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Vordenberg SE, Kirch M, Singer D, Solway E, Roberts JS, Zikmund-Fisher BJ, Kullgren JT. Interest in Medication Deprescribing Among US Adults Aged 50-80. J Gen Intern Med 2024:10.1007/s11606-024-08945-x. [PMID: 39020227 DOI: 10.1007/s11606-024-08945-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 07/05/2024] [Indexed: 07/19/2024]
Affiliation(s)
- Sarah E Vordenberg
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church St, Suite 2568A, Ann Arbor, MI, 48109, USA.
| | - Matthias Kirch
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Dianne Singer
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Erica Solway
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - J Scott Roberts
- Department of Health Behavior & Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Brian J Zikmund-Fisher
- Department of Health Behavior & Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Jeffrey T Kullgren
- Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Yu W, Chen D, Ding X, Qiao L, Zhang L, Gao X, Yan Y, Mo W, Ma J, Yin M. A critical appraisal of clinical practice guidelines on surgical treatments for spinal metastasis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:1868-1898. [PMID: 38407614 DOI: 10.1007/s00586-023-08127-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 12/26/2023] [Accepted: 12/29/2023] [Indexed: 02/27/2024]
Abstract
PURPOSE As an important treatment for spinal metastasis, surgery has strict applicable conditions. Although various organizations have formulated different guidelines on surgical treatment for spinal metastasis (SM), there are certain differences in the content, standardization and quality of the guidelines and it is necessary to make a critical appraisal of them. We aim to systematically review and appraise the current guidelines on surgical treatments of SM and summarize the related recommendations with the quality evaluation of supporting evidence, as to provide a reference for the standardization of surgical treatment plans, and help clinical front-line medical workers can make safe and effective clinical decisions faster. METHODS We searched Pubmed, Web of Science, and Embase for three major databases and online guideline databases. According to certain inclusion and exclusion criteria, the latest guidelines on the surgical treatment of SM were sorted out. AGREE II was used to evaluated the guideline's quality, and we extracted and compared the recommended treatment content of each guideline with evaluating by the evidence-grading scale. RESULTS Eight guidelines from 2013 to 2019 were included. Seven guidelines are comprehensive guidelines and one related to the reconstructive surgery of SM. Five guidelines were evaluated as "recommended," and three guidelines were evaluated as "recommended with modifications." Regarding the indications of surgery with SM, four guidelines, seven guidelines, seven guidelines, three guidelines and three guidelines recommended surgical treatment for patients with SM with intractable pain, mechanical instability, metastatic epidural spinal cord compression (MESCC), recurrent spinal metastasis (RSM), and survival predication, respectively. Regarding the surgical strategies, three guidelines recommended minimally invasive therapy but had strict indications. Six guidelines and five guidelines recommend palliative surgery and with receiving radiation therapy, respectively. For the aggressive surgery, only one guideline recommended to apply to patients in good general conditions who has isolated symptomatic SM. Regarding the surgical reconstructions, one guideline didn't recommend iliac bone graft and three guidelines recommended PMMA bone cement. CONCLUSION Most of the guidelines do not provide clear criteria for surgical application and provide more of a basic framework. The level of evidence for these surgical recommendations ranges from LOE B to D, and almost all guidelines recommend vertebroplasty and kyphoplasty, but for palliative and more aggressive surgery, which recommended to personalize specific surgical strategies with multidisciplinary collaboration.
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Affiliation(s)
- Wenlong Yu
- Department of Orthopedic, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Dingbang Chen
- Department of Orthopedic Oncology, Changzheng Hospital, Second Affiliated Hospital of Naval Medical University, Shanghai, 200003, China
| | - Xing Ding
- Department of Orthopedic, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Liang Qiao
- Department of Orthopedic, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Luosheng Zhang
- Department of Orthopedic Oncology, Changzheng Hospital, Second Affiliated Hospital of Naval Medical University, Shanghai, 200003, China
| | - Xin Gao
- Department of Orthopedic Oncology, Changzheng Hospital, Second Affiliated Hospital of Naval Medical University, Shanghai, 200003, China
| | - Yinjie Yan
- Department of Orthopedic, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Wen Mo
- Department of Orthopedic, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China.
| | - Junming Ma
- Department of Orthopedic, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China.
| | - Mengchen Yin
- Department of Orthopedic, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China.
- Department of Orthopedic Oncology, Changzheng Hospital, Second Affiliated Hospital of Naval Medical University, Shanghai, 200003, China.
