Gabriella Engstrom

Red cell distribution width, haemoglobin A1c and incidence of diabetes mellitus

Hyperglycaemia has multiple effects on the red blood cell (RBC), including glycation of haemoglobin, reduced deformability and reduced lifespan. Red cell distribution width (RDW) is a measure of the heterogeneity of erythrocyte volumes. The aim of this study was to explore the relationships between RDW and glucose, haemoglobin A1c (HbA1c) and incidence of diabetes mellitus (DM).

Root Cause Analyses of Transfers of Skilled Nursing Facility Patients to Acute Hospitals: Lessons Learned for Reducing Unnecessary Hospitalizations.

BACKGROUNDnPerforming root cause analyses (RCA) on transfers of skilled nursing facility (SNF) patients to acute hospitals can help identify opportunities for care process improvements and education that may help prevent unnecessary emergency department (ED) visits, hospitalizations, and hospital readmissions.nnnOBJECTIVESnTo describe the results of structured, retrospective RCAs performed by SNF staff on hospital transfers to identify lessons learned for reducing these transfers.nnnDESIGNnSNFs enrolled in a randomized, controlled implementation trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program submitted RCAs on hospital transfers during a 12-month implementation period.nnnSETTINGnSNFs from across the United States that volunteered and met the enrollment criteria for the implementation trial.nnnPARTICIPANTSnSixty-four of 88 SNFs randomized to the intervention group performed and submitted retrospective RCAs on hospital transfers.nnnINTERVENTIONSnSNFs received education and technical assistance in INTERACT implementation.nnnMEASURESnData were summarized from the INTERACT Quality Improvement (QI) tool, a structured, retrospective RCA on hospital transfers.nnnRESULTSnA total of 4856 QI tools were submitted during the 12-month implementation period. Most transfers were precipitated by multiple symptoms and signs, many of them nonspecific. Patient and/or family preference or insistence was noted to have played a role in 16% of the transfers. Hospital transfers were relatively equally distributed among days of the week, and 29% occurred on the night or evening shift. Approximately 1 in 5 transfers occurred within 6 days of SNF admission from a hospital, and 1 in 10 occurred within 2 days of SNF admission. After completing the RCA, SNF staff identified 1044 (23%) of the transfers as potentially preventable. Common reasons for these ratings included recognition that the condition could have been detected earlier and/or could have been managed safely in the SNF, and that earlier advance care planning and discussions with patients and families about preferences for care may have prevented some transfers.nnnCONCLUSIONnSummarizing findings from RCAs of transfers of SNF patients to acute hospitals can provide important insights into areas of focus for care process improvements and related education that may help prevent unnecessary ED visits, hospital admissions, and readmissions.

'Paddling upstream' : Fathers' involvement during pregnancy as described by expectant fathers and mothers

AIMS AND OBJECTIVESnTo describe the perspectives of expectant mothers and fathers on fathers involvement during pregnancy.nnnBACKGROUNDnBecoming a father is a major life event and paternal involvement during pregnancy has a positive influence on the family. However, research into both expectant mothers and fathers perspectives on fathers involvement during pregnancy is relatively scarce.nnnDESIGNnA descriptive qualitative study was used.nnnMETHODSnThirty expectant parents (20 women and 10 men) were interviewed either as part of one of four focus groups or in an individual interview. Qualitative content analysis was performed on the interview transcripts.nnnRESULTSnA theme of Paddling upstream emerged as an expression of the latent content of the interviews concerning perspectives on fathers involvement. Five sub-themes described the manifest content: trying to participate, trying to be understanding, trying to learn, trying to be a calming influence and trying to find a balanced life. Expectant parents suggested several ways to improve fathers involvement and to meet parents need for shared involvement.nnnCONCLUSIONnExpectant mothers and fathers wanted the father to be more involved in the pregnancy. Although fathers attempted different strategies, they did not always perceive what was expected of them and encountered many barriers as they tried to navigate through this unique experience. The best support for the father was the mother. Expectant parents wanted their healthcare to include the father more thoroughly and to focus on the whole family.nnnRELEVANCE TO CLINICAL PRACTICEnPrenatal care professionals can overcome barriers that prevent paternal involvement. Although fathers are not able to engage in the pregnancy on the same level as the mother, we suggest that their specific needs also be recognised through an increased awareness of gender norms in healthcare.

Hospital Transfers of Skilled Nursing Facility (SNF) Patients Within 48 Hours and 30 Days After SNF Admission.

