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Chen M, Santa Mina D, Au D, Karkouti K, Alibhai S, Zywiel M, Randall I. Hospital-perspective cost-analysis of a nonrandomized trial of prehabilitation before major elective surgery. Can J Anaesth 2024; 71:550-552. [PMID: 38347312 DOI: 10.1007/s12630-024-02693-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/06/2023] [Accepted: 12/14/2023] [Indexed: 04/01/2024] Open
Affiliation(s)
- Maggie Chen
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Daniel Santa Mina
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada.
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada.
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Darren Au
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Shabbir Alibhai
- Department of Medicine, University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Michael Zywiel
- Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Ian Randall
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Sibley D, Sellers D, Randall I, Englesakis M, Culos-Reed SN, Singh M, Mina DS. Evaluating the effect of preoperative interventions on sleep health in the perioperative period: a systematic review. J Sleep Res 2023:e14124. [PMID: 38124447 DOI: 10.1111/jsr.14124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023]
Abstract
Surgery and general anaesthesia have deleterious effects on sleep and disrupted perioperative sleep health is a risk factor for poor surgical outcomes. The objective of this systematic review was to summarise preoperative interventions that report sleep outcomes. Studies that delivered an intervention initiated >24 h prior to surgery among an adult sample without a diagnosed sleep disorder were included. Studies were excluded if they were preclinical or were not published in English. MEDLINE, MEDLINE ePubs Ahead of Print and In-process Citations, Embase, Cochrane Central Register of Controlled Trials, APA PsycINFO, CINAHL, and the Web of Science were searched on February 2, 2023. This review was reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and was registered with the International Prospective Register of Systematic Reviews (identifier: CRD42021260578). Risk of bias was assessed using the Cochrane Risk-of Bias 2 tool for randomised trials and the Risk Of Bias In Non-randomised Studies - of Interventions for non-randomised trials. Certainty of findings were assessed using the Grading of Recommendations, Assessment, Development and Evaluation framework. The searching yielded 10,938 total citations, and after screening resulted in 28 randomised and 19 non-randomised trials (47 total) with 4937 participants. Sleep was a primary outcome in 16 trials; a sleep outcome was significantly improved relative to comparator in 23 trials. This review demonstrates that preoperative sleep is modifiable via a variety of interventions, including pharmacological, non-pharmacological, and nursing interventions delivered preoperatively or perioperatively. Our results should be considered with caution due to an overall intermediate to high risk of bias in the included trials, and low to very low certainty of evidence. This review supports the modifiability of sleep health among surgical patients and provides the groundwork for preoperative sleep optimisation research.
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Affiliation(s)
- Daniel Sibley
- Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
| | - Daniel Sellers
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ian Randall
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marina Englesakis
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | | | - Mandeep Singh
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Santa Mina
- Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
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Sibley D, Chen M, West MA, Matthew AG, Santa Mina D, Randall I. Potential mechanisms of multimodal prehabilitation effects on surgical complications: a narrative review. Appl Physiol Nutr Metab 2023; 48:639-656. [PMID: 37224570 DOI: 10.1139/apnm-2022-0272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Continuous advances in prehabilitation research over the past several decades have clarified its role in improving preoperative risk factors, yet the evidence demonstrating reduced surgical complications remains uncertain. Describing the potential mechanisms underlying prehabilitation and surgical complications represents an important opportunity to establish biological plausibility, develop targeted therapies, generate hypotheses for future research, and contribute to the rationale for implementation into the standard of care. In this narrative review, we discuss and synthesize the current evidence base for the biological plausibility of multimodal prehabilitation to reduce surgical complications. The goal of this review is to improve prehabilitation interventions and measurement by outlining biologically plausible mechanisms of benefit and generating hypotheses for future research. This is accomplished by synthesizing the available evidence for the mechanistic benefit of exercise, nutrition, and psychological interventions for reducing the incidence and severity of surgical complications reported by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). This review was conducted and reported in accordance with a quality assessment scale for narrative reviews. Findings indicate that prehabilitation has biological plausibility to reduce all complications outlined by NSQIP. Mechanisms for prehabilitation to reduce surgical complications include anti-inflammation, enhanced innate immunity, and attenuation of sympathovagal imbalance. Mechanisms vary depending on the intervention protocol and baseline characteristics of the sample. This review highlights the need for more research in this space while proposing potential mechanisms to be included in future investigations.
