Patient perspectives on states worse than death: A qualitative study with implications for patient-centered outcomes and values elicitation

Background: Seriously ill patients rate several health outcomes as states worse than death. It is unclear what factors underlie such valuations, and whether consideration of such states is useful when making medical decisions. Aim: We sought to (1) use qualitative approaches to identify states worse than death, (2) identify attributes common to such undesirable health states, and (3) determine how participants might use information on these states in making medical decisions. Design: Qualitative study of semi-structured interviews utilizing content analysis with constant comparison techniques. Setting, Participants: We interviewed adults age 65 or older with serious illnesses after discharge home from one of two urban, academic hospitals. Eligible patients were purposively sampled to achieve balance in gender and race. Results: Of 29 participants, 15 (52%) were female, and 15 were white (52%), with a median age of 72 (interquartile range 69, 75). Various physical, cognitive, and social impairments were identified as states worse than death. The most commonly reported attributes underlying states worse than death were perceived burden on loved ones and inability to maintain human connection. Patients believed information on states worse than death must be individualized, and were concerned their opinions could change with time and fluctuations in health status. Conclusions: Common factors underlying undesirable states suggest that for care to be patient-centered it must also be family-centered. Patients’ views on using states worse than death in decision making highlight barriers to using avoidance of such states as a quality measure, but also suggest opportunities for eliciting patients’ values.

Vaccination Hesitancy among Health-Care-Workers in Academic Hospitals Is Associated with a 12-Fold Increase in the Risk of COVID-19 Infection: A Nine-Month Greek Cohort Study

Health-Care-Workers (HCWs) are considered at high risk for SARS-CoV-2 infection. We sought to compare rates and severity of Coronavirus disease 2019 (COVID-19) among vaccinated and unvaccinated HCWs conducting a retrospective cohort study in two tertiary Academic Hospitals, namely Laiko and Attikon, in Athens, Greece. Vaccinated by BNT162b2 Pfizer-BioNTech COVID-19 mRNA vaccine and unvaccinated HCWs were included and data were collected between 1 January 2021 and 15 September 2021. Overall, 2921 of 3219 HCWs without a history of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection were fully vaccinated during the study period (90.7% at each Hospital). Demographic characteristics were comparable between 102/2921 (3.5%) vaccinated and 88/298 (29.5%) unvaccinated HCWs with COVID-19, although age and occupation differed significantly. None were in need of hospital admission in the vaccinated Group, whereas in the unvaccinated Group 4/88 (4.5%) were hospitalized and one (1.1%) died. Multivariable logistic regression analysis revealed that lack of vaccination was an independent risk factor for COVID-19 with an odds ratio 11.54 (95% CI: 10.75–12.40). Vaccination hesitancy among HCWs resulted to highly increased COVID-19 rates; almost one in three unvaccinated HCWs was SARS-CoV-2 infected during the 9-month period. The absolute need of vaccination of HCWs, including boosting dose, is highlighted. Evidence should be used appropriately to overcome any hesitancy.

Comorbidities Associated with Complicated Hospital Course and Death in COVID-19 Patients: A Retrospective Study from Iran

Objective There are limited data regarding the impact of comorbidities on hospitalized patients with coronavirus disease 2019 (COVID-19) in Iran. Methods We evaluated the risk of serious adverse outcomes in 1368 Iranian COVID-19 patients, admitted to five academic hospitals in Tehran between February-June 2020. The composite end-points were defined as admission to an intensive care unit, invasive ventilation, or death. The Cox proportional survival model determined the potential comorbidities associated with death. Results Overall, 576 patients (42.3%) reached the composite end-point (280 death). Adjusted for age, sex, duration of hospitalization, and the presence of the other comorbidities, patients with diabetes (RR=1.25, 95%CI; 1.08-1.44), heart failure (RR=1.45, 95%CI; 1.10-1.91), chronic kidney disease (RR=1.32, 95%CI; 1.04-1.67), malignancy (RR=1.79, 95%CI; 1.41-2.28), and lung diseases (RR=1.53, 95%CI; 1.27-1.84) were more likely to reach the composite end-point than those without the very comorbidity. Moreover, patients aged less than 65 years had a greater risk of death in the presence of two (HR=2.68, 95%CI; 1.46-4.95, p=0.002) or more (HR=3.47, 95%CI; 1.69-7.12, p=0.001) comorbidities, compared to those without any comorbidity. Conclusion To conclude, having two or more comorbidities in patients less than 65 years is associated with a greater risk of death during hospitalization.

