scholarly journals Crisis standards of care in a pandemic: navigating the ethical, clinical, psychological and policy-making maelstrom

2020 ◽  
Author(s):  
Attila J Hertelendy ◽  
Gregory R Ciottone ◽  
Cheryl L Mitchell ◽  
Jennifer Gutberg ◽  
Frederick M Burkle
Keyword(s):  
Resource Allocation ◽  
Moral Distress ◽  
Point Of Care ◽  
Treatment Options ◽  
Healthcare Providers ◽  
Population Based ◽  
Standards Of Care ◽  
Clinical Decisions ◽  
Societal Benefit ◽  
Life Saving

Abstract The COVID-19 pandemic has caused clinicians at the frontlines to confront difficult decisions regarding resource allocation, treatment options and ultimately the life-saving measures that must be taken at the point of care. This article addresses the importance of enacting crisis standards of care (CSC) as a policy mechanism to facilitate the shift to population-based medicine. In times of emergencies and crises such as this pandemic, the enactment of CSC enables concrete decisions to be made by governments relating to supply chains, resource allocation and provision of care to maximize societal benefit. This shift from an individual to a population-based societal focus has profound consequences on how clinical decisions are made at the point of care. Failing to enact CSC may have psychological impacts for healthcare providers particularly related to moral distress, through an inability to fully enact individual beliefs (individually focused clinical decisions) which form their moral compass.

Inequalities of health insurance guidelines for the treatment of symptomatic varicose veins

2013 ◽  
Vol 29 (4) ◽  
pp. 236-246 ◽  
Author(s):  
M W Schul ◽  
T King ◽  
L S Kabnick
Keyword(s):  
Evidence Based Medicine ◽  
Varicose Veins ◽  
Treatment Options ◽  
Healthcare Delivery ◽  
Healthcare Providers ◽  
Standards Of Care ◽  
Evidence Based ◽  
Treatment Providers ◽  
Based Medicine ◽  
Vein Disease

Objectives The emerging model of US healthcare delivery is aimed at reducing costs, standardizing care, and improving outcomes. Although it is necessary for healthcare providers and insurance carriers to work together to achieve those goals, insurers have the added duty of assuring physicians and patients that they comprehend the medical evidence and, based on that understanding, construct policies. Are US insurers meeting that responsibility or are they simply creating policies to serve their own needs? Methods The medical policies of several US health insurers were analysed. The goal was to see whether it could readily be determined if these carriers used evidence-based medicine consistently to create uniform policies for the treatment of patients with symptomatic varicose veins. The literature was also reviewed to determine whether increased insurance documentation requirements have affected cost reduction, standardization of care and/or improvement of outcomes related to chronic vein disease management. Results There is a dramatic lack of uniformity among the insurance policies reviewed. Insurers appear to not choose important papers to create policy but use carefully chosen articles to reinforce what they want their policies to say. In so doing, conflicting policy criteria are being created. Complicating this inconsistency, rules for medical necessity are modified frequently, raising frustration levels among vein providers and their patients. What is clear is that costs are not being lowered, care is not being standardized and little is being done to prevent potential complications resulting from chronic vein disease. Conclusions Patients and physicians are increasingly ill-served by, and frustrated with, the clear lack of consistency in the medical policy criteria being created by US insurance carriers in covering the treatment of patients with symptomatic varicose veins. The contradictory coverage requirements, seemingly based on no understanding of evidence-based medicine guidelines, and total variability in reimbursement for various types of treatment options is particularly worrisome. Collaboration between venous treatment providers and insurance carriers, to create evidence-based standards of care, would be timely and beneficial in creating guidelines for optimal patient care.

