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The association between patient activation and medication adherence, hospitalization, and emergency room utilization in patients with chronic illnesses: a systematic review

Wed, 07/20/2016 - 9:50am

OBJECTIVE: A systematic review of the published literature on the association between the PAM (Patient Activation Measure) and hospitalization, emergency room use, and medication adherence among chronically ill patient populations.

METHODS: A literature search of several electronic databases was performed. Studies published between January 1, 2004 and June 30, 2014 that used the PAM measure and examined at least one of the outcomes of interest among a chronically ill study population were identified and systematically assessed.

RESULTS: Ten studies met the eligibility criteria. Patients who scored in the lower PAM stages (Stages 1 and 2) were more likely to have been hospitalized. Patients who scored in the lowest stage were also more likely to utilize the emergency room. The relationship between PAM stage and medication adherence was inconclusive in this review.

CONCLUSION: Chronically ill patients reporting low stages of patient activation are at an increased risk for hospitalization and ER utilization.

PRACTICAL IMPLICATIONS: Future research is needed to further understand the relationship between patient activation and medication adherence, hospitalization and/or ER utilization in specific chronically ill (e.g. diabetic, asthmatic) populations. Research should also consider the role of patient activation in the development of effective interventions which seek to address the outcomes of interest.

Family income, parental education and brain structure in children and adolescents

Wed, 07/20/2016 - 9:50am

Socioeconomic disparities are associated with differences in cognitive development. The extent to which this translates to disparities in brain structure is unclear. We investigated relationships between socioeconomic factors and brain morphometry, independently of genetic ancestry, among a cohort of 1,099 typically developing individuals between 3 and 20 years of age. Income was logarithmically associated with brain surface area. Among children from lower income families, small differences in income were associated with relatively large differences in surface area, whereas, among children from higher income families, similar income increments were associated with smaller differences in surface area. These relationships were most prominent in regions supporting language, reading, executive functions and spatial skills; surface area mediated socioeconomic differences in certain neurocognitive abilities. These data imply that income relates most strongly to brain structure among the most disadvantaged children.

GBPs take AIM at Francisella

Wed, 07/20/2016 - 9:50am

Guanylate-binding proteins (GBPs) induced by type I interferon signaling cause lysis ofFrancisella bacteria that have reached the host-cell cytosol. The liberated bacterial DNA is then sensed by the cytosolic AIM2 inflammasome, which activates caspase-1 and leads to pyroptotic cell death.

Home is where the patient is: a ground-level perspective on the Patient-Centered Medical Home

Wed, 07/20/2016 - 9:50am

Imagine a medical model that would improve satisfaction for patients, providers, and staff, save costs, and improve quality and safety outcomes. Imagine this could be implemented broadly across systems and revive our exhausted primary care networks. Too good to be true? Perhaps. But these are the hopes pinned on the Patient Centered Medical Home (PCMH).

Trauma care does not discriminate: The association of race and health insurance with mortality following traumatic injury

Wed, 07/20/2016 - 9:50am

BACKGROUND: Previous studies have reported that black race and lack of health insurance coverage are associated with increased mortality following traumatic injury. However, the association of race and insurance status with trauma outcomes has not been examined using contemporary, national, population-based data.

METHODS: We used data from the National Inpatient Sample on 215,615 patients admitted to 1 of 836 hospitals following traumatic injury in 2010. We examined the effects of race and insurance coverage on mortality using two logistic regression models, one for patients younger than 65 years and the other for older patients.

RESULTS: Unadjusted mortality was low for white (2.71%), black (2.54%), and Hispanic (2.03%) patients. We found no difference in adjusted survival for nonelderly black patients compared with white patients (adjusted odds ratio [AOR], 1.04; 95% confidence interval [CI], 0.90-1.19; p = 0.550). Elderly black patients had a 25% lower odds of mortality compared with elderly white patients (AOR, 0.75; 95% CI, 0.63-0.90; p = 0.002). After accounting for survivor bias, insurance coverage was not associated with improved survival in younger patients (AOR, 0.91; 95% CI, 0.77-1.07; p = 0.233).

CONCLUSION: Black race is not associated with higher mortality following injury. Health insurance coverage is associated with lower mortality, but this may be the result of hospitals' inability to quickly obtain insurance coverage for uninsured patients who die early in their hospital stay. Increasing insurance coverage may not improve survival for patients hospitalized following injury.

