Effects of an electronic health record-based mobility assessment and automated referral for inpatient physical therapy on patient outcomes: A quasi-experimental study

Objective

To assess the effectiveness of a hospital physical therapy (PT) referral triggered by scores on a mobility assessment embedded in the electronic health record (EHR) and completed by nursing staff on hospital admission.

Data Sources

EHR and billing data from 12 acute care hospitals in a western Pennsylvania health system (January 2017–February 2018) and 11 acute care hospitals in a northeastern Ohio health system (August 2019–July 2021).

Study Design

We utilized a regression discontinuity design to compare patients admitted to PA hospitals with stroke who reached the mobility score threshold for an EHR-PT referral (treatment) to those who did not (control). Outcomes were hospital length of stay (LOS) and 30-day readmission or mortality. Control variables included demographics, insurance, income, and comorbidities. Hospital systems with EHR-PT referrals were also compared to those without (OH hospitals as alternative control). Subgroup analyses based on age were also conducted.

Data Extraction

We identified adult patients with a primary or secondary diagnosis of stroke and mobility assessments completed by nursing (n = 4859 in PA hospitals, n = 1749 in OH hospitals) who completed their inpatient stay.

Principal Findings

In the PA hospitals, patients with EHR-PT referrals had an 11.4 percentage-point decrease in their 30-day readmission or mortality rates (95% CI −0.57, −0.01) relative to the control. This effect was not observed in the OH hospitals for 30-day readmission (β = 0.01; 95% CI −0.25, 0.26). Adults over 60 years old with EHR-PT referrals in PA had a 26.2 percentage-point (95% CI −0.88, −0.19) decreased risk of readmission or mortality compared to those without. Unclear relationships exist between EHR-PT referrals and hospital LOS in PA.

Conclusions

Health systems should consider methodologies to facilitate early acute care hospital PT referrals informed by mobility assessments.     

Sensitivity to masked conditioned stimuli predicts conditioned response magnitude under masked conditions

Expression of conditioned fear has been reported to be independent of perceptual awareness of conditioned stimuli (CSs). Previous studies have been criticized, however, for not adequately assessing perceptual awareness. We fear-conditioned participants to one of two symbols and measured skin conductance responses to dichoptically masked and unmasked CSs. Participants also performed a target detection task and sensitivity (d') to the masked conditioned stimuli (CS+, CS-) was measured. Results showed that sensitivity under masking conditions was related to conditioned responses to masked CSs but not unmasked CSs. Thus, a strong relationship between expression of conditioned fear and awareness of the CS+ emerges when the latter is assessed by signal detection methods. Without consensus on how awareness should be defined, these findings bring balance to previous studies that have typically used less sensitive assessments of awareness.     

Predictors of Parent Engagement Based on Child Care Providers’ Perspectives

Objective

Determine the predictors of child care providers’ parent engagement regarding child nutrition in child care centers (CCCs) and family child care homes (FCCHs).

Exploring Preconception Care: Insurance Status,Race/Ethnicity,and Health in the Pre-pregnancy Period

Objective To measure the association of preconception health insurance status with preconception health among women in New York City, and examine whether this association is modified by race/ethnicity. Methods Using data from the New York City Pregnancy Risk Assessment Monitoring System 2009–2011 (n?=?3929), we created a “Preconception Health Score” (PHS) capturing modifiable behaviors, healthcare services utilization, pregnancy intention, and timely entry into prenatal care. We then built multivariable logistic regression models to measure the association of PHS with health insurance status and race/ethnicity. Results We found PHS to be higher among women with private insurance (7.3?±?0.07) or public insurance (6.3?±?0.08) before pregnancy than no insurance (5.9?±?0.09) (p?<?.001). However, when stratified by race/ethnicity, the positive association of PHS with insurance was absent in the non-white population. Conclusions for Practice Having health insurance during the pre-pregnancy period is associated with greater health among white women, but not among black or Hispanic women in NYC.     

New insight into active muscarinic receptors with the novel radioagonist [H]iperoxo

Activation of G protein-coupled receptors involves major conformational changes of the receptor protein ranging from the extracellular transmitter binding site to the intracellular G protein binding surface. GPCRs such as the muscarinic acetylcholine receptors are commonly probed with radioantagonists rather than radioagonists due to better physicochemical stability, higher affinity, and indifference towards receptor coupling states of the former. Here we introduce tritiated iperoxo, a superagonist at muscarinic M₂ receptors with very high affinity. In membrane suspensions of transfected CHO-cells, [³H]iperoxo – unlike the common radioagonists [³H]acetylcholine and [³H]oxotremorine M – allowed labelling of each of the five muscarinic receptor subtypes in radioagonist displacement and saturation binding studies. [³H]iperoxo revealed considerable differences in affinity between the even- and the odd-numbered muscarinic receptor subtypes with affinities for the M₂ and M₄ receptor in the picomolar range. Probing ternary complex formation on the M₂ receptor, [³H]iperoxo dissociation was not influenced by an archetypal allosteric inverse agonist, reflecting activation-related rearrangement of the extracellular loop region. At the inner side of M₂, the preferred G_i protein acted as a positive allosteric modulator of [³H]iperoxo binding, whereas G_s and G_q were neutral in spite of their robust coupling to the activated receptor. In intact CHO-hM₂ cells, endogenous guanylnucleotides promoted receptor/G protein-dissociation resulting in low-affinity agonist binding which, nevertheless, was still reported by [³H]iperoxo. Taken together, the muscarinic superagonist [³H]iperoxo is the best tool currently available for direct probing activation-related conformational transitions of muscarinic receptors.     

A randomized controlled pilot study of Pentoxifylline in patients with non-alcoholic steatohepatitis (NASH)

Purpose Tumor necrosis factor-α (TNF-α) is implicated in non-alcoholic steatohepatitis (NASH). Pentoxifylline inhibits TNF-α. We wanted to evaluate the efficacy of Pentoxifylline on NASH patients. Methods Patients with biopsy proven NASH and persistently elevated alanine aminotransferase (ALT) greater than 1.5 times the upper limit of normal were randomized to 3 months of treatment with a step 1 American Heart Association diet and daily exercise with Pentoxifylline or placebo. Liver function tests, serum lipids and TNF-α, Interleukin 6 (IL-6), and plasma hyaluronic acid were measured at baseline, at weeks 6 and 12. Categorical data were analyzed by Fisher’s exact test while independent sample t-test and Mann–Whitney test were used for continuous data. Results Eleven patients were randomized into the Pentoxifylline and nine to the placebo group. After 3 months of treatment body mass index (BMI), ALT and aspartate aminotransferase (AST) decreased significantly in both groups. There was no difference between the two groups in reduction of BMI (P = 0.897). There was significantly greater reduction in AST in the Pentoxifylline group (P = 0.038). There was a trend toward lower ALT level (P = 0.065) in the Pentoxifylline group. TNF-α and IL-6 decreased significantly in both groups after treatment, but there was no significant difference between the two groups. Conclusion Three months of Pentoxifylline treatment in combination with diet and exercise results in significantly greater reduction in AST levels in patients with NASH as compared with controls. This study was funded by the National Healthcare Group Small Innovative Grant NHG-grant number. RPR/04029. It received ethics approval by the National Healthcare Group Domain Specific Research Board D-registration number DSRB-D/04/083.