BACKGROUNDnClose to 1 in 5 patients admitted to a skilled nursing facility (SNF) are readmitted to the acute hospital within 30xa0days, and a substantial percentage are readmitted within 2xa0days of the SNF admission. These rapid returns to the hospital may provide insights for improving care transitions between the acute hospital and the SNF.nnnOBJECTIVESnTo describe the characteristics of SNF to hospital transfers that occur within 48xa0hours and 30xa0days of SNF admission based on root cause analyses (RCAs) performed by SNF staff, and identify potential areas of focus for improving transitions between hospitals and SNFs.nnnDESIGNnTrained staff from SNFs enrolled in a randomized, controlled clinical trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program performed retrospective RCAs on hospital transfers during a 12-month implementation period.nnnSETTINGnSNFs from across the United States.nnnPARTICIPANTSn64 of 88 SNFs randomized to the intervention group submitted RCAs.nnnINTERVENTIONSnSNFs were implementing the INTERACT quality improvement program.nnnMEASURESnData were abstracted from the INTERACT Quality Improvement (QI) tool, a structured, retrospective RCA on hospital transfers.nnnRESULTSnAmong 4658 transfers for which data on the time between SNF admission and hospital transfer were available, 353 (8%) occurred within 48xa0hours of SNF admission, 524 (11%) 3 to 6xa0days after SNF admission, 1450 (31%) 7 to 29xa0days after SNF admission, and 2331 (50%) occurred 30xa0days or longer after admission. Comparisons between transfers that occurred within 48xa0hours and within 30xa0days of SNF admission to transfers that occurred 30xa0days or longer after SNF admission revealed several statistically significant differences between patient risk factors for transfer, symptoms and signs precipitating the transfers, and other characteristics of the transfers. Hospitalization in the last 30xa0days and year was significantly more common among those with rapid returns to the hospital. Shortness of breath was significantly more common among those transferred within 48xa0hours or 30xa0days, and falls, functional decline, suspected respiratory infection, and new urinary incontinence less common. SNF staff rated a higher proportion of transfers within 30xa0days versus 30xa0days or longer as potentially preventable (25.1% vs 21.5%, Pxa0=xa0.005). Case descriptions derived from the QI tools of transfers back to the hospital within 48xa0hours of SNF admission illustrate several factors underlying these rapid returns to the hospital.nnnCONCLUSIONnRCAs on transfers back to the hospital shortly after SNF admission provide insights into strategies that both hospitals and SNFs can consider in collaborative efforts to reduce potentially avoidable hospital readmissions.

Effects of an intervention to reduce hospitalizations from nursing homes: A randomized implementation trial of the INTERACT program

Importance Medicare payment initiatives are spurring efforts to reduce potentially avoidable hospitalizations. Objective To determine whether training and support for implementation of a nursing home (NH) quality improvement program (Interventions to Reduce Acute Care Transfers [INTERACT]) reduced hospital admissions and emergency department (ED) visits. Design, Setting, and Participants This analysis compared changes in hospitalization and ED visit rates between the preintervention and postintervention periods for NHs randomly assigned to receive training and implementation support on INTERACT to changes in control NHs. The analysis focused on 85 NHs (36 717 NH residents) that reported no use of INTERACT during the preintervention period. Interventions The study team provided training and support for implementing INTERACT, which included tools that help NH staff identify and evaluate acute changes in NH resident condition and document communication between physicians; care paths to avoid hospitalization when safe and feasible; and advance care planning and quality improvement tools. Main Outcomes and Measures All-cause hospitalizations, hospitalizations considered potentially avoidable, 30-day hospital readmissions, and ED visits without admission. All-cause hospitalization rates were calculated for all resident-days, high-risk days (0-30 days after NH admission), and lower-risk days (≥31 days after NH admission). Results We found that of 85 NHs, those that received implementation training and support exhibited statistically nonsignificant reductions in hospitalization rates compared with control NHs (net difference, −0.13 per 1000 resident-days; Pu2009=u2009.25), hospitalizations during the first 30 days after NH admission (net difference, −0.37 per 1000 resident-days; Pu2009=u2009.48), hospitalizations during periods more than 30 days after NH admission (net difference, −0.09 per 1000 resident-days; Pu2009=u2009.39), 30-day readmission rates (net change in rate among hospital discharges, −0.01; Pu2009=u2009.36), and ED visits without admission (net difference, 0.02 per 1000 resident-days; Pu2009=u2009.83). Intervention NHs exhibited a reduction in potentially avoidable hospitalizations overall (net difference, −0.18 per 1000 resident-days, Pu2009=u2009.01); however, this effect was not robust to a Bonferroni correction for multiple comparisons. Conclusions and Relevance Training and support for INTERACT implementation as carried out in this study had no effect on hospitalization or ED visit rates in the overall population of residents in participating NHs. The results have several important implications for implementing quality improvement initiatives in NHs. Trial Registration clinicaltrials.gov Identifier: NCT02177058

