Meenu Sandhu

The West Los Angeles Preterm Birth Prevention Project. I. Program impact on high-risk women

Abstract OBJECTIVE: The primary objective of this prospective study was to test whether preterm birth prevention education plus increased clinic visits and selected prophylactic interventions reduce preterm birth. STUDY DESIGN: Eight West Los Angeles prenatal county clinics, comparable with respect to selected demographics, were randomized to be either experimental or control clinics. High-risk patients in all clinics were identified with a risk scoring system derived from a similar population. High-risk patients ( N = 1774) in experimental clinics were offered a program of education and more frequent visits and were randomized to receive various secondary intervention protocols in addition to the basic interventions of education and more frequent visits. Control clinic patients ( N = 880) received standard county care. RESULTS: Preterm birth rates were 19% lower among the experimental high-risk patients (7.4% vs 9.1%), and differences were significant ( p CONCLUSION: The 19% reduction in preterm birth rate observed in the experimental clinics suggest an overall program benefit from a protocol that offered education, more frequent visits, and greater attention given to patients while the selected interventions were applied. (AM J OBSTET GYNECOL 1994;170:54-62.)

Impact of California’s Licensed Nurse-Patient Ratios on Unit-Level Nurse Staffing and Patient Outcomes

This article presents the first analysis of the impact of mandated minimum-staffing ratios on nursing hours of care and skill mix in adult medical and surgical and definitive-observation units in a convenience sample of 68 acute hospitals participating in the California Nursing Outcomes Coalition project. Findings, stratified by unit type and hospital size, reveal expected changes as hospitals made observable efforts toward regulatory compliance. These data cannot affirm compliance with ratios per shift, per unit, at all times; however, they give evidence of overall compliance. Assessment of the impacts of the mandated ratios on two common indicators of patient care quality, the incidence of patient falls and the prevalence of pressure ulcers, did not reveal significant changes despite research linking nurse staffing with these measures. These findings contribute to understanding unit level impacts of regulatory staffing mandates and the preliminary effect of this legislation on core quality of care indicators.

Mandated Nurse Staffing Ratios in California: A Comparison of Staffing and Nursing-Sensitive Outcomes Pre- and Postregulation:

This article examines the impact of mandated nursing ratios in California on key measures of nursing quality among adults in acute care hospitals. This study is a follow-up and extension of our first analysis exploring nurse staffing and nursing-sensitive outcomes comparing 2002 pre-ratios regulation data to 2004 postratios regulation data. For the current study we used postregulation ratios data from 2004 and 2006 to assess trends in staffing and outcomes. Findings for nurse staffing affirmed the trends noted in 2005 and indicated that changes in nurse staffing were consistent with expected increases in the proportion of licensed staff per patient. This report includes an exploratory examination of the relationship between staffing and nursing-sensitive patient outcomes. However anticipated improvements in nursing-sensitive patient outcomes were not observed. This report contributes to the growing understanding of the impacts of regulatory staffing mandates on hospital operations and patient outcomes.

Physician education and report cards: do they make the grade? Results from a randomized controlled trial

PURPOSE We sought to determine whether tailored educational interventions call improve the quality of care, as measured by the provision of preventive care services recommended by the US Preventive Services Task Force, as well as lead to better patient satisfaction. SUBJECT AND METHODS We performed a randomized controlled study among 41 primary care physicians who cared for 1,810 randomly selected patients aged 65 to 75 years old at Kaiser Permanente Woodland Hills, a group-model health maintenance organization in southern California. All physicians received ongoing education. Physicians randomly assigned to the comprehensive intervention group also received peer-comparison feedback and academic detailing. Baseline and postintervention (2 to 2.5 years later) surveys examining the provision of preventive care and patient satisfaction were performed and medical records were reviewed. RESULTS Based on the results of patient surveys, there were significant improvements over time in the provision of preventive care in both the education and the comprehensive intervention groups for influenza immunization (79% versus 89%, P <0.01, and 80% versus 91%, P <0.01), pneumococcal immunization (42% versus 73%, P < 0.01 and 34% versus 73%, P < 0.01), and tetanus immunization (64% versus 72%, P <0.01, and 59% versus 79%, P <0.01). Mammography (90% versus 80%, P <0.01) and clinical breast examination (85% versus 79%, P <0.05) scores worsened in the education only group but not in the comprehensive intervention group. However, there were few differences in rates of preventive services between the groups at the end of the study, and the improvements in preventive care were not confirmed by medical record review. Patient satisfaction scores improved significantly in the comprehensive intervention group (by 0.06 points on a 1 to 5 scale, P = 0.02) but not in the education only group (by 0.02 points, P = 0.42); however, the improvement was not significantly greater in the comprehensive intervention group (P = 0.20). CONCLUSION A physician-targeted approach of education, peer-comparison feedback, and academic detailing has modest effects on patient satisfaction and possibly on the offering of selected preventive care services. The lack of agreement between patient reports and medical records review raises concerns about current methods of ascertaining compliance with guidelines for preventive care.