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Green E, Hamm M, Gowl C, Van Deusen R, Liebschutz JM, Wilson JD, Merlin J. Optimizing evidence-based practice implementation: a case study on simulated patient protocols in long-term opioid therapy. Implement Sci Commun 2024; 5:44. [PMID: 38649982 PMCID: PMC11034104 DOI: 10.1186/s43058-024-00575-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 03/21/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Substantial work has been done to update or create evidence-based practices (EBPs) in the changing health care landscape. However, the success of these EBPs is limited by low levels of clinician implementation. OBJECTIVE The goal of this study is to describe the use of standardized/simulated patient/person (SP) methodology as a framework to develop implementation bundles to increase the effectiveness, sustainability, and reproducibility of EBPs across health care clinicians. DESIGN We observed 12 clinicians' first-time experiences with six unique decision-making algorithms, developed previously using rigorous Delphi methods, for use with patients exhibiting concerning behaviors associated with long-term opioid therapy (LTOT) for chronic pain. Clinicians were paired with two SPs trained to portray individuals with one of the concerning behaviors addressed by the algorithms in a telehealth environment. The SP evaluations were followed by individual interviews, guided by the Consolidated Framework for Implementation Research (CFIR), with each of the clinician participants. PARTICIPANTS Twelve primary care clinicians and 24 SPs in Western Pennsylvania. MAIN MEASUREMENT The primary outcome was identifying likely facilitators for the successful implementation of the EBP using the SP methodology. Our secondary outcome was to assess the feasibility of using SPs to illuminate likely implementation barriers and facilitators. RESULTS The SP portrayal illuminated factors that were pertinent to address in the implementation bundle. SPs were realistic in their portrayal of patients with concerning behaviors associated with LTOT for chronic pain, but clinicians also noted that their patients in practice may have been more aggressive about their treatment plan. CONCLUSIONS SP simulation provides unique opportunities for obtaining crucial feedback to identify best practices in the adoption of new EBPs for high-risk patients. SETTING Zoom simulated patient evaluations.
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Affiliation(s)
- Ellen Green
- College of Health Solutions, Arizona State University, Tempe, AZ, USA.
| | - Megan Hamm
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Catherine Gowl
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Reed Van Deusen
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - J Deanna Wilson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Jessica Merlin
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Graham ND, Graham ID, Vanderspank-Wright B, Varin MD, Nadalin Penno L, Fergusson DA, Squires JE. A systematic review and critical appraisal of guidelines and their recommendations for sedation interruptions in adult mechanically ventilated patients. Aust Crit Care 2023; 36:889-901. [PMID: 36522246 DOI: 10.1016/j.aucc.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 10/03/2022] [Accepted: 10/09/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE The objectives of the review were to (i) assess the methodological quality of all accessible and published guidelines and care bundles that offer a recommendation related to sedation interruptions, using the AGREE-II instrument, to (ii) determine what is the recommended best practice for sedation interruptions from the available guidelines, and then to have (iii) a closer inspection of the overall credibility and applicability of the recommendations using the AGREE-REX instrument. This review will benefit the outcomes of critically ill patients and the multidisciplinary team responsible for the care of mechanically ventilated adults with continuous medication infusions by providing a synthesis of the recommended action(s), actor(s), contextual information, target(s), and timing related to sedation interruptions from current best practice. REVIEW METHOD USED We conducted a systematic review. DATA SOURCES We applied a peer-reviewed search strategy to four electronic databases from 2010 to November 2021-MEDLINE, CINAHL, Embase, and The Cochrane Database of Systematic Reviews-and included grey literature. REVIEW METHOD Findings are reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses checklist. We assessed overall quality using the validated Appraisal of Guidelines for Research and Evaluation II and AGREE Recommendation Excellence tools. RESULTS We identified 11 clinical practice guidelines and care bundles comprising 15 recommendations related to sedation interruption. There are three key findings: (i) deficiencies exist with the methodological quality of included guidelines, (ii) sedation interruption is recommended practice for the care of adult mechanically ventilated patients, and (iii) the current evidence is of low quality, which impacts overall credibility and applicability of the recommendations. CONCLUSIONS Sedation interruptions are currently best practice for adult mechanically ventilated patients; however, the available guidelines and recommendations have several deficiencies. Future research is needed to further understand the role of the nurse and other actors to enact this practice.
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Affiliation(s)
- Nicole D Graham
- University of Ottawa, Faculty of Health Sciences, School of Nursing, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.
| | - Ian D Graham
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, P.O. Box 711, Ottawa ON, K1H 8L6, Canada; Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; University of Ottawa, Faculty of Health Sciences, School of Nursing, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.
| | - Brandi Vanderspank-Wright
- University of Ottawa, Faculty of Health Sciences, School of Nursing, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.
| | - Melissa Demery Varin
- University of Ottawa, Faculty of Health Sciences, School of Nursing, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.
| | - Letitia Nadalin Penno
- University of Ottawa, Faculty of Health Sciences, School of Nursing, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, P.O. Box 711, Ottawa ON, K1H 8L6, Canada; Department of Medicine, University of Ottawa, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, P.O. Box 711, Ottawa ON, K1H 8L6, Canada.
| | - Janet E Squires
- University of Ottawa, Faculty of Health Sciences, School of Nursing, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, P.O. Box 711, Ottawa ON, K1H 8L6, Canada.