Moral distress in nurses caring for patients with Covid-19

2021 ◽  
pp. 096973302110032
Author(s):  
Henry J Silverman ◽  
Raya Elfadel Kheirbek ◽  
Gyasi Moscou-Jackson ◽  
Jenni Day
Keyword(s):  
New York ◽  
Ethical Climate ◽  
Moral Distress ◽  
Qualitative Content Analysis ◽  
Healthcare Providers ◽  
Resource Scarcity ◽  
Standards Of Care ◽  
Medical Systems ◽  
Institutional Review ◽  
Good Patient Care

Background: Moral distress occurs when constraints prevent healthcare providers from acting in accordance with their core moral values to provide good patient care. The experience of moral distress in nurses might be magnified during the current Covid-19 pandemic. Objective: To explore causes of moral distress in nurses caring for Covid-19 patients and identify strategies to enhance their moral resiliency. Research design: A qualitative study using a qualitative content analysis of focus group discussions and in-depth interviews. We purposively sampled 31 nurses caring for Covid-19 patients in the acute care units within large academic medical systems in Maryland and New York City during April to June 2020. Ethical considerations: We obtained approval from the Institutional Review Board at the University of Maryland, Baltimore. Results: We identified themes and sub-themes representative of major causes of moral distress in nurses caring Covid-19 patients. These included (a) lack of knowledge and uncertainty regarding how to treat a new illness; (b) being overwhelmed by the depth and breadth of the Covid-19 illness; (c) fear of exposure to the virus leading to suboptimal care; (d) adopting a team model of nursing care that caused intra-professional tensions and miscommunications; (e) policies to reduce viral transmission (visitation policy and PPE policy) that prevented nurses to assume their caring role; (f) practicing within crisis standards of care; and (g) dealing with medical resource scarcity. Participants discussed their coping mechanisms and suggested future strategies. Discussion/Conclusion: Our study affirms new causes of moral distress related to the Covid-19 pandemic. Institutions need to develop a supportive ethical climate that can restore nurses’ moral resiliency. Such a climate should include non-hierarchical interdisciplinary spaces where all providers can meet together as moral peers to discuss their experiences.

Outcomes of conservatively managed localized prostate cancer

2009 ◽  
Vol 27 (15_suppl) ◽  
pp. 5010-5010
Author(s):  
G. Lu-Yao ◽  
P. C. Albertsen ◽  
D. F. Moore ◽  
Y. Lin ◽  
W. Shih ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Treatment Options ◽  
Specific Antigen ◽  
Healthcare Providers ◽  
Cancer Registries ◽  
Population Based ◽  
The Past ◽  
History Of ◽  
Better Than ◽  
Overall Mortality

5010 Background: The natural history of screen-detected prostate cancer has not been well described. Methods: Cancer-specific and overall mortality, assessed through competing risk analyses, were determined for 14,516 men aged 65 years or older diagnosed between 1992–2002 and did not receive surgery or radiation within 6 months of cancer diagnosis. The population-based cohort was identified from US cancer registries, which had 98% completeness in case ascertainment. Results: Compared to earlier era studies, survival has improved considerably for conservatively managed patients diagnosed in the contemporary prostate specific antigen (PSA) era ( Table ). Conclusions: Men diagnosed with prostate cancer in the PSA era have survival outcomes significantly better than those in the past. Patients and healthcare providers may need to reassess some treatment options in light of these data. [Table: see text] No significant financial relationships to disclose.

scholarly journals Personalized treatment options for chronic diseases using precision cohort analytics

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Kenney Ng ◽  
Uri Kartoun ◽  
Harry Stavropoulos ◽  
John A. Zambrano ◽  
Paul C. Tang
Keyword(s):  
Decision Making ◽  
Chronic Diseases ◽  
Primary Care Physicians ◽  
Treatment Guidelines ◽  
Point Of Care ◽  
Data Extraction ◽  
Treatment Options ◽  
Personalized Treatment ◽  
Medical Decision ◽  
Similarity Model

AbstractTo support point-of-care decision making by presenting outcomes of past treatment choices for cohorts of similar patients based on observational data from electronic health records (EHRs), a machine-learning precision cohort treatment option (PCTO) workflow consisting of (1) data extraction, (2) similarity model training, (3) precision cohort identification, and (4) treatment options analysis was developed. The similarity model is used to dynamically create a cohort of similar patients, to inform clinical decisions about an individual patient. The workflow was implemented using EHR data from a large health care provider for three different highly prevalent chronic diseases: hypertension (HTN), type 2 diabetes mellitus (T2DM), and hyperlipidemia (HL). A retrospective analysis demonstrated that treatment options with better outcomes were available for a majority of cases (75%, 74%, 85% for HTN, T2DM, HL, respectively). The models for HTN and T2DM were deployed in a pilot study with primary care physicians using it during clinic visits. A novel data-analytic workflow was developed to create patient-similarity models that dynamically generate personalized treatment insights at the point-of-care. By leveraging both knowledge-driven treatment guidelines and data-driven EHR data, physicians can incorporate real-world evidence in their medical decision-making process when considering treatment options for individual patients.

