Category Archives: Clinical research
Shreya Kangovi, MD, is an assistant professor of medicine at the University of Pennsylvania Perelman School of Medicine, executive director of the Penn Center for Community Health Workers, and a Robert Wood Johnson Foundation/U.S. Department of Veterans Affairs Clinical Scholars program alumna.
“What do you think will help you stay healthy after discharge?”
Mr. Manzi, a soft-spoken man in his early 60s, paused to consider. No one had asked him this question before. He had come to the hospital because of blurry vision and thirst too severe to ignore. The doctors told him that he had severe diabetes and hypertension, and that he needed to adhere to a long list of new medications, tests, and appointments.
“Not just medical stuff,” Anthony, the community health worker, continued. “Talk to me about anything. Dealing with shut-off notices, housing issues, whatever you think you need to stay healthy.”
Mr. Manzi opened up. He explained that he was originally from Ghana but had been living and working odd jobs in Philadelphia for 20 years as an undocumented immigrant. He had not had a job in six months and twice, his home had gone into foreclosure. Mr. Manzi was uninsured and had not been able to get outpatient care before coming to the hospital.
“I’m willing to do whatever it takes to stay healthy,” he concluded. “But I need to make sure I can pay for all of these medications and a doctor. And I need some help with the foreclosure—I can’t take care of myself if I lose my home.”
Mr. Manzi’s answers became the basis for his tailored intervention. IMPaCT (Individualized Management for Patient-Centered Targets) is an innovative model of care in which community health workers (CHWs) provide tailored support to help patients achieve individualized goals. Anthony, an IMPaCT CHW, shares socioeconomic background with patients like Mr. Manzi. He and other IMPaCT CHWs are selected for traits such as empathy, active listening, and reliability.
About 19 in every 100,000 American children under the age of five suffers from an inflammatory illness called Kawasaki Disease (KD) that can cause irreversible damage to the heart. If diagnosed early, it can usually be treated effectively, and children can be returned to health in just a few days. But between 10 and 20 percent of treated patients suffer from a persistent fever, or one that recurs after treatment, and they are at elevated risk of developing coronary artery aneurysms. A new study, led by Robert Wood Johnson Foundation (RWJF) Harold Amos Medical Faculty Development Program Scholar Adriana H. Tremoulet, MD, MAS, and published yesterday in The Lancet, offers new hope for patients with KD.
The symptoms of KD include prolonged fever associated with a rash, swollen neck glands, red eyes, swollen red lips, a condition physicians call strawberry tongue, and swollen hands and feet with peeling skin. Current treatment is infusion of intravenous immunoglobulin (IVIG) and aspirin. The IVIG carries the pooled antibodies from the blood plasma of more than 100,000 donors, and in the KD patient, it decreases the inflammation that causes heart damage. The treatment usually works, but some patients’ IVIG-resistance puts them at greater risk and in need of further treatment.
Tremoulet, a pediatric infectious disease specialist at Rady Children’s Hospital in San Diego, conducted a Phase III trial in which a synthetic antibody called infliximab was added to the standard IVIG and aspirin treatment. While the protocol did not affect the patients’ resistance, it had important positive results. “In our study,” Tremoulet said, “we demonstrated that a single dose of infliximab is safe in children with Kawasaki Disease and that this treatment reduced the inflammation in the body overall as well as in the arteries of the heart faster than just using standard treatment with intravenous immunoglobulin.”
This is part of the February 2014 issue of Sharing Nursing’s Knowledge.
Nurses’ Perceptions of Their Workplaces
A new survey offers insights into how hospital nurses perceive their workplace and profession. Jackson Healthcare, a health care staffing company, surveyed 1,333 hospital nurses. Among the findings:
- Nearly two-thirds of surveyed nurses (64 percent) say they are satisfied or very satisfied with their jobs.
- Sixty-seven percent say they have less time at patients’ bedsides than they wish because they must perform activities that other hospital personnel could be doing, including looking for equipment and supplies, and restocking supply areas.
- Sixty-six percent cite inadequate staffing levels in their hospitals, saying that limited coverage and clinical support force nurses to divide their time between more patients.
