Publications

OBJECTIVES: To assess the feasibility of the Toolkit for Optimal Recovery after Concussion (TOR-C), the first mind-body program aiming to prevent persistent concussion symptoms among young adults with anxiety, and an active control (Health Enhancement after Concussion; HE-C). We also tested preliminary improvements in outcome measures and putative mechanistic targets.

DESIGN: Single-blind, 2-arm, randomized controlled trial.

SETTING: Academic medical center in the US Northeast.

PARTICIPANTS: Fifty young adults (ages 18-35) with a recent concussion (3-10 weeks prior) and anxiety (≥5 on the GAD7 questionnaire).

INTERVENTIONS: Both interventions consisted of four 45-minute 1:1 sessions with a clinician over Zoom. TOR-C (n=25) taught mind-body, cognitive-behavioral, and return-to-activity skills. HE-C (n=25) taught health education (e.g., sleep, nutrition) without skills.

MAIN OUTCOME MEASURES: Primary: feasibility outcomes (e.g., recruitment, credibility, expectancy, acceptability, safety, feasibility of assessments, fidelity, satisfaction, TOR-C homework adherence) with a-priori-set benchmarks. Secondary: intervention outcomes were concussion symptoms (PCSS), physical function (WHODAS), anxiety (GAD7/HAD-A), depression (HADS-D) and pain (NRS). TOR-C mechanistic targets were pain catastrophizing (PCS), mindfulness (CAMS-R), fear avoidance (FAB-TBI), limiting behavior and all-or-nothing behavior (BRIQ).

RESULTS: Both interventions met all feasibility benchmarks and were associated with significant improvements in outcomes (concussion symptoms, physical function, anxiety, depression and pain; d=0.44-1.21) and TOR-C mechanistic targets (pain catastrophizing, mindfulness, fear-avoidance, and limiting behavior; Cohen's d=0.41-1.24). Improvements in all-or-nothing behavior were only significant in TOR-C (d=0.52). Improvements in all mechanistic targets except all-or-nothing behavior following TOR-C were significantly associated with improvements in at least one outcome.

CONCLUSION: Findings provide strong support for the feasibility of TOR-C and HE-C, and preliminary evidence for improvements in mechanistic targets and outcomes. Findings inform a future fully-powered RCT testing efficacy of TOR-C vs. HE-C.

IMPORTANCE: Despite guidelines recommending avoidance of benzodiazepine administration to older patients, many of them now receive benzodiazepines as a part of anesthesia care. The effectiveness of clinician- and patient-facing interventions to discourage such use remains insufficiently characterized.

OBJECTIVE: To evaluate the effect of clinician peer comparison, patient informational mail, or a combination of these interventions compared with usual care on the rate of perioperative benzodiazepine administration to older patients.

DESIGN, SETTING, AND PARTICIPANTS: This 2 × 2 factorial, stepped-wedge, cluster randomized clinical trial of a corporate quality improvement initiative was conducted between August 8, 2022, and May 28, 2023, across 415 hospitals, surgery centers, and physician offices in 8 US states served by anesthesia clinicians from a national anesthesia practice. Participants were adults aged 65 years or older who underwent an elective surgical or endoscopic procedure with general anesthesia. Data analyses followed the intention-to-treat principle.

INTERVENTION: Patients were randomly assigned to 1 of 4 groups-clinician peer comparison (wherein clinicians received feedback regarding their performance compared with other clinicians in the practice), patient informational mail (wherein patients received an informational letter encouraging them to have a discussion regarding medication selection with their clinician on the day of surgery), both interventions, or usual care (no intervention).

MAIN OUTCOMES AND MEASURES: Rate of benzodiazepine administration during anesthesia care and patient satisfaction with anesthesia care (measured by the Anesthesia Patient Satisfaction Questionnaire, version 2).

