Patient-Centered Care

Importance: Nonoperative management (NOM) has emerged as a potential alternative to surgery for acute uncomplicated appendicitis in children; however, while short-term outcomes are often favorable, concerns remain about treatment durability, complication rates, and long-term failure. An updated meta-analysis of randomized clinical trials (RCTs) may help clarify the comparative safety and effectiveness of NOM vs appendectomy.

Objective: To evaluate the safety and effectiveness of NOM compared with appendectomy for uncomplicated appendicitis in children using the highest level of available evidence.

Data sources: A systematic review of PubMed, Embase, Scopus, Cochrane, and Web of Science was conducted from inception through March 2025 to identify randomized clinical trials comparing NOM with surgical management in pediatric patients.

Study selection: RCTs comparing NOM vs surgical management in pediatric patients younger than 18 years were included. Nonrandomized and quasi-randomized studies were excluded.

Data extraction and synthesis: Data were extracted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Meta-analyses were conducted using random-effects models. Risk of bias was assessed independently by multiple reviewers. Trial sequential analysis was performed to determine whether the evidence was sufficiently robust and conclusive.

Main outcomes and measures: The primary outcomes were treatment failure and treatment success in 1 year and major complications (Clavien-Dindo grade ≥IIIb). Secondary outcomes included time to return to school and time to return to normal activity.

Results: Of 1246 studies screened, 7 RCTs, including 1480 pediatric patients, met inclusion criteria. Treatment failure was significantly higher in the NOM group than in the appendectomy group at 1 year (risk ratio [RR], 4.97; 95% CI, 3.57-6.91; I2 = 0.0%). Treatment success was significantly lower in the NOM group at 1 year (RR, 0.67; 95% CI, 0.60-0.75; I2 = 31.1%). Major complications classified as Clavien-Dindo grade IIIb or worse were more frequent in the NOM group (RR, 33.37; 95% CI, 7.89-141.05; I2 = 9.5%). Appendicitis recurred at a rate of 18.47 events/100 observations (95% CI, 12.62-25.07 events/100 observations; I2 = 48.5%) among patients who received NOM. NOM, compared with appendectomy, was associated with a modestly faster return to school (mean difference, -1.36 days; 95% CI, -2.64 to -0.08 days; P = .04; I2 = 57.7%) and return to normal activities (-4.93 days; 95% CI, -8.68 to -1.19 days; P = .01; I2 = 87.2%), although this may be offset by subsequent readmissions or reintervention. Trial sequential analysis demonstrated the robustness and conclusiveness of primary outcomes.

Conclusions and relevance: In contrast to earlier studies, this meta-analysis found significantly higher treatment failure and major complication rates within a year with NOM among children and adolescents. The meta-analysis provides pediatricians and pediatric surgeons with up-to-date data to inform shared decision-making with families and encourage individualized, patient-centered treatment.

Author/s:

Isabella Faria, Ana Carolina Godinho Cintra, Luiz Gustavo Albuquerque Mello de Oliveira

A Person-Centered Approach to Supplemental Oxygen Therapy in the Outpatient Setting: A Review

Erin Blanchette — Tue, 08 Apr 2025 21:43:25 +0000

Date Added:

April 8, 2025

Journal/Publication:

JAMA Internal Medicine

Publisher:

American Medical Association

Publication Date:

April 7, 2025

URL:

A Person-Centered Approach to Supplemental Oxygen Therapy in the Outpatient Setting: A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamainternmed.2025.0279

Keywords

PMID (1):

40193114

MeSH

Oxygen Saturation

outpatients

Pulmonary Heart Disease

Pulmonary Disease

pulmonary disease, chronic obstructive

chronic disease

Patient-Centered Care

A review of a number of issues involved in prescribing oxygen therapy in the outpatient setting. James W. Mold, MD, MPH

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Importance: Approximately 1.5 million adults in the US use supplemental oxygen annually in the outpatient setting. However, many do not receive delivery systems that adequately meet their needs, and few receive education about devices or how to maintain independence. This Review summarizes guidelines and evidence on outpatient supplemental oxygen across several cardiopulmonary conditions, highlights evidence gaps where benefits are unclear, and discusses outcomes that inform a person-centered framework for supplemental oxygen therapy.

Observations: Most studies of supplemental oxygen have been conducted in chronic obstructive pulmonary disease, with limited high-quality data in other cardiopulmonary conditions. Data strongly support supplemental oxygen therapy in people with severe resting desaturation (oxygen saturation [SpO2] of 88% or less), with demonstrated improvement in mortality. Whether supplemental oxygen improves symptoms or function in patients with isolated severe exertional desaturation remains inconclusive, prompting an individualized approach and exertional oxygen testing if a patient is mobile and reporting exertional symptoms. Apart from cor pulmonale, evidence does not support supplemental oxygen therapy in patients with moderate resting or exertional desaturation (SpO2 of 89% to 93%). Supplemental oxygen's broad impact on patient-centered outcomes; the supplemental oxygen landscape of devices, testing, prescription, and delivery; and how to weigh the potential harms vs benefits with patients are summarized. These data inform a person-centered supplemental oxygen framework to help patients minimize loss of independence and improve quality of life across the following domains: (1) health care values and preferences; (2) functional status, mobility, and frailty; (3) cognition and supplemental oxygen education; (4) physical symptoms; (5) psychological and social impact; and (6) caregiver support. Guidance on deimplementation and future directions are also summarized.

