VA Ann Arbor Healthcare System

Background:Carpal tunnel syndrome is the most common entrapment neuropathy. Prior studies have documented racial and ethnic disparities in use of carpal tunnel release (CTR), but few have examined differences in the use of both operative and nonoperative treatments and differences in an equal-access healthcare system.Methods:We conducted a retrospective cohort study of 366,009 veterans diagnosed with carpal tunnel syndrome across the Veterans Health Administration from 2010 to 2020. We assessed the association of race/ethnicity with receipt of CTR, surgical consultation, nonoperative management modalities, and time to treatment using multilevel logistic regression and Cox proportional hazards models. Predictors included demographic, clinical, structural, and care process variables.Results:Among the study cohort, 12.7% underwent CTR within 2 years. After adjustment, Black and Hispanic veterans had significantly lower odds of receiving CTR compared with White veterans (Black: odds ratio 0.61; Hispanic: odds ratio 0.80). Similar trends were observed for surgical consultation, although the magnitude of disparity was attenuated. Time-to-event analyses showed prolonged time to surgical consultation and CTR for Black and Hispanic veterans compared with White veterans. Black and Hispanic patients were more likely to receive nonoperative treatments, including splinting and specific therapeutic modalities.Conclusions:Despite the Veterans Health Administration’s equal-access model, significant racial and ethnic differences exist in surgical consultation, receipt of CTR, and timeliness of care. These differences seem to emerge across the surgical care continuum and are not fully explained by clinical or structural factors. Interventions targeting pre- and perioperative processes are needed to ensure equitable surgical care delivery.

The unpredictability of seizures is one of the most challenging aspects of uncontrolled epilepsy for patients. Prior work forecasting seizure risk has measured changes in passive intracranial electroencephalographic (EEG) signals, but currently, there are no such clinical devices available. Based upon dynamical theory, we hypothesized that the response of the brain to perturbing stimulation provides a robust measurement of seizure risk that outperforms the results from passive EEG. To test the hypothesis, we performed more than 8 weeks of periodic electrical stimulation and continuous EEG recordings in epileptic rats induced by intrahippocampal injection of tetanus toxin, in which seizures started spontaneously. Using the perturbation-evoked responses as a predictive biomarker of seizure risk, we built a preictal detection system that had excellent accuracy (area under the receiver operating characteristic curve > .95) at distinguishing the preictal from the interictal states. In comparison, a similar preictal detection system that used only passive features from the same experimental animals was unable to identify the preictal state better than chance. Our results advocate for perturbation to be used for seizure prediction purposes, which could improve the efficacy of seizure forecasting when applied clinically.

Qualitative study designs provide critical insights into pressing health care problems by answering why, how, and what questions: Why do patients not adhere to medications? How do providers use guidelines? What clinic features contribute to quality of care? Qualitative methods often consist of interviews or focus groups but also can include observations or archival data. These methods elucidate patient and provider experiences, behaviors, or beliefs; describe phenomena; and provide rich insights into local contexts. While family medicine has long acknowledged the value of qualitative research, clinicians and medical educators may have limited exposure. Our objectives are to (a) orient clinicians to qualitative research, and (b) guide them through the stages of qualitative study design, from planning, to data collection, to analyses, on through dissemination of a final product. We describe the tenets of qualitative inquiry: an insider perspective, holism, attention to power dynamics, reflexivity, and flexibility. We explain how to choose among qualitative data collection methods, such as interviews, focus groups, observation, and archival data review. Lastly, we provide key considerations for analyzing qualitative data, disseminating final product(s), and maximizing methodological quality. This practical guide for clinicians gives a grand tour of the overall purpose of and approaches to qualitative study designs and offers considerations when using qualitative methods in research and quality improvement studies.