RESULTS: Among the 509 269 enrolled participants (255 871 females [50.2%]; mean [SD] age, 74 [7] years), 81 363 (16.0%) were assigned to clinician peer comparison, 98 520 (19.3%) to patient informational mail, 169 712 (33.3%) to both interventions, and 159 674 (31.4%) to usual care. Among patients who received benzodiazepine during anesthesia care, 24.5% were in the usual care group compared with 19.7% in the clinician peer comparison group, 20.0% in the patient informational mail group, and 19.7% in the combination group. After adjustment for time, none of the study interventions were associated with lower odds of benzodiazepine administration compared with usual care (odds ratio [OR], 1.02 [95% CI, 0.98-1.07]; P = .35 for clinician peer comparison; OR, 1.01 [95% CI, 0.96-1.05]; P = .81 for patient informational mail; and OR, 1.11 [95% CI, 1.05-1.16]; P < .001 for combined interventions). Satisfaction scores were high in all groups and did not vary by treatment assignment.

CONCLUSIONS AND RELEVANCE: This randomized clinical trial found that clinician peer comparison, patient informational mail, or a combination of both interventions did not reduce benzodiazepine administration to older patients compared with usual care; patient satisfaction remained high throughout the study. Overall, the findings suggest a need to explore other patient-targeted interventions to improve anesthesia care.

TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT05436392.

IMPORTANCE: Social determinant of health (SDOH) data are essential to individualized care and reducing health disparities. However, there is little standardization in the way that SDOH data are collected, and barriers to increasing the collection of such data exist at both the patient and clinician levels.

OBJECTIVE: To evaluate clinician, patient, and care partner perspectives on the barriers to and facilitators of patients sharing SDOH information with their clinicians.

DESIGN, SETTING, AND PARTICIPANTS: This qualitative study included clinicians, patients, and care partners across the United States. Focus groups were conducted between September 2022 and February 2023 to understand the experience of collecting, documenting, and exchanging SDOH data.

MAIN OUTCOMES AND MEASURES: Rapid assessment procedures were used to analyze focus group transcripts, creating summaries, codes, and themes mapped directly to the project research questions.

RESULTS: A total of 235 individuals participated, including 109 (46.4%) clinicians (60 [55.0%] male; 25 [22.9%] Asian, 2 [1.8%] Black, and 74 [67.9%] White) and 126 (53.6%) patients and care partners (45 [35.7%] male; 1 [0.8%] Asian, 48 [38.1%] Black, and 64 [50.8%] White). Clinicians and patients agreed that SDOH data are important for clinicians to know. Both clinicians and patients wanted a structured, standardized way to collect SDOH data in the future, accompanied by time for more in-depth discussion during the visit. However, they highlighted numerous issues that impact collecting these data, including beliefs about how the information will be used, the clinician-patient relationship, having enough of the right staff, time needed to collect SDOH information, and technology used to collect the data (eg, usability, standardization).

CONCLUSIONS AND RELEVANCE: This qualitative study of the experience of collecting, documenting, and exchanging SDOH data underscores the ongoing barriers to widespread adoption of uniform approaches to SDOH data documentation as well as factors that may help lower those barriers, such as trusting patient-clinician relationships, greater transparency in how the data will be used, and targeted resources. A multifaceted approach to addressing the concerns raised by clinicians, patients, and care partners is required to ensure that such data can be captured in a way that improves care and allows for progress toward an equitable health care system.

BACKGROUND: Increased intraoperative electroencephalographic (EEG) burst suppression is associated with postoperative delirium. Cerebral desaturation is considered as one of the factors associated with burst suppression. Our study investigates the association between cerebral desaturation and burst suppression by analyzing their concurrence. Additionally, we aim to examine their association with cardiac surgical phases to identify potential for targeted interventions.

METHODS: We retrospectively analyzed intraoperative 1-minute interval observations in 51 patients undergoing cardiac surgery. Processed EEG and cerebral oximetry were collected, with the anesthesiologists blinded to the information. The associations between cerebral desaturation (defined as a 10% decrease from baseline) and burst suppression, as well as with phase of cardiac surgery, were analyzed using the Generalized Logistic Mixed Effect Model. The results were presented as odds ratio and 95% confidence intervals (CIs). A value of P < .05 was considered statistically significant.