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Marget M, Virkud YV, Shreffler WG, Martin VM, Yuan Q. Factors influencing age of common allergen introduction in early childhood. Front Pediatr 2023; 11:1207680. [PMID: 37497302 PMCID: PMC10366355 DOI: 10.3389/fped.2023.1207680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/26/2023] [Indexed: 07/28/2023] Open
Abstract
Objectives We evaluated factors influencing the timing of allergen introduction in the U.S., including updated peanut introduction guidelines. Study design The Gastrointestinal Microbiome and Allergic Proctocolitis (GMAP) study is a prospective observational cohort in suburban Massachusetts. Infants' caregivers enrolled between 2014 and 2017, and they reported when they introduced common allergens to their child. Multivariable linear and survival regression analyses were used to examine factors influencing time of introduction of allergens. Results By 9 months, children old enough to be potentially affected by NIAID's 2017 peanut introduction guidelines were more often introduced to peanut than children enrolled well before guidelines publication [54% vs. 42%, OR: 1.63, CI: (1.03, 2.57), P = 0.03]. At any given time, Black children were 73% [HR: 0.27, CI: (0.11, 0.69), P = 0.006] less likely to be introduced to peanut as early as White children. Asian children were, respectively, 36% [HR: 0.64, CI: (0.47, 0.86), P = 0.003] and 26% [HR: 0.74, CI: (0.55, 0.97), P = 0.03] less likely to be introduced to peanut and egg as early as White children. A first child was 27% [HR: 1.27, CI: (1.04, 1.56), P = 0.02] more likely to have been introduced to peanut earlier than a non-first child. There was no association between age of introduction and sex, gestational age, family history of food allergy, or other allergic comorbidities. Conclusion Updated introduction guidelines, race, and birth order all influenced earlier introduction of peanut. Further studies to evaluate current practices for allergen introduction with a focus on potential disparities are needed.
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Affiliation(s)
- Michael Marget
- Food Allergy Center, Massachusetts General Hospital, Boston, MA, United States
- Division of Pediatric Allergy and Immunology,Massachusetts General Hospital, Boston, MA, United States
| | - Yamini V. Virkud
- Food Allergy Center, Massachusetts General Hospital, Boston, MA, United States
- Division of Pediatric Allergy and Immunology,Massachusetts General Hospital, Boston, MA, United States
- Division of Pediatric Allergy & Immunology, University of North Carolina, Chapel Hill, NC, United States
| | - Wayne G. Shreffler
- Food Allergy Center, Massachusetts General Hospital, Boston, MA, United States
- Division of Pediatric Allergy and Immunology,Massachusetts General Hospital, Boston, MA, United States
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Victoria M. Martin
- Food Allergy Center, Massachusetts General Hospital, Boston, MA, United States
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Massachusetts General Hospital, Boston, MA, United States
| | - Qian Yuan
- Food Allergy Center, Massachusetts General Hospital, Boston, MA, United States
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Massachusetts General Hospital, Boston, MA, United States
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Canadian Health Care Professionals' Familiarity with Chronic Cough Guidelines and Experiences with Diagnosis and Management: A Cross-Sectional Survey. Lung 2023; 201:47-55. [PMID: 36808540 DOI: 10.1007/s00408-023-00604-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 02/01/2023] [Indexed: 02/21/2023]
Abstract
INTRODUCTION Educational programs on chronic cough may improve patient care, but little is known about how Canadian physicians manage this common debilitating condition. We aimed to investigate Canadian physicians' perceptions, attitudes, and knowledge of chronic cough. METHODS We administered a 10-min anonymous, online, cross-sectional survey to 3321 Canadian physicians in the Leger Opinion Panel who managed adult patients with chronic cough and had been in practice for > 2 years. RESULTS Between July 30 and September 22, 2021, 179 physicians (101 general practitioners [GPs] and 78 specialists [25 allergists, 28 respirologists, and 25 ear/nose/throat specialists]) completed the survey (response rate: 5.4%). In a month, GPs saw a mean of 27 patients with chronic cough, whereas specialists saw 46. About one-third of physicians appropriately identified a duration of > 8 weeks as the definition for chronic cough. Many physicians reported not using international chronic cough management guidelines. Patient referrals and care pathways varied considerably, and patients frequently experienced lost to follow-up. While physicians endorsed nasal and inhaled corticosteroids as common treatments for chronic cough, they rarely used other guideline-recommended treatments. Both GPs and specialists expressed high interest in education on chronic cough. CONCLUSION This survey of Canadian physicians demonstrates low uptake of recent advances in chronic cough diagnosis, disease categorization, and pharmacologic management. Canadian physicians also report unfamiliarity with guideline-recommended therapies, including centrally acting neuromodulators for refractory or unexplained chronic cough. This data highlights the need for educational programs and collaborative care models on chronic cough in primary and specialist care.
