Providence St. Joseph Health Digital Commons
Not a member yet
12290 research outputs found
Sort by
Staff Engagement in the Implementation of a Primary Care Value-Based Payment Program Increases Outpatient Care Utilization: A Mixed Methods Study.
No full textThis convergent parallel mixed-methods study examined how a primary care value-based payment (VBP) model affected patient health care use and captured implementation experiences from select clinics. Focusing on outpatient care as a key step to improving outcomes, we used a difference-in-differences model to compare outpatient utilization between PCPM (the VBP model) and non-PCPM clinics, and semi-structured interviews with a subset of participating clinics to explore implementation efforts on the ground. We identified our quantitative study population (cases N = 68 807; control N = 71 695) and outcomes from Oregon\u27s All Payer All Claims (APAC) data system and, qualitatively, we conducted 12 interviews with operational/administrative staff at 7 PCPM clinics. Our findings indicated that PCPM patients experienced greater connection to primary and specialty care-both the proportion who used care and the average amount of care used per member-relative to the control group. Primary care use rose by 4.2 percentage points (95% CI: 3.3%, 5.1%; P \u3c .001), and specialty care by 1.1 points (95% CI: 0.4%, 1.8%; P = .002). Among users, primary care visits increased by 136.9 per 1000 member months (95% CI: 107.2, 166.6; P \u3c .001), and specialty care by 32.1 (95% CI: 10.5, 53.7; P = .004). Qualitative findings added further context: (1) staff communication about PCPM efforts connects directly to improvements in care delivery and patient outcomes; (2) success depends on care team staff being involved in the creation of new workflows and processes; and (3) access to program data helps to identify care gaps and improve patient care delivery. We concluded that care team staff engagement in VBP models is strengthened by making the connection between VBP and direct improvements to patient care. Models that motivate staff can lead to increased connection to primary and specialty care among the clinic\u27s patient population
Cytomegalovirus DNAemia in Hospitalized Adults With SARS-CoV-2 Infection Requiring Supplemental Oxygen: Virologic and Clinical Characteristics and Association With Outcomes.
No full textBACKGROUND: Cytomegalovirus (CMV) reactivation occurs in the context of coronavirus disease 2019 (COVID-19); however, the viral kinetics, risk factors, and clinical outcomes are poorly defined.
METHODS: We examined the association of CMV DNAemia with clinical outcomes among participants of a randomized trial of remdesivir with or without baricitinib (National Institute of Allergy and Infectious Diseases [NIAID], Adaptive COVID-19 Treatment Trial 2 [ACTT-2]). Plasma CMV DNAemia from CMV-seropositive participants with COVID-19 (NIAID ordinal scale [OS] 5, 6, or 7 at entry) were assessed longitudinally by quantitative polymerase chain reaction. Factors associated with CMV DNAemia, and clinical outcomes were analyzed by Cox regression and proportional odds models.
RESULTS: Of 772 trial participants with available samples, 643 (83%) were CMV seropositive. Baseline CMV serostatus was not associated with COVID-19 outcomes. The cumulative incidence of CMV DNAemia among seropositive persons by day 28 was overall 11% (baseline OS 5, 6.3%; OS 6, 16.4%; OS 7, 24.7%), and was associated with older age, baseline OS, male sex, lymphopenia, and systemic corticosteroid use, while remdesivir and baricitinib did not affect risk. CMV DNAemia was associated with a lower probability of improvement by day 29 (adjusted hazard ratio, 0.3 [95% confidence interval, .17-.56]), with a more pronounced delay of recovery with higher CMV viral load. CMV DNAemia was also associated with higher severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral load and death.
CONCLUSIONS: In hospitalized adults with COVID-19 requiring oxygen, CMV viremia occurs within well-defined clinical risks and is independently associated with delayed recovery from illness, higher SARS-CoV-2 viral load, and increased mortality
Use of Cobalt-Chromium 64 Wires Surpass Evolve for the Treatment of Remnant Intracranial Aneurysms: A Subanalysis From the SEASE International Registry.
