Ms Noguera), and Research Program Lead (Dr Letzkus), University of Virginia Health System; Assistant Professor (Drs Quatrara and Keim-Malpass), University of Virginia School of Nursing; Assistant Professor (Dr Pannone), Department of Public Health Sciences, University of Virginia School of Medicine; and Professor (Dr Guterbock), University of Virginia Center for Survey Research, Charlottesville.

Objective: The aim of this study was to explore clinical nurses' perspectives of shift length.

Background: Discussions about scheduling practices, work rotations, and shift length are pervasive among nurses and nursing leadership. However, the science surrounding nurse perceptions of longer shifts is limited.

Methods: A survey instrument was developed and distributed to nurses engaged in the state's professional association.

Results: Data from 190 clinical nurses were included. When working a 40-hour work week, 76.3% reported a preference for 10-hour shifts, whereas 83.5% preferred a 12-hour shift during a 36-hour week. Those who chose longer shifts perceived improved work life balance and better patient care. Those identifying 8-hour shifts also pointed to work life balance as benefit.

Conclusions: The results capture the voice of the nurse regarding shift length. The preference for the 10-hour shift within the 40-hour work week is novel. These results may assist with efforts to initiate change, improve the work environment and enhance home life.
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http://dx.doi.org/10.1097/NNA.0000000000000915DOI Listing
September 2020

Early Detection of In-Patient Deterioration: One Prediction Model Does Not Fit All.

Crit Care Explor 2020 May 11;2(5):e0116. Epub 2020 May 11.

Division of Cardiovascular Medicine, Department of Medicine, University of Virginia, Charlottesville, VA.

Objectives: Early detection of subacute potentially catastrophic illnesses using available data is a clinical imperative, and scores that report risk of imminent events in real time abound. Patients deteriorate for a variety of reasons, and it is unlikely that a single predictor such as an abnormal National Early Warning Score will detect all of them equally well. The objective of this study was to test the idea that the diversity of reasons for clinical deterioration leading to ICU transfer mandates multiple targeted predictive models.

Design: Individual chart review to determine the clinical reason for ICU transfer; determination of relative risks of individual vital signs, laboratory tests and cardiorespiratory monitoring measures for prediction of each clinical reason for ICU transfer; and logistic regression modeling for the outcome of ICU transfer for a specific clinical reason.

Setting: Cardiac medical-surgical ward; tertiary care academic hospital.

Patients: Eight-thousand one-hundred eleven adult patients, 457 of whom were transferred to an ICU for clinical deterioration.

Interventions: None.

Measurements And Main Results: We calculated the contributing relative risks of individual vital signs, laboratory tests and cardiorespiratory monitoring measures for prediction of each clinical reason for ICU transfer, and used logistic regression modeling to calculate receiver operating characteristic areas and relative risks for the outcome of ICU transfer for a specific clinical reason. The reasons for clinical deterioration leading to ICU transfer were varied, as were their predictors. For example, the three most common reasons-respiratory instability, infection and suspected sepsis, and heart failure requiring escalated therapy-had distinct signatures of illness. Statistical models trained to target-specific reasons for ICU transfer performed better than one model targeting combined events.

Conclusions: A single predictive model for clinical deterioration does not perform as well as having multiple models trained for the individual specific clinical events leading to ICU transfer.
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http://dx.doi.org/10.1097/CCE.0000000000000116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7259568PMC
May 2020

Assisters Succeed in Insurance Navigation for People Living with HIV and People at Increased Risk of HIV in a Complex Coverage Landscape.

AIDS Res Hum Retroviruses 2020 10 12;36(10):842-851. Epub 2020 Aug 12.

University of Virginia, School of Nursing, Charlottesville, Virginia, USA.

