Innovative technologies and social inequalities in health: A scoping review of the literature

Effectiveness of a Multifaceted Implementation Strategy to Increase Equitable Hospital at Home Utilization: An Interrupted Time Series Analysis

BACKGROUND

The number of Hospital-at-Home (HaH) programs rapidly increased during the COVID-19 pandemic and after issuance of Centers for Medicare and Medicaid Services' (CMS) Acute Hospital Care at Home (AHCaH) waiver. However, there remains little evidence on effective strategies to equitably expand HaH utilization.

OBJECTIVE

Evaluate the effects of a multifaceted implementation strategy on HaH utilization over time.

DESIGN

Before and after implementation evaluation using electronic health record (EHR) data and interrupted time series analysis, complemented by qualitative interviews with key stakeholders.

PARTICIPANTS

Between December 2021 and December 2022, we identified adults hospitalized at six hospitals in North Carolina approved by CMS to participate in the AHCaH waiver program. Eligible adults met criteria for HaH transfer (HaH-eligible clinical condition, qualifying home environment). We conducted semi-structured interviews with 12 HaH patients and 10 referring clinicians.

INTERVENTIONS

Two strategies were studied. The discrete implementation strategy (weeks 1-12) included clinician-directed educational outreach. The multifaceted implementation strategy (weeks 13-54) included ongoing clinician-directed educational outreach, local HaH assistance via nurse navigators, involvement of clinical service line executives, and individualized audit and feedback.

MEASURES

We assessed weekly averaged HaH capacity utilization, weekly counts of unique referring providers, and patient characteristics. We analyzed themes from qualitative data to determine barriers and facilitators to HaH use.

RESULTS

Our evaluation showed week-to-week increases in HaH capacity utilization during the multifaceted implementation strategy period, compared to discrete-period trends (slope-change odds ratio-1.02, 1.01-1.04). Counts of referring providers also increased week to week, compared to discrete-period trends (slope-change means ratio-1.05, 1.03-1.07). The increase in HaH utilization was largest among rural residents (11 to 34%). Barriers included HaH-related information gaps and referral challenges; facilitators included patient-centeredness of HaH care.

CONCLUSIONS

A multifaceted implementation strategy was associated with increased HaH capacity utilization, provider adoption, and patient diversity. Health systems may consider similar, contextually relevant multicomponent approaches to equitably expand HaH.

A qualitative reflexive thematic analysis of innovation and regulation in hearing health care

BACKGROUND

The hearing health sector is an example of a health sector that is experiencing a period of rapid innovation driven by digital technologies. These innovations will impact the types of interventions and services available to support the communication of deaf and hard-of-hearing individuals. This study explored the perceptions of informed participants on the topic of innovation and regulation within hearing healthcare in Australia and the United Kingdom (UK).

METHODS

Participants (N = 29, Australia [n = 16], UK [n = 13]) were purposively sampled and joined one of two online workshops. Participants included adults with hearing loss and family members, hearing health professionals, academics/researchers, representatives of hearing device manufacturers, regulators and policymakers. Workshop data were analysed using reflexive thematic analysis.

RESULTS

Participants conceptualised the hearing health sector as a network of organisations and individuals with different roles, knowledge and interests, in a state of flux driven by innovation and regulation. Innovation and regulation were perceived as mechanisms to ensure quality and mitigate risk within a holistic approach to care. Innovations encompassed technological as well as non-technological innovations of potential benefit to consumers. Participants agreed it was essential for innovation and regulation to be congruent with societal values. Critical to ethical congruence was the involvement of consumers throughout both innovation and regulation stages, and the use of innovation and regulation to tackle stigma and reduce health disparities. Participants expressed the desire for accessible and inclusive innovation in the context of fair, transparent and trustworthy commercial practices.

CONCLUSIONS

This study explored how stakeholders within the hearing health sector understand and make sense of innovation and the role of regulation. Overall, and despite reservations relating to health care professionals' changing roles and responsibilities, innovation and regulation were conceptualised as beneficial when situated in the context of holistic, whole-person, models of care. The results of this study will inform considerations to support the development and implementation of innovations and regulation within the hearing sector and across other health sectors influenced by technological advances.

