Shantanu Nundy

Impact of Preoperative Briefings on Operating Room Delays: A Preliminary Report

HYPOTHESIS Preoperative briefings have the potential to reduce operating room (OR) delays through improved teamwork and communication. DESIGN Pre-post study. SETTING Tertiary academic center. PARTICIPANTS Surgeons, anesthesiologists, nurses, and other OR personnel. INTERVENTION An OR briefings program was implemented after training all OR staff in how to conduct preoperative briefings through in-service training sessions. During the preoperative briefings, the attending surgeon led OR personnel in a 2-minute discussion using a standardized format designed to familiarize caregivers with each other and the operative plan before each surgical procedure. MAIN OUTCOME MEASURES The OR Briefings Assessment Tool was distributed to OR personnel at the end of each operation. Survey items questioned OR personnel about unexpected delays during each procedure and the relationship between communication breakdowns and delays. Responses were compared before and after the initiation of the preoperative briefings program. RESULTS The use of preoperative briefings was associated with a 31% reduction in unexpected delays; 36% of OR personnel reported delays in the preintervention period, and 25% reported delays in the postintervention period (P<.04). Among surgeons alone, an 82% reduction in unexpected delays was observed (P<.001). A 19% reduction in communication breakdowns leading to delays was also associated with the use of briefings (P<.006). CONCLUSIONS Preoperative briefings reduced unexpected delays in the OR by 31% and decreased the frequency of communication breakdowns that lead to delays. Preoperative briefings have the potential to increase OR efficiency and thereby improve quality of care and reduce cost.

Feasibility and Usability of a Text Message-Based Program for Diabetes Self-Management in an Urban African-American Population

Purpose: We pilot-tested a text message-based diabetes care program in an urban African-American population in which automated text messages were sent to participants with personalized medication, foot care, and appointment reminders and text messages were received from participants on adherence. Methods: Eighteen patients participated in a 4-week pilot study. Baseline surveys collected data about demographics, historical cell phone usage, and adherence to core diabetes care measures. Exit interview surveys (using close-coded and open-ended questions) were administered to patients at the end of the program. A 1-month follow-up interview was conducted surveying patients on perceived self-efficacy. Wilcoxon signed-rank tests were used to compare baseline survey responses about self-management activities to those at the pilots end and at 1-month follow-up. Results: Eighteen urban African-American participants completed the pilot study. The average age was 55 and the average number of years with diabetes was 8. Half the participants were initially uncomfortable with text messaging. Example messages include “Did you take your diabetes medications today” and “How many times did you check your feet for wounds this week?” Participants averaged 220 text messages with the system, responded to messages 80% of the time, and on average responded within 6 minutes. Participants strongly agreed that text messaging was easy to perform and helped with diabetes self-care. Missed medication doses decreased from 1.6 per week to 0.6 (p = .003). Patient confidence in diabetes self-management was significantly increased during and 1 month after the pilot (p = .002, p = .008). Conclusions: Text messaging may be a feasible and useful approach to improve diabetes self-management in urban African Americans.

A Text Messaging Intervention to Improve Heart Failure Self-Management After Hospital Discharge in a Largely African-American Population: Before-After Study

Background There is increasing interest in finding novel approaches to reduce health disparities in readmissions for acute decompensated heart failure (ADHF). Text messaging is a promising platform for improving chronic disease self-management in low-income populations, yet is largely unexplored in ADHF. Objective The purpose of this pre-post study was to assess the feasibility and acceptability of a text message–based (SMS: short message service) intervention in a largely African American population with ADHF and explore its effects on self-management. Methods Hospitalized patients with ADHF were enrolled in an automated text message–based heart failure program for 30 days following discharge. Messages provided self-care reminders and patient education on diet, symptom recognition, and health care navigation. Demographic and cell phone usage data were collected on enrollment, and an exit survey was administered on completion. The Self-Care of Heart Failure Index (SCHFI) was administered preintervention and postintervention and compared using sample t tests (composite) and Wilcoxon rank sum tests (individual). Clinical data were collected through chart abstraction. Results Of 51 patients approached for recruitment, 27 agreed to participate and 15 were enrolled (14 African-American, 1 White). Barriers to enrollment included not owning a personal cell phone (n=12), failing the Mini-Mental exam (n=3), needing a proxy (n=2), hard of hearing (n=1), and refusal (n=3). Another 3 participants left the study for health reasons and 3 others had technology issues. A total of 6 patients (5 African-American, 1 White) completed the postintervention surveys. The mean age was 50 years (range 23-69) and over half had Medicaid or were uninsured (60%, 9/15). The mean ejection fraction for those with systolic dysfunction was 22%, and at least two-thirds had a prior hospitalization in the past year. Participants strongly agreed that the program was easy to use (83%), reduced pills missed (66%), and decreased salt intake (66%). Maintenance (mean composite score 49 to 78, P=.003) and management (57 to 86, P=.002) improved at 4 weeks, whereas confidence did not change (57 to 75, P=.11). Of the 6 SCHFI items that showed a statistically significant improvement, 5 were specifically targeted by the texting intervention. Conclusions Over half of ADHF patients in an urban, largely African American community were eligible and interested in participating in a text messaging program following discharge. Access to mobile phones was a significant barrier that should be addressed in future interventions. Among the participants who completed the study, we observed a high rate of satisfaction and preliminary evidence of improvements in heart failure self-management.