scholarly journals Stillbirth outcome capture and classification in population-based surveys: EN-INDEPTH study

2021 ◽  
Vol 19 (S1) ◽  
Author(s):  
Hannah Blencowe ◽  
◽  
Matteo Bottecchia ◽  
Doris Kwesiga ◽  
Joseph Akuze ◽  
...  
Keyword(s):  
Gestational Age ◽  
A Priori ◽  
Healthcare Providers ◽  
Population Based ◽  
Reproductive Age ◽  
Group Discussions ◽  
Cross Sectional ◽  
Vital Status ◽  
Neonatal Deaths ◽  
Adverse Pregnancy

Abstract Background Household surveys remain important sources of stillbirth data, but omission and misclassification are common. Classifying adverse pregnancy outcomes as stillbirths requires accurate reporting of vital status at birth and gestational age or birthweight for every pregnancy. Further categorisation, e.g. by sex, or timing (intrapartum/antepartum) improves data to understand and prevent stillbirth. Methods We undertook a cross-sectional population-based survey of women of reproductive age in five health and demographic surveillance system sites in Bangladesh, Ethiopia, Ghana, Guinea-Bissau and Uganda (2017–2018). All women answered a full birth history with pregnancy loss questions (FBH+) or a full pregnancy history (FPH). A sub-sample across both groups were asked additional stillbirth questions. Questions were evaluated using descriptive measures. Using an interpretative paradigm and phenomenology methodology, focus group discussions with women exploring barriers to reporting birthweight for stillbirths were conducted. Thematic analysis was guided by an a priori codebook. Results Overall 69,176 women reported 98,483 livebirths (FBH+) and 102,873 pregnancies (FPH). Additional questions were asked for 1453 stillbirths, 1528 neonatal deaths and 12,620 surviving children born in the 5 years prior to the survey. Completeness was high (> 99%) for existing FBH+/FPH questions on signs of life at birth and gestational age (months). Discordant responses in signs of life at birth between different questions were common; nearly one-quarter classified as stillbirths on FBH+/FPH were reported born alive on additional questions. Availability of information on gestational age (weeks) (58.1%) and birthweight (13.2%) was low amongst stillbirths, and heaping was common. Most women (93.9%) were able to report the sex of their stillborn baby. Response completeness for stillbirth timing (18.3–95.1%) and estimated proportion intrapartum (15.6–90.0%) varied by question and site. Congenital malformations were reported in 3.1% stillbirths. Perceived value in weighing a stillborn baby varied and barriers to weighing at birth a nd knowing birthweight were common. Conclusions Improving stillbirth data in surveys will require investment in improving the measurement of vital status, gestational age and birthweight by healthcare providers, communication of these with women, and overcoming reporting barriers. Given the large burden and effect on families, improved data must be made available to end preventable stillbirths.

scholarly journals Advocating for equity during the pandemic

BMJ Leader ◽  
2021 ◽  
pp. leader-2020-000380
Author(s):  
Onyinyechi F Eke ◽  
Alister Martin ◽  
Hazar Khidir ◽  
Onyeka Otugo ◽  
Andrew Marshall ◽  
...  
Keyword(s):  
Small Group ◽  
Health Equity ◽  
Healthcare Providers ◽  
The State ◽  
Standards Of Care ◽  
Community Members ◽  
Alternative Framework ◽  
Marginalised Groups