LEVEL OF EVIDENCE: Epidemiologic and prognostic study, level III.

Influence of light exposure during early life on the age of onset of bipolar disorder

Wed, 07/20/2016 - 9:50am

BACKGROUND: Environmental conditions early in life may imprint the circadian system and influence response to environmental signals later in life. We previously determined that a large springtime increase in solar insolation at the onset location was associated with a younger age of onset of bipolar disorder, especially with a family history of mood disorders. This study investigated whether the hours of daylight at the birth location affected this association.

METHODS: Data collected previously at 36 collection sites from 23 countries were available for 3896 patients with bipolar I disorder, born between latitudes of 1.4 N and 70.7 N, and 1.2 S and 41.3 S. Hours of daylight variables for the birth location were added to a base model to assess the relation between the age of onset and solar insolation.

RESULTS: More hours of daylight at the birth location during early life was associated with an older age of onset, suggesting reduced vulnerability to the future circadian challenge of the springtime increase in solar insolation at the onset location. Addition of the minimum of the average monthly hours of daylight during the first 3 months of life improved the base model, with a significant positive relationship to age of onset. Coefficients for all other variables remained stable, significant and consistent with the base model.

CONCLUSIONS: Light exposure during early life may have important consequences for those who are susceptible to bipolar disorder, especially at latitudes with little natural light in winter. This study indirectly supports the concept that early life exposure to light may affect the long term adaptability to respond to a circadian challenge later in life.

Changing Trends in, and Characteristics Associated with, Not Undergoing Cardiac Catheterization in Elderly Adults Hospitalized with ST-Segment Elevation Acute Myocardial Infarction

Wed, 07/20/2016 - 9:50am

OBJECTIVES: To describe decade- long trends (1999-2009) in the rates of not undergoing cardiac catheterization and percutaneous coronary intervention (PCI) in individuals aged 65 and older presenting with an ST-segment elevation acute myocardial infarction (STEMI) and factors associated with not undergoing these procedures.

DESIGN: Observational population-based study.

SETTING: Worcester, Massachusetts, metropolitan area.

PARTICIPANTS: Individuals aged 65 and older hospitalized for an STEMI in six biennial periods between 1999 and 2009 at 11 central Massachusetts medical centers (N=960).

MEASUREMENTS: Analyses were conducted to examine the characteristics of people who did not undergo cardiac catheterization overall and stratified into two age strata (65-74, > /=75).

RESULTS: Between 1999 and 2009, dramatic declines (from 59.4% to 7.5%) were observed in the proportion of older adults who did not undergo cardiac catheterization at all greater Worcester hospitals. These declines were observed in individuals aged 65 to 74 (58.4-6.7%) and in those aged 75 and older (69.4-13.5%). The proportion of individuals not undergoing PCI after undergoing cardiac catheterization decreased from 36.6% in 1999 to 6.5% in 2009. Women, individuals with a prior MI, those with do-not-resuscitate orders, and those with various comorbidities were less likely to have undergone these procedures than comparison groups.

CONCLUSION: Older adults who develop an STEMI are increasingly likely to undergo cardiac catheterization and PCI, but several high-risk groups remain less likely to undergo these procedures.

Mispricing in the medicare advantage risk adjustment model

Wed, 07/20/2016 - 9:50am

The Centers for Medicare and Medicaid Services (CMS) implemented hierarchical condition category (HCC) models in 2004 to adjust payments to Medicare Advantage (MA) plans to reflect enrollees' expected health care costs. We use Verisk Health's diagnostic cost group (DxCG) Medicare models, refined "descendants" of the same HCC framework with 189 comprehensive clinical categories available to CMS in 2004, to reveal 2 mispricing errors resulting from CMS' implementation. One comes from ignoring all diagnostic information for "new enrollees" (those with less than 12 months of prior claims). Another comes from continuing to use the simplified models that were originally adopted in response to assertions from some capitated health plans that submitting the claims-like data that facilitate richer models was too burdensome. Even the main CMS model being used in 2014 recognizes only 79 condition categories, excluding many diagnoses and merging conditions with somewhat heterogeneous costs. Omitted conditions are typically lower cost or "vague" and not easily audited from simplified data submissions. In contrast, DxCG Medicare models use a comprehensive, 394-HCC classification system. Applying both models to Medicare's 2010-2011 fee-for-service 5% sample, we find mispricing and lower predictive accuracy for the CMS implementation. For example, in 2010, 13% of beneficiaries had at least 1 higher cost DxCG-recognized condition but no CMS-recognized condition; their 2011 actual costs averaged US$6628, almost one-third more than the CMS model prediction. As MA plans must now supply encounter data, CMS should consider using more refined and comprehensive (DxCG-like) models.