How Do Mobile Phone Diabetes Programs Drive Behavior Change? Evidence From a Mixed Methods Observational Cohort Study

Purpose The purpose of this study was to investigate the behavioral effects of a theory-driven, mobile phone–based intervention that combines automated text messaging and remote nursing, using an automated, interactive text messaging system. Methods This was a mixed methods observational cohort study. Study participants were members of the University of Chicago Health Plan (UCHP) who largely reside in a working-class, urban African American community. Surveys were conducted at baseline, 3 months (mid-intervention), and 6 months (postintervention) to test the hypothesis that the intervention would be associated with improvements in self-efficacy, social support, health beliefs, and self-care. In addition, in-depth individual interviews were conducted with 14 participants and then analyzed using the constant comparative method to identify new behavioral constructs affected by the intervention. Results The intervention was associated with improvements in 5 of 6 domains of self-care (medication taking, glucose monitoring, foot care, exercise, and healthy eating) and improvements in 1 or more measures of self-efficacy, social support, and health beliefs (perceived control). Qualitatively, participants reported that knowledge, attitudes, and ownership were also affected by the program. Together these findings were used to construct a new behavioral model. Conclusions This study’s findings challenge the prevailing assumption that mobile phones largely affect behavior change through reminders and support the idea that behaviorally driven mobile health interventions can address multiple behavioral pathways associated with sustained behavior change.

Using mobile health to support the chronic care model: developing an institutional initiative

Background. Self-management support and team-based care are essential elements of the Chronic Care Model but are often limited by staff availability and reimbursement. Mobile phones are a promising platform for improving chronic care but there are few examples of successful health system implementation. Program Development. An iterative process of program design was built upon a pilot study and engaged multiple institutional stakeholders. Patients identified having a “human face” to the pilot program as essential. Stakeholders recognized the need to integrate the program with primary and specialty care but voiced concerns about competing demands on clinician time. Program Description. Nurse administrators at a university-affiliated health plan use automated text messaging to provide personalized self-management support for member patients with diabetes and facilitate care coordination with the primary care team. For example, when a patient texts a request to meet with a dietitian, a nurse-administrator coordinates with the primary care team to provide a referral. Conclusion. Our innovative program enables the existing health system to support a de novo care management program by leveraging mobile technology. The program supports self-management and team-based care in a way that we believe engages patients yet meets the limited availability of providers and needs of health plan administrators.

Incidence of Remission in Adults With Type 2 Diabetes: The Diabetes & Aging Study

OBJECTIVE To estimate the incidence of remission in adults with type 2 diabetes not treated with bariatric surgery and to identify variables associated with remission. RESEARCH DESIGN AND METHODS We quantified the incidence of diabetes remission and examined its correlates among 122,781 adults with type 2 diabetes in an integrated healthcare delivery system. Remission required the absence of ongoing drug therapy and was defined as follows: 1) partial: at least 1 year of subdiabetic hyperglycemia (hemoglobin A1c [HbA1c] level 5.7–6.4% [39–46 mmol/mol]); 2) complete: at least 1 year of normoglycemia (HbA1c level <5.7% [<39 mmol/mol]); and 3) prolonged: complete remission for at least 5 years. RESULTS The incidence density (remissions per 1,000 person-years; 95% CI) of partial, complete, or prolonged remission was 2.8 (2.6–2.9), 0.24 (0.20–0.28), and 0.04 (0.01–0.06), respectively. The 7-year cumulative incidence of partial, complete, or prolonged remission was 1.47% (1.40–1.54%), 0.14% (0.12–0.16%), and 0.007% (0.003–0.020%), respectively. The 7-year cumulative incidence of achieving any remission was 1.60% in the whole cohort (1.53–1.68%) and 4.6% in the subgroup with new-onset diabetes (<2 years since diagnosis) (4.3–4.9%). After adjusting for demographic and clinical characteristics, correlates of remission included age >65 years, African American race, <2 years since diagnosis, baseline HbA1c level <5.7% (<39 mmol/mol), and no diabetes medication at baseline. CONCLUSIONS In community settings, remission of type 2 diabetes does occur without bariatric surgery, but it is very rare.