Depressive symptoms postpartum among parents are associated with marital separation : A Swedish cohort study

Aims: To study whether there is an association between dyadic consensus, depressive symptoms, and parental stress during early parenthood and marital separation 6–8 years after childbirth, among couples in Sweden. Methods: At baseline, 393 couples were included. The couples answered three questionnaires, including: Dyadic consensus at 1 week post-partum, depressive symptoms at 3 months post-partum and parental stress at 18 months post-partum. The parents’ addresses were followed up after 6–8 years, to study the marital separation rate. Results: We found, 6–8 years after childbirth, that 20% of study couples were separated. Separation was associated with less dyadic consensus (mothers p < 0.001; fathers p < 0.001), depressive symptoms (mothers p = 0.022; fathers p = 0.041) and parental stress (mothers p = 0.002; fathers p = 0.040). The hazard ratio (HR) for marital separation was related to dyadic consensus for fathers (HR 0.51; 95% CI 0.28–0.92), depressive symptoms for mothers (HR 1.69; 95% CI 1.01–2.84) and fathers (HR 1.92; 95% CI 1.12–3.28), and the mother’s parental stress (HR 2.16; 95% CI 1.14–4.07). Conclusions: Understanding how dyadic consensus, depressive symptoms and parental stress are associated with marital separation is important for health professionals. It could be useful in developing interventions to provide parents with adequate support during pregnancy and early parenthood. This knowledge is also important for the public. Parents should get support in pregnancy and while bringing up children, which may help prevent marital separation and optimize conditions for the children.

Parental stress and dyadic consensus in early parenthood among mothers and fathers in Sweden

BACKGROUNDnParental stress can negatively affect the parent-child relationship and reduce the well-being of the whole family. Family disagreement is associated with parental divorce and with psychological problems in children.nnnAIMSnThe aim was to examine perceived parental stress and draw comparisons among mothers and among fathers, in relation to educational level, parental experience, existence of a parental role model and sense of coherence. The aim was also to examine perceived dyadic consensus and its association with perceived parental stress within couples.nnnMETHODSnQuestionnaires were completed by 320 mothers and 315 fathers at 1 week and 18 months post-partum. The Swedish Parenthood Stress Questionnaire, the Sense of Coherence Scale and the Dyadic Consensus Subscale were used.nnnRESULTSnLow education, lack of a role model and poor sense of coherence promoted stress in mothers in the subareas social isolation and spouse relationship problems, while lack of a role model and poor sense of coherence promoted stress in fathers in the subarea social isolation. Furthermore, parental experiences promoted stress among mothers in the subarea incompetence while this was not seen among fathers. Mothers perceived a higher level of dyadic consensus than fathers in the items recreational activities, friends, aims and life goals, time spent together, and decisions regarding career and personal development. Household tasks was the only item where fathers perceived a higher level of dyadic consensus than mothers. Additionally, there were associations between perceived parental stress and dyadic consensus in several items and in the total score.nnnCONCLUSIONSnTo promote parents health and family stability, health professionals should consider factors affecting stress and stress reactions, and take gender roles into account.

Association between parental depressive symptoms and impaired bonding with the infant

Impaired bonding with the infant is associated with maternal postpartum depression but has not been investigated extensively in fathers. The primary study aim was to evaluate associations between maternal and paternal depressive symptoms and impaired bonding with their infant. A secondary aim was to determine the associations between parents’ marital problems and impaired bonding with the infant. The study is part of a population-based cohort project (UPPSAT) in Uppsala, Sweden. The Edinburgh Postnatal Depression Scale (EPDS) at 6xa0weeks and 6xa0months postpartum and the Postpartum Bonding Questionnaire at 6xa0months postpartum were completed by 727 couples. The prevalence of impaired bonding was highest among couples in which both spouses had depressive symptoms. Impaired bonding was associated with higher EPDS scores in both mothers and fathers, as well as with experiencing a deteriorated marital relationship. The association between maternal and paternal impaired bonding and the mothers’ and fathers’ EPDS scores remained significant even after adjustment for relevant confounding factors. Depressive symptoms at 6xa0weeks postpartum are associated with impaired bonding with the infant at 6xa0months postpartum for both mothers and fathers. It is critical to screen for and prevent depressive symptoms in both parents during early parenthood.