Perceptions and Attitudes Towards COVID-19 Vaccination Amongst Pregnant and Postpartum Individuals

Introduction: This study aims to characterize attitudes towards COVID-19 vaccination and to evaluate factors associated with vaccine uptake amongst pregnant individuals. Methods: An anonymous survey was distributed to a convenience sample of pregnant individuals receiving prenatal care at two large urban academic hospitals in a single healthcare network in Massachusetts. Individual demographic variables were included in the survey along with questions assessing attitudes towards COVID-19 and vaccination in pregnancy. Results: Of 477 respondents, 233 (49.3%) had received or were scheduled to receive a COVID-19 vaccine. Age, White race, non-Hispanic/LatinX ethnicity, working from home, and typical receipt of the influenza vaccine were associated with COVID-19 vaccination. 276 respondents (58.4%) reported that their provider recommended the COVID-19 vaccine in pregnancy; these participants were more likely to have received a vaccine (OR 5.82, 95% confidence interval [CI] 3.68-9.26). Vaccinated individuals were less likely to be worried about the effects of the vaccine on themselves (OR 0.18, 95% CI 0.12-0.27) or their developing babies (OR 0.17, 95% CI 0.11-0.26). Unvaccinated individuals were less likely to report that it is easy to schedule a COVID-19 vaccine (OR 0.56, 95% CI 0.34-0.93), to travel to receive a vaccine (OR 0.19, 95% CI 0.10-0.36), and to miss work to receive a vaccine (OR 0.30, 95% CI 0.18-0.48). Conclusions: Strategies are needed to improve patient education regarding vaccine side effects and safety in pregnancy and to change policy to make it feasible for pregnant patients to schedule and miss work without loss of pay to get vaccinated.

Does circumferential casting prevent fracture redisplacement in reduced distal radius fractures? A retrospective multicentre study

Background This study evaluates whether a circumferential cast compared to a plaster splint leads to less fracture redisplacement in reduced extra-articular distal radius fractures (DRFs). Methods This retrospective multicentre study was performed in four hospitals (two teaching hospitals and two academic hospitals). Adult patients with a displaced extra-articular DRF, treated with closed reduction, were included. Patients were included from a 5-year period (January 2012–January 2017). According to the hospital protocol, fractures were immobilized with a below elbow circumferential cast (CC) or a plaster splint (PS). The primary outcome concerned the difference in the occurrence of fracture redisplacement at one-week follow-up. Results A total of 500 patients were included in this study (PS n = 184, CC n = 316). At one-week follow-up, fracture redisplacement occurred in 52 patients (17%) treated with a CC compared to 53 patients (29%) treated with a PS. This difference was statistically significant (p = 0.001). Conclusion This study suggests that treatment of reduced DRFs with a circumferential cast might cause less fracture redisplacement at 1-week follow-up compared to treatment with a plaster splint. Level of Evidence Level III, Retrospective study.

Statin Use and In-hospital Mortality in Patients with COVID-19 and Coronary Heart Disease

The worsening progress of coronavirus disease 2019 (COVID-19) is attributed to the proinflammatory state, leading to increased mortality. Statin works with its anti-inflammatory effects and may attenuate the worsening of COVID-19. COVID-19 patients were retrospectively enrolled from two academic hospitals in Wuhan, China, from 01/26/2020 to 03/26/2020. Adjusted in-hospital mortality was compared between the statin and the non-statin group by CHD status using multivariable Cox regression model after propensity score matching. Our study included 3133 COVID-19 patients (median age: 62y, female: 49.8%), and 404 (12.9%) received statin. Compared with the non-statin group, the statin group was older, more likely to have comorbidities but with a lower level of inflammatory markers. The Statin group also had a lower adjusted mortality risk (6.44% vs. 10.88%; adjusted hazard ratio [HR] 0.47; 95% CI, 0.29–0.77). Subgroup analysis of CHD patients showed a similar result. Propensity score matching showed an overall 87% (HR, 0.13; 95% CI, 0.05–0.36) lower risk of in-hospital mortality for statin users than nonusers. Such survival benefit of statin was obvious both among CHD and non-CHD patients (HR = 0.30 [0.09–0.98]; HR = 0.23 [0.1–0.49], respectively). Statin use was associated with reduced in-hospital mortality in COVID-19. The benefit of statin was both prominent among CHD and non-CHD patients. These findings may further reemphasize the continuation of statins in patients with CHD during the COVID-19 era.

