Implementation of US Post-Acute Care Payment Reform and COVID-19 Policies: Examining Experiences of Health System Leaders, Staff, Patients, and Family Caregivers-A Protocol

In fiscal year 2020, new national Medicare payment models were implemented in the two most common post-acute care settings (i.e., skilled nursing facilities (SNFs) and home health agencies (HHAs)), which were followed by the emergence of COVID-19. Given concerns about the unintended consequence of these events, this study protocol will examine how organizations responded to these policies and whether there were changes in SNF and HHA access, care delivery, and outcomes from the perspectives of leadership, staff, patients, and families. We will conduct a two-phase multiple case study guided by the Institute of Medicine's Model of Healthcare Systems. Phase I will include three cases for each setting and a maximum of fifty administrators per case. Phase II will include a subset of Phase I organizations, which are grouped into three setting-specific cases. Each Phase II case will include a maximum of four organizations. Semi-structured interviews will explore the perspectives of frontline staff, patients, and family caregivers (Phase II). Thematic analysis will be used to examine the impact of payment policy and COVID-19 on organizational operations, care delivery, and patient outcomes. The results of this study intend to develop evidence addressing concerns about the unintended consequences of the PAC payment policy during the COVID-19 pandemic.

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit

OBJECTIVE

To identify a risk profile for harmful medication errors in the neonatal intensive care unit (NICU).

STUDY DESIGN

A retrospective cross-sectional study on NICU medication error reports submitted to MEDMARX between 1 January 1999, and 31 December 2005. The Rao-Scott modified chi(2) test was used for analysis.

RESULT

6749 NICU medication error reports were submitted by 163 health-care facilities. Administering errors accounted for approximately one half of errors, and human factors were the most frequently cited cause of error. Patient age was not associated with an increased likelihood of an error being harmful (P=0.11). Error reports involving Institute for Safe Medication Practices (ISMP) High-Alert Medications, occurring in the prescribing phase of medication processing, or involving equipment/delivery device failures were more likely to be harmful (P< or =0.05).

CONCLUSION

Risk factors for harmful medication error reports include use of ISMP High-Alert Medications, the prescribing phase of the medication use process, and failure of equipment/delivery devices.

Disease-specific alterations in frontal cortex brain proteins in schizophrenia, bipolar disorder, and major depressive disorder. The Stanley Neuropathology Consortium

Severe psychiatric disorders such as schizophrenia, bipolar disorder and major depressive disorder are brain diseases of unknown origin. No biological marker has been documented at the pathological, cellular, or molecular level, suggesting that a number of complex but subtle changes underlie these illnesses. We have used proteomic technology to survey postmortem tissue to identify changes linked to the various diseases. Proteomics uses two-dimensional gel electrophoresis and mass spectrometric sequencing of proteins to allow the comparison of subsets of expressed proteins among a large number of samples. This form of analysis was combined with a multivariate statistical model to study changes in protein levels in 89 frontal cortices obtained postmortem from individuals with schizophrenia, bipolar disorder, major depressive disorder, and non-psychiatric controls. We identified eight protein species that display disease-specific alterations in level in the frontal cortex. Six show decreases compared with the non-psychiatric controls for one or more diseases. Four of these are forms of glial fibrillary acidic protein (GFAP), one is dihydropyrimidinase-related protein 2, and the sixth is ubiquinone cytochrome c reductase core protein 1. Two spots, carbonic anhydrase 1 and fructose biphosphate aldolase C, show increase in one or more diseases compared to controls. Proteomic analysis may identify novel pathogenic mechanisms of human neuropsychiatric diseases.

