Shift workers have higher blood pressure medication use, but only when they are short sleepers who prefer mornings: A UK Biobank Study Introduction: Poor sleep quality is a risk factor for cardiovascular disease (CVD). Shift work influences sleep patterns and duration, but this study examines how shift work and sleep influence cardiovascular health. Methods: Baseline (BL) and 5-year follow-up (5YFU) data from the UK Biobank cohort study (N=11,259) were used to generate separate logistic regression models of shift workers and non-shift workers to examine the moderating effects of shift work on the relationship between sleep duration (short ≤6hrs; adequate 7-8hrs; long ≥9hrs) and chronotype (morning; evening) at BL with incident blood pressure (BP) medication (med) use from BL to 5YFU. All models were adjusted for family history of CVD, depression status, insomnia, narcolepsy, and alcohol intake. Results: The sample was predominately female (57.6%), White (97.8%), had not attended college (50.4%) and reported a mean age of 55.2 ± 7.4 years. Most were adequate sleepers (7-8hrs) (72.1%), morning chronotype (60.4%), and currently employed (66.5%) with 8.2% identifying as shift workers at BL. Only 7.7% reported incident BP med use from BL to 5YFU. Analysis demonstrated significant moderation for both sleep duration (p=0.02) and chronotype (p=0.04) in those working shifts. Among shift workers, short sleepers (≤6hrs) had a 2-fold increased odds of incident BP med use compared to adequate sleepers (OR=2.14, 95% CI=1.24-3.67, p=0.006); those with morning chronotype had a 78% increased odds of incident BP med use compared to evening chronotype (OR=1.78, 95% CI=1.03-3.12, p=0.04). Among non-shift workers, short versus adequate sleepers and those reporting morning versus evening chronotype had only a 3% increased (OR=1.03, 95% CI=0.85-1.25, p=0.76) and a 5% decreased (OR=0.95, 95% CI=0.81-1.13, p=0.60) odds of incident BP med use, respectively. Conclusions: The relationship between sleep duration and chronotype with incident BP med use was significant among shift workers and not in non-shift workers. Shift workers who are short sleepers or of morning time preference have increased incident blood pressure medication use.
Background: Novel therapies such as angiotensin receptor-neprilysin inhibitors (ARNI), sodium-glucose cotransporter-2 Inhibitors (SGLT2i), and glucagon-like peptide-1 receptor agonists (GLP-1 RA) have well-established benefit, but use remains low for heart failure (HF) and coronary artery disease (CAD). Methods: Patients were identified by diagnosis codes for HF, myocardial infarction, or coronary revascularization between 2017-2021 at 114 sites within the Veterans Health Administration (VA). HF and CAD cohorts included 82,376 and 74,210 patients, respectively. Hospital-level data for ARNI, SGLT2i, and GLP-1 RA were assessed for filled outpatient prescriptions at hospital admission, discharge, or within 6 months of discharge. Patient and site-level characteristics were compared by high-, low-, or mixed-level use of novel medications compared with median prescribing. Results: In HF patients, rates of both ARNI and SGLT2i prescription were 20% and 21%, respectively, in 2021. In CAD patients, SGLT2i or GLP-1 RA use was 30% in 2021. Patient characteristics were similar among sites by high-, mixed- and low-level prescribing of novel medication usage. Sites in the "high" group compared with the "low" group of medication utilization had a greater number of patient-years per site (236 patient-years vs 127 patient-years, respectively, p=0.003) and a greater average number of hospital beds (157 vs 81 beds, respectively, p<0.001). Though nearly all sites (95%) had an academic affiliation, a numerically greater proportion of sites in the "high" group of novel medication use had academic affiliation than the "low" group (100% vs 90% with academic affiliation, respectively, p=0.236). Conclusions: In the VA, sites with the highest utilization ARNI, SGLT2i, and GLP-1 RA use for HF and CAD had greater patient volume and number of beds than sites in the lowest-use sites. This may suggest that centers with more experience in treating HF and CAD have a more rapid uptake of novel cardiovascular therapies.