No full textBACKGROUND: The use of the Surpass Evolve flow diverter for intracranial aneurysms (IAs) has shown promising results, but there are no studies that evaluated its effectiveness for remnant previously treated IAs. This study aimed to evaluate the safety and effectiveness of Surpass Evolve for previously treated IAs.
METHODS: This subanalysis is derived from the SEASE (Safety and Effectiveness Assessment of Surpass Evolve) registry, a retrospective, multicentric, international cohort conducted across 15 academic institutions in North America and Europe between July 2020 and October 2022. Adult patients undergoing Surpass Evolve implantation for single saccular IAs were grouped into those with previously treated IAs by coiling or intrasaccular-devices and those with untreated IAs. Baseline characteristics and outcomes were compared.
RESULTS: This study included 257 patients with IAs. Of those, 66 patients had previously treated IAs (median time between diagnosis and initial treatment and retreatment: 6.28 months), and 191 patients had untreated IAs. Of the 246 patients with 10.5 months of imaging follow-up, the core lab adjudicated complete occlusion was less in previously treated IAs compared with untreated IAs (59.7% versus 72.3%; adjusted odds ratio, 0.43 [95% CI, 0.21-0.88];
CONCLUSION: Our results revealed reasonable rates of occlusion and an acceptable safety profile for the use of Surpass Evolve to treat previously treated IAs. Future prospective studies with longer follow-ups are warranted to explore the findings further
Continuous glucose monitoring improves detection of glycemic excursions in hemodialysis patients with type 2 diabetes.
No full textBACKGROUND: Optimal glucose management in individuals with type 2 diabetes (T2D) and end-stage kidney disease (ESKD) on hemodialysis is challenging. We compared the detection of glycemic excursions with continuous glucose monitoring (CGM) and capillary glucose testing (CBG) in this population.
METHODS: In this prospective observational study, insulin-treated adults with T2D on hemodialysis for ≥90 days wore a Dexcom G6-Pro CGM. Participants were instructed to perform CBG up to 4 times daily. We compared differences in glucose metrics and described CGM patterns in relation to dialysis sessions.
RESULTS: Among 59 participants (age 57. 7±9years, HbA1c 7.09%), mean glucose measured by CBG and CGM was 165.7 ± 41.8 and 188.9 ± 45.0, with a time-in-range (TIR) of 68%±23 and 51%±26, respectively (p \u3c 0.001). CGM detected that all participants had hyperglycemic episodes of 180mg/dL, with time-above-range (TAR) 180mg/dL of 47.8%±27, and 90% had episodes of \u3e250mg/dL, with TAR \u3e250mg/dL of 20.9%±21.7. CGM detected higher rates of hypoglycemia \u3c 70mg/dL, (47% vs. 25%, p=0.005) and \u3c 54mg/dL, (25% vs. 12%, p=0.08) than CBG testing. Nocturnal and prolonged hypoglycemia \u3c 70mg/dL were only detected by CGM (29% and 12%, respectively). CGM showed a pattern of improved glucose levels on pre-dialysis days, lower glucose levels during hemodialysis, and a rapid rise during the post-dialysis period.
CONCLUSIONS: In participants with T2D and ESKD on hemodialysis, CGM improved the detection of hyperglycemic and hypoglycemic events, particularly nocturnal and prolonged episodes. CGM revealed distinct glycemic patterns related to dialysis sessions, potentially enabling more personalized management
Pembrolizumab plus chemotherapy in advanced or recurrent endometrial cancer: overall survival and exploratory analyses of the NRG GY018 phase 3 randomized trial.