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Affiliation(s)
- Daniel Sibley
- Faculty of Kinesiology, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Maggie Chen
- Faculty of Kinesiology, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Malcolm A West
- Faculty of Medicine, Cancer Sciences, University of Southampton, UK
- NIHR Southampton Biomedical Research Centre, Perioperative and Critical Care, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Andrew G Matthew
- Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Daniel Santa Mina
- Faculty of Kinesiology, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Ian Randall
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Sibley D, Chen M, Mina DS, Gillis C, Matthew A, Randall I. Mechanisms of Multi-modal Prehabilitation Effects on Surgical Complications: A Narrative Review. Arch Phys Med Rehabil 2022. [DOI: 10.1016/j.apmr.2022.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Randall I. Who pulled the trigger? Gun muzzle exhaust may complicate analysis of crime scenes. Science 2021. [DOI: 10.1126/science.abj0986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Abstract
Caffeine is well known for its central nervous system–stimulating effect. Toxicity may occur following high-dose caffeine ingestions. We describe a case of caffeine intoxication secondary to reported ingestion of a large dose of caffeine (60,000 mg in tablet form) with an initial serum caffeine level of 608 μmol/L (known lethal serum level starting from 412 μmol/L). This case demonstrates the key clinical manifestations of caffeine intoxication and the effect of its associated massive adrenergic surge with neurologic symptoms, cardiovascular instability, metabolic abnormalities, and the significant risk of mortality. We highlight important kidney management considerations, including protective measures against electrolyte disturbances such as hypokalemia and hypophosphatemia, and the use of prolonged hemodialysis for caffeine elimination. We share our practical decision making and approach to dialysis discontinuation if serum caffeine level reporting is unavailable or delayed.
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Affiliation(s)
- Mohamed Elbokl
- Division of Nephrology, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | - Ian Randall
- Department of Anesthesia, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | - Charmaine Lok
- Division of Nephrology, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
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Randall I. Why adding salt makes fruit—and candy—sweeter. Science 2020. [DOI: 10.1126/science.abf1394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Brahmbhatt P, Sabiston CM, Lopez C, Chang E, Goodman J, Jones J, McCready D, Randall I, Rotstein S, Santa Mina D. Feasibility of Prehabilitation Prior to Breast Cancer Surgery: A Mixed-Methods Study. Front Oncol 2020; 10:571091. [PMID: 33072603 PMCID: PMC7544900 DOI: 10.3389/fonc.2020.571091] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/28/2020] [Indexed: 12/05/2022] Open
Abstract
Background Breast cancer surgery results in numerous acute and long-term adverse outcomes; the degree to which these can be mitigated or prevented through prehabilitation is unknown. Methods We conducted a longitudinal, single-arm, mixed-methods study to examine the feasibility of prehabilitation in 22 women undergoing breast cancer surgery. All participants received an individualized exercise prescription including upper quadrant-specific resistance and mobility training and aerobic exercise for the duration of their surgical wait time. Feasibility was assessed by recruitment, adherence, attrition, and intervention-related adverse event rates. An exploratory investigation of intervention efficacy was conducted via a 6-min walk test, upper-quadrant strength and range of motion, volumetric chances associated with lymphedema, and participant-reported quality of life, fatigue, pain, and disability. Outcome assessments were conducted at baseline, prior to surgery, and at six and 12 weeks after surgery. Semi-structured interviews with a subset of participants (n = 5) and health-care providers (H; n = 2) were conducted to provide further insights about intervention feasibility. Qualitative data were analyzed using a hybrid inductive and deductive thematic analysis approach. Results Recruitment and attrition rates were 62 and 36%, respectively. Average prehabilitation duration was 31 days (range = 7–69 days). Seventy six percent of participants complied with at least 70% of their prehabilitation prescription. There was a clinically significant increase in the 6-min walk distance from baseline to the preoperative assessment (57 m, 95% CI = −7.52, 121.7). The interviews revealed that the intervention was favorably received by participants and HCPs and included suggestions that prehabilitation (i) should be offered to all surgical candidates, (ii) is an avenue to regain control in the preoperative period, (iii) is a facilitator of postoperative recovery, and (iv) is an opportunity to provide education regarding postoperative rehabilitation protocols. A preference for multimodal prehabilitation (including dietetic and psychological counseling) was also highlighted. Conclusion Our findings suggest that surgical prehabilitation in women with breast cancer is feasible. Data are hampered by study sample size and lack of a control group. Thus, randomized controlled trials to examine prehabilitation efficacy in people with breast cancer, especially interventions employing a multimodal strategy, are warranted.