Sociodemographic characteristics associated with cervical cancer screening participation by send-to-all and opt-in HPV self-sampling: Who benefits? Results from a randomized controlled trial among long-term non-attending women in Norway

With the objective to investigate associations between sociodemographic characteristics and participation in interventions designed to increase participation in cervical cancer screening among under-screened women, we randomized a random sample of 6000 women in Norway aged 35-69 years who had not attended cervical screening for ≥10 years to receive either (i) a reminder to attend regular screening (control), (ii) an offer to order a self-sampling kit (opt-in), or (iii) a self-sampling kit unsolicited (send-to-all). We analyzed how sociodemographic characteristics were associated with screening participation within and between screening arms. In the send-to-all arm, increased screening participation ranged from 17.1% (95% confidence interval [95% CI] = 10.3% to 23.8%) to 30.0% (95% CI = 21.5% to 38.6%) between sociodemographic groups. In the opt-in arm, we observed smaller, and at times, non-significant increases within the range 0.7% (95% CI = -5.8% to 7.3%) to 19.1% (95% CI = 11.6% to 26.7%). In send-to-all versus control comparisons, there was greater increase in participation for women in the workforce versus not (6.1%, 95% CI = 1.6% to 10.6%), with higher versus lower income (7.6%, 95% CI = 2.2% to 13.1%), and with university versus primary education (8.5%, 95% CI = 2.4% to 14.6%). In opt-in versus control comparisons, there was greater increase in participation for women in the workforce versus not (4.6%, 95% CI = 0.7% to 8.5%), with higher versus lower income (6.3%, 95% CI = 1.5% to 11.1%), but lower increase for Eastern European versus Norwegian background (-12.7%, 95% CI = -19.7% to -5.7%). Self-sampling increased cervical screening participation across all sociodemographic levels, but inequalities in participation should be considered when introducing self-sampling, especially with the goal to reach long-term non-attending women.

Demographic factors effect stoke-related healthcare utilisation among Australian stroke survivors

Health equity is a fast emerging priority for most healthcare systems around the world. Factors impacting health equity include education level, geographical location, age, gender, employment status and income. However, research examining the effect of these demographic variables on health service utilisation among mid-aged and older post-stroke adults is limited. Data was obtained from a sub-study of the Sax Institute's 45 and Up Study, which is conducted in Australia. The sub-study survey collected demographic, health service utilisation and health status information from 576 participants who had a previous stroke diagnosis. Poisson regression was used to examine the association between demographic characteristics and number of consultations with a doctor and/or an allied health practitioner over a 12 month period. All demographic measures were significantly associated with the number of consultations with doctors and/or allied health practitioners. The number of doctor consultations increased for those who struggled to live on their available income (IRR = 1.41), but decreased for females (IRR = 0.81), those who reside in an inner regional area (IRR = 0.83), those who were separated, divorced or widowed (IRR = 0.61), and for those who completed a trade, apprenticeship or diploma (IRR = 0.83). The number of allied health practitioner consultations increased for those who completed a trade, apprenticeship or diploma (IRR = 1.27), and for those who struggled to live on their available income (IRR = 1.38), but decreased for increasing age (IRR = 0.87), females (IRR = 0.78), and for those who reside in an outer regional or remote area (IRR = 0.49). We identified several demographic factors associated with a lower frequency and type of health care services used by post-stroke adults. These possible barriers need to be explored further, as reduced use of healthcare services may lead to poorer stroke outcomes in these demographics. Specifically, researching strategies to best support individuals facing these additional challenges is necessary to ensure equitable healthcare for all Australians.

Digital health and equitable access to care

Research on digital health equity has developed in important ways especially since the onset of the COVID-19 pandemic, with a series of clear recommendations now established for policy and practice. However, research and policy addressing the health system dimensions of digital health equity is needed to examine the appropriate roles of digital technologies in enabling access to care. We use a highly cited framework by Levesque et al on patient-centered access to care and the World Health Organization's framework on digitally enabled health systems to generate insights into the ways that digital solutions can support access to needed health care for structurally marginalized communities. Specifically, we mapped the frameworks to identify where applications of digital health do and do not support access to care, documenting which dimensions of access are under-addressed by digital health. Our analysis suggests that digital health has disproportionately focused on downstream enablers of access to care, which are low-yield when equity is the goal. We identify important opportunities for policy makers, funders and other stakeholders to attend more to digital solutions that support upstream enablement of peoples' abilities to understand, perceive, and seek out care. These areas are an important focal point for digital interventions and have the potential to be more equity-enhancing than downstream interventions at the time that care is accessed. Overall, we highlight the importance of taking a health system perspective when considering the roles of digital technologies in enhancing or inhibiting equitable access to needed health care.