Cognitive decline is a disabling and variable feature of Parkinson disease (PD). While cholinergic system degeneration is linked to cognitive impairments in PD, most prior research reported cross-sectional associations. We aimed to fill this gap by investigating whether baseline regional cerebral vesicular acetylcholine transporter ligand [18F]-fluoroethoxybenzovesamicol ([18F]-FEOBV) binding predicts longitudinal cognitive changes in mild-moderate, non-demented PD subjects. Seventy-five non-demented, mild-moderate PD subjects underwent baseline [18F]-FEOBV PET and standardized cognitive evaluations, with repeat cognitive testing after 2 years. Participants were classified into four cognitive classes: persistent normal (no MCI at either time point; N = 41), persistent MCI (MCI at both; N = 21), MCI conversion (normal to MCI; N = 6), and MCI reversion (MCI to normal; N = 7). We performed whole-brain voxel comparisons (controls and between classes) and used linear and multinomial regression to predict follow-up cognitive status. Whole-brain voxel analyses revealed class-specific [18F]-FEOBV binding deficits. Persistent MCI showed the most widespread reductions, extending into frontal regions. Compared with MCI reverter and persistently normal groups, persistent MCI had lower binding in occipito-temporal and temporo-parieto-frontal regions, respectively, while MCI reverters showed higher occipital binding than converters. Binding in occipital, temporo-parietal, and medial frontal regions predicted follow-up cognitive decline, with medial frontal binding showing the strongest association (esp. global cognition, memory, and visuospatial domains). Baseline cholinergic system changes associate with varying cognitive trajectories in mild-moderate PD. Assessment of regional cholinergic deficits may be useful for prediction of cognitive trajectories in this population, enhancing subject selection and stratification for intervention trials aimed at improving cognition in PD.

Cardiac rehabilitation (CR) could be an important opportunity for optimization of guideline-directed medical therapies (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF). We set out to describe GDMT prescribing among enrollees in CR with HFrEF. We queried the electronic health record of an academic medical center and identified patients with HFrEF who attended CR between 2016 and 2023. We defined CR cycles as at least 6 CR sessions with fewer than 6 months between sessions. Using a validated algorithm, we generated medication optimization scores (MOS, 0%-100% optimized) at the first and final CR session. The algorithm's input included GDMT, New York Heart Association classification, systolic blood pressure, heart rate, creatinine, potassium, allergies, and race. Wilcoxon Signed-Rank analysis was used to compare MOS. A total of 172 CR cycles were completed by 152 patients (64% male, 78% White, 67.5 ± 12.1 years old). Mean sessions per CR cycle was 26.4 ± 10.6. At the end of CR, 85 (49%) patients were on a beta-blocker, 84 (49%) a renin-angiotensin-aldosterone inhibitor, and 31 (18%) a mineralocorticoid receptor antagonist. Accounting for contraindications, patients were eligible for initiation or uptitration of at least 1 GDMT class after 84% of cycles. Median MOS at the start of CR was 39% (IQR: 14, 57) and 35% (IQR: 14, 57) at the end of CR ( P = .90). GDMT utilization among patients with HFrEF in CR is suboptimal. There is a substantial opportunity to develop and validate strategies to improve GDMT prescribing during CR.

An older adult affordable housing community and a Federally Qualified Health Center partnered to improve the health of low-income older adults. The Unite Care Model included establishing onsite primary care, wellness support, and social needs assistance. The RE-AIM framework guided our mixed-methods evaluation. We sought to determine whether the model was associated with change in blood pressure, social or physical environment and understand model reach and implementation. Of the 251 residents, 13.1% had a clinic visit, and of respondents 70% attended at least one wellness event, and 35% received social needs assistance (reach). Clinic utilization was not associated with improved blood pressure or environment change (effectiveness). Residents reported barriers to clinic utilization including an established provider, uncertainty in transferring care, lack of urgent visits, and insurance barriers. Administrators echoed policy, staffing, and patient barriers to utilization (implementation). Expanding appointment options, increasing staffing, and overcoming insurance barriers may increase effectiveness.