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Affiliation(s)
- Priya Brahmbhatt
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada.,Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Catherine M Sabiston
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Christian Lopez
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Eugene Chang
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jack Goodman
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Jennifer Jones
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - David McCready
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Ian Randall
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Sarah Rotstein
- Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Daniel Santa Mina
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
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Randall I. Watch a half-dead sea urchin get menaced by a hungry crab—and live to tell the tale. Science 2020. [DOI: 10.1126/science.abc3777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Randall I, Booth H, Bousie J, Chakraborty N. Predicting assessment outcomes in an
EIP
team from referral letter information. Prog Neurol Psychiatry 2020. [DOI: 10.1002/pnp.668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Ian Randall
- Dr Randall is Consultant Psychiatrist at the East Midlands EIP service
| | - Hanna Booth
- Dr Booth is Specialty Doctor at the East Midlands EIP service
| | - Jonathan Bousie
- Mr Bousie is Senior Staff Nurse at the East Midlands EIP service
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Randall I. The real ‘paleo diet’ may have been full of toxic metals. Science 2020. [DOI: 10.1126/science.abb3098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Randall I. The world’s best drink cooler may come from pineapple scraps. Science 2019. [DOI: 10.1126/science.aba0322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Randall I. Why walnuts are such tough nuts to crack. Science 2019. [DOI: 10.1126/science.aaz3669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Randall I. Being strangled may save this tree’s life. Science 2017. [DOI: 10.1126/science.aan6932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Randall I. Descartes’s brain had a bulging frontal cortex. Science 2017. [DOI: 10.1126/science.aal1139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Randall I, Mohr DC, Maynard C. VHA Patient-Centered Medical Home Associated With Lower Rate of Hospitalizations and Specialty Care Among Veterans With Posttraumatic Stress Disorder. J Healthc Qual 2017; 39:168-176. [PMID: 28481843 DOI: 10.1111/jhq.12092] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The Veterans Health Administration (VHA) implemented a patient-centered medical home (PCMH) model, termed Patient Aligned Care Teams (PACT), in 2010. We assessed the association between PACT and the use of health services among U.S. veterans with posttraumatic stress disorder (PTSD). METHODS VHA clinical and administrative data were obtained for the pre-PACT period of April 1, 2009 to March 31, 2010 and post-PACT period of June 1, 2011 to May 31, 2012. Outcomes included hospitalizations, primary, specialty and mental health visits, and emergency department and urgent care visits. We utilized negative binomial regression and extended estimating equation models for the full sample. The analysis contained 696,379 unique veterans in both pre- and post-PACT periods. We estimated the linear incremental effect of PACT on utilization outcomes. RESULTS PACT were associated with a decrease in hospitalizations (incremental effect [IE]: -0.02; 95% confidence interval [CI]: -0.03, -0.01), a decrease in specialty care visits (IE: -0.45; 95% CI: -0.07, -0.23), and an increase in primary care visits (IE: 0.96; 95% CI: 0.67, 1.25). CONCLUSIONS The period following PACT implementation was associated with a lower rate of hospitalizations and specialty care visits, and a higher rate of primary care visits for veterans with PTSD, indicating enhanced access to primary care.