Wealth and its associations with enteric parasitic infections in a low-income community in Peru: use of principal component analysis.

The association of wealth and infections with Giardia, Cryptosporidium, Cyclospora, and microsporidia were examined in a longitudinal cohort conducted in Peru from 2001 to 2006. Data from 492 participants were daily clinical manifestations, weekly copro-parasitological diagnosis, and housing characteristics and assets owned (48 variables), and these data were used to construct a global wealth index using principal component analysis. Data were analyzed using continuous and categorical (wealth tertiles) models. Participants mean age was 3.43 years (range = 0-12 years), with average follow-up of 993 days. Univariate and multivariate analyses identified significant associations between wealth and infections with Giardia and microsporidia. Participants with greater wealth indexes were associated with protection against Giardia (P < 0.001) and persistent Giardia infections (> 14 days). For microsporidia, greater wealth was protective (P = 0.066 continuous and P = 0.042 by tertiles). Contrarily, infections with Cryptosporidium and Cyclospora were independent of wealth. Thus, subtle differences in wealth may affect the frequency of specific parasitic infections within low-income communities.

Using Patient-Generated Health Data From Mobile Technologies for Diabetes Self-Management Support: Provider Perspectives From an Academic Medical Center

Background: Mobile health and patient-generated health data are promising health IT tools for delivering self-management support in diabetes, but little is known about provider perspectives on how best to integrate these programs into routine care. We explored provider perceptions of a patient-generated health data report from a text-message-based diabetes self-management program. The report was designed to relay clinically relevant data obtained from participants’ responses to self-assessment questions delivered over text message. Methods: Likert-type scale response surveys and in-depth interviews were conducted with primary care physicians and endocrinologists who pilot tested the patient-generated health data report in an actual clinical encounter. Interview guides were designed to assess providers’ perceptions of the feasibility and utility of patient-generated health data in routine clinical practice. Interviews were audiotaped, transcribed, and analyzed using the constant comparative method. Results: Twelve providers successfully piloted the summary report in clinic. Although only a minority of providers felt the report changed the care they provided (3 of 12 or 25%), most were willing to use the summary report in a future clinical encounter (9 of 12 or 75%). Perceived benefits of patient-generated health data included agenda setting, assessment of self-care, and identification of patient barriers. Major themes discussed included patient selection, reliability of patient-generated health information, and integration into clinical workflow. Conclusion: Providers perceived multiple benefits of patient-generated health data in overcoming common barriers to self-management support in clinical practice and found the summary report feasible and usable in a clinical context.

A web-based patient tool for preventive health: preliminary report.

Background: The Internet is a promising medium for engaging the community in preventive care and health promotion, particularly among those who do not routinely access health care. Objective: The authors pilot-tested a novel website that translates evidence-based preventive health guidelines into a patient health education tool. The web-based tool allows individuals to enter their health risk factors and receive a tailored checklist of recommended preventive health services based on up-to-date guidelines from the US Preventive Services Task Force and the Advisory Committee on Immunization Practices. Methods: The authors conducted surveys and in-depth interviews among a purposive sample of adults from an urban African American community who pilot-tested the website in a standardized setting. Interviews were designed to assess the usability, navigability, and content of the website and capture patient perceptions about its educational value and usefulness. Each interview was audiotaped, transcribed, and examined using the constant comparative method. Results: Twenty-five participants piloted the tool: 96% found it easy to use and 64% reported learning something new. Many participants reported that, in addition to improving clinical preventive care (the intended purpose), the website could serve as a stand-alone tool to improve self-awareness and motivate behavior change. Conclusions: A web-based tool designed to translate preventive health guidelines for the community may serve the dual purpose of improving the delivery of preventive health care and encouraging health promotion. The website developed here is publicly available for use by practitioners and the community.