In response to an imminent surge in COVID-19 cases, the state of Massachusetts (MA) released its Crisis Standards of Care (CSC) guidelines in April 2020. A small group of Boston healthcare providers, community members, lawyers, ethicists and disability advocates brought to bear our collective strengths to forge a formidable coalition now known as the Massachusetts Coalition for Health Equity, to champion the rights of marginalised groups that would be adversely affected by the implementation of the original MA CSC guidelines. In this coalition, members of marginalised communities were adequately represented, led discussions on the implications of implementing inequitable elements of the CSC guidelines and actively involved in creating an alternative framework. In this article, we discuss the process of building a coalition whose concerted advocacy efforts led to the revision of the MA CSC guidelines.

scholarly journals Young adults’ perceptions of living with atopic dermatitis in relation to the concept of self-management: a qualitative study

BMJ Open ◽  
2021 ◽  
Vol 11 (6) ◽  
pp. e044777
Author(s):  
Susanne Lundin ◽  
Marina Jonsson ◽  
Carl-Fredrik Wahlgren ◽  
Emma Johansson ◽  
Anna Bergstrom ◽  
...  
Keyword(s):  
Young Adults ◽  
Atopic Dermatitis ◽  
Qualitative Study ◽  
Healthcare Providers ◽  
Transition Process ◽  
Population Based ◽  
Self Management ◽  
School Age ◽  
Perceived Availability ◽  
Semistructured Interviews

ObjectivesLearning to take control of one’s health is an important part of the transition from adolescence to adulthood. This study aimed to explore young adults’ perceptions of living with atopic dermatitis (AD) in relation to the concept of self-management.DesignA qualitative study with an inductive approach was performed through semistructured interviews (n=15). The interviews were recorded, transcribed verbatim and analysed with systematic text condensation.ParticipantsYoung adults (mean age 23,4 years) with persistent AD in a longitudinal population-based birth cohort. To capture experience of living with persistent AD (preschool/school-age onset) of different severity (mild to severe/very severe), a purposive selection was performed. In total, 15 young adults were included. Persistent AD (preschool/school-age onset) was defined as dry skin in combination with itchy rash of typical localisation in the 12 months preceding the 16-year and the 24-year follow-ups. Severity was self-assessed using the Patient Oriented Eczema Measure.ResultsDespite having experience of AD since childhood, the respondents expressed uncertainty about treatment and how it affected their bodies. Their uncertainties and feelings affected how they used topical corticosteroids. The respondents emphasised that they perceived availability of healthcare and knowledge about treatment of AD among healthcare providers to be limited. The participants did not state any experiences of support to self-management from healthcare, which affect young adults’ possibilities to take full control of their AD care.ConclusionsYoung adults with preschool/school-age onset of AD are unsure how to treat and manage the disease. One explanation may be insufficient transition process.

scholarly journals Immunotherapy in hepatocellular carcinoma: evaluation and management of adverse events associated with atezolizumab plus bevacizumab

2021 ◽  
Vol 13 ◽  
pp. 175883592110311
Author(s):  
Chiun Hsu ◽  
Lorenza Rimassa ◽  
Hui-Chuan Sun ◽  
Arndt Vogel ◽  
Ahmed O. Kaseb
Keyword(s):  
Hepatocellular Carcinoma ◽  
Adverse Events ◽  
Kinase Inhibitor ◽  
Treatment Options ◽  
Healthcare Providers ◽  
Safety Data ◽  
Standard Of Care ◽  
Antiangiogenic Agents ◽  
Efficacy And Safety ◽  
First Line

In light of positive efficacy and safety findings from the IMbrave150 trial of atezolizumab plus bevacizumab, this novel combination has become the preferred first-line standard of care for patients with unresectable hepatocellular carcinoma (HCC). Several additional trials are ongoing that combine an immune checkpoint inhibitor with another agent such as a multiple kinase inhibitor or antiangiogenic agent. Therefore, the range of first-line treatment options for unresectable HCC is likely to increase, and healthcare providers need succinct information about the use of such combinations, including their efficacy and key aspects of their safety profiles. Here, we review efficacy and safety data on combination immunotherapies and offer guidance on monitoring and managing adverse events, especially those associated with atezolizumab plus bevacizumab. Because of their underlying liver disease and high likelihood of portal hypertension, patients with unresectable HCC are at particular risk of gastrointestinal bleeding, and this risk may be exacerbated by treatments that include antiangiogenic agents. Healthcare providers also need to be alert to the risks of proteinuria and hypertension, colitis, hepatitis, and reactivation of hepatitis B or C virus infection. They should also be aware of the possibility of rarer but potentially life-threatening adverse events such as pneumonitis and cardiovascular events. Awareness of the risks associated with these therapies and knowledge of adverse event monitoring and management will become increasingly important as the therapeutic range broadens in unresectable HCC.