Conclusions and relevance: Supplemental oxygen therapy should follow a person-centered approach that empowers patients and caregivers; helps patients improve independence and quality of life by optimizing function, mobility, and social well-being; weighs benefits and burdens; and engages in shared decision-making when the evidence is unclear.

Author/s:

Angela O Suen, Susan S Jacobs, Mary R Kitlowski, Richard D Branson, Anand S Iyer

Migraine — Treatment and Preventive Therapies

Aubrey Delammermore — Thu, 13 Oct 2022 05:00:00 +0000

Date Added:

October 13, 2022

Journal/Publication:

New England Journal of Medicine

Publisher:

Massachusetts Medical Society

Publication Date:

October 13, 2022

Issue:

e35

Volume:

387

URL:

Migraine — Treatment and Preventive Therapies

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Video

DOI (1):

10.1056/NEJMp2212749

Keywords

migraine treatment

preventative therapies

injectable monoclonal antibodies

patient care

treatment

MeSH

Patient-Centered Care

An 11 minute video review of our current understanding of migraine and an update on newer therapies. James W. Mold, MD, MPH

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In this instructional video, Drs. Cynthia Armand and Elizabeth Loder discuss the clinical presentation and pathophysiology of migraine and treatment options for patients.

This video provides essential and useful information for any clinician caring for patients with this common condition. Newer acute and preventive therapies — including triptans, gepants, ditans, and injectable monoclonal antibodies — are discussed, as are the importance of a patient-centered approach and the need to tackle challenges of access to these newer agents.

Author/s:

Armand, C.E., Loder, E., Ropper, A. H.

Revising the advanced access model pillars: a multimethod study

Aubrey Delammermore — Sat, 24 Sep 2022 05:00:00 +0000

Date Added:

September 24, 2022

Journal/Publication:

CMAJOpn

Publisher:

CMA Impact Inc

Publication Date:

September 6, 2022

Issue:

Volume:

Pages:

E799-E806

URL:

Revising the advanced access model pillars: a multimethod study

Type:

Practice Management Research Results

Format:

Article

DOI (1):

10.9778/cmajo.20210314

Keywords

Family Physicians

social workers

referral and consultation

nurse practitioners

scheduling models

MeSH

primary health care

health services accessibility

access to information

Patient-Centered Care

Population Health

A highly conceptual report on the design and improvement of advance access scheduling models based upon research and clinical and administrative experience. James W. Mold, MD, MPH

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Background: The advanced access model was developed 20 years ago and has been implemented in several countries. We aimed to revise and operationalize the pillars and subpillars of the advanced access model based on its contemporary practice by professionals in primary health care.

Methods: This multimethod sequential study was informed by a literature review and an expert panel of provincial and local decision-makers, primary health care clinic members (family physicians, nurses and administrative staff), patients and researchers from the province of Quebec. Throughout the consultation process, participants were asked to develop a common vision of the pillars and subpillars that make up the advanced access model and to react to suggested definitions or content.

Results: The revised advanced access model is defined by 5 pillars, of which 2 were updated from the original model (“Appointment system” and “Interprofessional practice”), 1 was merged with a revised pillar (“Develop contingency plans” with “Planning of needs and supply”) and 1 underwent major transformations (“Backlog reduction” to “Continuous adjustment”). A new pillar concerning communication emerged from the consultation process. Subsequent steps for operationalizing definitions of subpillars confirmed the nature of the revised advanced access pillars and stabilized their content.

Interpretation: The overall consultation process resulted in a revised contemporary advanced access model, with strong consensus among participating experts. The revised model will be used to develop a reflective tool for primary health care professionals to evaluate their advanced access practice.

Timely access is a cornerstone of strong primary health care and a key component of a patient-centred medical home for ensuring population health.1 Numerous innovations have been implemented to improve timely access,2 with one of the most recommended around the world being the advanced access model, also called open access.2,3 Based on greater accessibility linked with patients’ relational and informational continuity with a primary health care professional or team, the advanced access model aims to ensure that patients obtain access to health care services at a time and date convenient for them when needed, regardless of the urgency of the demand.4 Originally developed in the United States in the early 2000s, advanced access is defined by Murray and Berwick as having 5 pillars: balance supply and demand, reduce the backlog of previously scheduled appointments, review the appointment system, integrate interprofessional practice and develop contingency plans.5,6 Several scientific papers on the foundations of advanced access have been published over the past 20 years, and its benefits have been reported in many countries, including the US, the United Kingdom and Canada.6–9

Over the last 2 decades, primary health care practice has evolved to increase interdisciplinarity in clinical teams. Thus, the need for a model that incorporates new practices and professionals has necessitated development of an updated advanced access model. Furthermore, advanced access was originally developed in a context that prioritized implementing a new way of doing, with less emphasis on the ongoing practice and sustainability of the model.10,11 However, changes in primary health care practice require revisions to the advanced access model to adapt it to the contemporary context.

