Is it time to study routine car seat tolerance screening in a randomized controlled trial? An international survey of current practice and clinician equipoise.
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ABSTRACT:
SUBMITTER: Jensen EA
PROVIDER: S-EPMC8882206 | biostudies-literature | 2022 Apr
REPOSITORIES: biostudies-literature
Publications
Is it time to study routine car seat tolerance screening in a randomized controlled trial? An international survey of current practice and clinician equipoise.
Jensen Erik A EA Greenspan Jay S JS Aghai Zubair H ZH Carola David L DL Eichenwald Eric C EC DeMauro Sara B SB Dysart Kevin K
Journal of perinatology : official journal of the California Perinatal Association 20210827 4
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Project description:Background and objectivesThe American Academy of Pediatrics recommends preterm newborns undergo car seat tolerance screening (CSTS) before discharge despite limited evidence supporting the practice. We examined subsequent health care utilization in screened and unscreened late preterm and low birth weight newborns.MethodsThis observational study included late preterm (34-36 weeks) and term low birth weight (<2268 g) newborns born between 2014 and 2018 at 4 hospitals with policies recommending CSTS for these infants. Birth hospitalization length of stay (LOS) in addition to 30-day hospital revisits and brief resolving unexplained events were examined. Unadjusted and adjusted rates were compared among 3 groups: not screened, pass, and fail.ResultsOf 5222 newborns, 3163 (61%) were discharged from the nursery and 2059 (39%) from the NICU or floor. Screening adherence was 91%, and 379 of 4728 (8%) screened newborns failed the initial screen. Compared with unscreened newborns, adjusted LOS was similar for newborns who passed the CSTS (+5.1 hours; -2.2-12.3) but significantly longer for those who failed (+16.1; 5.6-26.7). This differed by screening location: nursery = +12.6 (9.1-16.2) versus NICU/floor = +71.2 (28.3-114.1) hours. Hospital revisits did not significantly differ by group: not screened = 7.3% (reference), pass = 5.2% (aOR 0.79; 0.44-1.42), fail = 4.4% (aOR 0.65; 0.28-1.51).ConclusionsHospital adherence to CSTS recommendations was high, and failed screens were relatively common. Routine CSTS was not associated with reduced health care utilization and may prolong hospital LOS, particularly in the NICU/floor. Prospective trials are needed to evaluate this routine practice for otherwise low-risk infants.
| S-EPMC9647635 | biostudies-literature
Project description:ObjectivesTo assess whether adherence to institutional car seat tolerance screening (CSTS) guidelines differed for infants born preterm (PTM), term low birth weight (T-LBW), or both preterm and low birth weight (P-LBW), and to examine the association between CSTS adherence and patient characteristics.Study designWithin two large academic and community hospitals, we retrospectively reviewed all infants meeting institutional criteria (< 37 weeks' gestation and/or < 2.27 kg) for CSTS from 2014 to 2018. Multivariable logistic regression evaluated the association of patient characteristics with institutional CSTS guideline adherence.Results4374 eligible infants were born PTM (50.9%), T-LBW (6.5%), or P-LBW (42.6%). Adherence rates were 92.7% in the neonatal intensive care unit (NICU) and 95.2% in the well-baby nursery with initial CSTS failure rates of 6.1% and 9.9%, respectively. Adherence was lowest among T-LBW (80.7%) compared to PTM (95.1%) or P-LBW (92.2%) infants in the NICU (p < 0.001) and well-baby nursery (81.6%, 96.7% and 97.1%, respectively, p < 0.001). In bivariate analyses, gestational age, birth weight, insurance, race, hospital type, discharge year, and preferred language were associated with adherence. In fully-adjusted models, adherence was positively associated with lower gestational age, higher birth weight, non-Medicaid insurance, and later discharge year (NICU) and lower gestational age and later discharge year (well-baby nursery).ConclusionsAdherence was lower for T-LBW than PTM or P-LBW infants, despite similar CSTS failure rates. Disparities in adherence among Medicaid-insured patients in the NICU warrant further study. Future studies are needed to clarify the benefit of CSTS and increase adherence in high-risk populations.