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Patel MI, Murillo A, Agrawal M, Coker T. Health Care Professionals' Perspectives on Implementation, Adoption, and Maintenance of a Community Health Worker-Led Advance Care Planning and Cancer Symptom Screening Intervention: A Qualitative Study. JCO Oncol Pract 2023; 19:e138-e149. [PMID: 36201710 PMCID: PMC10166359 DOI: 10.1200/op.22.00209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 07/14/2022] [Accepted: 07/17/2022] [Indexed: 01/12/2023] Open
Abstract
PURPOSE Advance care planning (ACP) and symptom screening are nationally recommended for all patients with advanced stages of cancer. Yet, routine delivery of such care remains challenging because of multilevel barriers. We hired and trained community health workers (CHWs) to assist with delivery of these services across the United States. The aim of this study was to explore health care professionals' perspectives on barriers and facilitators to these team-based approaches. METHODS We conducted semistructured interviews with 44 health care professionals in 21 cancer clinics in seven US cities using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. We recorded, transcribed, and analyzed interviews using the framework analysis approach. RESULTS Participants noted barriers and facilitators to implementation, adoption, and maintenance of CHW-led ACP and symptom management approaches. Participants were initially skeptical; however, they noted a positive shift in their views over time because of personal experiences and effectiveness in their clinics. There was significant variation in adoption with some using a prescriptive top-down approach and others a bottom-up approach. Most agreed that the combination of top-down and bottom-up approaches would be most efficient and effective for promoting team-based care. All participants discussed implementation and provided suggestions for maintenance including organizational support, leadership, and CHW retention. CONCLUSION CHW-led ACP and proactive symptom management interventions are effective and accepted by cancer care professionals at scale. Tailoring on the basis of organization and local contexts is required to ensure successful adoption, implementation, and maintenance of these effective team-based care delivery approaches.
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Affiliation(s)
- Manali I. Patel
- Division of Oncology, Stanford University School of Medicine, Stanford, CA
- Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
- Center for Primary Care and Outcomes Research/Health Research and Policy, Stanford University School of Medicine, Stanford, CA
| | - Ariana Murillo
- Division of Oncology, Stanford University School of Medicine, Stanford, CA
| | | | - Tumaini Coker
- Seattle Children's Research Institute, Seattle, WA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
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Eltalakat S, Gariba BA, Peleg R, Kaplan D, Treister-Gotzman Y. Medical screening tests and vaccination among hospital-based physicians in Israel. BMC Health Serv Res 2022; 22:1335. [DOI: 10.1186/s12913-022-08714-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 10/21/2022] [Indexed: 11/11/2022] Open
Abstract
Abstract
Background
Very few studies have evaluated physician participation in screening tests and vaccinations. The aim was to evaluate attitudes and actual practice of screening tests and vaccinations among hospital-based physicians and to identify factors that predict actual performance.
Methods
A cross-sectional study including 220 physicians in various specializations. The study was conducted between January 1, 2017 and December 10, 2017. The statistical analysis was performed during October, 2020 and completed in October 25, 2020.
Results
The vast majority of physicians (94%) believed in the importance of screening tests for physicians, but less than half actually underwent the tests themselves. A high percentage of physicians measured their BMI (84.5%) and had a serum lipid profile test (67.7%) and complete blood counts (75%) over the previous five years, but less than a third of female physicians over 50 years of age had a mammogram and only 8% of the physicians over 50 had a fecal occult blood test. A high percentage of physicians were vaccinated for Hepatitis A and B, chickenpox and measles (66-96% for the various vaccinations), but only 41% had an influenza vaccination in the previous year. In a multivariate logistic regression model, physicians who believed that hospital physicians bore a responsibility for recommending screening tests to their patients were more likely to have their BMI and their blood pressure checked (OR = 2.234, P = 0.007). They were more likely to undergo laboratory testing (OR = 4.082, P < 0.0001) and tended to get vaccinated more (OR = 1.907, P = 0.051).
