1
|
Freundlich RE, Wanderer JP, French B, Moore RP, Hernandez A, Shah AS, Byrne DW, Pandharipande PP. Protocol for a randomised controlled trial: reducing reintubation among high-risk cardiac surgery patients with high-flow nasal cannula (I-CAN). BMJ Open 2022; 12:e066007. [PMID: 36428016 PMCID: PMC9703331 DOI: 10.1136/bmjopen-2022-066007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Heated, humidified, high-flow nasal cannula oxygen therapy has been used as a therapy for hypoxic respiratory failure in numerous clinical settings. To date, limited data exist to guide appropriate use following cardiac surgery, particularly among patients at risk for experiencing reintubation. We hypothesised that postextubation treatment with high-flow nasal cannula would decrease the all-cause reintubation rate within the 48 hours following initial extubation, compared with usual care. METHODS AND ANALYSIS Adult patients undergoing cardiac surgery (open surgery on the heart or thoracic aorta) will be automatically enrolled, randomised and allocated to one of two treatment arms in a pragmatic randomised controlled trial at the time of initial extubation. The two treatment arms are administration of heated, humidified, high-flow nasal cannula oxygen postextubation and usual care (treatment at the discretion of the treating provider). The primary outcome will be all-cause reintubation within 48 hours of initial extubation. Secondary outcomes include all-cause 30-day mortality, hospital length of stay, intensive care unit length of stay and ventilator-free days. Interaction analyses will be conducted to assess the differential impact of the intervention within strata of predicted risk of reintubation, calculated according to our previously published and validated prognostic model. ETHICS AND DISSEMINATION Vanderbilt University Medical Center IRB approval, 15 March 2021 with waiver of written informed consent. Plan for publication of study protocol prior to study completion, as well as publication of results. TRIAL REGISTRATION NUMBER clinicaltrials.gov, NCT04782817 submitted 25 February 2021. DATE OF PROTOCOL 29 August 2022. Version 2.0.
Collapse
Affiliation(s)
- Robert E Freundlich
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Benjamin French
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ryan P Moore
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniel W Byrne
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Pratik P Pandharipande
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
2
|
Gettel CJ, Yiadom MYA, Bernstein SL, Grudzen CR, Nath B, Li F, Hwang U, Hess EP, Melnick ER. Pragmatic clinical trial design in emergency medicine: Study considerations and design types. Acad Emerg Med 2022; 29:1247-1257. [PMID: 35475533 PMCID: PMC9790188 DOI: 10.1111/acem.14513] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 04/04/2022] [Accepted: 04/25/2022] [Indexed: 01/25/2023]
Abstract
Pragmatic clinical trials (PCTs) focus on correlation between treatment and outcomes in real-world clinical practice, yet a guide highlighting key study considerations and design types for emergency medicine investigators pursuing this important study type is not available. Investigators conducting emergency department (ED)-based PCTs face multiple decisions within the planning phase to ensure robust and meaningful study findings. The PRagmatic Explanatory Continuum Indicator Summary 2 (PRECIS-2) tool allows trialists to consider both pragmatic and explanatory components across nine domains, shaping the trial design to the purpose intended by the investigators. Aside from the PRECIS-2 tool domains, ED-based investigators conducting PCTs should also consider randomization techniques, human subjects concerns, and integration of trial components within the electronic health record. The authors additionally highlight the advantages, disadvantages, and rationale for the use of four common randomized study design types to be considered in PCTs: parallel, crossover, factorial, and stepped-wedge. With increasing emphasis on the conduct of PCTs, emergency medicine investigators will benefit from a rigorous approach to clinical trial design.
Collapse
Affiliation(s)
- Cameron J. Gettel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT, USA
| | - Maame Yaa A.B. Yiadom
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Bidisha Nath
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Geriatrics Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA
| | - Erik P. Hess
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Edward R. Melnick
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| |
Collapse
|
3
|
Lindsell CJ, Gatto CL, Dear ML, Buie R, Rice TW, Pulley JM, Hartert TV, Kripalani S, Harrell FE, Byrne DW, Edgeworth MC, Steaban R, Dittus RS, Bernard GR. Learning From What We Do, and Doing What We Learn: A Learning Health Care System in Action. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2021; 96:1291-1299. [PMID: 33635834 DOI: 10.1097/acm.0000000000004021] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Different models of learning health systems are emerging. At Vanderbilt University Medical Center, the Learning Health Care System (LHS) Platform was established with the goal of creating generalizable knowledge. This differentiates the LHS Platform from other efforts that have adopted a quality improvement paradigm. By supporting pragmatic trials at the intersection of research, operations, and clinical care, the LHS Platform was designed to yield evidence for advancing content and processes of care through carefully designed, rigorous study. The LHS Platform provides the necessary infrastructure and governance to leverage translational, transdisciplinary team science to inform clinical and operational decision making across the health system. The process transforms a clinical or operational question into a research question amenable to a pragmatic trial. Scientific, technical, procedural, and human infrastructure is maintained for the design and execution of individual LHS projects. This includes experienced pragmatic trialists, project management, data science inclusive of biostatistics and clinical informatics, and regulatory support. Careful attention is paid to stakeholder engagement, including health care providers and the community. Capturing lessons from each new study, the LHS Platform continues to mature with plans to integrate implementation science and to complement clinical and process outcomes with cost and value considerations. The Vanderbilt University Medical Center LHS Platform is now a pillar of the health care system and leads the evolving culture of learning from what we do and doing what we learn.
