A Proposal for the Study of a Conceptual Framework to Inform Optimal Use of Telehealth for Postoperative Upper Extremity Care.
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ABSTRACT:
SUBMITTER: Wolff AL
PROVIDER: S-EPMC8077986 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:This rater-blinded, randomized control trial (RCT) investigated the effectiveness of a Glove Rehabilitation Application for Stroke Patients (GRASP) virtual reality home exercise program (HEP) for upper extremity (UE) motor recovery following stroke. The GRASP system facilitates the use of the affected UE in simulated instrumental activities of daily living (IADLs). Participants were asked to use the system at home in asynchronous telehealth sessions 4 times per week over 8 weeks. A non-blinded occupational therapist (OT) provided synchronous telehealth visits biweekly. Analysis comparing pre- and post-assessment results for the Fugl-Meyer UE assessment (FMUE) shows a clinically important and statistically significant between-group difference for participants completing the GRASP HEP protocol compared with usual and customary care controls. Statistically significant and clinically important differences were also found in Motor Activity Log (MAL) scores. This evidence provides support for the effectiveness of home-based, IADL-focused, virtual reality therapy with telehealth support.
| S-EPMC10499117 | biostudies-literature
Project description:PurposeTo identify targets for corrective interventions and guide improved opioid stewardship, we studied opioid prescribing patterns of attending surgeons compared with surgical trainees for 2 upper-extremity surgeries: open reduction internal fixation (ORIF) of distal radius fractures (DRF), and carpal tunnel release (CTR).MethodsWe retrospectively reviewed records for all patients who underwent CTR or DRF ORIF at 6 hospitals across a large health system from 2016 to 2018. We collected prescriber training level (attending vs trainee), analgesic prescribed, and amount initially prescribed after surgery converted to oral morphine equivalents (OMEs). Regression models evaluated OMEs by prescriber and surgery type. Our final models included an interaction term between prescriber training level and year of surgery to assess group changes over time. No prescription guidelines or formal training was provided during the study period.ResultsWe included 707 CTR and 383 DRF ORIF patients. Opioids prescribed by trainees ranged from 90 to 300 OMEs (median, 180 OMEs). Opioids prescribed by attendings ranged from 100 to 225 OMEs (median, 150 OMEs). Early in the analyses, trainees prescribed significantly more than attendings (320 versus 180). Over time, trainees reduced overprescribing significantly more, by an additional 40 OME/y. By the end of the analysis period, trainees were prescribing less OME than were attendings (112.5 vs 150). Both groups continued to prescribe more than recently suggested amounts for both procedures.ConclusionsOur study found that both attendings and trainees overprescribed opioids after surgery. Trainees prescribed more than attendings over the study period; however, when analyzing for improvement over time and with no formal intervention or training, trainees showed greater improvement, eventually dropping to levels at or below that of attendings. Considering that most change was seen at the trainee level, education for established providers may be an area in which more improvement can be made.Clinical relevanceUnderstanding which providers are more likely to overprescribe opioids can help guide interventions that improve opioid stewardship.
| S-EPMC8991875 | biostudies-literature
Project description:Experts disagree about the optimal classification of upper extremity disorders. To explore whether differential response to treatments offers a basis for choosing between case definitions, we analyzed previously published research.We screened 183 randomized controlled trials (RCTs) of treatments for upper extremity disorders identified from the bibliographies of 10 Cochrane reviews and 4 other systematic reviews, and a search in Medline, Embase, and Google Scholar to June 2010. From these, we selected RCTs that allowed estimates of benefit (expressed as relative risks [RRs]) for >1 case definition to be compared when other variables (treatment, comparison group, followup time, outcome measure) were effectively held constant. Comparisons of RRs for paired case definitions were summarized by their ratios, with the RR for the simpler and broader definition as the denominator.Two RCT reports allowed within-trial comparison of RRs and 13 others allowed between-trial comparisons. Together these provided 17 ratios of RRs (5 for shoulder treatments, 12 for elbow treatments, and none for wrist/hand treatments). The median ratio of RRs was 1.0 (range 0.3-1.7, interquartile range 0.6-1.3).Although the evidence base is limited, our findings suggest that for musculoskeletal disorders of the shoulder and elbow, clinicians in primary care will often do best to apply simpler and broader case definitions. Researchers should routinely publish secondary analyses for subgroups of patients by different diagnostic features at trial entry to expand the evidence base on optimal case definitions for patient management.