Barriers to translational research in Windsor Ontario: a survey of clinical care providers and health researchers

Background Translational research is an ideology focussed on streamlining the transition of novel research into clinical practice to ultimately benefit populations. Central to this approach is overcoming barriers to research involvement and interdisciplinary collaboration. Identifying barriers has been the subject of several studies focused on communities with large academic hospitals. The Windsor-Essex region is currently built around community hospitals which have less of an emphasis on research, employ fewer physicians holding academic appointments and generally do not provide incentivised time for research and training. In this study, we surveyed clinicians and researchers working in Windsor-Essex to gain insight into barriers to translational research important to those working in smaller sized, community-based research networks. Methods Using an anonymous close-ended Qualtrics survey distributed via email, we surveyed faculty members from The University of Windsor and clinical care providers from Windsor-Essex (n = 68). This included 24 physicians, 14 allied health professionals, and 30 non-clinician researchers. Results Managing competing interests, lack of time, funding, infrastructure, and networks were identified by greater than 75% of participants as barriers to research involvement. 62% of physicians identified the lack of permanent post-graduate medical trainees as a barrier. Clinicians were consistently less experienced in research skills compared to others; particularly in publishing results and applying for funding (p < 0.001). Schedule incompatibility, funding issues and identifying interested collaborators with overlapping interests were identified as barriers to interdisciplinary collaboration by 80% of participants. Moreover, 46% of those surveyed were unhappy with their research involvement and these individuals were 13% more likely to perceive research as important for their career progression (p = 0.244). Conclusions This study identifies several important barriers to translational research in Windsor-Essex and suggests that many motivated researchers are unhappy with their current involvement. These results will inform decision making in the research community of Windsor-Essex and provides insight for communities of similar size and research capacity. Ultimately, enabling the translation of clinical research in all communities is required to ensure equitable access to cutting edge care.

Examining of the effect of HRM in mitigating negative effects of LM&SS on employee well-being in health care

Purpose This study aims to examine the effect of human resource management (HRM) in mitigating negative effects of Lean management and Six Sigma (LM&SS) on employee well-being in health care. The authors subdivide well-being into three components: happiness, trust and health. Design/methodology/approach This is a cross-sectional, multisite survey study in internal service units of hospitals. Data analyzed using multivariate regression come from a sample of 1,886 survey respondents (42 units, N = 218 supervisors, N = 1,668 employees) in eight Dutch academic hospitals that have implemented LM&SS. Findings The present study findings show no or weak effects of LM&SS on the happiness and health component of employee well-being. In addition, the authors found a significant but weak direct positive effect (ß = 0.07) of the LM&SS bundle on the trusting relationships component of well-being. Therefore, moderating effects of HRM practices on the relationship between LM&SS and employee well-being seem less relevant because an existing relationship between LM&SS and employee well-being is a prerequisite for moderation (Hayes, 2009). There were unexpected side effects. Inspired by research that discusses direct effects of HRM on employee well-being, the authors tested this relationship and found that HRM has a direct positive effect on trust and happiness of employees in health care. For the health component of well-being, the present results show a weak negative effect of HRM. Practical implications This study results in a cautiously optimistic view about LM&SS in health care, provided that it is applied in a targeted manner (to improve the performance of their processes) and that HRM is strategically aligned with the goals of LM&SS to improve employees’ happiness and trusting relationships. Originality/value Unique features of the study are the focus on the consequences for employees’ well-being related to LM&SS in health care, the role of HRM in regard to this relationship and the participation of all eight Dutch academic hospitals in this research.

A survey on Canadian pediatric hospital clinical/medical teaching unit implementation during the first and second wave of the COVID-19 pandemic

Background As the COVID-19 pandemic heightened, infection control and prevention experts recommended clinical training opportunities be modified or discontinued, substantially impacting the function of clinical or medical teaching units (CTU). A CTU is structured to involve medical learners such that they become active participants of the health care team. Since a review of the literature demonstrates a paucity of data to guide pediatric CTU implementation during pandemic phases, we developed and disseminated a survey to assess Canadian practices. Method A group of infectious disease specialists and pediatric hospitalists developed, tested, and disseminated surveys to understand CTU clinical rounding and teaching practices during the waves of the COVID-19 pandemic. Result Our surveys demonstrate the variability in adapting rounding practices during this pandemic and highlights the opportunities to share our approaches and lessons learned to optimize learner experience and patient centered care during unprecedented times in our academic hospitals. We also show the pragmatic implementation of our new pediatric hospital CTU process that was informed by our survey results. Conclusion Our study demonstrates the variability in adapting rounding practices during this pandemic and highlights the opportunities to share our approaches and lessons learned to optimize learner experience and patient centered care during unprecedented times in our academic hospitals.