Arrhythmia discrimination using a smart phone

Wed, 07/20/2016 - 9:50am

We hypothesize that our smartphone-based arrhythmia discrimination algorithm with data acquisition approach reliably differentiates between normal sinus rhythm (NSR), atrial fibrillation (AF), premature ventricular contractions (PVCs) and premature atrial contraction (PACs) in a diverse group of patients having these common arrhythmias. We combine root mean square of successive RR differences and Shannon entropy with Poincare plot (or turning point ratio method) and pulse rise and fall times to increase the sensitivity of AF discrimination and add new capabilities of PVC and PAC identification. To investigate the capability of the smartphone-based algorithm for arrhythmia discrimination, 99 subjects, including 88 study participants with AF at baseline and in NSR after electrical cardioversion, as well as seven participants with PACs and four with PVCs were recruited. Using a smartphone, we collected 2-min pulsatile time series from each recruited subject. This clinical application results show that the proposed method detects NSR with specificity of 0.9886, and discriminates PVCs and PACs from AF with sensitivities of 0.9684 and 0.9783, respectively.

Combined measure of neighborhood food and physical activity environments and weight-related outcomes: The CARDIA study

Wed, 07/20/2016 - 9:49am

Engagement in healthy lifestyle behaviors likely reflects access to a diverse and synergistic set of food and physical activity resources, yet most research examines discrete characteristics. We characterized neighborhoods with respect to their composition of features, and quantified associations with diet, physical activity (PA), body mass index (BMI), and insulin resistance (IR) in a longitudinal biracial cohort (n=4143; aged 25-37; 1992-2006). We used latent class analysis to derive population-density-specific ( < vs. > /=1750 people per sq km) clusters of neighborhood indicators: road connectivity, parks and PA facilities, and food stores/restaurants. In lower population density areas, a latent class with higher food and PA resource diversity (relative to other clusters) was significantly associated with higher diet quality. In higher population density areas, a cluster with relatively more natural food/specialty stores; fewer convenience stores; and more PA resources was associated with higher diet quality. Neighborhood clusters were inconsistently associated with BMI and IR, and not associated with fast food consumption, walking, biking, or running.

Sleep disturbance and longitudinal risk of inflammation: Moderating influences of social integration and social isolation in the Coronary Artery Risk Development in Young Adults (CARDIA) study

Wed, 07/20/2016 - 9:49am

Both sleep disturbance and social isolation increase the risk for morbidity and mortality. Systemic inflammation is suspected as a potential mechanism of these associations. However, the complex relationships between sleep disturbance, social isolation, and inflammation have not been examined in a population-based longitudinal study. This study examined the longitudinal association between sleep disturbance and systemic inflammation, and the moderating effects of social isolation on this association. The CARDIA study is a population-based longitudinal study conducted in four US cities. Sleep disturbance - i.e., insomnia complaints and short sleep duration - was assessed in 2962 African-American and White adults at baseline (2000-2001, ages 33-45years). Circulating C-reactive protein (CRP) was measured at baseline and follow-up (2005-2006). Interleukin-6 (IL-6) and subjective and objective social isolation (i.e., feelings of social isolation and social network size) were measured at follow-up. Sleep disturbance was a significant predictor of inflammation five years later after full adjustment for covariates (adjusted betas: 0.048, P=0.012 for CRP; 0.047, P=0.017 for IL-6). Further adjustment for baseline CRP revealed that sleep disturbance also impacted the longitudinal change in CRP levels over five years (adjusted beta: 0.044, P=0.013). Subjective social isolation was a significant moderator of this association between sleep disturbance and CRP (adjusted beta 0.131, P=0.002). Sleep disturbance was associated with heightened systemic inflammation in a general population over a five-year follow-up, and this association was significantly stronger in those who reported feelings of social isolation. Clinical interventions targeting sleep disturbances may be a potential avenue for reducing inflammation, particularly in individuals who feel socially isolated.