Leveraging Artificial Intelligence to Optimize Transcranial Direct Current Stimulation for Long COVID Management: A Forward-Looking Perspective

Long COVID (Coronavirus disease), affecting millions globally, presents unprecedented challenges to healthcare systems due to its complex, multifaceted nature and the lack of effective treatments. This perspective review explores the potential of artificial intelligence (AI)-guided transcranial direct current stimulation (tDCS) as an innovative approach to address the urgent need for effective Long COVID management. The authors examine how AI could optimize tDCS protocols, enhance clinical trial design, and facilitate personalized treatment for the heterogeneous manifestations of Long COVID. Key areas discussed include AI-driven personalization of tDCS parameters based on individual patient characteristics and real-time symptom fluctuations, the use of machine learning for patient stratification, and the development of more sensitive outcome measures in clinical trials. This perspective addresses ethical considerations surrounding data privacy, algorithmic bias, and equitable access to AI-enhanced treatments. It also explores challenges and opportunities for implementing AI-guided tDCS across diverse healthcare settings globally. Future research directions are outlined, including the need for large-scale validation studies and investigations of long-term efficacy and safety. The authors argue that while AI-guided tDCS shows promise for addressing the complex nature of Long COVID, significant technical, ethical, and practical challenges remain. They emphasize the importance of interdisciplinary collaboration, patient-centered approaches, and a commitment to global health equity in realizing the potential of this technology. This perspective article provides a roadmap for researchers, clinicians, and policymakers involved in developing and implementing AI-guided neuromodulation therapies for Long COVID and potentially other neurological and psychiatric conditions.

Digital health technologies and inequalities: A scoping review of potential impacts and policy recommendations

Digital health technologies hold promises for reducing health care costs, enhancing access to care, and addressing labor shortages. However, they risk exacerbating inequalities by disproportionately benefitting a subset of the population. Use of digital technologies accelerated during the Covid-19 pandemic. Our scoping review aimed to describe how inequalities related to their use were conceptually assessed during and after the pandemic and understand how digital strategies and policies might support digital equity. We used the PRISMA Extension for scoping reviews, identifying 2055 papers through an initial search of 3 databases in 2021 and complementary search in 2022, of which 41 were retained. Analysis was guided by the eHealth equity framework. Results showed that digital inequalities were reported in the U.S. and other high-income countries and were mainly assessed through differences in access and use according to individual sociodemographic characteristics. Health disparities related to technology use and the interaction between context and technology implementation were more rarely documented. Policy recommendations stressed the adoption of an equity lens in strategy development and multilayered and intersectoral collaboration to align interventions with the needs of specific subgroups. Finally, findings suggested that evaluations of health and wellbeing distribution related to the use of digital technologies should inform digital strategies and health policies.

Leveraging digital health technologies in heart failure self-care interventions to improve health equity

For patients with heart failure, self-care is crucial, but recommendations for self-care are often not adhered to. Digital health interventions have the potential to help patients improve their self-care and, ultimately, their health outcomes, but without careful examination, digital interventions may generate further inequality. In this study, we use a digital health equity framework to examine challenges and opportunities related to digital health interventions across many domains of influence that may affect health equity. We draw from our own experience in conducting a decentralized clinical trial with multiple sensors and apps to help patients with heart failure improve adherence to key self-care behaviors. Finally, we provide recommendations for leveraging digital health interventions in research and practice to address health equity.

Variation in telemedicine usage in gynecologic cancer: Are we widening or narrowing disparities?

INTRODUCTION

Telemedicine rapidly increased with the COVID-19 pandemic and could reduce cancer care disparities. Our objective was to evaluate sociodemographic (race, insurance), patient, health system, and cancer factors associated with telemedicine use in gynecologic cancers.