Collapse
Affiliation(s)
- Christopher J Lindsell
- C.J. Lindsell is professor of biostatistics, associate director, Center for Clinical Quality and Implementation Research, director, Vanderbilt Institute for Clinical and Translational Research Methods Program, and co-director, Center for Health Data Science, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cheryl L Gatto
- C.L. Gatto is research assistant professor of biostatistics and associate director, Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mary Lynn Dear
- M.L. Dear is project manager, Learning Health Care System Platform, Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Reagan Buie
- R. Buie is health policy service analyst, Learning Health Care System Platform, Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd W Rice
- T.W. Rice is associate professor of medicine, Department of Allergy, Pulmonary and Critical Care Medicine, vice president for clinical trial innovation and operations, Vanderbilt Institute for Clinical and Translational Research, and medical director, Vanderbilt Human Research Protection Program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jill M Pulley
- J.M. Pulley is research associate professor of medicine, Department of Allergy, Pulmonary and Critical Care Medicine, and executive director, Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tina V Hartert
- T.V. Hartert is professor of medicine, Department of Allergy, Pulmonary and Critical Care Medicine, director, Center for Asthma Research, assistant vice president for translational science, and Lulu H. Owen Chair in Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunil Kripalani
- S. Kripalani is professor of medicine, Department of General Internal Medicine and Public Health, director, Center for Clinical Quality and Implementation Research, and co-director, Center for Effective Health Communication, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Frank E Harrell
- F.E. Harrell is professor and founding chair, Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel W Byrne
- D.W. Byrne is senior associate in biostatistics and director, Quality Improvement and Program Evaluation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mitchell C Edgeworth
- M.C. Edgeworth was chief executive officer, Vanderbilt University Hospital, Vanderbilt University Medical Center, Nashville, Tennessee, at the time this manuscript was written
| | - Robin Steaban
- R. Steaban is chief nursing officer, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert S Dittus
- R.S. Dittus is the Albert and Bernard Werthan Professor of Medicine, Division of General Internal Medicine and Public Health, senior vice president and chief innovation officer, Vanderbilt Health Affiliated Network, executive vice president for public health and health care, and senior associate dean for population health sciences, Vanderbilt University Medical Center and VA Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center, Nashville, Tennessee
| | - Gordon R Bernard
- G.R. Bernard is the Melinda Owen Bass Professor of Medicine, Department of Allergy, Pulmonary and Critical Care Medicine, executive vice president for research, senior associate dean for clinical sciences, and director, Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
4
|
Xuan S, Colayco D, Hashimoto J, Barca J, Dekivadia D, Padula WV, McCombs J. Impact of Adding Pharmacists and Comprehensive Medication Management to a Medical Group's Transition of Care Services. Med Care 2021; 59:519-527. [PMID: 33734196 DOI: 10.1097/mlr.0000000000001520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Evaluate the impact of pharmacist-provided transition of care (TOC) services on hospital readmissions. METHODS Starting March 2014, TOC services were provided to all hospitalized patients from an at-risk medical group. Data covering all inpatient and outpatient services and prescription drugs were retrieved for all adult patients discharged between January 2010 and December 2018. The overall impact of TOC was estimated using a generalized estimating equation with logistic regression. Longitudinal TOC effects were estimated using generalized estimating equation in an interrupted time series model. Parallel analyses were conducted using data from an affiliated medical group in a neighboring county without access to the TOC intervention. RESULTS The study included 13,256 hospital discharges for adult patients for the 30-day readmission analysis and 10,740 discharges for the 180 days analysis. The TOC program reduced 30-day readmission risk by 34.9% [odds ratio (OR)=0.651 (range, 0.590-0.719)] and 180-day readmissions by 33.4% [OR=0.666 (range, 0.604-0.735)]. The interrupted time series results found the 30-day readmission rate to be stable over the pre-TOC period (OR=0.00; not significant) then to decreased by 1.5% per month in the post-TOC period [OR=0.985 (range, 0.980-0.991)]. For 180-day readmissions, risk decreased by 1% per month after TOC implementation [OR=0.990 (range, 0.984-0.996)]. Referral to the medical group's pre-existing Priority Care clinic also reduced readmission risk. Results from the comparison medical group found 180-day readmission declined by 1% per month after March 2014 [OR=0.990 (0.891-1.00)]. CONCLUSIONS Adding a pharmacist-led TOC program to the medical group's existing outpatient services reduced 30- and 180-day readmissions by "bending the curve" for readmission risk over time.