Multivariate analysis of RNA levels from postmortem human brains as measured by three different methods of RT-PCR. Stanley Neuropathology Consortium

The analysis of RNA from postmortem human brain tissue by reverse transcription-polymerase chain reaction (RT-PCR) provides a practical method to measure both normal and abnormal brain gene expression. A major limitation in using human material is that yields can vary dramatically from individual to individual, making comparisons between samples difficult. In this report, we study the association of pH and several pre- and postmortem factors on the RNA yields from 89 postmortem human occipital cortices. Glyceraldehyde phosphate dehydrogenase (GAPdH) mRNA levels were measured by RT-PCR. A major variant in this method is the priming used in the reverse transcription reaction. Three different methods of reverse transcription were performed and the resultant levels of products compared against the pre- and postmortem factors and pH. The levels of GAPdH correlated significantly to pH and pH itself to the rapidity of death (RoD) (agonal state) indicating that premortem factors may play the greatest role in determining postmortem RNA levels. The three methods of priming showed different sensitivities, most notably that oligo dT priming alone is vulnerable to long freezer intervals (FI). We conclude that premortem factors are the major affectors of RNA levels variations and that the polyA tail region of the molecule appears to be adversely affected by extended freezer storage.

The fate of a thiazolidinedione antidiabetic agent in rat and dog

1. The fate of [14C]BRL 49653C, a novel thiazolidinedione antidiabetic agent, has been studied following oral administration to the rat and dog. 2. Clearance was almost exclusively by metabolism, with only small amounts of unchanged BRL 49653 being excreted by either species. 3. Phase I metabolism resulted in ring hydroxylation, N-demethylation and oxidative removal of the pyridinylamino function to yield a phenoxyacetic acid derivative. 4. Sulphation of phase I metabolites occurred in both species, but glucuronidation was only observed in the rat. 5. The parent compound was the major circulating component in both species at early times, but at later times sulphate conjugates of phase 1 metabolites were predominant.

Patients' and healthcare providers' opinions regarding advance directives

PURPOSE/OBJECTIVES

To gain a better understanding of patients' and healthcare providers' preferences regarding when, how, and by whom advance directive information should be given and to explore the nursing role in advance directives.

DESIGN

A qualitative study using focus group methodology.

SETTING

A National Cancer Institute-designated comprehensive cancer center located within a large, university-affiliated, tertiary care hospital in the northeastern United States.

SAMPLE

Two samples participated in the study: eight adult ambulatory patients with cancer and 15 healthcare providers (4 physicians, 10 nurses, and 1 social worker).

METHODS

Separate patient and provider focus groups were conducted in private rooms by experienced facilitators using an interview guide with questions based on the literature, the hospital's advance directive materials, and the investigators' experience; sessions were audio-taped, transcribed, and analyzed using qualitative data analysis techniques.

FINDINGS

Patients and healthcare providers discussed focus group questions and commented that advance directive discussions should be provided early in the treatment or illness, presented in a short and simple format with reading materials at a level appropriate for the patient, and continued throughout the illness with those who desire follow-up. Nurses, doctors, social workers, or a designated/trained advance directive person were individuals that the patients identified as people with whom they could have advance directive discussions.

CONCLUSIONS

Results suggested that advance directive information should be given prior to hospital admission, be provided in a variety of formats, and that nurses, social workers, doctors, or designated staff representatives could all be part of the advance directive process.

NURSING IMPLICATIONS

Nursing roles should include early assessment of patients to determine needs for discussion, advocacy on behalf of patients, and provision of information. Future research should examine use of specific personnel for facilitating advance directives and compare different formats for presenting advance directive information to patients.

Chronic recurrent multifocal osteomyelitis and psoriasis--a report of a new association and review of related disorders

In summary, we have described two patients with CRMO and psoriasis, and have reviewed the musculoskeletal manifestations associated with pustular eruptions of the palms and soles. In view of the frequent occurrence of PPP in patients with CRMO, we suggest that the occurrence of psoriasis in our two patients is more than coincidence, and that noninfectious, inflammatory lesions of bone may be another musculoskeletal manifestation of psoriasis. This rare association, as well as the association of PPP with disorders associated with new bone formation, may shed new insights on the relatively common finding of periosteal elevation associated with psoriatic arthritis and the occasional severe juxta-articular osteolytic destructive bone lesions seen in psoriatic arthritis.