Conclusion
The rate of screening tests and vaccinations among hospital-based physicians is sub-optimal and very low for fecal occult blood testing and mammograms. Structured programs are required to implement screening tests and vaccinations among physicians.
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Guan Y, Haardörfer R, McBride CM, Lipscomb J, Escoffery C. Factors Associated with Mammography Screening Choices by Women Aged 40-49 at Average Risk. J Womens Health (Larchmt) 2022; 31:1120-1126. [PMID: 35171027 DOI: 10.1089/jwh.2021.0232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The U.S. Preventive Services Task Force (USPSTF) does not recommend routine mammogram screening for women aged 40-49 years at average risk for breast cancer. We aimed to assess the extent to which women were following guideline recommendations and to examine whether guideline awareness and other individual-level factors were associated with adherence. Materials and Methods: We surveyed a nationally representative panel of 383 U.S. women aged 40-49 years at low risk for hereditary breast cancer in October 2019. Results: Only 29% of women reported not having initiated screening mammography. Most women (80%) were unaware of the USPSTF screening guideline related to age of initiation and frequency of mammography. Being aware of the recommendation to initiate screening at age 50 increased the odds of not initiating screening (odds ratio [OR] = 6.70, p < 0.001), whereas being older than 45 years (OR = 0.22, p < 0.001) and having a primary care doctor decreased the odds of not initiating screening (OR = 0.25, p < 0.001). Conclusions: Mammogram screening in excess of USPSTF recommendations is prevalent among U.S. women aged 40-49 years. Efforts are needed to increase women's awareness of the rationale for guidelines and the opportunities to discuss with providers whether delaying mammograms is appropriate.
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Affiliation(s)
- Yue Guan
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Regine Haardörfer
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Colleen M McBride
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Joseph Lipscomb
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Cam Escoffery
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Patel D, Msosa YJ, Wang T, Mustafa OG, Gee S, Williams J, Roberts A, Dobson RJB, Gaughran F. An implementation framework and a feasibility evaluation of a clinical decision support system for diabetes management in secondary mental healthcare using CogStack. BMC Med Inform Decis Mak 2022; 22:100. [PMID: 35421974 PMCID: PMC9009062 DOI: 10.1186/s12911-022-01842-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/25/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Improvements to the primary prevention of physical health illnesses like diabetes in the general population have not been mirrored to the same extent in people with serious mental illness (SMI). This work evaluates the technical feasibility of implementing an electronic clinical decision support system (eCDSS) for supporting the management of dysglycaemia and diabetes in patients with serious mental illness in a secondary mental healthcare setting. METHODS A stepwise approach was taken as an overarching and guiding framework for this work. Participatory methods were employed to design and deploy a monitoring and alerting eCDSS. The eCDSS was evaluated for its technical feasibility. The initial part of the feasibility evaluation was conducted in an outpatient community mental health team. Thereafter, the evaluation of the eCDSS progressed to a more in-depth in silico validation. RESULTS A digital health intervention that enables monitoring and alerting of at-risk patients based on an approved diabetes management guideline was developed. The eCDSS generated alerts according to expected standards and in line with clinical guideline recommendations. CONCLUSIONS It is feasible to design and deploy a functional monitoring and alerting eCDSS in secondary mental healthcare. Further work is required in order to fully evaluate the integration of the eCDSS into routine clinical workflows. By describing and sharing the steps that were and will be taken from concept to clinical testing, useful insights could be provided to teams that are interested in building similar digital health interventions.