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Randall I, Maynard C, Chan G, Devine B, Johnson C. Assessing the effect of the VHA PCMH model on utilization patterns among veterans with PTSD. Am J Manag Care 2017; 23:291-296. [PMID: 28738685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES The Veterans Health Administration (VHA) implemented a patient-centered medical home (PCMH)-based Patient Aligned Care Teams (PACT) model in 2010. We examined its effects on the utilization of health services among US veterans with posttraumatic stress disorder (PTSD). STUDY DESIGN We analyzed VHA clinical and administrative data to conduct an interrupted time series study. Encounter-level data were obtained for the period of April 1, 2005, through March 31, 2014. We identified 642,660 veterans with PTSD who were assigned to either a high- or low-PCMH implementation group using a validated VHA PCMH measurement instrument. METHODS We measured the effect of high-PCMH implementation on the count of hospitalizations and primary care, specialty care, specialty mental health, emergency department (ED), and urgent care encounters compared with low-PCMH implementation. We fit a multilevel, mixed-effects, negative binomial regression model and estimated average marginal effects and incidence rate ratios. RESULTS Compared with patients in low-PCMH implementation clinics, patients who received care in high-PCMH implementation clinics experienced a decrease in hospitalizations (incremental effect [IE], -0.036; 95% confidence interval [CI], -0.0371 to -0.0342), a decrease in specialty mental health encounters (IE, -0.009; 95% CI, -0.009 to -0.008), a decrease in urgent care encounters (IE, -0.210; 95% CI, -0.212 to -0.207), and a decrease in ED encounters (IE, -0.056; 95% CI, -0.057 to -0.054). CONCLUSIONS High PCMH implementation positively affected utilization patterns by reducing downstream use of high-cost inpatient and specialty services. Future research should investigate whether a reduction in utilization of health services indeed results in higher levels of virtual and non-face-to-face access, or if the PACT model has reduced necessary access to care.
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Affiliation(s)
- Ian Randall
- Health Management Associates, 601 Union St. Ste. 2704, Seattle, WA 98101. E-mail:
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Randall I. Earthquake detectors can pick up helicopters, too. Science 2017. [DOI: 10.1126/science.aal1034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Al-Hemiary N, Al-Nuaimi AS, Al-Saffar H, Randall I. Why People Apply to Medical School in Iraq? J Med Educ Curric Dev 2017; 4:2382120517726997. [PMID: 29349341 PMCID: PMC5736275 DOI: 10.1177/2382120517726997] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 07/19/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND The motivations behind why people choose to study medicine in Iraqi medical schools are unknown. Such information could help school pupils to make more informed career decisions and assist medical schools in enhancing the student selection process. AIMS To investigate why people choose to study medicine in Iraq. SUBJECTS AND METHODS The first-year students admitted on the academic year 2015-2016 to Baghdad College of Medicine, University of Baghdad, were invited to complete a structured questionnaire, which was administered through the college electronic education portal. The data were analyzed using IBM SPSS version 21 software. RESULTS A total of 152 (50% response rate) students responded. Women constituted 69.1% of respondents. Most students (61.8%) had made their choice by themselves without family pressure. The most frequent reasons that affected this choice were "humanitarian reasons and a wish to provide help to others" as well as "childhood dream," "positive community appraisal of doctors," and "ready availability of work for physicians." About three-quarters (73.6%) of the students made some inquiry about medical school before making their choice, and the people asked were most frequently a medical student or a doctor. Information provided by the consulted parties was regarded as satisfactory by 64.2% of the surveyed students, had a positive value in 47.2%, and affected their decision in 34.9%. The highest proportion (42.2%) of the study sample was thinking about studying medicine since primary school. In addition, students with personal preference made their choice at a significantly younger age. CONCLUSIONS Reasons to apply for medical schools in Iraq are similar to those in many countries. Most of the students who inquired about studying medicine had not contacted the medical school itself.