| S-EPMC8369874 | biostudies-literature
Project description:BackgroundAtrial fibrillation (AF) can be managed with rhythm- or rate-control strategies. There are few data from routine clinical practice on the frequency with which each strategy is used and their correlates in terms of patients' clinical characteristics, AF control, and symptom burden.MethodsRealiseAF was an international, cross-sectional, observational survey of 11,198 patients with AF. The aim of this analysis was to describe patient profiles and symptoms according to the AF management strategy used. A multivariate logistic regression identified factors associated with AF management strategy at the end of the visit.ResultsAmong 10,497 eligible patients, 53.7% used a rate-control strategy, compared with 34.5% who used a rhythm-control strategy. In 11.8% of patients, no clear strategy was stated. The proportion of patients with AF-related symptoms (EHRA Class > = II) was 78.1% (n = 4396/5630) for those using a rate-control strategy vs. 67.8% for those using a rhythm-control strategy (p<0.001). Multivariate logistic regression analysis revealed that age <75 years or the paroxysmal or persistent form of AF favored the choice of a rhythm-control strategy. A change in strategy was infrequent, even in patients with European Heart Rhythm Association (EHRA) Class > = II.ConclusionsIn the RealiseAF routine clinical practice survey, rate control was more commonly used than rhythm control, and a change in strategy was uncommon, even in symptomatic patients. In almost 12% of patients, no clear strategy was stated. Physician awareness regarding optimal management strategies for AF may be improved.
| S-EPMC4723091 | biostudies-literature
Project description:Current literature shows that intertrochanteric osteotomies can produce excellent results in selected hip disorders in specific groups of patients. However, it appears that this surgical option is considered an historical one that has no role to play in modern practice. In order to examine current awareness of and views on intertrochanteric osteotomies among international hip surgeons, an online survey was carried out. The survey consisted of a set of questions regarding current clinical practice and awareness of osteotomies. The second part of the survey consisted of five clinical cases and sought to elicit views on preoperative radiological investigations and preferred (surgical) treatments. The results of our survey showed that most of these experts believe that intertrochanteric osteotomies should still be performed in selected cases. Only 56% perform intertrochanteric osteotomies themselves and of those, only 11% perform more than five per year. The responses to the cases show that about 30-40% recommend intertrochanteric osteotomies in young symptomatic patients. This survey shows that the role of intertrochanteric osteotomies is declining in clinical practice.
| S-EPMC2219926 | biostudies-other
Project description:BackgroundLarge international humanitarian actors support and directly deliver health services for millions of people in crises annually, and wield considerable power to decide which health services to provide, how and to whom, across a vast spectrum of health areas. Despite decades of reform aiming to improve accountability in the sector, public health practice among humanitarian actors is not heavily scrutinized in either the countries where they are headquartered or those where they provide healthcare. We surveyed current healthcare governance practice among large international humanitarian actors to better understand what organisations are doing to ensure oversight and accountability for health services in humanitarian responses.MethodsThe term 'healthcare governance' was defined and categorised into seven domains: implementation of health management information systems (HMIS) and use of resulting data; professional development of health sector staff; audits of health service performance; management of clinical incidents; evidence-based practice; pharmaceutical supply; and beneficiary engagement. Senior health professionals at 32 leading international actors providing humanitarian health services were contacted between July and August 2019 to complete a 109-question online survey about their organisation's practice in these domains.ResultsRespondents from 13 organisations completed the questionnaire. Healthcare governance practices were undertaken to varying degrees by all organisations but were often driven by donor requirements and external factors rather than improvement of programme performance. Common strengths were the inclusion of governance in organisational policies, high availability of technical guidelines, and close monitoring of pharmaceutical services. Recurring weaknesses were poor beneficiary engagement, inconsistent use of health information for decision making, unsystematic implementation of healthcare audits, inconsistent management of clinical incidents, and lack of training and professional development opportunities.ConclusionsTo our knowledge, this is the first study to describe healthcare governance practice among humanitarian actors. Leading international humanitarian healthcare providers are already implementing many healthcare governance activities; however, these are inconsistently applied and generally not reflective of systematic policies or earmarked organisational resources. There is a need for sector-wide consensus on how the humanitarian sector defines healthcare governance, the domains that constitute it, which actors in the humanitarian system are implicated, and how malpractice should be systematically addressed.