Health-Related Quality of Life and Pain Intensity Among Ethnically Diverse Community-Dwelling Older Adults.

Chronic pain is highly prevalent in older adults and often negatively associated with health-related quality of life (HRQoL). This study compared HRQoL, including physical health and mental health, in persons of differing ethnicities, and identified factors associated with pain intensity and HRQoL in ethnically diverse older adults. Older adults with chronic pain from four ethnic groups (African Americans, Afro-Caribbeans, Hispanics, and European Americans) were recruited from the Florida Atlantic University Healthy Aging Research Initiative (HARI) registry. The Medical Outcomes Study Short Form-36 (SF-36)xa0was used to evaluate HRQoL, including functional status, emotionalxa0well-being, and social functioning. Of 593 persons in the four ethnic groups in the registry, 174 met the inclusion criteria (pain level of four or higher on an 11-point scale, lasting 3 months or longer). Among these 174, African Americans reported the highest level of pain intensity, followed by Afro-Caribbeans, Hispanics, and European Americans. Hispanics reported the highest physical health scores and the lowest mental health scores. In contrast, African Americans reported the highest mental health scores and the lowest physical health scores. Multivariate linear regression analysis revealed that ethnicity, lower physical health scores, and lower mental health scores were significantly (p ≤ .01) associated with pain intensity. Understanding ethnic variations in response to pain intensity may address gaps in knowledge about HRQoL to reduce disparities in optimal care. Health care providers should consider ethnic norms and cultural diversity to provide optimal interventions for this population.

Lessons Learned From Root Cause Analyses of Transfers of Skilled Nursing Facility (SNF) Patients to Acute Hospitals: Transfers Rated as Preventable Versus Nonpreventable by SNF Staff

BACKGROUNDnDetermining if a transfer of a skilled nursing facility (SNF) patient/resident to an acute hospital is potentially avoidable or preventable is challenging. Most previous research on potentially avoidable or preventable hospitalizations is based on diagnoses without in-depth root cause analysis (RCA), and few studies have examined SNF staff perspective on preventability of transfers.nnnOBJECTIVESnTo examine factors associated with hospital transfers rated as potentially preventable versus nonpreventable by SNF staff.nnnDESIGNnTrained staff from SNFs enrolled in a randomized controlled clinical trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program performed retrospective RCAs on hospital transfers during a 12-month implementation period.nnnSETTINGnSNFs from across the United States.nnnPARTICIPANTSnSixty-four of 88 SNFs randomized to the intervention group submitted RCAs with a rating of whether the transfer was determined to be potentially preventable or nonpreventable.nnnINTERVENTIONSnSNFs were implementing the INTERACT Quality Improvement (QI) program.nnnMEASURESnData were abstracted from the INTERACT QI tool, a structured, retrospective RCA on hospital transfers.nnnRESULTSnA total of 4527 RCAs with a rating of preventability were submitted during the 12-month implementation period, of which 1044 (23%) were rated as potentially preventable by SNF staff. In unadjusted univariate analyses, factors associated with ratings of potentially preventable included acute changes in condition of fever, decreased food or fluid intake, functional decline, shortness of breath, and new urinary incontinence; other factors included the clinician, resident, and/or family insisting on the transfer, transfers that occurred fewer than 30xa0days from SNF admission and that occurred on weekends, transfers ordered by a covering physician (as opposed to the primary physician), and transfers that resulted in an emergency department (ED) visit with return to the SNF. Factors associated with ratings of nonpreventable included on-site evaluation by a physician or other clinician, and transfers related to falls. Among factors precipitating the transfers, clinician and resident and/or family insistence on transfer, and transfers related to fever and falls remained significant in a multivariate analysis. There were no significant differences among characteristics of SNFs that rated a relatively high versus low proportion of transfers as potentially preventable.nnnCONCLUSIONnSNF staff rated a substantial proportion of transfers as potentially preventable on retrospective RCAs. Factors associated with ratings of preventability, as well as illustrative case examples, provide important insights that can assist SNFs in focusing education and care process improvements in order to reduce unnecessary hospital transfers and their associated morbidity and costs.