| S-EPMC3428871 | biostudies-literature
Project description:BackgroundPrevious research has reported that public-academic partnerships (PAPs) can effectively promote PAP leaders' use of research evidence in improving youth outcomes. However, the existing literature has not yet clarified whether and how PAP leaders' use of research evidence evolves along the PAP life cycle and whether PAP partners' concordant perceptions of usefulness of their PAP has an impact on PAP leaders' use of research evidence. Developing a conceptual framework that recognizes the PAP life cycle and empirically identifying contexts and mechanisms of PAPs that promote PAP leaders' use of research evidence from the PAP life cycle perspective are imperative to guide researchers and policymakers to successfully lead PAPs and foster policymakers' use of research evidence for improving youth outcomes.ObjectiveUtilizing an integrated framework of organizational life cycle perspective, a social partnership perspective, and a realist evaluation, this study examines the extent to which PAP development and PAP leaders' use of research evidence can be characterized into life cycle stages and identifies PAP contexts and mechanisms that explain the progress of PAPs and PAP leaders' use of research evidence through life cycle stages.MethodsRecruiting PAPs across the United States that aim to improve mental health and promote well-being of youth aged 12-25 years, the study conducts a document analysis and an online survey of PAPs to inform policymakers and academic researchers on the contexts and mechanisms to increase PAP sustainability and promote policymakers' use of research evidence in improving youth outcomes.ResultsFifty-three PAPs that meet the recruitment criteria have been identified, and document review of PAPs and participant recruitment for the online survey of PAP experience have been conducted.ConclusionsThis paper will help policymakers and researchers gain a deeper knowledge of the contexts and mechanisms for each PAP life cycle stage in order to optimize PAP leaders' use of research evidence in achieving positive youth outcomes.International registered report identifier (irrid)DERR1-10.2196/14382.
| S-EPMC6555116 | biostudies-literature
Project description:The Kidney Disease Outcome Quality Initiative and Fistula First Breakthrough Initiative call for the indiscriminate creation of arteriovenous fistulas (AVFs) over arteriovenous grafts (AVGs) without providing patient-specific criteria for vascular access selection. Although the U.S. AVF rate has increased dramatically, several reports have found that this singular focus on increasing AVFs has resulted in increased AVF nonmaturation/early failure and a high prevalence of catheter dependence. The objective of this study was to determine the appropriateness of vascular access procedures in clinical scenarios constructed with combinations of relevant factors potentially influencing outcomes.The RAND/UCLA Appropriateness Method was used. Accordingly, a comprehensive literature search was performed and a synthesis of results compiled. The RAND/UCLA Appropriateness Method was applied to 2088 AVF and 1728 AVG clinical scenarios with varying patient characteristics. Eleven international vascular access experts rated the appropriateness of each scenario in two rounds. On the basis of the distribution of the panelists' scores, each scenario was determined to be appropriate, inappropriate, or indeterminate.Panelists achieved agreement in 2964 (77.7%) scenarios; 860 (41%) AVF and 588 (34%) AVG scenarios were scored appropriate, 686 (33%) AVF and 480 (28%) AVG scenarios were scored inappropriate, and 542 (26%) AVF and 660 (38%) AVG scenarios were indeterminate. Younger age, larger outflow vein diameter, normal or obese body mass index (vs morbidly obese), larger inflow artery diameter, and higher patient functional status were associated with appropriateness of AVF creation. Older age, dialysis dependence, and smaller vein size were associated with appropriateness of AVG creation. Gender, diabetes, and coronary artery disease were not associated with AVF or AVG appropriateness. Dialysis status was not associated with AVF appropriateness. Body mass index and functional status were not associated with AVG appropriateness. To simulate the surgeon's decision-making, scenarios were combined to create situations with the same patient characteristics and both AVF and AVG options for access. Of these 864 clinical situations, 311 (36%) were rated appropriate for AVG but inappropriate or indeterminate for AVF.The results of this study indicate that patient-specific situations exist wherein AVG is as appropriate as or more appropriate than AVF. These results provide patient-specific recommendations for clinicians to optimize vascular access selection criteria, to standardize care, and to inform payers and policy. Indeterminate scenarios will guide future research.
| S-EPMC5533515 | biostudies-other
Project description:ObjectiveTo determine the extent to which estimates of sample and effect size in stroke rehabilitation trials can be affected by simple summation of ordinal Upper Extremity Fugl-Meyer (UEFM) items compared with a Rasch-rescaled UEFM.DesignRasch analysis of Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE) phase III trial data, comparing 3 upper extremity (UE) motor treatments in stroke survivors enrolled 45.8±22.4 days poststroke. Participants underwent a structured UE motor training known as the Accelerated Skill Acquisition Program, usual and customary care, or dose-equivalent care. UEFM data from baseline, postintervention, and 6 and 12 months later were included for analysis.SettingOutpatient stroke rehabilitation.ParticipantsICARE participants (N=361).InterventionsNot applicable.Main outcome measuresItem difficulties, person abilities, and sample size.ResultsBecause of their ordinality, summed raw UEFM scores measured motor impairment inconsistently across different ranges of stroke severity relative to the rescaled UEFM. In the full ICARE sample, raw UEFM understated scores relative to the rescaled UEFM by 7.4 points for the most severely impaired, but overstated scores by up to 8.4 points toward the ceiling. As a result, 50.9% of all UEFM observations showed a residual error greater than 10% of the total UEFM score. Relative to the raw scores, the rescaled UEFM improved the effect size of change in motor impairment between baseline and 1 year (d=0.35). For a hypothetical 3-arm trial resembling ICARE, UEFM rescaling reduced the required sample size by 32% (n=108) compared with raw UEFM (n=159).ConclusionsIn UE rehabilitation trials, a rescaled UEFM potentially decreases sample size by one-third, decreasing costs, duration, and the number of subjects exposed to experimental risks. This benefit is obtained through increased measurement efficiency. Reductions in ceiling effects are also possible. These findings apply to ICARE-like trials. Confirmatory validation in another phase III trial is needed.