| S-EPMC8035763 | biostudies-literature
Project description:PurposeInternational clinical practice guidelines call for initial volume resuscitation of at least 30 mL/kg body weight for patients with sepsis-induced hypotension or shock. Although not considered in the guidelines, preexisting cardiac dysfunction may be an important factor clinicians weigh in deciding the quantity of volume resuscitation for patients with septic shock.MethodsWe conducted a multicenter survey of clinicians who routinely treat patients with sepsis to evaluate their beliefs, behaviors, knowledge, and perceived structural barriers regarding initial volume resuscitation for patients with sepsis and concomitant heart failure with reduced ejection fraction (HFrEF) <40%. Initial volume resuscitation preferences were captured as ordinal values, and additional testing for volume resuscitation preferences was performed using McNemar and Wilcoxon signed rank tests as indicated. Univariable logistic regression models were used to identify significant predictors of ≥30 mL/kg fluid administration.ResultsA total of 317 clinicians at 9 US hospitals completed the survey (response rate 47.3%). Most respondents were specialists in either internal medicine or emergency medicine. Substantial heterogeneity was found regarding sepsis resuscitation preferences for patients with concomitant HFrEF. The belief that patients with septic shock and HFrEF should be exempt from current sepsis bundle initiatives was shared by 39.4% of respondents. A minimum fluid challenge of ∼30 mL/kg or more was deemed appropriate in septic shock by only 56.4% of respondents for patients with concomitant HFrEF, compared to 89.1% of respondents for patients without HFrEF (P < .01). Emergency medicine physicians were most likely to feel that <30 mL/kg was most appropriate in patients with septic shock and HFrEF.ConclusionsClinical equipoise exists regarding initial volume resuscitation for patients with sepsis-induced hypotension or shock and concomitant HFrEF. Future studies and clinical practice guidelines should explicitly address resuscitation in this subpopulation.
| S-EPMC7039763 | biostudies-literature
Project description:BackgroundUse of digital health services, such as digital patient-reported outcomes, depends on many different human factors as well as digital design solutions. One factor is clinicians' attitude towards the system, their reasoning behind the using system and their perceptions of patients' ability to engage with digital health systems. This study aimed to explore hospital clinicians' attitudes towards digital patient-reported outcomes used in the routine care and treatment of inflammatory bowel disease, and to explore the potential role of clinicians' attitudes in influencing patients' use of digital patient-reported outcomes.ResultsTwelve clinicians using digital patient-reported outcome assessments in the care of inflammatory bowel disease were interviewed about their experiences of, and perspectives on, using this service. Most participants supported the use of digital patient-reported outcome assessments in the care of most patients. Participants reported that most patients found the digital solution easy to use. They perceived digital patient-reported outcomes to have three main purposes: prioritising resources; improving patients' quality of life; and improving quality of care. The patient-clinician relationship was of great importance to participants. Participants varied in their intention to use digital PRO, as some viewed the system as a positive but optional add-on for patients, whilst others intended to use the system with all eligible patients.ConclusionClinicians' general support of using digital patient-reported outcomes might facilitate their use among patients with inflammatory bowel disease. The participants saw benefits in doing so for patients, clinicians and the wider health service. Clinicians' attitudes towards the use of digital PRO in the care of their patients may influence patients' uptake of health service.