Collapse
Affiliation(s)
- Si Xuan
- Department of Pharmaceutical and Health Economics, School of Pharmacy, Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
| | | | | | | | | | - William V Padula
- Department of Pharmaceutical and Health Economics, School of Pharmacy, Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
| | - Jeffrey McCombs
- Department of Pharmaceutical and Health Economics, School of Pharmacy, Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
| |
Collapse
|
5
|
Hall ET, Maduro RS, Morgan MK, McGee GW, Zimbro KS. Impact of a Telephonic Outreach Program on Patient Outcomes Within the Heart Failure Community. J Nurs Care Qual 2021; 36:14-19. [PMID: 32282507 DOI: 10.1097/ncq.0000000000000488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Telephonic outreach programs (TOPs) can be an effective measure to improve 30-day readmissions and self-management behaviors. LOCAL PROBLEM Our health care providers identified that patients admitted with heart failure (HF) were among those with the highest readmission rate, so we implemented a TOP specific to HF. METHODS This project evaluated retrospective data from a convenience sample of adult patients admitted to our hospitals between January 2015 and June 2017, with a primary diagnosis of HF, and discharged home (N = 6271). Of those, 1708 patients also had at least partial TOP data, and a subset had timestamped TOP data (n = 1524). INTERVENTIONS The TOP program included patient education and personal follow-up via an automatic voice calling system that employed a series of 4 phone calls over a 27-day period. RESULTS Results showed that the TOP enhanced our hospital discharge process and contributed to program outcomes when the patients completed all 4 of the calls, with those patients having 11 times lower odds of having a 30-day readmission. CONCLUSIONS The proportion of patients who completed the program reported more use of self-management behaviors compared with those who answered fewer than 4 calls. Our findings related to the lower frequency of self-management behaviors of patients who did not complete all vendor calls stress the important issue of vendor management.
Collapse
Affiliation(s)
- Esscence T Hall
- Sentara Leigh Hospital, Norfolk, Virginia (Dr Hall); and Sentara Healthcare, Virginia Beach, Virginia (Drs Maduro, Morgan, and Zimbro and Ms McGee)
| | | | | | | | | |
Collapse
|
6
|
Impact of a Follow-up Telephone Call Program on 30-Day Readmissions (FUTR-30): A Pragmatic Randomized Controlled Real-world Effectiveness Trial. Med Care 2020; 58:785-792. [PMID: 32732787 DOI: 10.1097/mlr.0000000000001353] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Telephone call programs are a common intervention used to improve patients' transition to outpatient care after hospital discharge. OBJECTIVE To examine the impact of a follow-up telephone call program as a readmission reduction initiative. RESEARCH DESIGN Pragmatic randomized controlled real-world effectiveness trial. SUBJECTS We enrolled and randomized all patients discharged home from a hospital general medicine service to a follow-up telephone call program or usual care discharge. Patients discharged against medical advice were excluded. The intervention was a hospital program, delivering a semistructured follow-up telephone call from a nurse within 3-7 days of discharge, designed to assess understanding and provide education, and assistance to support discharge plan implementation. MEASURES Our primary endpoint was hospital inpatient readmission within 30 days identified by the electronic health record. Secondary endpoints included observation readmission, emergency department revisit, and mortality within 30 days, and patient experience ratings. RESULTS All 3054 patients discharged home were enrolled and randomized to the telephone call program (n=1534) or usual care discharge (n=1520). Using a prespecified intention-to-treat analysis, we found no evidence supporting differences in 30-day inpatient readmissions [14.9% vs. 15.3%; difference -0.4 (95% confidence interval, 95% CI), -2.9 to 2.1; P=0.76], observation readmissions [3.8% vs. 3.6%; difference 0.2 (95% CI, -1.1 to 1.6); P=0.74], emergency department revisits [6.1% vs. 5.4%; difference 0.7 (95% CI, -1.0 to 2.3); P=0.43], or mortality [4.4% vs. 4.9%; difference -0.5 (95% CI, -2.0 to 1.0); P=0.51] between telephone call and usual care groups. CONCLUSIONS We found no evidence of an impact on 30-day readmissions or mortality due to the postdischarge telephone call program.
Collapse
|
7
|
Hadden KB, Kripalani S. Health Literacy 2.0: Integrating Patient Health Literacy Screening with Universal Precautions. Health Lit Res Pract 2019; 3:e280-e285. [PMID: 31893260 PMCID: PMC6901362 DOI: 10.3928/24748307-20191028-02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 03/18/2019] [Indexed: 11/20/2022] Open
Affiliation(s)
- Kristie B. Hadden
- Address correspondence to Kristie B. Hadden, PhD, Center for Health Literacy, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Slot #599A, Little Rock, AR 72205-7199;
| | | |
Collapse
|