| S-EPMC7854957 | biostudies-literature
Project description:Large knowledge gaps currently exist that limit our ability to understand and characterise dynamics and patterns of land-use intensity: in particular, a comprehensive conceptual framework and a system of measurement are lacking. This situation hampers the development of a sound understanding of the mechanisms, determinants, and constraints underlying changes in land-use intensity. On the basis of a review of approaches for studying land-use intensity, we propose a conceptual framework to quantify and analyse land-use intensity. This framework integrates three dimensions: (a) input intensity, (b) output intensity, and (c) the associated system-level impacts of land-based production (e.g. changes in carbon storage or biodiversity). The systematic development of indicators across these dimensions would provide opportunities for the systematic analyses of the trade-offs, synergies and opportunity costs of land-use intensification strategies.
| S-EPMC3798045 | biostudies-literature
Project description:IntroductionOne-third of adults in the United States who use tobacco regularly use two or more types of tobacco products. As the use of e-cigarettes and other noncombusted tobacco products increases-making multiple tobacco product (MTP) use increasingly common-it is essential to evaluate the complex factors that affect product use.Aims and methodsIn this update to our 2019 conceptual framework, we review and evaluate recent literature and expand the model to include ways in which MTP use may be affected by market factors such as the introduction of new products and socioenvironmental factors like marketing and advertising.Results and conclusionsMTP use patterns are complex, dynamic, and multiply determined by factors at the level of individuals, products, situations or contexts, and marketplace. Substitution, or using one product with the intent of decreasing use of another, and complementarity, or using multiple products for different reasons or purposes, explain patterns in MTP use. Moreover, substitution and complementarity may inform our understanding of how market changes targeted at one product, for instance, new product standards, bans, product pricing, and taxation, affect consumption of other tobacco products. New data from natural experiments and novel laboratory-based techniques add additional data and expand the framework.ImplicationsA substantial proportion of people who use tobacco use more than one product. This review synthesizes and evaluates recent evidence on the diverse factors that affect MTP use in addition to expanding our framework. Our review is accompanied by suggested research questions that can guide future study.
| S-EPMC9278823 | biostudies-literature
Project description:Background:Past work showed that an in-person, therapist-guided, parent-implemented multicomponent intervention increased the motor functioning of the more affected upper extremity (UE) in infants with asymmetric cerebral palsy. The authors document treatment fidelity and provide initial testing of telehealth intervention delivery in a new subject sample. Methods:The authors adapted the intervention manual used in the previous trial for telehealth. Infants (6-24 months) were randomly assigned to intervention (n = 7) or waitlist (n = 6). The intervention prescribed soft-constraint wear on the less affected UE for 6 hours, 5 d/wk, and exercises. After an initial in-person training session, three 15- to 45-minute telehealth sessions were performed. Results:Median weekly constraint wear was 21 hours (interquartile range = 10.3-29.7); average parent-treatment fidelity was 95.7% (SD 11.2). A significant large (Cohen d = 0.92) between-group differences occurred on fine motor functioning of more affected UEs. Conclusion:The telehealth intervention was feasible and potentially effective, but a larger trial is needed to evaluate efficacy.
| S-EPMC7517997 | biostudies-literature
Project description:BackgroundTreatment of patients with traumatic axonotmesis presents challenges. Processed human umbilical cord membrane has been recently developed with improved handling and resorption time compared to other amniotic membrane wraps, and may be beneficial in nerve reconstruction. This study evaluates postoperative outcomes after traumatic peripheral nerve injury after placement of commercially available processed human umbilical cord membrane.MethodsWe performed a prospective, single-center pilot study of patients undergoing multi-level surgical reconstruction for exposed, non-transected peripheral nerve. Functional outcomes including pain, range of motion, pinch and grip strength, and the QuickDASH and SF-36 patient-reported outcome measures were recorded, when possible, at the 1-week and 3, 6, and 9 months postop visit. One-tailed paired t-tests were performed to evaluate outcome improvement at final follow-up.ResultsTwenty patients had processed human umbilical cord membrane placement without surgical complications. Mean follow-up was 7.5 months (range: 3-10 months) and mean age was 39 years (range: 15-65). Twelve (67%) patients were male, and the majority of placement sites were in the upper extremity (85%). Mean preoperative visual analog scale pain score was significantly reduced at most recent follow-up, as were QuickDASH scores. All patients had improved functional outcomes at the 9-month follow-up, and SF-36 outcomes at 9 months showed improvement across all dimensions.ConclusionThis study indicates that processed human umbilical cord membrane may be a useful adjunct in nerve surgery with noted improvements in postoperative function, pain, and patient-reported outcome measures. Future studies are needed to assess long-term outcomes after traumatic nerve injury treated with processed human umbilical cord membrane.
| S-EPMC8188973 | biostudies-literature