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Affiliation(s)
- Nesif Al-Hemiary
- Section of Psychiatry, Department of Medicine, College of Medicine, University of Baghdad, Baghdad, Iraq
| | - Ahmed Sameer Al-Nuaimi
- Department of Family and Community Health, College of Medicine, University of Baghdad, Baghdad, Iraq
| | - Hilal Al-Saffar
- Department of Medicine, College of Medicine, University of Baghdad, Baghdad, Iraq
| | - Ian Randall
- The Bradgate Mental Health Unit, Leicester, UK
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Randall I. Fracking can prime faults for subsequent quakes. Science 2016. [DOI: 10.1126/science.aal0400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Randall I. Exercise doesn’t just tire your muscles—it makes your eyes sleepy. Science 2016. [DOI: 10.1126/science.aag0561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Randall I. How earthquakes might trigger faraway volcanoes. Science 2016. [DOI: 10.1126/science.aaf9960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Randall I. Don’t want to slip? Here’s the best stone floor to walk on. Science 2016. [DOI: 10.1126/science.aaf4121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Randall I. Hyperactive magnetic field may have led to one of Earth’s major extinctions. Science 2016. [DOI: 10.1126/science.aaf4072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Till A, Anandaram A, Dapaah A, Ibrahim R, Kansagra A, Prasad R, Randall I, Serrecchia C, Thomas P, Trickey R, McKimm J. Postgraduate leadership development: a cross specialty trainees’ perspective. BMJ 2016. [DOI: 10.1136/bmj.i374] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Randall I. New space robot would hop—not drive—across other worlds. Science 2016. [DOI: 10.1126/science.aae0198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Randall I. Slideshow: Glowing predators of the deep. Science 2015. [DOI: 10.1126/science.aac8986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Randall I. Earthquake sensors could help predict rockfalls. Science 2015. [DOI: 10.1126/science.aac4562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Randall I. Blue lights could prevent bird strikes. Science 2015. [DOI: 10.1126/science.aab2480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Randall I. Hurricane rain slows storms up to 30%. Science 2015. [DOI: 10.1126/science.aab2438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Nelson KM, Helfrich C, Sun H, Hebert PL, Liu CF, Dolan E, Taylor L, Wong E, Maynard C, Hernandez SE, Sanders W, Randall I, Curtis I, Schectman G, Stark R, Fihn SD. Implementation of the patient-centered medical home in the Veterans Health Administration: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use. JAMA Intern Med 2014; 174:1350-8. [PMID: 25055197 DOI: 10.1001/jamainternmed.2014.2488] [Citation(s) in RCA: 227] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE In 2010, the Veterans Health Administration (VHA) began implementing the patient-centered medical home (PCMH) model. The Patient Aligned Care Team (PACT) initiative aims to improve health outcomes through team-based care, improved access, and care management. To track progress and evaluate outcomes at all VHA primary care clinics, we developed and validated a method to assess PCMH implementation. OBJECTIVES To create an index that measures the extent of PCMH implementation, describe variation in implementation, and examine the association between the implementation index and key outcomes. DESIGN, SETTING, AND PARTICIPANTS We conducted an observational study using data on more than 5.6 million veterans who received care at 913 VHA hospital-based and community-based primary care clinics and 5404 primary care staff from (1) VHA clinical and administrative databases, (2) a national patient survey administered to a weighted random sample of veterans who received outpatient care from June 1 to December 31, 2012, and (3) a survey of all VHA primary care staff in June 2012. Composite scores were constructed for 8 core domains of PACT: access, continuity, care coordination, comprehensiveness, self-management support, patient-centered care and communication, shared decision making, and team-based care. MAIN OUTCOMES AND MEASURES Patient satisfaction, rates of hospitalization and emergency department use, quality of care, and staff burnout. RESULTS Fifty-three items were included in the PACT Implementation Progress Index (Pi2). Compared with the 87 clinics in the lowest decile of the Pi2, the 77 sites in the top decile exhibited significantly higher patient satisfaction (9.33 vs 7.53; P < .001), higher performance on 41 of 48 measures of clinical quality, lower staff burnout (Maslach Burnout Inventory emotional exhaustion subscale, 2.29 vs 2.80; P = .02), lower hospitalization rates for ambulatory care-sensitive conditions (4.42 vs 3.68 quarterly admissions for veterans 65 years or older per 1000 patients; P < .001), and lower emergency department use (188 vs 245 visits per 1000 patients; P < .001). CONCLUSIONS AND RELEVANCE The extent of PCMH implementation, as measured by the Pi2, was highly associated with important outcomes for both patients and providers. This measure will be used to track the effectiveness of implementing PACT over time and to elucidate the correlates of desired health outcomes.