Neighborhood availability of convenience stores and diet quality: findings from 20 years of follow-up in the coronary artery risk development in young adults study

Wed, 07/20/2016 - 9:49am

OBJECTIVES: We examined the association between neighborhood convenience stores and diet outcomes for 20 years of the Coronary Artery Risk Development in Young Adults study.

METHODS: We used dietary data from the Coronary Artery Risk Development in Young Adults study years 1985-1986, 1992-1993, and 2005-2006 (n = 3299; Birmingham, AL; Chicago, IL; Minneapolis, MN; and Oakland, CA) and geographically and temporally matched neighborhood-level food resource and US Census data. We used random effects repeated measures regression to estimate associations between availability of neighborhood convenience stores with diet outcomes and whether these associations differed by individual-level income.

RESULTS: In multivariable-adjusted analyses, greater availability of neighborhood convenience stores was associated with lower diet quality (mean score = 66.3; SD = 13.0) for participants with lower individual-level income (b = -2.40; 95% CI = -3.30, -1.51); associations at higher individual-level income were weaker. We observed similar associations with whole grain consumption across time but no statistically significant associations with consumption of sugar-sweetened beverages, artificially sweetened beverages, snacks, processed meats, fruits, or vegetables.

CONCLUSIONS: The presence of neighborhood convenience stores may be associated with lower quality diets. Low-income individuals may be most sensitive to convenience store availability.

Dyslexia and language impairment associated genetic markers influence cortical thickness and white matter in typically developing children

Wed, 07/20/2016 - 9:49am

Dyslexia and language impairment (LI) are complex traits with substantial genetic components. We recently completed an association scan of the DYX2 locus, where we observed associations of markers in DCDC2, KIAA0319, ACOT13, and FAM65B with reading-, language-, and IQ-related traits. Additionally, the effects of reading-associated DYX3 markers were recently characterized using structural neuroimaging techniques. Here, we assessed the neuroimaging implications of associated DYX2 and DYX3 markers, using cortical volume, cortical thickness, and fractional anisotropy. To accomplish this, we examined eight DYX2 and three DYX3 markers in 332 subjects in the Pediatrics Imaging Neurocognition Genetics study. Imaging-genetic associations were examined by multiple linear regression, testing for influence of genotype on neuroimaging. Markers in DYX2 genes KIAA0319 and FAM65B were associated with cortical thickness in the left orbitofrontal region and global fractional anisotropy, respectively. KIAA0319 and ACOT13 were suggestively associated with overall fractional anisotropy and left pars opercularis cortical thickness, respectively. DYX3 markers showed suggestive associations with cortical thickness and volume measures in temporal regions. Notably, we did not replicate association of DYX3 markers with hippocampal measures. In summary, we performed a neuroimaging follow-up of reading-, language-, and IQ-associated DYX2 and DYX3 markers. DYX2 associations with cortical thickness may reflect variations in their role in neuronal migration. Furthermore, our findings complement gene expression and imaging studies implicating DYX3 markers in temporal regions. These studies offer insight into where and how DYX2 and DYX3 risk variants may influence neuroimaging traits. Future studies should further connect the pathways to risk variants associated with neuroimaging/neurocognitive outcomes.

Long-term outcomes of secondary atrial fibrillation in the community: the Framingham Heart Study

Wed, 07/20/2016 - 9:49am

BACKGROUND: Guidelines have proposed that atrial fibrillation (AF) can occur as an isolated event, particularly when precipitated by a secondary, or reversible, condition. However, knowledge of long-term AF outcomes after diagnosis during a secondary precipitant is limited.