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Affiliation(s)
- Dipen Patel
- National Institute for Health Research, Maudsley Biomedical Research Centre, South London and Maudsley National Health Service Foundation Trust, De Crespigny Park, London, SE5 8AB UK
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, De Crespigny Park, London, SE5 8AB UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Yamiko J Msosa
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, De Crespigny Park, London, SE5 8AB UK
- National Institute for Health Research, Maudsley Biomedical Research Centre, South London and Maudsley National Health Service Foundation Trust, De Crespigny Park, London, SE5 8AB UK
| | - Tao Wang
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, De Crespigny Park, London, SE5 8AB UK
- National Institute for Health Research, Maudsley Biomedical Research Centre, South London and Maudsley National Health Service Foundation Trust, De Crespigny Park, London, SE5 8AB UK
| | - Omar G Mustafa
- Department of Diabetes, King’s College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS UK
- Centre for Education, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Siobhan Gee
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Julie Williams
- Health Service and Population Research Department, Centre for Implementation Science, King’s College London, London, UK
| | - Angus Roberts
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, De Crespigny Park, London, SE5 8AB UK
- National Institute for Health Research, Maudsley Biomedical Research Centre, South London and Maudsley National Health Service Foundation Trust, De Crespigny Park, London, SE5 8AB UK
| | - Richard JB Dobson
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, De Crespigny Park, London, SE5 8AB UK
- National Institute for Health Research, Maudsley Biomedical Research Centre, South London and Maudsley National Health Service Foundation Trust, De Crespigny Park, London, SE5 8AB UK
- Institute for Health Informatics, University College London, London, UK
- Health Data Research UK London, University College London, London, UK
| | - Fiona Gaughran
- National Institute for Health Research, Maudsley Biomedical Research Centre, South London and Maudsley National Health Service Foundation Trust, De Crespigny Park, London, SE5 8AB UK
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, De Crespigny Park, London, SE5 8AB UK
- South London and Maudsley NHS Foundation Trust, London, UK
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Low Rates of Clinician Monitoring for Second Generation Antipsychotic Medications in Community Pediatric Practice. Community Ment Health J 2022; 58:541-546. [PMID: 34050858 DOI: 10.1007/s10597-021-00852-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 05/25/2021] [Indexed: 10/21/2022]
Abstract
Second generation antipsychotic (SGA) medications are frequently prescribed to pediatric patients in the United States. This retrospective observational study sought to ascertain the extent of adherence to established pediatric SGA monitoring guidelines in community practice. The team used the electronic health record to determine clinician adherence to SGA monitoring guidelines at baseline, 12-week, and annual times relative to prescribing an SGA. At the time of their SGA prescription, 5.5% of pediatric patients had received all of the orders according to the monitoring guidelines. Annually, 2.5% of patients had received the necessary orders to completely adhere to monitoring guidelines; 42% of patients received no monitoring orders. Monitoring was more likely for children who had multiple types of providers and interacted with the healthcare system beyond a traditional office visit. This research informs healthcare providers about the gap between prescribing and monitoring for SGA medications in community practice for pediatric populations.
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Cullen L, Hanrahan K, Edmonds SW, Reisinger HS, Wagner M. Iowa Implementation for Sustainability Framework. Implement Sci 2022; 17:1. [PMID: 34983585 PMCID: PMC8725573 DOI: 10.1186/s13012-021-01157-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 09/15/2021] [Indexed: 11/23/2022] Open
Abstract
Background An application-oriented implementation framework designed for clinicians and based on the Diffusion of Innovations theory included 81 implementation strategies with suggested timing for use within four implementation phases. The purpose of this research was to evaluate and strengthen the framework for clinician use and propose its usefulness in implementation research. Methods A multi-step, iterative approach guided framework revisions. Individuals requesting the use of the framework over the previous 7 years were sent an electronic questionnaire. Evaluation captured framework usability, generalizability, accuracy, and implementation phases for each strategy. Next, nurse leaders who use the framework pile sorted strategies for cultural domain analysis. Last, a panel of five EBP/implementation experts used these data and built consensus to strengthen the framework. Results Participants (n = 127/1578; 8% response) were predominately nurses (94%), highly educated (94% Master’s or higher), and from across healthcare (52% hospital/system, 31% academia, and 7% community) in the USA (84%). Most (96%) reported at least some experience using the framework and 88% would use the framework again. A 4-point scale (1 = not/disagree to 4 = very/agree) was used. The framework was deemed useful (92%, rating 3–4), easy to use (72%), intuitive (67%), generalizable (100%), flexible and adaptive (100%), with accurate phases (96%), and accurate targets (100%). Participants (n = 51) identified implementation strategy timing within four phases (Cochran’s Q); 54 of 81 strategies (66.7%, p < 0.05) were significantly linked to a specific phase; of these, 30 (55.6%) matched the original framework. Next, nurse leaders (n = 23) completed a pile sorting activity. Anthropac software was used to analyze the data and visualize it as a domain map and hierarchical clusters with 10 domains. Lastly, experts used these data and implementation science to refine and specify each of the 75 strategies, identifying phase, domain, actors, and function. Strategy usability, timing, and groupings were used to refine the framework. Conclusion The Iowa Implementation for Sustainability Framework offers a typology to guide implementation for evidence-based healthcare. This study specifies 75 implementation strategies within four phases and 10 domains and begins to validate the framework. Standard use of strategy names is foundational to compare and understand when implementation strategies are effective, in what dose, for which topics, by whom, and in what context. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-021-01157-5.