Insurance enrollment is complex for people living with HIV (PLWH) and people at increased risk for HIV, in part, owing to needing to ensure access to adequate provider networks and appropriate formularies. Insurance for PLWH facilitates access to HIV care/treatment and, ultimately, viral suppression, which has the individual benefit of longevity and the public health benefit of decreased HIV transmission. For people at increased risk for HIV, access to insurance facilitates improved access to HIV biomedical prevention, which has the individual benefit of elimination of transmission risk and the public health benefit of decreased HIV transmission. The objective of this study was to explore perceptions of priorities related to plan navigation, barriers and facilitators for enrolling and maintaining insurance coverage, and questions related to regional, state, and federal policies impacting plans provided both on and off the Affordable Care Act (ACA) marketplace. We interviewed a national sample of assisters ( = 40), who specialize in insurance plan selection for these populations. We found that assisters tailor their approaches to HIV-specific and person-specific concerns by navigating challenges related to affordability, formularies, and provider networks. In a complex coverage landscape during a time of uncertainty about the long-term future of the ACA, assisters have mastered the ability to simplify the insurance selection process for a vulnerable population. Assisters have excelled at incorporating insurance literacy education and encouraging client engagement in the process. Assisters play an essential role in the current complicated and fragmented United States' health care delivery system for PLWH and people at increased risk for HIV and could be incorporated into the Ending the HIV Epidemic initiative.
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http://dx.doi.org/10.1089/AID.2020.0013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7548024PMC
October 2020

Analyzing the concept of spillover effects for expanded inclusion in health economics research.

J Comp Eff Res 2020 08 16;9(11):755-766. Epub 2020 Jun 16.

Department of Acute and Specialty Care, University of Virginia School of Nursing, Charlottesville, VA 22903, USA.

The incorporation of spillover effects in health economic research is recognized by regulatory agencies as useful for valuing health interventions and technologies. To date, spillover effects are not universally used within economic evaluations and conceptual definitions of spillover effects are vague within the context of health economics research. In an effort to enhance awareness of spillover effects for health economic evaluations, a concept analysis using Walker and Avant's approach was performed to elucidate the key attributes, definitions, antecedents and consequences of spillover effects across a range of disciplines. Key attributes included lack of intention, positive and negative impacts, and two entity/domain involvement. Antecedents included an initial action and desired outcome. Consequences involved spillovers across industries, work life to personal life domains, patient to family member domains and across healthcare markets. The analysis provides greater clarification around the dimensions of spillover effects and reveals opportunities to enhance methodological approaches to assessing spillovers.
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http://dx.doi.org/10.2217/cer-2020-0051DOI Listing
August 2020

The association between legalization of recreational marijuana use and birth outcomes in Colorado and Washington state.

Birth Defects Res 2020 05 30;112(9):660-669. Epub 2020 Apr 30.

School of Nursing, University of Virginia, Charlottesville, Virginia, USA.

Objective: To identify trends in birth outcomes that may be associated with legalization of recreational marijuana which occurred in 2013 using vital records from Colorado and Washington states for the period of 2008-2016.

Methods: Data were from birth certificates of live births (between 22 and 44 weeks gestation) of which there were 576,369 singleton births included for Colorado and 771,547 for Washington State. Outcomes included preterm birth defined as <37 completed weeks of gestation; small for gestational age (SGA) defined using <10th percentile birthweight z-score; and birth prevalence of congenital anomalies defined using a variable from the birth certificate that indicated any major defect. The outcomes of interest were analyzed using a change-point approach to logistic regression adjusting for maternal socio-demographics, body mass index, smoking, and infant sex.

Results: There was evidence of an increased birth prevalence of congenital anomalies in both Colorado and Washington State when comparing prevalence before and after legalization. Only in Colorado did we observe an increase in preterm births post legalization, and there was no association with fetal growth in either state.

Conclusion: This time trend analysis indicates that the birth prevalence of all congenital anomalies combined in Washington and Colorado has increased in parallel with the timing of legalization of marijuana in those two states. However, this finding can only generate hypotheses as no pregnancy exposure information for marijuana was available in this dataset. More research is needed on the effect of marijuana use on birth outcomes.
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http://dx.doi.org/10.1002/bdr2.1680DOI Listing
May 2020

Perceptions of Clinical Trial Participation Among Women of Varying Health Literacy Levels.