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Affiliation(s)
- Karin M Nelson
- Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington2General Internal Medicine Service, VA Puget Sound Health Care System, Seattle, Washington 3Department of Medicine, University o
| | - Christian Helfrich
- Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington4Department of Health Services, University of Washington School of Public Health, Seattle
| | - Haili Sun
- Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington4Department of Health Services, University of Washington School of Public Health, Seattle
| | - Paul L Hebert
- Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington4Department of Health Services, University of Washington School of Public Health, Seattle
| | - Chuan-Fen Liu
- Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington4Department of Health Services, University of Washington School of Public Health, Seattle
| | - Emily Dolan
- Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Leslie Taylor
- Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Edwin Wong
- Department of Health Services, University of Washington School of Public Health, Seattle
| | - Charles Maynard
- Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington4Department of Health Services, University of Washington School of Public Health, Seattle
| | - Susan E Hernandez
- Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington4Department of Health Services, University of Washington School of Public Health, Seattle
| | - William Sanders
- Office of Analytics and Business Intelligence, Veterans Health Administration, Washington, DC
| | - Ian Randall
- Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington4Department of Health Services, University of Washington School of Public Health, Seattle
| | - Idamay Curtis
- Office of Analytics and Business Intelligence, Veterans Health Administration, Washington, DC
| | - Gordon Schectman
- Office of Patient Care Services, US Department of Veterans Affairs, Washington, DC
| | - Richard Stark
- Office of Clinical Operations, US Department of Veterans Affairs, Washington, DC
| | - Stephan D Fihn
- General Internal Medicine Service, VA Puget Sound Health Care System, Seattle, Washington 3Department of Medicine, University of Washington School of Medicine, Seattle5Office of Analytics and Business Intelligence, Veterans Health Administration, Washingt
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Gray S, Borgundvaag B, Sirvastava A, Randall I, Kahan M. Feasibility and reliability of the SHOT: A short scale for measuring pretreatment severity of alcohol withdrawal in the emergency department. Acad Emerg Med 2010; 17:1048-54. [PMID: 21040105 DOI: 10.1111/j.1553-2712.2010.00885.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Use of a symptom-triggered scale to measure the severity of alcohol withdrawal could reduce the rate of seizures and other complications. The current standard scale, the Clinical Institute of Withdrawal Assessment (CIWA), takes a mean (±SD) of 5 minutes to complete, requiring 30 minutes of nursing time per patient when multiple measures are required. OBJECTIVES The objective was to assess the feasibility and reliability of a brief scale of alcohol withdrawal severity. METHODS The SHOT is a brief scale designed to assess alcohol withdrawal in the emergency department (ED). It includes four items: sweating, hallucinations, orientation, and tremor (SHOT). It was developed based on a literature review and a consensus process by emergency and addiction physicians. The SHOT was first piloted in one ED, and then a prospective observational study was conducted at a different ED to measure its feasibility and reliability. Subjects included patients who were in alcohol withdrawal. One nurse administered the SHOT and CIWA, and the physician repeated the SHOT independently. The SHOT was done only at baseline, before treatment was administered. RESULTS In the pilot study (12 patients), the SHOT took 1 minute to complete on average, and the CIWA took 5 minutes. Sixty-one patients participated in the prospective study. For the SHOT and the CIWA done by the same nurse, the kappa was 0.88 (95% confidence interval [CI] = 0.52 to 1.0; p < 0.0001), and the Pearson's r was 0.71 (p < 0.001). The kappa for the nurse's CIWA score and the physician's SHOT score was 0.61 (95% CI = 0.25 to 0.97; p < 0.0006), and the Pearson's r was 0.48 (p = 0.002). The SHOTs performed by the nurse and physician agreed on the need for benzodiazepine treatment in 30 of 37 cases (82% agreement, kappa = 0.35, 95% CI = 0.03 to 0.67; p < 0.02). The mean (±SD) time taken by nurses and physicians to complete the SHOT was 1 (± 0.52) minute (median = 0.6 minutes). Seventeen percent of patients scored positive on the SHOT for hallucinations or disorientation. CONCLUSIONS The SHOT has potential as a feasible and acceptable tool for measuring pretreatment alcohol withdrawal severity in the ED. Further research is needed to validate the SHOT, to assess the utility of serial measurements of the SHOT, and to demonstrate that its use reduces length of stay and improves clinical outcomes.
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Affiliation(s)
- Sara Gray
- Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
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Randall I. Innovative program helps physicians lower risk, improve care. Mich Med 2007; 106:8. [PMID: 17710861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
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Randall I. Insurance costs drove this Pennsylvania doc to Michigan. Mich Med 2007; 106:14. [PMID: 17375695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
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