No full textHistorically, the treatment of patients with advanced stage or recurrent endometrial cancer included paclitaxel plus carboplatin. Immunotherapy in combination with chemotherapy resulted in improved clinical outcomes in several solid tumors. In the phase 3 NRG GY018 study, pembrolizumab plus chemotherapy significantly improved investigator-assessed progression-free survival (PFS; primary endpoint) versus placebo plus chemotherapy in patients with advanced/metastatic/recurrent endometrial cancer regardless of mismatch repair status. Here we report on key secondary endpoints and exploratory analyses. Patients were women ≥18 years old with newly diagnosed stage III or IVA endometrial cancer with measurable disease, or stage IVB or recurrent endometrial cancer with or without measurable disease. Patients (n = 810) were randomized (1:1) to pembrolizumab or placebo plus paclitaxel-carboplatin followed by maintenance pembrolizumab or placebo for up to 24 months. Overall survival was a secondary endpoint and PFS per RECIST v.1.1 by blinded independent central review was an exploratory endpoint. Overall survival data were immature; hazard ratios favored pembrolizumab (mismatch repair-proficient: 0.79 (0.53-1.17); 1-sided nominal P = 0.1157; mismatch repair-deficient: 0.55 (0.25-1.19); 1-sided nominal P = 0.0617). Hazard ratios (95% confidence intervals) for PFS per blinded independent central review favored pembrolizumab (mismatch repair-proficient: 0.64 (0.49-0.85); P = 0.0008; mismatch repair-deficient: 0.45 (0.27-0.73); P = 0.0005). These findings further support the use of pembrolizumab plus chemotherapy as first-line treatment for patients with advanced stage or recurrent endometrial cancer regardless of mismatch repair status. ClinicalTrials.gov identifier: NCT03914612
Influenza Talk Proposed Titles
No full texthttps://digitalcommons.providence.org/special_pathogens_conferences/1007/thumbnail.jp
Learning from Real Life: Alaska Edition
No full texthttps://digitalcommons.providence.org/special_pathogens_conferences/1005/thumbnail.jp
Imaging for Thoracic Aortic Dissections and Other Acute Aortic Syndromes.
No full textImaging for aortic dissections and other acute aortic syndromes relies heavily on computed tomography (CT) scans. There is an ongoing need to educate providers and imaging specialists regarding the different protocols for CT scans and the heightened value of aortic protocol scans for acute aortic syndromes. Current dissection guidelines recommend the treatment for patients with acute aortic syndromes be performed at a high-volume center by a multidisciplinary team that includes an imaging specialist. MRI and echocardiography can provide additional information and possibly at lower radiation exposure compared to CT scans. All imaging modalities are evolving with new and future uses and capabilities
The response to anti-PD-1 and anti-LAG-3 checkpoint blockade is associated with regulatory T cell reprogramming.
No full textImmune checkpoint blockade (ICB) has revolutionized cancer treatment; however, many patients develop therapeutic resistance. We previously identified and validated a pretreatment peripheral blood biomarker, characterized by a high frequency of LAG-3+ lymphocytes, that predicts resistance in patients receiving anti-PD-1 (aPD-1) ICB. To better understand the mechanism of aPD-1 resistance, we identified murine tumor models with a high LAG-3+ lymphocyte frequency (LAG-3hi), which were resistant to aPD-1 therapy, and LAG-3lo murine tumor models that were aPD-1 sensitive, recapitulating the predictive biomarker we previously described in patients. LAG-3hi tumor-bearing mice were sensitive to aPD-1 + anti-LAG-3 (aLAG-3) therapy, and this benefit was CD8+ T cell dependent. The efficacy of combination therapy was enhanced in LAG-3hi (but not LAG-3lo) mice with depletion of CD4+ T cells. Furthermore, responses to aPD-1 + aLAG-3 correlated with regulatory T cell (Treg) phenotypic plasticity in LAG-3hi mice, suggesting a specific role for Tregs in response to aPD-1 + aLAG-3 treatment. Using Treg fate-tracking Foxp3GFP-Cre-ERT2 × ROSAYFP reporter mice, we demonstrated that expanded populations of unstable Tregs correlated with improved response to combination therapy in LAG-3hi mice. Complementing these preclinical data, an increased proportion of unstable Tregs also correlated with higher response rate and improved survival after aPD-1 + aLAG-3 therapy in a cohort of patients with metastatic melanoma (n = 117). These data indicate that Treg phenotypic plasticity affects aPD-1 + aLAG-3 responsiveness, which may represent a biomarker to aid patient selection and a rational therapeutic target for a subset of PD-1-refractory patients
Alarm with Care – A Falls Alarm Deimplementation
No full texthttps://digitalcommons.providence.org/covenant_nurses_week_2025/1009/thumbnail.jp