Oncol Nurs Forum 2020 05;47(3):273-280

University of Virginia.

Purpose: To understand the perceptions of risk, benefit, and the informed consent process after enrolling in and completing a phase 2 clinical trial using intraoperative radiation therapy (IORT) for early-stage breast cancer, and to determine how perceptions varied based on women's health literacy levels.

Participants & Setting: 20 participants who had already completed a phase 2 IORT clinical trial for early-stage breast cancer at an academic medical center.

Methodologic Approach: A qualitative descriptive study was conducted using structured interviews consisting of questions aimed to elicit responses from participants regarding experiences of informed consent and the research process. A validated brief health literacy questionnaire was used to determine health literacy levels of participants. The authors analyzed themes using inductive thematic analysis.

Findings: Women with lower levels of health literacy reported feeling confident enough in the provider to make the decision to enroll in the clinical trial during the initial consultation, and, in general, women reported relying heavily on provider recommendation for enrolling in the clinical trial.

Implications For Nursing: Tailored approaches for patients with limited health literacy are needed during the clinical trial consent process. Additional longitudinal research with a larger sample size can extend study results and provide insight into the most effective way to modify the informed consent process for patients with limited health literacy.
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http://dx.doi.org/10.1188/20.ONF.273-280DOI Listing
May 2020

Pediatric Concurrent Hospice Care: A Scoping Review and Directions for Future Nursing Research.

J Hosp Palliat Nurs 2020 06;22(3):238-245

In 2010, forgoing curative therapies were removed as a hospice eligibility criterion for children through section 2302 of the Patient Protection and Affordable Care Act called Concurrent Care for Children. Given that concurrent care is a federally mandated option for children and their families, no review of the science has been conducted. The purpose of this study was to systematically collect the evidence on concurrent hospice care, critically appraise the evidence, and identify areas for future nursing research. Of the 186 articles identified for review, 14 met the inclusion and exclusion criteria. Studies in this review described concurrent hospice care from a variety of perspectives: policy, legal, and ethics. However, only 1 article evaluated the impact of concurrent hospice care on outcomes, whereas several studies explained clinical and state-level implementation. There is a need for further studies that move beyond conceptualization and generate baseline and outcomes data. Understanding the effectiveness of concurrent hospice care might provide important information for future nursing research. The approaches used to disseminate and implement concurrent hospice care at state, provider, and family levels should be explored.
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http://dx.doi.org/10.1097/NJH.0000000000000648DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7716801PMC
June 2020

Evaluating the Long-Term Impact of a Cooperative Group Trial on Radiation Use and Adjuvant Endocrine Therapy Adherence Among Older Women.

Ann Surg Oncol 2020 Sep 8;27(9):3458-3465. Epub 2020 Apr 8.

Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Virginia, Charlottesville, VA, USA.

Background: Using long-term survival data from the C9343 trial as a temporal reference point, this study aimed to determine radiation therapy (RT) treatment trends for older patients with early-stage breast cancer. The study also examined rates of adherence to adjuvant endocrine therapy (AET).

Methods: The surveillance, epidemiology, and end results-medicare database was used to identify women with a diagnosis of breast cancer from 2007 through 2016. Bivariate associations were calculated to determine variable characteristics by time frame (group 1: 2007-2012 vs. group 2: 2013-2016). Multivariate logistic regression was used to estimate the effect of group on the RT use and AET adherence. The temporal rates for both RT and AET adherence over time were plotted.

Results: The final study cohort included 12,210 Medicare beneficiaries. Use of RT differed significantly between the groups, with a higher proportion omitting RT in the later period (25% of group 2 vs. 20% of group 1; p < 0.001). In both groups, after adjustment for covariates, the patients with RT omitted were statistically less likely to adhere to AET [group 1: odds ratio (OR), 0.74; p < 0.001 vs. group 2: OR, 0.66; p < 0.001].