METHODS

We conducted a retrospective cohort study of patients with endometrial cancer and epithelial ovarian cancer with at least one visit from March 2020 to October 2021, using a real-world electronic health record-derived database, representing approximately 800 sites in US academic (14%) and community practices (86%). We used multivariable Poisson regression modeling to analyze the association of ever using telemedicine with patient, sociodemographic, health system, and cancer factors.

RESULTS

Of 3950 patients with ovarian cancer, 1119 (28.3%) had at least one telemedicine visit. Of 2510 patients with endometrial cancer, 720 (28.7%) had at least one telemedicine visit. At community cancer practices, patients who identified as Black were less likely to have a telemedicine visit than patients who identified as white in both ovarian and endometrial cancer (Ovarian: RR 0.62, 95% CI 0.42-0.9; Endometrial: RR 0.56, 95% CI 0.38-0.83). Patients in the Southeast, Midwest, West, and Puerto Rico were less likely to have telemedicine visits than patients in the Northeast. Uninsured patients were less likely, and patients with Medicare were more likely, to have one or more telemedicine visit than patients with private insurance.

CONCLUSIONS

In this national cohort study, <30% of patients ever used telemedicine, and significant racial and regional disparities existed in utilization. Telemedicine expansion efforts should include programs to improve equity in access to telemedicine.

The Political Economy of Digital Health Equity: Structural Analysis

Digital technologies have produced many innovations in care delivery and enabled continuity of care for many people when in-person care was impossible. However, a growing body of research suggests that digital health can also exacerbate health inequities for those excluded from its benefits for reasons of cost, digital literacy, and structural discrimination related to characteristics such as age, race, ethnicity, and socioeconomic status. In this paper, we draw on a political economy perspective to examine structural barriers to progress in advancing digital health equity at the policy level. Considering the incentive structures and investments of powerful actors in the field, we outline how characteristics of neoliberal capitalism in Western contexts produce and sustain digital health inequities by describing 6 structural challenges to the effort to promote health equity through digital health, as follows: (1) the revenue-first incentives of technology corporations, (2) the influence of venture capital, (3) inequitable access to the internet and digital devices, (4) underinvestment in digital health literacy, (5) uncertainty about future reimbursement of digital health, and (6) justified mistrust of digital health. Building on these important challenges, we propose future immediate and long-term directions for work to support meaningful change for digital health equity.

Estimating preferences and willingness to pay for pharmacogenetic testing in populations who are medically underserved: a discrete choice experiment

Background: The implementation of pharmacogenetic (PGx) testing may contribute to health disparities if access to testing is inequitable, as medically underserved patients are prescribed higher rates of drugs with PGx guidelines and often experience the benefits of emerging health technologies last. Limited research has evaluated potential implementation of PGx testing in populations who are medically underserved and none have evaluated their preferences regarding PGx test characteristics and cost. Our study endeavored to assess the willingness to pay for PGx testing and key PGx test preferences in a nationwide cohort of medically underserved respondents. Methods: A survey was developed to assess willingness to pay and preferences for PGx testing through a discrete choice experiment (DCE). Five attributes of PGx tests were included in the DCE: doctor recommendation, wait time, number of actionable results, benefit of the test (avoid a side effect or address a health problem), and out-of-pocket cost. A convenience sample of U.S. adults with an average yearly household income of $42,000 or less was collected utilizing an online survey fielded by Qualtrics Research Services (Provo, UT). For the DCE analysis, conditional logit and mixed-logit regression models were utilized to determine relative utility of attributes and levels, conditional relative importance for each attribute, and marginal willingness to pay. Results: Respondents completed the survey with an 83.1% response completion rate. Following quality control procedures, 1,060 respondents were included in the final nationwide cohort. Approximately, 82% of respondents were willing to pay less than $100 for PGx testing, and a strong price ceiling was identified at $200. Out-of-pocket cost was the attribute identified as having the greatest relative importance on choice, while wait time had the lowest importance. Greater utility was observed if the PGx test was doctor recommended, had a higher number of actionable results, and resolved major or minor health problems compared with avoiding side effects. Conclusion: This first-of-its-kind study provides important insights into the willingness to pay for PGx testing and PGx test preferences of a large medically underserved population. Applying these findings can potentially lead to improvements in the successful implementation of PGx testing in this population.