- Almost half of nurses surveyed reported a nursing shortage at one or more of the units in their hospitals, with 35 percent citing the medical-surgical department as short-staffed, 18 percent pointing to critical care, and 17 percent to the emergency department.
Human Capital Blog: How does your study differ from previous research exploring the link between adverse working conditions and depression?
Sarah Burgard: The main contribution of this study was in the way we measured working conditions. Most studies that have looked at adverse working conditions and depression, or other measures of health, have looked at one adverse working condition at a time, such as job strain, job insecurity, or job dissatisfaction. But every job comes with a whole package of working conditions. We felt that capturing multiple indicators at the same time might give us a truer sense of the size, the magnitude, and the power of the association between work and depression.
Also, while some previous studies relied on longitudinal data that included multiple interviews with workers over time, they often excluded workers who did not participate in every interview because those workers didn’t have a measure of the focal working condition at every possible interview. That’s a problem because people who have worse jobs are probably more likely to drop out of longitudinal studies or leave work. Our approach was different; we analyzed data from everyone who participated in at least one interview, using all possible working conditions measure collected at each wave. We created an “overall working conditions score” at each wave using item response theory models. As a result, were able to get a more representative picture.
Adopting best practices from home-based hospice care in the inpatient environment can reduce suffering at the end of life, according to a study published in the Journal of General Internal Medicine. Researchers at the Birmingham Veterans Affairs Medical Center and the University of Alabama at Birmingham said the study is the first to show that palliative care techniques usually used in home settings can have an impact on those who die in hospitals.
The Best Practices for End-of-Life Care for Our Nation’s Veterans (BEACON) trial was conducted at six Veterans Affairs Medical Centers from 2005 to 2011 and involved training more than 1,620 staff members in aspects of care for more than 6,000 dying patients. Although focused on veterans, the study can have a wider impact, researchers said, because most Americans will die in the inpatient setting of a hospital or nursing home.
“We only die once, and therefore there is only one opportunity to provide excellent care to a patient in the last days of life,” wrote lead author F. Amos Bailey, MD, director of the Safe Harbor Palliative Care Program at the Birmingham Veterans Affairs Medical Center, professor in the Division of Gerontology, Geriatrics and Palliative Care at the University of Alabama at Birmingham School of Medicine, and a 2000 Robert Wood Johnson Foundation Community Health Leader. “The keys to excellent end-of-life care are recognizing the imminently dying patient, communicating the prognosis, identifying goals of care, and anticipating and palliating symptoms. Since it is not possible to predict with certainty which symptoms will arise, it is prudent to have a flexible plan ready.”
Federal health care workforce and research programs will receive modest funding boosts in this fiscal year under a new omnibus spending bill cleared in January by Congress, according to a summary released by the American Association of Colleges of Nursing (AACN). The programs affect nursing and other health professions.
Under the Consolidated Appropriations Act of 2014, signed into law on Jan. 17, two health care workforce agencies are slated for increases in fiscal year 2014.
The Health Resources and Services Administration will receive $6.3 billion, an 8 percent increase over the last fiscal year, and the Bureau of Health Professions will get $469.2 million, a 7 percent increase, according to AACN. Nursing workforce development programs under Title VIII of the Public Health Service Act will get $223.8 million in fiscal year 2014, a 3 percent increase.
SreyRam Kuy, MD, MHS, is an alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program, and a vascular surgery fellow at the Medical College of Wisconsin.
Gallbladder disease, and specifically gallstones, can present as pain in the upper abdomen, usually after eating fatty foods. More severely, gallstones can progress to an inflammation and infection called cholecystitis or cholangitis, both of which require prompt surgical treatment. Gallbladder disease is an important medical problem as it accounts for $650 billion in health care costs annually in the United States[i], making it the second most costly digestive disease in the country.[ii] With more than 700,000 cholecystectomies (surgeries to remove the gallbladder) performed annually in the United States, gallbladder disease is the number one reason for abdominal surgery in the nation.[i] Cholecystectomies can be done with traditional surgery (open cholecystectomy) or performed minimally invasively (laparoscopic cholecystectomy).