Conclusion: This study, 15 years after publication of the of the C9343 trial results, showed minimal change in practice, with most older women receiving RT. Importantly, AET adherence was significantly lower in the non-RT group. For women who meet the criteria to have adjuvant RT omitted, nonadherence to AET could result in undertreatment of their breast cancer, and RT should not be considered overtreatment.
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http://dx.doi.org/10.1245/s10434-020-08430-9DOI Listing
September 2020

Dynamic data in the ED predict requirement for ICU transfer following acute care admission.

J Clin Monit Comput 2020 Mar 19. Epub 2020 Mar 19.

AMP3D, Advanced Medical Predictive Devices, Diagnostics, and Displays, Inc, Charlottesville, VA, USA.

Misidentification of illness severity may lead to patients being admitted to a ward bed then unexpectedly transferring to an ICU as their condition deteriorates. Our objective was to develop a predictive analytic tool to identify emergency department (ED) patients that required upgrade to an intensive or intermediate care unit (ICU or IMU) within 24 h after being admitted to an acute care floor. We conducted a single-center retrospective cohort study to identify ED patients that were admitted to an acute care unit and identified cases where the patient was upgraded to ICU or IMU within 24 h. We used data available at the time of admission to build a logistic regression model that predicts early ICU transfer. We found 42,332 patients admitted between January 2012 and December 2016. There were 496 cases (1.2%) of early ICU transfer. Case patients had 18.0-fold higher mortality (11.1% vs. 0.6%, p < 0.001) and 3.4 days longer hospital stays (5.9 vs. 2.5, p < 0.001) than those without an early transfer. Our predictive analytic model had a cross-validated area under the receiver operating characteristic of 0.70 (95% CI 0.67-0.72) and identified 10% of early ICU transfers with an alert rate of 1.6 per week (162.2 acute care admits per week, 1.9 early ICU transfers). Predictive analytic monitoring based on data available in the emergency department can identify patients that will require upgrade to ICU or IMU if admitted to acute care. Incorporating this tool into ED practice may draw attention to high-risk patients before acute care admit and allow early intervention.
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http://dx.doi.org/10.1007/s10877-020-00500-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223530PMC
March 2020

To Improve the Inpatient Experience, Invest in the Human Side of Health Care.

Pediatrics 2020 03 3;145(3). Epub 2020 Feb 3.

Department of Acute and Specialty Care, School of Nursing and.

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http://dx.doi.org/10.1542/peds.2019-3760DOI Listing
March 2020

Self-Management Characterization for Families of Children With Medical Complexity and Their Social Networks: Protocol for a Qualitative Assessment.

JMIR Res Protoc 2020 Jan 23;9(1):e14810. Epub 2020 Jan 23.

School of Nursing, University of Virginia, Charlottesville, VA, United States.

Background: Children with medical complexity (CMC) present rewarding but complex challenges for the health care system. Transforming high-quality care practices for this population requires multiple stakeholders and development of innovative models of care. Importantly, care coordination requires significant self-management by families in home- and community-based settings. Self-management often requires that families of CMC rely on vast and diverse social networks, encompassing both online and offline social relationships with individuals and groups. The result is a support network surrounding the family to help accomplish self-management of medical tasks and care coordination.

Objective: The goal of this study is to use a theoretically driven perspective to systematically elucidate the range of self-management experiences across families of CMC embedded in diverse social networks and contextual environments. This approach will allow for characterization of the structure and process of self-management of CMC with respect to social networks, both in person and digitally. This research proposal aims to address the significant gaps in the self-management literature surrounding CMC, including the following: (1) how self-management responsibilities are distributed and negotiated among the social network and (2) how individual-, family-, and system-level factors influence self-management approaches for CMC from a theoretically driven perspective.