In this study, we redefine the pillars and subpillars of the advanced access model by integrating an interdisciplinary team–based focus, while considering the integration of primary health care professionals, such as nurse practitioners, registered nurses, social workers and other allied professionals, in primary health care practices. The objective of this study was to revise and operationalize the pillars and subpillars of the advanced access model.

Author/s:

Breton, M., Gaboury, I., Beaulieu, C., Sasseville, M., Hudon, C., Malham, S. A., Duhoux, A., Rodrigues, I., Haggerty, J.

Revising the advanced access model pillars: a multimethod study

Aubrey Delammermore — Sat, 24 Sep 2022 05:00:00 +0000

Date Added:

September 24, 2022

Journal/Publication:

CMAJOpn

Publisher:

CMA Impact Inc

Publication Date:

September 6, 2022

Issue:

Volume:

Pages:

E799-E806

URL:

Revising the advanced access model pillars: a multimethod study

Type:

Practice Management Research Results

Format:

Article

DOI (1):

10.9778/cmajo.20210314

Keywords

Family Physicians

social workers

referral and consultation

nurse practitioners

scheduling models

MeSH

primary health care

health services accessibility

access to information

Patient-Centered Care

Population Health

A highly conceptual report on the design and improvement of advance access scheduling models based upon research and clinical and administrative experience. James W. Mold, MD, MPH

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Author/s:

Breton, M., Gaboury, I., Beaulieu, C., Sasseville, M., Hudon, C., Malham, S. A., Duhoux, A., Rodrigues, I., Haggerty, J.

Stepped Exercise Program for Patients With Knee Osteoarthritis: A Randomized Controlled Trial

Devin Evans — Thu, 14 Jan 2021 06:00:00 +0000

Date Added:

January 14, 2021

Journal/Publication:

BMC Musculoskeletal Disorder

Publication Date:

May 28, 2019

Issue:

254

Volume:

URL:

Stepped Exercise Program for Patients With Knee Osteoarthritis: A Randomized Controlled Trial

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1186/s12891-019-2627-8

Keywords

PMID (1):

31138256

MeSH

Physical Therapy Modalities

Patient-Centered Care

exercise therapy

An interesting type of stepped intervention that could be applied to other health conditions as well. James W. Mold, MD, MPH

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Background: Physical therapy (PT) and other exercise-based interventions are core components of care for knee osteoarthritis (OA), but both are underutilized, and some patients have limited access to PT services. This clinical trial is examining a STepped Exercise Program for patients with Knee OsteoArthritis (STEP-KOA). This model of care can help to tailor exercise-based interventions to patient needs and also conserve higher resource services (such as PT) for patients who do not make clinically relevant improvements after receiving less costly interventions.

Methods / design: Step-KOA is a randomized trial of 345 patients with symptomatic knee OA from two Department of Veterans Affairs sites. Participants are randomized to STEP-KOA and Arthritis Education (AE) Control groups with a 2:1 ratio, respectively. STEP-KOA begins with 3 months of access to an internet-based exercise program (Step 1). Participants not meeting response criteria for clinically meaningful improvement in pain and function after Step 1 progress to Step 2, which involves bi-weekly physical activity coaching calls for 3 months. Participants not meeting response criteria after Step 2 progress to in-person PT visits (Step 3). Outcomes will be assessed at baseline, 3, 6 and 9 months (primary outcome time point). The primary outcome is the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), and secondary outcomes are objective measures of physical function. Linear mixed models will compare outcomes between the STEP-KOA and AE control groups at follow-up. We will also evaluate patient characteristics associated with treatment response and conduct a cost-effectiveness analysis of STEP-KOA.

Discussion: STEP-KOA is a novel, efficient and patient-centered approach to delivering exercise-based interventions to patients with knee OA, one of the most prevalent and disabling health conditions. This trial will provide information on the effectiveness of STEP-KOA as a novel potential model of care for treatment of OA.

Author/s:

Allen, Kelli D., Bongiorni, Dennis, Caves, Kevin, Coffman, Cynthia J., Floegel, Theresa A., Greysen, Heather M., Hall, Katherine S., Heiderscheit, Bryan, Hoenig, Helen M., Huffman, Kim M., Morey, Miriam D., Ramasunder, Shalini, Severson, Herbert, Smith, Battista, Van Houtven, Courtney, Woolson, Sandra