Cardiac reoperations in octogenarians: analysis of outcomes

BACKGROUND With the rapid growth of the elderly segment of the population, more octogenarians are referred for complex cardiac interventions, including reoperations. Data regarding the outcomes, quality of life, and long-term results after reoperative open-heart surgical procedures in octogenarians are scarce. METHODS We retrospectively studied 113 consecutive octogenarians (mean age, 83+/-2.6 years) who underwent reoperative cardiac procedures within a 13-year period. Coronary artery bypass grafting (CABG) was performed in 49 patients (CABG group), valvular procedures (aortic, mitral, or tricuspid valve, alone or in combination) in 35 (valve group), and combined CABG and valve intervention in 29 (combined CABG and valve group). RESULTS The 30-day mortality rate was 8% (4 of 49) for the CABG group, 9% (3 of 35) for the valve group, and 17% (5 of 29) for the combined CABG and valve group. One- and 5-year actuarial survival rates were, respectively, 85%+/-5% and 58%+/-10% for the CABG group, 78%+/-7% and 53%+/-12% for the valve group, and 69%+/-9% and 63%+/-10% for the combined CABG and valve group. Sixty-one percent of patients in the CABG group, 40% in the valve group, and 38% in the combined CABG and valve group were in New York Heart Association class I or II postoperatively at a mean follow-up time of 2.1+/-2.4 years. Similarly, 91%, 85%, and 80%, respectively, thought that they had an improved quality of life and were satisfied with their functional status. CONCLUSIONS Cardiac reoperations can be performed successfully in most octogenarians, although with an increased risk, particularly in the combined CABG and valve group. Long-term survival is acceptable with improved quality of life and functional status. However, it is possible that these results could be improved in this high-risk group of patients with earlier referral and surgical intervention, for the effective use of health care resources.

Physicians’ Changing Attitudes Toward Guidelines

The objective of the study was to measure the change in physicians’ attitudes toward preventive care guidelines over a 2-year period. The study was conducted at a Southern California managed care medical group that was experiencing intense price competition. We analyzed individualized survey responses of 62 HMO primary care physicians over the study period. We found that physicians increasingly believed that clinical guidelines were being used for cost containment (first survey 71% vs second survey 92%, p<.005) and less for quality improvement (first survey 85% vs second survey 67%, p<.008) over time. These findings may create a barrier to physicians’ adoption of practice guidelines.

The West Los Angeles Preterm Birth Prevention Project

OBJECTIVE The primary objective of this prospective study was to test whether preterm birth prevention education plus increased clinic visits and selected prophylactic interventions reduce preterm birth. STUDY DESIGN Eight West Los Angeles prenatal county clinics, comparable with respect to selected demographics, were randomized to be either experimental or control clinics. High-risk patients in all clinics were identified with a risk scoring system derived from a similar population. High-risk patients (N = 1774) in experimental clinics were offered a program of education and more frequent visits and were randomized to receive various secondary intervention protocols in addition to the basic interventions of education and more frequent visits. Control clinic patients (N = 880) received standard county care. RESULTS Preterm birth rates were 19% lower among the experimental high-risk patients (7.4% vs 9.1%), and differences were significant (p < 0.05) when preterm risk was taken into account. There was no evidence to suggest that the secondary interventions provided added benefit over the primary intervention protocol of preterm birth prevention education and increased visits. CONCLUSION The 19% reduction in preterm birth rate observed in the experimental clinics suggest an overall program benefit from a protocol that offered education, more frequent visits, and greater attention given to patients while the selected interventions were applied.