Methods: This study will encompass a qualitative descriptive approach to understand self-management practices among CMC and their social networks. Data collection and analysis will be guided by a theoretical and methodological framework, which synthesizes perspectives from nursing, human factors engineering, public health, and family counseling. Data collection will consist of semistructured interviews with children, parents, and social network members, inclusive of individuals such as friends, neighbors, and community members, as well as online communities and individuals. Data analysis will consist of a combination of inductive and deductive methods of qualitative content analysis, which will be analyzed at both individual and multiadic levels, where interview data from two or more individuals, focused on the same experience, will be comparatively analyzed.

Results: This study will take approximately 18 months to complete. Our long-term goals are to translate the qualitative analysis into (1) health IT design guidance for innovative approaches to self-management and (2) direct policy guidance for families of CMC enrolled in Medicaid and private insurance.

Conclusions: Multiple innovative components of this study will enable us to gain a comprehensive and nuanced understanding of the lived experience of self-management of CMC. In particular, by synthesizing and applying theoretical and methodological approaches from multiple disciplines, we plan to create novel informatics and policy solutions to support their care within home and community settings.

International Registered Report Identifier (irrid): PRR1-10.2196/14810.
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http://dx.doi.org/10.2196/14810DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7005691PMC
January 2020

The Emergency Resiliency Initiative: A Pilot Mindfulness Intervention Program.

J Holist Nurs 2020 Jun 24;38(2):205-220. Epub 2019 Sep 24.

University of Virginia.

To assess the feasibility of a pilot mindfulness intervention program, the Emergency Resiliency Initiative (ERI), as well as to investigate changes in burnout scores and key drivers to burnout among registered nurses (RNs) and patient care technicians (PCTs) in a Level 1 trauma center emergency department (ED). A mixed methods pre/post study with data collection points before and after the 3-month intervention. Three mindfulness educational/experiential sessions were delivered once a month at staff meetings with topic themes of Introduction to Mindfulness, Practical Applications of Mindfulness, and Cultivating Compassion. Participants were asked to complete a minimum of two weekly 5-minute meditations. Burnout scores were assessed using the Maslach Burnout Inventory at preintervention (baseline) and postintervention. From the pre- ( = 35) to post- ( = 26) intervention period there was a significant increase in personal accomplishment scores ( = .01) and decrease in emotional exhaustion scores ( = .03) for RNs and PCTs combined. Qualitative interviews revealed five burnout-related themes: (a) prioritization distress, (b) change fatigue, (c) self-protection through superficiality, (d) intentional response, and (e) community amid chaos. The ERI was a feasible and acceptable program associated with improvements in burnout scores. Qualitative interviews revealed the positive impacts of mindfulness on ED clinician resiliency and identified future opportunities to address burnout from a holistic perspective.
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http://dx.doi.org/10.1177/0898010119874971DOI Listing
June 2020

Variability In States' Coverage Of Children With Medical Complexity Through Home And Community-Based Services Waivers.

Health Aff (Millwood) 2019 09;38(9):1484-1490

Lisa C. Letzkus is a nurse scientist in the School of Nursing, University of Virginia and University of Virginia Medical Center.

Even though children with medical complexity represent less than 1 percent of the US pediatric population, they are among the costliest users of the health care system. Much of the care for these children is delivered in home and community-based settings and covered by Medicaid waivers under Section 1915(c). Expenditures related to these waivers have been steadily increasing, with most recent estimates showing spending that exceeds $48 billion per year. Little is known about these waivers' economic impact or effectiveness, because their components and coverage have not previously been well defined. Our study addressed this paucity of data by analyzing the scope of coverage offered by the waivers and evaluating how states are using them to cover children with medical complexity. We found great variability in how states choose to interpret scope of coverage and services offered, and this variability may have an impact on child and family outcomes.
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http://dx.doi.org/10.1377/hlthaff.2018.05413DOI Listing
September 2019

Compassion and connectedness as motivational drivers in the care of children with medical complexity.