RESULTS: The odds of burst suppression increased 1.5 times with cerebral desaturation (odds ratio [OR], 1.52, 95% CI, 1.11-2.07; P = .009). Compared to precardiopulmonary bypass (pre-CPB), the odds of cerebral desaturation were notably higher during CPB (OR, 22.1, 95% CI, 12.4-39.2; P < .001) and post-CPB (OR, 18.2, 95% CI, 12.2-27.3; P < .001). However, the odds of burst suppression were lower during post-CPB (OR, 0.69, 95% CI, 0.59-0.81; P < .001) compared to pre-CPB. Compared to pre-CPB, the odds of concurrent cerebral desaturation and burst suppression were notably higher during CPB (OR, 52.3, 95% CI, 19.5-140; P < .001) and post-CPB (OR, 12.7, 95% CI, 6.39-25.2; P < .001). During CPB, the odds of cerebral desaturation (OR, 6.59, 95% CI, 3.62-12; P < .001) and concurrent cerebral desaturation and burst suppression (OR, 10, 95% CI, 4.01-25.1; P < .001) were higher in the period between removal of aortic cross-clamp and end of CPB. During the entire surgery, the odds of burst suppression increased 8 times with higher inhalational anesthesia concentration (OR, 7.81, 95% CI, 6.26-9.74; P < .001 per 0.1% increase).

CONCLUSIONS: Cerebral desaturation is associated with intraoperative burst suppression during cardiac surgery, most significantly during CPB, especially during the period between the removal of the aortic cross-clamp and end of CPB. Further exploration with simultaneous cerebral oximetry and EEG monitoring is required to determine the causes of burst suppression. Targeted interventions to address cerebral desaturation may assist in mitigating burst suppression and consequently enhance postoperative cognitive function.

The use of dietary supplements by patients with chronic liver disease is prevalent and rising. Despite the known risks of dietary supplements, including hepatotoxicity, adulteration, and contamination, patients with chronic liver disease often turn to dietary supplements to support their liver and/or overall health but are not necessarily empowered with the information or guidance from their liver practitioner to do so. This article provides practitioners with a framework for balancing the risks and benefits of dietary supplements in patients with chronic liver disease, offering examples of independent resources and certifications to use this framework in clinical practice. We offer 3 common clinical scenarios to highlight how the use of this framework can improve communication and decision-making in clinical practice. By adapting principles from Integrative Medicine, this article advocates for a patient-centered approach to dietary supplements in patients with chronic liver disease, encouraging open dialogue between clinicians and their patients to facilitate informed decision-making and personalized care.

IMPORTANCE: Although trial data support the omission of axillary surgery and radiation therapy (RT) in women aged 70 years or older with T1N0 hormone receptor-positive (HR+) breast cancer, potential overtreatment in older adults with frailty persists.

OBJECTIVE: To determine how much geospatial variation in locoregional therapy may be attributed to region vs patient factors.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cross-sectional study included women aged 70 years or older who were diagnosed with HR+/ERBB2-negative (ERBB2-) breast cancer from January 1, 2013, to December 31, 2017. Data came from Surveillance, Epidemiology, and End Results-Medicare. Hierarchical multivariable modeling was used to evaluate the variance in deescalated care attributable to 4 domains, ie, (1) random, (2) region (health service area [HSA]), (3) patient factors, and (4) unexplained. Patient factors included age, frailty (validated claims-based measure), Charlson Comorbidity Index (CCI), and socioeconomic status (Yost index). Analyses were performed from January to October 2023.

EXPOSURE: HSA.

MAIN OUTCOMES AND MEASURES: Deescalated care, defined as omission of axillary surgery, RT, or both. Standard therapy was defined as lumpectomy, axillary surgery, and RT or mastectomy with axillary surgery. Multivariable logistic regression was used to identify factors associated with deescalated care receipt.

RESULTS: Of 9173 patients (mean [SD] age, 76.5 [5.2] years), 2363 (25.8%) were aged 80 years or older, 705 (7.7%) had frailty, and 419 (4.6%) had a CCI of 2 or greater. While 4499 (49.1%) underwent standard therapy, 4674 (50.9%) underwent deescalated therapy (1193 [13.0%] of the population omitted axillary surgery and 4342 [55.5%] of patients undergoing lumpectomy omitted RT). Of the total variance, random variation explained 27.3%, region/HSA explained 35.3%, patient factors explained 2.8%, and 34.5% was unexplained. In adjusted models, frailty and increased age were associated with a higher likelihood of undergoing deescalated therapy (frailty: odds ratio [OR], 1.70; 95% CI, 1.43-2.02; age, by 1-year increment: OR, 1.10; 95% CI, 1.09-1.11), but CCI was not. Patients in rural areas compared with those in urban areas (OR, 0.82; 95% CI, 0.68-0.99) and Asian and Pacific Islander patients compared with non-Hispanic White patients (OR, 0.68; 95% CI, 0.54-0.85) had a lower likelihood of undergoing deescalated therapy.