METHODS AND RESULTS: In 1409 Framingham Heart Study participants with new-onset AF, we examined associations between first-detected AF episodes occurring with and without a secondary precipitant and both long-term AF recurrence and morbidity. We selected secondary precipitants based on guidelines (surgery, infection, acute myocardial infarction, thyrotoxicosis, acute alcohol consumption, acute pericardial disease, pulmonary embolism, or other acute pulmonary disease). Among 439 patients (31%) with AF diagnosed during a secondary precipitant, cardiothoracic surgery (n=131 [30%]), infection (n=102 [23%]), noncardiothoracic surgery (n=87 [20%]), and acute myocardial infarction (n=78 [18%]) were most common. AF recurred in 544 of 846 eligible individuals without permanent AF (5-, 10-, and 15-year recurrences of 42%, 56%, and 62% with versus 59%, 69%, and 71% without secondary precipitants; multivariable-adjusted hazard ratio, 0.65 [95% confidence interval, 0.54-0.78]). Stroke risk (n=209/1262 at risk; hazard ratio, 1.13 [95% confidence interval, 0.82-1.57]) and mortality (n=1098/1409 at risk; hazard ratio, 1.00 [95% confidence interval, 0.87-1.15]) were similar between those with and without secondary precipitants, although heart failure risk was reduced (n=294/1107 at risk; hazard ratio, 0.74 [95% confidence interval, 0.56-0.97]).

CONCLUSIONS: AF recurs in most individuals, including those diagnosed with secondary precipitants. Long-term AF-related stroke and mortality risks were similar between individuals with and without secondary AF precipitants. Future studies may determine whether increased arrhythmia surveillance or adherence to general AF management principles in patients with reversible AF precipitants will reduce morbidity.

Mental health problems in young male offenders with and without sex offences: a comparison based on the MAYSI-2

Wed, 07/20/2016 - 9:49am

BACKGROUND: There is a need for better knowledge about the relationship between sexual offending by young people and mental health problems.

AIM: This study aimed to compare mental health problems between young people who commit sexual offences and those who do not.

METHODS: After completion of the Massachusetts Youth Screening Instrument-Version 2 (MAYSI-2), 334 young people who, according to MAYSI-2 information, had committed a sex offence were compared with 334 young people whose MAYSI-2 data suggested that they had not committed a sex offence. They were matched for age, race/ethnicity, type of facility and adjudication status. We also examined the young sex offenders for within group differences.

RESULTS: The young sex offenders were less likely to report anger-irritability or substance misuse than the comparison youths. Within the sex offender group, older juveniles were more likely to report alcohol and drug use problems than younger ones, Caucasians were more likely to report anger and suicidal ideation than their non-Caucasian peers, those detained were more likely to report alcohol and drug use problems and somatic complaints than those on probation, and convicted youths were more likely to report alcohol and drug use problems and anger-irritability than those awaiting trial.

CONCLUSIONS: Juvenile sexual offending seems less likely to be committed in the context of an anti-social lifestyle than other offending. Important findings among young sex offenders are their higher levels of mental health problems among those detained and convicted than among those on probation or awaiting trial. Assessment of the mental health of young sex offenders seems to be even more important the further they are into the justice system.

Change in emergency department providers' beliefs and practices after use of new protocols for suicidal patients

Wed, 07/20/2016 - 9:49am

OBJECTIVE: The study examined changes in self-reported attitudes and practices related to suicide risk assessment among providers at emergency departments (EDs) during a three-phase quasi-experimental trial involving implementation of ED protocols for suicidal patients.

METHODS: A total of 1,289 of 1,828 (71% response rate) eligible providers at eight EDs completed a voluntary, anonymous survey at baseline, after introduction of universal suicide screening, and after introduction of suicide prevention resources (nurses) and a secondary risk assessment tool (physicians).

RESULTS: Among participants, the median age was 40 years old, 64% were female, and there were no demographic differences across study phases; 68% were nurses, and 32% were attending physicians. Between phase 1 and phase 3, increasing proportions of nurses reported screening for suicide (36% and 95%, respectively, p < .001) and increasing proportions of physicians reported further assessment of suicide risk (63% and 80%, respectively, p < .01). Although increasing proportions of providers said universal screening would result in more psychiatric consultations, decreasing proportions said it would slow down clinical care. Increasing proportions of nurses reported often or almost always asking suicidal patients about firearm access (18%-69%, depending on the case), although these numbers remained low relative to ideal practice. Between 35% and 87% of physicians asked about firearms, depending on the case, and these percentages did not change significantly over the study phases.

CONCLUSIONS: These findings support the feasibility of implementing universal screening for suicide in EDs, assuming adequate resources, but providers should be educated to ask suicidal patients about firearm access.

Clinical Operations Variables are Associated With Blood Pressure Outcomes

Wed, 07/20/2016 - 9:49am

BACKGROUND: Uncontrolled blood pressure (BP), among patients diagnosed and treated for the condition, remains an important clinical challenge; aspects of clinical operations could potentially be adjusted if they were associated with better outcomes.