J Pediatr Rehabil Med 2019;12(3):279-284

School of Nursing, The University of Virginia, Charlottesville, VA, USA.

Employing a cross-sectional qualitative descriptive design, using individual, semi-structured interviews collected from primary care and specialty clinicians who routinely care for children with medical complexity (CMC) in a largely rural area in central Virginia, this study aimed to better understand the current state of care, the motivations, and barriers for expansion of care for CMC in a semi-rural academic hospital center. Five themes emerged describing the current practice of the participants: (1) complexities of care, (2) compassion and empathy for families, (3) limited resources, (4) essential nature of coordination and teamwork, and (5) proximity to care. Each of the five themes that emerged from our interviews present both challenges and rewards. The theme of compassion for families of CMC is seen as a key potential motivational driver for expansion and reorganization of clinical care for CMC.
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http://dx.doi.org/10.3233/PRM-190611DOI Listing
June 2020

Built and Natural Environment Barriers and Facilitators to Physical Activity in Rural, Suburban, and Small Urban Neighborhoods.

Oncol Nurs Forum 2019 09;46(5):545-555

University of Virginia.

Purpose: To explore built and natural environment barriers and facilitators to walking for exercise in cancer survivors.

Participants & Setting: Cancer survivors (N = 7) living in rural, suburban, and small urban neighborhoods in central Virginia.

Methodologic Approach: The authors used a qualitative descriptive design with photovoice to explore the cancer survivors' experience with residential walkability.

Findings: The following three themes were identified from the data.

Implications For Nursing: Clinicians should consider an evaluation of the built and natural environment to support walking in cancer survivors. These findings may be used in conjunction with known individual-level barriers to physical activity to develop guidance for oncology nurses to help survivors safely achieve physical activity goals.
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http://dx.doi.org/10.1188/19.ONF.545-555DOI Listing
September 2019

Predictive analytics in the pediatric intensive care unit for early identification of sepsis: capturing the context of age.

Pediatr Res 2019 11 31;86(5):655-661. Epub 2019 Jul 31.

Center for Advanced Medical Analytics, University of Virginia, Charlottesville, VA, USA.

Background: Early recognition of patients at risk for sepsis is paramount to improve clinical outcomes. We hypothesized that subtle signatures of illness are present in physiological and biochemical time series of pediatric-intensive care unit (PICU) patients in the early stages of sepsis.

Methods: We developed multivariate models in a retrospective observational cohort to predict the clinical diagnosis of sepsis in children. We focused on age as a predictor and asked whether random forest models, with their potential for multiple cut points, had better performance than logistic regression.

Results: One thousand seven hundred and eleven admissions for 1425 patients admitted to a mixed cardiac and medical/surgical PICU were included. We identified, through individual chart review, 187 sepsis diagnoses that were not within 14 days of a prior sepsis diagnosis. Multivariate models predicted sepsis in the next 24 h: cross-validated C-statistic for logistic regression and random forest were 0.74 (95% confidence interval (CI): 0.71-0.77) and 0.76 (95% CI: 0.73-0.79), respectively.

Conclusions: Statistical models based on physiological and biochemical data already available in the PICU identify high-risk patients up to 24 h prior to the clinical diagnosis of sepsis. The random forest model was superior to logistic regression in capturing the context of age.
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http://dx.doi.org/10.1038/s41390-019-0518-1DOI Listing
November 2019

A New Era in Pediatric Hospice Care for Military Families.

Am J Nurs 2019 08;119(8):66-69

Marsha G. Wilson Smith is a case manager, PANDA Palliative Care Team and Blood and Marrow Transplant Service, Children's National Health System, Washington, DC, where Deborah A. LaFond is an NP. Jessica Keim-Malpass is an assistant professor, School of Nursing and School of Medicine, Department of Pediatrics, University of Virginia, Charlottesville. Lisa C. Lindley is an associate professor, College of Nursing, University of Tennessee, Knoxville. Marianne Matzo is the director of research, Hospice and Palliative Nurses Association, Oklahoma City, OK, and the coordinator of Perspectives on Palliative Nursing: The authors have disclosed no potential conflicts of interest, financial or otherwise.