| S-EPMC9117590 | biostudies-literature
Project description:BackgroundTraumatic brain injury (TBI) and stroke have devastating consequences and are major global public health issues. For patients that require a cerebral decompression after suffering a TBI or stroke, a decompressive craniectomy (DC) is the most commonly performed operation. However, retrospective non-randomized studies suggest that a decompressive craniotomy (DCO; also known as hinge or floating craniotomy), where a bone flap is replaced but not rigidly fixed, has comparable outcomes to DC. The primary aim of this project was to understand the current extent of usage of DC and DCO for TBI and stroke worldwide.MethodA questionnaire was designed and disseminated globally via emailing lists and social media to practicing neurosurgeons between June and November 2019.ResultsWe received 208 responses from 60 countries [40 low- and middle-income countries (LMICs)]. DC is used more frequently than DCO, however, about one-quarter of respondents are using a DCO in more than 25% of their patients. The three top indications for a DCO were an acute subdural hematoma (ASDH) and a GCS of 9-12, ASDH with contusions and a GCS of 3-8, and ASDH with contusions and a GCS of 9-12. There were 8 DCO techniques used with the majority (60/125) loosely tying sutures to the bone flap. The majority (82%) stated that they were interested in collaborating on a randomized trial of DCO vs. DC.ConclusionOur results show that DCO is a procedure carried out for TBI and stroke, especially in LMICs, and most commonly for an ASDH. The majority of the respondents were interested in collaborating on a is a future randomized trial.
| S-EPMC8053664 | biostudies-literature
Project description:Background and purposeThe uptake of new technologies has varied internationally and there have often been barriers to implementation. On-line adaptive radiotherapy (ART) promises to improve patient outcome. This survey focuses on the implementation phase of delivering ART and professional roles and responsibilities currently involved in the workflow and changes which may be expected in the future.Materials and methodsA 38 question survey included aspects on current practice; professional responsibilities; benefits and barriers; and decision making and responsibilities. For the purposes of the questionnaire and paper, ART was considered where tumour and /or organs at risk were contoured and re-planning was performed on-line. The questionnaire was electronically distributed via radiotherapy networks.ResultsNineteen international responses were received. Europe (n = 11), United States of America (n = 4); Canada (n = 2), Australia (n = 1) and Hong Kong (n = 1). The majority of centres started using ART in either 2018 (n = 7) or 2019 (n = 6). Four centres started treating with ART between 2015 and 2017, and the first was in 2014. Centres initially treated prostate and oligometastases patients, expanding to treat prostate, oligometastases, pancreas and rectum. The majority of centres were working in conventional roles, however moving towards radiographers taking more responsibility in contouring organs at risk (OAR), target and dosimetry. The three most important criteria chosen by medical doctors to determine if ART should be used were overall gross anatomy changes of target and OAR, target not covered by planning target volume (PTV) and OAR close to the high dose area. There was no clear consensus on the minimum improvement in dose to target or reduction in dose to OAR to warrant adaption.ConclusionOn-line ART has been implemented successfully internationally. Initial practice maintains conventional professional roles and responsibilities, however there is trend to changing roles for the future. There is little consensus regarding the triggers of adaption.
| S-EPMC7501460 | biostudies-literature
Project description:A variety of clinical and imaging findings are used by clinicians to determine utility of renal angioembolization (AE) in managing renal trauma. Our purpose was to investigate specific criteria that clinicians who manage high-grade renal trauma (HGRT) utilize in decision-making for primary or delayed AE.A total of 413 urologists and interventional radiologists (IRs) who practice at level 1 or 2 trauma centers within the United States were provided an original survey via email on experience and opinions regarding the utility of AE for HGRT. We described overall practice patterns and assessed differences by clinician type, using the Fisher's exact test.A total of 79 (20 %) clinicians completed the survey. All clinicians had AE capability for HGRT management. A higher proportion of IRs reported using AE for grade I-II (33 vs. 3 %, p = 0.002), grade III (65 vs. 26 %, p = 0.001), and penetrating injuries (83 vs. 58 %, p = 0.02). A greater proportion of urologists reported using AE for grade V injuries (81 vs. 56 %, p = 0.03). Clinicians most commonly cited computed tomography evidence of active arterial bleeding (97 %), or arteriovenous fistula/pseudoaneurysm (94 %) as indications for primary AE, and 62 % identified concurrent visceral injury as factor that would necessitate surgical intervention.In a survey of clinicians, we report that IRs and urologists utilize AE differently when managing HGRT, as a higher proportion of IRs use AE to manage lower grade as well as penetrating injuries. Validation studies are needed to establish algorithms to identify patients with HGRT who would benefit from selective renal AE.
| S-EPMC4153381 | biostudies-literature