Influence of vein valves in the development of arteriosclerosis in venoarterial grafts in the rabbit

Coronary saphenous vein grafts in human beings have a more limited long-term patency rate than internal thoracic artery grafts, primarily because of more rapid development of arteriosclerosis. The factors responsible for this increased susceptibility are not completely understood. To test the hypothesis that vein valves may influence this process, we studied 48 hypercholesterolemic rabbits with jugular vein grafts interposed into the carotid arterial circulation. In 24 animals (group A), the vein segments did not contain a vein valve. In the other 24 animals (group B), a vein valve was present. Both groups were further divided in four subgroups of six to be put to death at 2, 4, 6, and 8 weeks after the operation. All animals were fed a 2% cholesterol diet. At postmortem examination, alternate 2 mm sections were either stained with hematoxylin and eosin for histologic and morphometric studies or frozen in liquid nitrogen for immunohistochemistry and in situ hybridization studies. Proliferating cell nuclear antigen immunostaining was used to study cell proliferation. Wall thickness of vein grafts increased with time. During the first 2 weeks intimal and medial thickening was primarily due to an increase in numbers of cells. Between 2 and 6 weeks further intimal and medial thickening occurred, but without additional increase in cell numbers. After 6 weeks, foam cells and lipid deposits started to appear. By 8 weeks, changes identical to those seen in arteriosclerotic plaques in human beings were evident. These changes developed sooner and with more intensity in group B animals (p < 0.01 to 0.001), and they developed faster and with more severity in segments of vein located distal to the valve than in the segments located proximal to the valve (p < 0.001). This is the first controlled experiment demonstrating that the presence of valves in the vein segments is associated with augmented and accelerated intimal changes leading to vein atheromatosis.

Benchmarking for Small Hospitals: Size Didn't Matter!

&NA; Benchmarking is an indispensable tool as hospital leaders face challenges to balance efficiency with safe and effective care. Selection of appropriate “like” hospitals is critical to the benchmarking aim of understanding comparative performance. Based on 10 years of observed outcome differences between small and large hospitals, the Collaborative Alliance for Nursing Outcomes (CALNOC) sought to empirically define small hospitals, and to determine if there were statistical differences between small and large hospitals for selected nursing sensitive outcome indicators. This article reports the examination of hospital size as a proxy characteristic to define “like” hospitals for the purpose of benchmarking outcomes. Findings suggest that optimal classifications into small and large hospital size based on the outcome indicators of falls, falls with injury, and hospital‐acquired pressure ulcers stage 2 or worse (HAPU 2+) were not consistent with historical administrative categories based on average daily census and not consistent by outcome. Statistical differences were only found with HAPU 2+ in critical care units, with no differences in the fall outcomes. These data did not support the use of size‐based categories to define like hospitals for benchmark comparisons.

Disparities and relative risk ratio of preterm birth in six Central and Eastern European centers.

Aim To identify characteristic risk factors of preterm birth in Central and Eastern Europe and explore the differences from other developed countries. Method Data on 33 794 term and 3867 preterm births (<37 wks.) were extracted in a retrospective study between January 1, 2007 and December 31, 2009. The study took place in 6 centers in 5 countries: Czech Republic, Hungary (two centers), Romania, Slovakia, and Ukraine. Data on historical risk factors, pregnancy complications, and special testing were gathered. Preterm birth frequencies and relevant risk factors were analyzed using Statistical Analysis System (SAS) software. Results All the factors selected for study (history of smoking, diabetes, chronic hypertension, current diabetes, preeclampsia, progesterone use, current smoking, body mass index, iron use and anemia during pregnancy), except the history of diabetes were predictive of preterm birth across all participating European centers. Preterm birth was at least 2.4 times more likely with smoking (history or current), three times more likely with preeclampsia, 2.9 times more likely with hypertension after adjusting for other covariates. It had inverse relationship with the significant predictor body mass index, with adjusted risk ratio of 0.8 to 1.0 in three sites. Iron use and anemia, though significant predictors of preterm birth, indicated mixed patterns for relative risk ratio. Conclusion Smoking, preeclampsia, hypertension and body mass index seem to be the foremost risk factors of preterm birth. Implications of these factors could be beneficial for design and implementation of interventions and improve the birth outcome.