OBJECTIVES: To assess clinical operations factors' effects on normalization of uncontrolled BP.

RESEARCH DESIGN: Observational cohort study.

SUBJECTS: Patients diagnosed with hypertension from a large urban clinical practice (2005-2009).

MEASURES: We obtained clinical data on BP, organized by person-month, and administrative data on primary care provider (PCP) staffing. We assessed the resolution of an episode of uncontrolled BP as a function of time-varying covariates including practice-level appointment volume, individual clinicians' appointment volume, overall practice-level PCP staffing, and number of unique PCPs.

RESULTS: Among the 7409 unique patients representing 50,403 person-months, normalization was less likely for the patients in whom the episode starts during months when the number of unique PCPs were high [the top quintile of unique PCPs was associated with a 9 percentage point lower probability of normalization (P < 0.01) than the lowest quintile]. Practice appointment volume negatively affected the likelihood of normalization [episodes starting in months with the most appointments were associated with a 6 percentage point reduction in the probability of normalization (P=0.01)]. Neither clinician appointment volume nor practice clinician staffing levels were significantly associated with the probability of normalization.

CONCLUSIONS: Findings suggest that clinical operations factors can affect clinical outcomes like BP normalization, and point to the importance of considering outcome effects when organizing clinical care.

In patients stratified by preoperative risk, endovascular repair of ruptured abdominal aortic aneurysms has a lower in-hospital mortality and morbidity than open repair

Wed, 07/20/2016 - 9:49am

OBJECTIVE: Previous studies have reported that endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs) has lower postoperative mortality than open repair (OR). However, comparisons involved heterogeneous populations that lacked adjustment for preoperative risk. We hypothesize that for RAAA patients stratified by a validated measure of preoperative mortality risk, EVAR has a lower in-hospital mortality and morbidity than does OR.

METHODS: In-hospital mortality and morbidity after EVAR and OR of RAAA were compared in patients from the Vascular Quality Initiative (2003-2013) stratified by the validated Vascular Study Group of New England RAAA risk score into low-risk (score 0-1), medium-risk (score 2-3), and high-risk (score 4-6) groups.

RESULTS: Among 514 patients who underwent EVAR and 651 patients who underwent OR of RAAA, EVAR had lower in-hospital mortality (25% vs 33%, P = .001). In risk-stratified patients, EVAR trended toward a lower mortality in the low-risk group (n = 626; EVAR, 10% vs OR, 15%; P = .07), had a significantly lower mortality in the medium-risk group (n = 457; EVAR, 37% vs OR, 48%; P = .02), and no advantage in the high-risk group (n = 82; EVAR, 95% vs OR, 79%; P = .17). Across all risk groups, cardiac complications (EVAR, 29% vs OR, 38%; P = .001), respiratory complications (EVAR, 28% vs OR, 46%; P < .0001), renal insufficiency (EVAR, 24% vs OR, 38%; P < .0001), lower extremity ischemia (EVAR, 2.7% vs OR, 8.1%; P < .0001), and bowel ischemia (EVAR, 3.9% vs OR, 10%; P < .0001) were significantly lower after EVAR than after OR. Across all risk groups, median (interquartile range) intensive care unit length of stay (EVAR, 2 [1-5] days vs OR, 6 [3-13] days; P < .0001) and hospital length of stay (EVAR, 6 [4-12] days vs OR, 13 [8-22] days; P < .0001) were lower after EVAR.

CONCLUSIONS: This novel risk-stratified comparison using a national clinical database showed that EVAR of RAAA has a lower mortality and morbidity compared with OR in low-risk and medium-risk patients and that EVAR should be used to treat these patients when anatomically feasible. For RAAA patients at the highest preoperative risk, there is no benefit to using EVAR compared with OR.

Taking complaints seriously: using the patient safety lens

Wed, 07/20/2016 - 9:49am

Yet few healthcare institutions see patient complaints as adverse events. Instead, at most institutions, patient complaints are handled by patient relations or risk management departments, with a primary goal of mollifying the patient and avoiding litigation, missing the opportunity not only to meet the affected patients’ needs but also to improve the quality of care going forward by identifying root causes and developing prevention plans.