Abstract Background Health services researchers within the Veterans Health Administration (VA) seek to improve the delivery of care to the Veteran population, whose medical needs often differ from the general population. The COVID-19 pandemic and restricted access to medical centers and offices forced VA researchers and staff to transition to remote work. This study aimed to characterize the work experience of health service researchers during the COVID-19 pandemic. Methods A REDCap survey developed from the management literature was distributed in July 2020 to 800 HSR&D researchers and staff affiliated with VA Centers of Innovation. We requested recipients to forward the survey to VA colleagues. Descriptive analyses and logistic regression modeling were conducted on multiple choice and Likert scaled items. Manifest content analysis was conducted on open-text responses. Results Responses were received from 473 researchers and staff from 37 VA Medical Centers. About half (48%; n = 228) of VA HSR&D researchers and staff who responded to the survey experienced some interference with their research due to the COVID-19 pandemic, yet 55% ( n = 260) reported their programs of research did not slow or stop. Clinician investigators reported significantly greater odds of interference than non-clinician investigators and support staff. The most common barriers to working remotely were loss of face-to-face interactions with colleagues (56%; n = 263) and absence of daily routines (25%; n = 118). Strategies teams used to address COVID-19 related remote work challenges included videoconferencing (79%; n = 375), virtual get-togethers (48%; n = 225), altered timelines (42%; n = 199), daily email updates (30%; n = 143) and virtual team huddles (16%; n = 74). Pre-pandemic VA information technology structures along with systems created to support multidisciplinary research teams working across a national healthcare system maintained and enhanced staff engagement and well-being. Conclusions This study identifies how the VA structures and systems put in place prior to the COVID-19 pandemic to support a dispersed workforce enabled the continuation of vital scientific research, staff engagement and well-being during a global pandemic. These findings can inform remote work policies and practices for researchers during the current and future crises.
Chronically ill adults insured by Medicaid experience health inequities following hospitalisation.Postacute outcomes, including rates of 30-day readmissions and postacute emergency department (ED), were higher among Medicaid-insured individuals compared with commercially insured individuals and social needs were inconsistently addressed.An interdisciplinary team introduced a clinical pathway called 'THRIVE' to provide postacute wrap-around services for individuals insured by Medicaid.Enrolment into the THRIVE clinical pathway occurred during hospitalisation and multidisciplinary services were deployed into homes within 48 hours of discharge to address clinical and social needs.Compared with those not enrolled in THRIVE (n=437), individuals who participated in the THRIVE clinical pathway (n=42) experienced fewer readmissions (14.3% vs 28.4%) and ED visits (14.3% vs 28.8 %).THRIVE is a promising clinical pathway that increases access to ambulatory care after discharge and may reduce readmissions and ED visits.
Background Readmissions following hospitalization for common surgical procedures are prevalent among older adults and are disproportionally experienced by Hispanic patients. One potential explanation for these disparities is that Hispanic patients may receive care in hospitals with lower-quality nursing care. Objectives The objective of this study was to evaluate the relationship between the hospital-level work environment of nurses and hospital readmissions among older Hispanic patients. Methods Using linked data sources from 2014 to 2016, we conducted a cross-sectional analysis of 522 hospitals and 732,035 general, orthopedic, and vascular surgical patients (80,978 Hispanic patients and 651,057 non-Hispanic White patients) in four states. Multivariable logistic regression models were employed to determine the relationship between the work environment and older Hispanic patient readmissions at multiple time periods (7, 30, and 90 days). Results In final adjusted models that included an interaction between work environment and ethnicity, an increase in the quality of the work environment resulted in a decrease in the odds of readmission that was greater for older Hispanic surgical patients at all time periods. Specifically, an increase in three of the five work environment subscales (Nurse Participation in Hospital Affairs, Nursing Foundations for Quality of Care, and Staffing and Resource Adequacy) was associated with a reduction in the odds of readmission that was greater for Hispanic patients than their non-Hispanic White counterparts. Discussion System-level investments in the work environment may reduce Hispanic patient readmission disparities. This study’s findings may be used to inform the development of targeted interventions to prevent hospital readmissions for Hispanic patients.