The National Health and Nutrition Examination Survey estimates 6.3 million men and 14.2 million women in the United States have gallbladder disease.[iii] It occurs two times more frequently in women than in men.[i][iv] However, during the reproductive years, women have a four-fold higher prevalence of gallstones than men.[iii] As a result of its disproportionate burden on women, gallbladder disease is a critically important topic in women’s health.
There is currently a lack of consensus on whether a patient’s gender affects how soon they get surgery for cholecystitis, what type of surgery they get (open versus laparoscopic cholecystectomy), and how they do after surgery. My prior work and that of my colleagues has clearly shown that older age negatively impacts how patients do following cholecystectomy.[v] Therefore, to determine whether gender, independent of other factors, affects outcome, we examined a national group of patients hospitalized with cholecystitis over an eight-year period, age-matched to account for the effect of age, and identified gender-based differences in patients hospitalized with cholecystitis. We measured outcomes of women compared with men who underwent cholecystectomy during that admission for cholecystitis, and identified factors associated with outcome.
Human Capital News Roundup: Television ads for statins, advanced nursing education, treatment for gunshot wounds, and more.
Around the country, print, broadcast and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) leaders, scholars, fellows and grantees. Some recent examples:
In a piece about the growing need for advanced nursing education, Nurse.com interviewed a group of nurse leaders working to fulfill a recommendation from the Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health, which calls for doubling the number of doctorate-level nurses by 2020. Among those quoted: Christine Kovner, RN, PhD, FAAN, co-principal of RWJF’s RN Work Project; RWJF Executive Nurse Fellows alumna Jane Kirschling, RN, DNS, FAAN; and Susan Bakewell-Sachs, RN, PhD, PNP-BC, program director for the New Jersey Nursing Initiative, a program of RWJF and the New Jersey Chamber of Commerce Foundation.
Nurse.com and Infection Control Today report on an RWJF-supported study that finds hospitals that have higher percentages of nurses with baccalaureate degrees have lower rates of postsurgical mortality. The study, published in the March issue of Health Affairs, stems from the Future of Nursing: Campaign for Action. Read more about the study.
“I recently traveled to Singapore, where I met with other doctors and told about being the emergency department (ED) doctor at the University of Colorado Hospital the morning of the Aurora theater shootings on July 20, 2012,” RWJF Clinical Scholars alumna Comilla Sasson, MD, MS, FACEP, writes in an op-ed for the Denver Post. “One thing dawned on me as I spoke: I had seen more gunshot wound victims in that one night than these doctors will see in their entire careers.” Read a post Sasson wrote for the RWJF Human Capital Blog about the Aurora theater shootings, and learn more about her experience talking to the national news media afterward.
Project L/EARN is an intensive, 10-week summer internship for undergraduate college students who are from socioeconomic, ethnic, and cultural groups that have been traditionally underrepresented in graduate education. The program, funded in part by the Robert Wood Johnson Foundation, provides students with training, experience and mentoring to make them stronger candidates for admission to graduate programs. Interns attend lecture sessions, complete Graduate Record Examinations (GRE) preparation, and work with mentors to write a research paper, which they present as a poster. This year’s program was held at the Institute for Health, Health Care Policy and Aging Research at Rutgers University. This is part of a series of posts where scholars who completed the program discuss the experience. Learn more about Project L/EARN.
Hometown: Jersey City, NJ
Rising junior at Rutgers University
Internship Research Project: Breast Cancer Survivors’ Perceptions of Quality Cancer-Related Care from Primary Care Providers
Human Capital Blog: What aspect of the Project L/EARN internship has been most helpful and why?
Stephanie Jimenez: The most helpful part of my Project L/EARN experience this summer was the guidance that I received from my mentor as well as the things I learned from my instructional staff. The feedback I gained from my presentation helped me gain perspective.
RWJF Scholars in Health Policy Research National Program Director Alan B. Cohen, Sc.D., had a letter in the December 29, 2010 New York Times (Avastin: Judging the Risks vs. Benefits), noting that Food & Drug Administration (FDA) approval of new drugs “commonly opens the floodgates to widespread use, often by many patients for whom the benefits are questionable.” Cohen argues that the FDA and the manufacturers of new drugs “should be required to consider the varying effects of a new drug on different groups of people so that drug approval decisions can be targeted at those who will really benefit while preventing or minimizing adverse effects for those who won’t.”