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Affiliation(s)
- Laura Cullen
- Department of Nursing Services and Patient Care, University of Iowa Hospitals & Clinics, 200 Hawkins Dr., Iowa City, IA, 52242, USA.
| | - Kirsten Hanrahan
- Department of Nursing Services and Patient Care, University of Iowa Hospitals & Clinics, 200 Hawkins Dr., Iowa City, IA, 52242, USA
| | - Stephanie W Edmonds
- Department of Nursing Services and Patient Care, University of Iowa Hospitals & Clinics, 200 Hawkins Dr., Iowa City, IA, 52242, USA
| | - Heather Schacht Reisinger
- Department of Internal Medicine, University of Iowa, 200 Hawkins Dr., Iowa City, IA, 52242, USA.,Institute for Clinical and Translational Science, University of Iowa, 200 Hawkins Dr., Iowa City, IA, 52242, USA
| | - Michele Wagner
- Department of Nursing Services and Patient Care, University of Iowa Hospitals & Clinics, 200 Hawkins Dr., Iowa City, IA, 52242, USA
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Tanabe P, Blewer AL, Bonnabeau E, Bosworth HB, Clayton DH, Crego N, Earls MF, Eason K, Forlines G, Rains G, Young M, Shah N. Dissemination of Evidence-Based Recommendations for Sickle Cell Disease to Primary Care and Emergency Department Providers in North Carolina: A Cost Benefit Analysis. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2021; 8:18-28. [PMID: 33829067 PMCID: PMC8016663 DOI: 10.36469/jheor.2021.21535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 03/10/2021] [Indexed: 06/12/2023]
Abstract
Background: Sickle cell disease (SCD) is a genetic condition affecting primarily individuals of African descent, who happen to be disproportionately impacted by poverty and who lack access to health care. Individuals with SCD are at high likelihood of high acute care utilization and chronic pain episodes. The multiple complications seen in SCD contribute to significant morbidity and premature mortality, as well as substantial costs to the healthcare system. Objectives: SCD is a complex chronic disease resulting in the need for primary, specialty and emergency care. Many providers do not feel prepared to care for individuals with SCD, despite the existence of evidence-based guidelines. We report the development of a SCD toolbox and the dissemination process to primary care and emergency department (ED) providers in North Carolina (NC). We report the effect of this dissemination on health-care utilization, cost of care, and overall cost-benefit. Methods: The SCD toolbox was adapted from the National Heart, Lung, and Blood Institute recommendations. Toolbox training was provided to quality improvement specialists who then disseminated the toolbox to primary care providers (PCPs) affiliated with the only NC managed care coordination system and ED providers. Tools were made available in paper, online, and in app formats to participating managed care network practices (n=1 800). Medicaid claims data were analyzed for total costs and benefits of the toolbox dissemination for a 24-month pre- and 18-month post-intervention period. Results: There was no statistically significant shift in the number of outpatient specialty visits, ED visits or hospitalizations. There was a small decrease in the number of PCP visits in the post-implementation period. The dissemination resulted in a net cost-savings of $361 414 ($14.03 per-enrollee per-month on average). However, the estimated financial benefit associated with the dissemination of the SCD toolbox was not statistically significant. Conclusions: Although we did not find the expected shift to increased PCP visits and decreased ED visits and hospitalizations, there were many lessons learned.
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Affiliation(s)
- Paula Tanabe
- School of Nursing, Duke University, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA
| | - Audrey L Blewer
- Department of Family Medicine and Community Health, School of Medicine, Duke University, Durham, NC, USA; Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
| | | | - Hayden B Bosworth
- School of Nursing, Duke University, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA; Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA; Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Medical Center (DVAMC), Durham, NC, USA
| | | | - Nancy Crego
- School of Nursing, Duke University, Durham, NC, USA
| | | | - Kern Eason
- Previously - Community Care North Carolina, Cary, NC, USA
| | | | - Gary Rains
- Duke University School of Medicine, Durham, NC, USA
| | | | - Nirmish Shah
- Duke University School of Medicine, Durham, NC, USA
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Milton S, McIntosh J, Yogaparan T, Alphonse P, Saya S, Karnchanachari N, Nguyen P, Lau P, Macrae F, Emery J. Clinicians' opinions on recommending aspirin to prevent colorectal cancer to Australians aged 50-70 years: a qualitative study. BMJ Open 2021; 11:e042261. [PMID: 33550247 PMCID: PMC7925937 DOI: 10.1136/bmjopen-2020-042261] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Australian guidelines recommend all adults aged 50-70 years old without existing contraindications consider taking low-dose aspirin (100-300 mg per day) for at least 2.5 years to reduce their risk of developing colorectal cancer. We aimed to explore clinicians' practices, knowledge, opinions, and barriers and facilitators to the implementation of these new guidelines. METHODS Semistructured interviews were conducted with clinicians to whom the new guidelines may be applicable (Familial Cancer Clinic staff (geneticists, oncologists and genetic counsellors), gastroenterologists, pharmacists and general practitioners (GPs)). The Consolidated Framework for Implementation Research (CFIR) underpinned the development of the interview guide. Coding was inductive and themes were developed through consensus between the authors. Emerging themes were mapped onto the CFIR domains: characteristics of the intervention, outer setting, inner setting, individual characteristics and process. RESULTS Sixty-four interviews were completed between March and October 2019. Aspirin was viewed as a safe and cheap option for cancer prevention. GPs were considered by all clinicians as the most important health professionals for implementation of the guidelines. Cancer Council Australia, as a trusted organisation, was an important facilitator to guideline adoption. Uncertainty about aspirin dosage and perceived strength of the evidence, precise wording of the recommendation, previous changes to guidelines about aspirin and conflicting findings from trials in older populations were barriers to implementation. CONCLUSION Widespread adoption of these new guidelines could be an important strategy to reduce the incidence of bowel cancer, but this will require more active implementation strategies focused on primary care and the wider community. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (ACTRN12620001003965).