Abstract Introduction Few rural hospital medicine programs include workforce development training that provides social and professional support for interdisciplinary teams. Even fewer include training that creates supportive learning environments that result in higher staff satisfaction, lower burnout, and reduced turnover. The Acute Inpatient Medicine—High Reliability, Learning Environment, and Workforce Development Initiative (AIM‐HI) aims to create supportive learning environments in Veterans Health Administration (VA) rural hospital medicine teams. Methods AIM‐HI is a type II hybrid implementation study utilizing a convergent mixed methods approach to evaluate the Relational Playbook, a workforce development intervention, and three implementation strategies: behavioral nudges, learning and leadership collaboratives, and leadership coaching. AIM‐HI implementation will occur in waves, enrolling additional hospitals every 12 months. In the first wave, AIM‐HI will be implemented at three tertiary VA hospitals that treat at least 1000 rural Veterans annually and have an active inpatient hospital medicine program. The primary outcomes in year 1 will be the acceptability, appropriateness, and feasibility of AIM‐HI assessed through participant surveys and interviews. In subsequent years, trends in the learning environment, job satisfaction, burnout, and turnover scores will be assessed using a linear mixed‐effect model. Discussion The anticipated impact of AIM‐HI is to evaluate the utility of the implementation strategies and assess trends in Playbook intervention outcomes. The Playbook has strong face validity; however, before large‐scale adoption across the VA enterprise, it is essential to establish the acceptability, appropriateness, and feasibility of the Playbook and implementation strategies, as well as to gather data on AIM‐HI effectiveness.
Background: Self-care is essential in people with chronic heart failure (HF). The process of self-care was refined in the revised situation specific theory of HF self-care, so we updated the instrument measuring self-care to match the updated theory. The aim of this study was to test the psychometric properties of the revised 29-item Self-Care of Heart Failure Index (SCHFI). Methods: A cross-sectional design was used in the primary psychometric analysis using data collected at 5 sites in the United States. A longitudinal design was used at the site collecting test-retest data. We tested SCHFI validity with confirmatory factor analysis and predictive validity in relation to health-related quality of life. We tested SCHFI reliability with Cronbach α, global reliability index, and test-retest reliability. Results: Participants included 631 adults with HF (mean age, 65 ± 14.3 years; 63% male). A series of confirmatory factor analyses supported the factorial structure of the SCHFI with 3 scales: Self-Care Maintenance (with consulting behavior and dietary behavior dimensions), Symptom Perception (with monitoring behavior and symptom recognition dimensions), and Self-Care Management (with recommended behavior and problem-solving behavior dimensions). Reliability estimates were 0.70 or greater for all scales. Predictive validity was supportive with significant correlations between SCHFI scores and health-related quality-of-life scores. Conclusions: Our analysis supports validity and reliability of the SCHFI v7.2. It is freely available to users on the website: www.self-care-measures.com.
The aim was to develop and psychometrically test the self-care of chronic illness Inventory, a generic measure of self-care.Existing measures of self-care are disease-specific or behaviour-specific; no generic measure of self-care exists.Cross-sectional survey.We developed a 20-item self-report instrument based on the Middle Range Theory of Self-Care of Chronic Illness, with three separate scales measuring Self-Care Maintenance, Self-Care Monitoring, and Self-Care Management. Each of the three scales is scored separately and standardized 0-100 with higher scores indicating better self-care. After demonstrating content validity, psychometric testing was conducted in a convenience sample of 407 adults (enrolled from inpatient and outpatient settings at five sites in the United States and ResearchMatch.org). Dimensionality testing with confirmatory factor analysis preceded reliability testing.The Self-Care Maintenance scale (eight items, two dimensions: illness-related and health-promoting behaviour) fit well when tested with a two-factor confirmatory model. The Self-Care Monitoring scale (five items, single factor) fitted well. The Self-Care Management scale (seven items, two factors: autonomous and consulting behaviour), when tested with a two-factor confirmatory model, fitted adequately. A simultaneous confirmatory factor analysis on the combined set of items supported the more general model.The self-care of chronic illness inventory is adequate in reliability and validity. We suggest further testing in diverse populations of patients with chronic illnesses.