scholarly journals Symposium report: breast cancer in India—trends, environmental exposures and clinical implications

2021 ◽  
Vol 32 (6) ◽  
pp. 567-575
Author(s):  
Jasmine A. McDonald ◽  
Roshni Rao ◽  
Marley Gibbons ◽  
Rajiv Janardhanan ◽  
Surinder Jaswal ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Scientific Evidence ◽  
Treatment Options ◽  
Environmental Exposures ◽  
Population Based ◽  
Clinical Implications ◽  
Think Tank ◽  
Case Control Studies ◽  
Short Term

Abstract Purpose Incidence of breast cancer (BC), particularly in young women, are rising in India. Without population-based mammography screening, rising rates cannot be attributed to screening. Investigations are needed to understand the potential drivers of this trend. Methods An international team of experts convened to discuss the trends, environmental exposures, and clinical implications associated with BC in India and outlined recommendations for its management. Results Panels were structured across three major BC themes (n = 10 presentations). The symposium concluded with a semi-structured Think Tank designed to elicit short-term and long-term goals that could address the challenges of BC in India. Conclusion There was consensus that the prevalence of late-stage BC and the high BC mortality rates are associated with the practice of detection, which is primarily through clinical and self-breast exams, as opposed to mammography. Triple-Negative BC (TNBC) was extensively discussed, including TNBC etiology and potential risk factors, the limited treatment options, and if reported TNBC rates are supported by rigorous scientific evidence. The Think Tank session yielded long-term and short-term goals to further BC reduction in India and included more regional etiological studies on environmental exposures using existing India-based cohorts and case–control studies, standardization for molecular subtyping of BC cases, and improving the public’s awareness of breast health.

scholarly journals Chemotherapy alone versus definitive concurrent chemoradiotherapy for cT4b esophageal squamous cell carcinoma: a population-based study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Chia-Chin Li ◽  
Chih-Yi Chen ◽  
Ying-Hsiang Chou ◽  
Chih-Jen Huang ◽  
Hsiu-Ying Ku ◽  
...  
Keyword(s):  
Squamous Cell Carcinoma ◽  
Esophageal Squamous Cell Carcinoma ◽  
Cell Carcinoma ◽  
Squamous Cell ◽  
Concurrent Chemoradiotherapy ◽  
Statistical Significance ◽  
Treatment Options ◽  
Population Based ◽  
Primary Analysis

Abstract Background The role of radiotherapy for cT4bNanyM0 esophageal squamous cell carcinoma (ESqCC) is relatively unclear, with both chemotherapy (C/T) alone and definitive concurrent chemoradiotherapy (dCCRT) being treatment options in the current guidelines. We aimed to compare the survival of dCCRT versus C/T for these patients via a population-based approach. Methods Eligible cT4b ESqCC patients diagnosed between 2011 and 2017 were identified via the Taiwan Cancer Registry. We used propensity score (PS) weighting to balance the observable potential confounders between groups. The hazard ratio (HR) of death and incidence of esophageal cancer mortality (IECM) were compared between dCCRT and C/T. We also evaluated OS in subgroups of either low or standard radiotherapy doses. Results Our primary analysis consisted of 247 patients in whom covariates were well balanced after PS weighing. The HR for death when dCCRT was compared with C/T was 0.36 (95% confidence interval 0.24–0.53, P < 0.001). Similar results were found for IECM. Statistical significance was only observed in the standard RT dose but not in the low dose in subgroup analyses. Conclusions In this population-based nonrandomized study of cT4bNanyM0 ESqCC patients from Asia (Taiwan), we found that the use of radiotherapy with chemotherapy was associated with better overall survival than chemotherapy alone. Further studies (especially RCTs) are needed to confirm our findings.

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