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Affiliation(s)
- Shakira Milton
- Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Jennifer McIntosh
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
- Department of Software Systems and Cybersecurity, Monash University, Melbourne, Victoria, Australia
| | - Thivagar Yogaparan
- Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Pavithran Alphonse
- Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Sibel Saya
- Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Napin Karnchanachari
- Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter Nguyen
- Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Phyllis Lau
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Finlay Macrae
- Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jon Emery
- Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
- The Primary Care Unit, University of Cambridge, Cambridge, UK
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Savioli G, Ceresa IF, Maggioni P, Lava M, Ricevuti G, Manzoni F, Oddone E, Bressan MA. Impact of ED Organization with a Holding Area and a Dedicated Team on the Adherence to International Guidelines for Patients with Acute Pulmonary Embolism: Experience of an Emergency Department Organized in Areas of Intensity of Care. MEDICINES 2020; 7:medicines7100060. [PMID: 32987644 PMCID: PMC7598623 DOI: 10.3390/medicines7100060] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/07/2020] [Accepted: 09/11/2020] [Indexed: 02/07/2023]
Abstract
Background: Adherence to guidelines by physicians of an emergency department (ED) depends on many factors: guideline and environmental factors; patient and practitioner characteristics; the social-political context. We focused on the impact of the environmental influence and of the patients’ characteristics on adherence to the guidelines. It is our intention to demonstrate how environmental factors such as ED organization more affect adherence to guidelines than the patient’s clinical presentation, even in a clinically insidious disease such as pulmonary embolism (PE). Methods: A single-center observational study was carried out on all patients who were seen at our Department of Emergency and Acceptance from 1 January to 31 December 2017 for PE. For the assessment of adherence to guidelines, we used the European guidelines 2014 and analyzed adherence to the correct use of clinical decision rule (CDR as Wells, Geneva, and YEARS); the correct initiation of heparin therapy; and the management of patients at high risk for short-term mortality. The primary endpoint of our study was to determine whether adherence to the guidelines as a whole depends on patients’ management in a holding area. The secondary objective was to determine whether adherence to the guidelines depended on patient characteristics such as the presence of typical symptoms or severe clinical features (massive pulmonary embolism; organ damage). Results: There were significant differences between patients who passed through OBI and those who did not, in terms of both administration of heparin therapy alone (p = 0.007) and the composite endpoints of heparin therapy initiation and observation/monitoring (p = 0.004), as indicated by the guidelines. For the subgroups of patients with massive PE, organ damage, and typical symptoms, there was no greater adherence to the decision making, administration of heparin therapy alone, and the endpoints of heparin therapy initiation and guideline-based observation/monitoring. Conclusions: Patients managed in an ED holding area were managed more in accordance with the guidelines than those who were managed only in the visiting ED rooms and directly hospitalized from there.
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Affiliation(s)
- Gabriele Savioli
- Emergency Department, Irccs Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (P.M.); (M.A.B.)
- PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Correspondence: ; Tel.: +39-340-9070-001
| | - Iride Francesca Ceresa
- Emergency Department, Irccs Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (P.M.); (M.A.B.)
| | - Paolo Maggioni
- Emergency Department, Irccs Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (P.M.); (M.A.B.)
| | - Massimiliano Lava
- Neuro Radiodiagnostic, Irccs Policlinico San Matteo, 27100 Pavia, Italy;
| | - Giovanni Ricevuti
- Department of Drug Science, University of Pavia, Italy, Saint Camillus International University of Health Sciences, 00131 Rome, Italy;
| | - Federica Manzoni
- Clinical Epidemiology and Biometry Unit, Irccs Policlinico San Matteo, 27100 Pavia, Italy;
| | - Enrico Oddone
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy;
| | - Maria Antonietta Bressan
- Emergency Department, Irccs Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (P.M.); (M.A.B.)
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