CONCLUSIONS AND RELEVANCE: In this retrospective cross-sectional study of women aged 70 years or older diagnosed with T1N0 HR+/ERBB2- breast cancer, region/HSA contributed more to the variation in deescalated therapy use than patient factors. Unexplained variation may be attributed to unmeasured characteristics, such as multidisciplinary environment and patient preference. Decision support efforts to address overtreatment should target regions with low rates of evidence-based deescalation.

BACKGROUND: Wide pulse pressure (PP) is associated with cardiovascular events and the progression of chronic kidney disease (CKD) to kidney failure. PP naturally widens with age, but it is unclear whether the risks associated with greater PP are the same across all ages.

METHODS: We used Cox proportional hazards models to investigate the association of PP with (i) atherosclerotic cardiovascular disease (ASCVD) events or death and (ii) a 50% reduction in estimated glomerular filtration rate or kidney failure in the chronic renal insufficiency cohort (CRIC). We evaluated the association of time-updated PP with these outcomes, accounting for time-updated confounders using inverse probability weighting.

RESULTS: Among 5,621 participants with CKD, every 10-mmHg greater PP was associated with a 6% higher risk of an ASCVD event or death (hazard ratio [HR] = 1.06, 95% CI 1.04, 1.08) and 17% higher risk of the composite kidney outcome (HR = 1.17, 95% CI 1.16, 1.18). Greater PP was associated with a higher risk of ASCVD events or death among participants in the lowest age tertile (21-61 years), but a higher risk of the composite kidney outcome in the oldest age tertile (71-79 years). While wide PP in participants that experienced the primary outcomes was predominantly driven by elevated SBP, PP remained significantly associated with the composite kidney outcome across all ages and with ASCVD events or death in the first age tertile when SBP was added to the Cox regression model.

CONCLUSIONS: Our findings suggest that the mechanism by which PP is associated with adverse outcomes may differ by age.

Dynamic teaming is required whenever people must coordinate with one another in a fluid context, particularly when the fundamental structures of a team, such as membership, priorities, tasks, modes of communication, and location are in near-constant flux. This is certainly the case in the contemporary ambulatory care diagnostic process, where circumstances and conditions require a shifting cast of individuals to coordinate dynamically to ensure patient safety. This article offers an updated perspective on dynamic teaming commonly required during the ambulatory diagnostic process. Drawing upon team science, it clarifies the characteristics of dynamic diagnostic teams, identifies common risk points in the teaming process and the practical implications of these risks, considers the role of providers and patients in averting adverse outcomes, and provides a case example of the challenges of dynamic teaming during the diagnostic process. Based on this, future research needs are offered as well as clinical practice recommendations related to team characteristics and breakdowns, team member knowledge/cognitions, teaming dynamics, and the patient as a team member.

The ambulatory diagnostic process is potentially complex, resulting in faulty communication, lost information, and a lack of team coordination. Patients and families have a unique position in the ambulatory diagnostic team, holding privileged information about their clinical conditions and serving as the connecting thread across multiple healthcare encounters. While experts advocate for engaging patients as diagnostic team members, operationalizing patient engagement has been challenging. The team science literature links improved team performance with shared mental models, a concept reflecting the team's commonly held knowledge about the tasks to be done and the expertise of each team member. Despite their proven potential to improve team performance and outcomes in other settings, shared mental models remain underexplored in healthcare. In this manuscript, we review the literature on shared mental models, applying that knowledge to the ambulatory diagnostic process. We consider the role of patients in the diagnostic team and adapt the five-factor model of shared mental models to develop a framework for patient-clinician diagnostic shared mental models. We conclude with research priorities. Development, maintenance, and use of shared mental models of the diagnostic process amongst patients, families, and clinicians may increase patient/family engagement, improve diagnostic team performance, and promote diagnostic safety.