: This series on palliative care is developed in collaboration with the Hospice and Palliative Nurses Association (HPNA; https://advancingexpertcare.org). The HPNA aims to guide nurses in preventing and relieving suffering and in giving the best possible care to patients and families, regardless of the stage of disease or the need for other therapies. The HPNA offers education, certification, advocacy, leadership, and research.
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http://dx.doi.org/10.1097/01.NAJ.0000577468.30510.60DOI Listing
August 2019

Publicly Funded Home and Community-Based Care for Children With Medical Complexity: Protocol for the Analysis of Medicaid Waiver Applications.

JMIR Res Protoc 2019 Jul 25;8(7):e13062. Epub 2019 Jul 25.

University of Virginia School of Nursing, Charlottesville, VA, United States.

Background: Children with medical complexity are a group of children with multiple chronic conditions and functional limitations that represent the highest health care utilization and often require a substantial number of home and community-based services (HCBS). In many states, HCBS are offered to target populations through 1915(c) Medicaid waivers. To date, no standard methods or approaches have been established to evaluate or compare 1915(c) waivers across states in the United States for children.

Objective: The purpose of this analysis was to develop a systematic and reproducible approach to evaluate 1915(c) Medicaid waivers for overall coverage of children with medical complexity.

Methods: Data elements were extracted from Medicaid 1915(c) approved waiver applications for all included waivers targeting any pediatric age range through October 31, 2018. Normalization criteria were established, and an aggregate overall coverage score was calculated for each waiver.

Results: Data extraction occurred in two phases: (1) waivers that were considered nonexpired through December 31, 2017, and (2) the final sample that included nonexpired waivers through October 31, 2018. A total of 142 waivers across 45 states in the United States were included in this analysis. We found that the existing adult HCBS taxonomy may not always be applicable for child and family-based service provision. Although there was uniformity in the Medicaid applications, there was high heterogeneity in how waiver eligibility, transition plans, and wait lists were defined. Study analysis was completed in January 2019, and after analyzing each individual waiver, results were aggregated at the level of the state and for each diagnostic subgroup. The published results are forthcoming.

Conclusions: To our knowledge, this is the first study to systematically evaluate 1915(c) Medicaid waivers targeting children with medical complexity that can be replicated without the threat of missing data.

International Registered Report Identifier (irrid): RR1-10.2196/13062.
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http://dx.doi.org/10.2196/13062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6686641PMC
July 2019

Towards development of alert thresholds for clinical deterioration using continuous predictive analytics monitoring.

J Clin Monit Comput 2020 Aug 20;34(4):797-804. Epub 2019 Jul 20.

AMP3D, Advanced Medical Predictive Devices, Diagnostics, and Displays, Inc, Charlottesville, VA, USA.

Patients who deteriorate while on the acute care ward and are emergently transferred to the Intensive Care Unit (ICU) experience high rates of mortality. To date, risk scores for clinical deterioration applied to the acute care wards rely on static or intermittent inputs of vital sign and assessment parameters. We propose the use of continuous predictive analytics monitoring, or data that relies on real-time physiologic monitoring data captured from ECG, documented vital signs, laboratory results, and other clinical assessments to predict clinical deterioration. A necessary step in translation to practice is understanding how an alert threshold would perform if applied to a continuous predictive analytic that was trained to detect clinical deterioration. The purpose of this study was to evaluate the positive predictive value of 'risk spikes', or large abrupt increases in the output of a statistical model of risk predicting clinical deterioration. We studied 8111 consecutive patient admissions to a cardiovascular medicine and surgery ward with continuous ECG data. We first trained a multivariable logistic regression model for emergent ICU transfer in a test set and tested the characteristics of the model in a validation set of 4059 patient admissions. Then, in a nested analysis we identified large, abrupt spikes in risk (increase by three units over the prior 6 h; a unit is the fold-increase in risk of ICU transfer in the next 24 h) and reviewed hospital records of 91 patients for clinical events such as emergent ICU transfer. We compared results to 59 control patients at times when they were matched for baseline risk including the National Warning Score (NEWS). There was a 3.4-fold higher event rate for patients with risk spikes (positive predictive value 24% compared to 7%, p = 0.006). If we were to use risk spikes as an alert, they would fire about once per day on a 73-bed acute care ward. Risk spikes that were primarily driven by respiratory changes (ECG-derived respiration (EDR) or charted respiratory rate) had highest PPV (30-35%) while risk spikes driven by heart rate had the lowest (7%). Alert thresholds derived from continuous predictive analytics monitoring are able to be operationalized as a degree of change from the person's own baseline rather than arbitrary threshold cut-points, which can likely better account for the individual's own inherent acuity levels. Point of care clinicians in the acute care ward settings need tailored alert strategies that promote a balance in recognition of clinical deterioration and assessment of the utility of the alert approach.
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http://dx.doi.org/10.1007/s10877-019-00361-5DOI Listing
August 2020

Diffusing an Innovation: Clinician Perceptions of Continuous Predictive Analytics Monitoring in Intensive Care.

Appl Clin Inform 2019 03 1;10(2):295-306. Epub 2019 May 1.

Departments of Cardiology and Biomedical Engineering, University of Virginia, Charlottesville, Virginia, United States.

Background: The purpose of this article is to describe neonatal intensive care unit clinician perceptions of a continuous predictive analytics technology and how those perceptions influenced clinician adoption. Adopting and integrating new technology into care is notoriously slow and difficult; realizing expected gains remain a challenge.

Methods: Semistructured interviews from a cross-section of neonatal physicians ( = 14) and nurses ( = 8) from a single U.S. medical center were collected 18 months following the conclusion of the predictive monitoring technology randomized control trial. Following qualitative descriptive analysis, innovation attributes from Diffusion of Innovation Theory-guided thematic development.

Results: Results suggest that the combination of physical location as well as lack of integration into work flow or methods of using data in care decisionmaking may have delayed clinicians from routinely paying attention to the data. Once data were routinely collected, documented, and reported during patient rounds and patient handoffs, clinicians came to view data as another vital sign. Through clinicians' observation of senior physicians and nurses, and ongoing dialogue about data trends and patient status, clinicians learned how to integrate these data in care decision making (e.g., differential diagnosis) and came to value the technology as beneficial to care delivery.

Discussion: The use of newly created predictive technologies that provide early warning of illness may require implementation strategies that acknowledge the risk-benefit of treatment clinicians must balance and take advantage of existing clinician training methods.
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http://dx.doi.org/10.1055/s-0039-1688478DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6494616PMC
March 2019

"Is this a STD? Please help!": Online Information Seeking for Sexually Transmitted Diseases on Reddit.

Proc Int AAAI Conf Weblogs Soc Media 2018 Jun;2018:660-663

Department of Systems and Information Engineering, University of Virginia.

Increasing incidence of sexually transmitted diseases (STDs) has prompted the public health and technology communities to innovate new measures to understand how individuals use Internet resources to attain relevant information, particularly for sensitive or stigmatized conditions. The purpose of this study is to examine recent health information seeking and needs of the r/STD community, a subreddit focused exclusively on STDs. We found that the majority of posts crowd-source information about intermediate, non-reportable STDs such as human papillomavirus (HPV). Crowdsourced information in this community focused on symptoms, treatment, as well as the social and emotional aspects of sexual health such as fear of misdiagnosis. From our analysis, it is clear that online communities focused on discussion of health symptoms have the ripe potential to influence information-seeking behavior and consumer action.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6460917PMC
June 2018