Socioeconomic inequalities in avoidable mortality in Italy: results from a nationwide longitudinal cohort

BACKGROUND

Disparities in avoidable mortality have never been evaluated in Italy at the national level. The present study aimed to assess the association between socioeconomic status and avoidable mortality.

METHODS

The nationwide closed cohort of the 2011 Census of Population and Housing was followed up for 2012-2019 mortality. Outcomes of preventable and of treatable mortality were separately evaluated among people aged 30-74. Education level (elementary school or less, middle school, high school diploma, university degree or more) and residence macro area (North-West, North-East, Center, South-Islands) were the exposures, for which adjusted mortality rate ratios (MRRs) were calculated through multivariate quasi-Poisson regression models, adjusted for age at death. Relative index of inequalities was estimated for preventable, treatable, and non-avoidable mortality and for some specific causes.

RESULTS

The cohort consisted of 35,708,459 residents (48.8% men, 17.5% aged 65-74), 34% with a high school diploma, 33.5% living in the South-Islands; 1,127,760 deaths were observed, of which 65.2% for avoidable causes (40.4% preventable and 24.9% treatable). Inverse trends between education level and mortality were observed for all causes; comparing the least with the most educated groups, a strong association was observed for preventable (males MRR = 2.39; females MRR = 1.65) and for treatable causes of death (males MRR = 1.93; females MRR = 1.45). The greatest inequalities were observed for HIV/AIDS and alcohol-related diseases (both sexes), drug-related diseases and tuberculosis (males), and diabetes mellitus, cardiovascular diseases, and renal failure (females). Excess risk of preventable and of treatable mortality were observed for the South-Islands.

CONCLUSIONS

Socioeconomic inequalities in mortality persist in Italy, with an extremely varied response to policies at the regional level, representing a possible missed gain in health and suggesting a reassessment of priorities and definition of health targets.

Family Caregiver Comfort with Telehealth Technologies: Differences by Race and Ethnicity in a Cross-Sectional Survey

Background: Telehealth has seen widespread use since the onset of the COVID-19 pandemic, and 82% patients required assistance in accessing their telehealth appointments. This assistance commonly comes from a family caregiver who may or may not be comfortable using the technologies associated with telehealth. The objective of our study was to analyze a demographically representative survey of U.S. family caregivers to understand the level of comfort using telehealth technologies among family caregivers. Methods: A secondary analysis of survey data collected during the COVID-19 pandemic in 2020. Level of caregiver comfort using computers, smartphones, and tablets was determined through three Likert-style questions. Proportional odds logistic regression was used to understand the associations between demographic variables and level of caregiver comfort using each technology, when adjusting for covariates. Results: A total of 340 caregivers were included in the analysis. Compared with non-Hispanic white caregivers, Asian caregivers had higher odds (odds ratio [OR] 3.14; 95% confidence interval [CI] 1.36, 8.02; p = 0.01) of expressing comfort using computers; black caregivers (OR 0.46; 95% CI 0.21, 0.98; p = 0.04) and Hispanic caregivers (OR 0.36; 95% CI 0.17, 0.79; p = 0.01) expressed lower odds of comfort using smartphones; and Asian caregivers had higher odds (OR 4.64; 95% CI 2.05, 11.69; p = 0.001) of expressing comfort using tablets. Conclusion and Implications: There are identified disparities in the level of technological comfort using computers, smartphones, and tablets by different racial and ethnic groups. Health systems should consider early stakeholder involvement in the design of telehealth technologies, culturally responsive training materials on telehealth technology use to reduce disparities in comfort using telehealth technologies.

"Technology has allowed us to do a lot more but it's not necessarily the panacea for everybody": Family physician perspectives on virtual care during the COVID-19 pandemic and beyond

INTRODUCTION

Early in the COVID-19 pandemic, Canadian primary care practices rapidly adapted to provide care virtually. Most family physicians lacked prior training or expertise with virtual care. In the absence of formal guidance, they made individual decisions about in-person versus remote care based on clinical judgement, their longitudinal relationships with patients, and personal risk assessments. Our objective was to explore Canadian family physicians' perspectives on the strengths and limitations of virtual care implementation for their patient populations during the COVID-19 pandemic and implications for the integration of virtual care into broader primary care practice.

METHODS

We conducted semi-structured qualitative interviews with family physicians working in four Canadian jurisdictions (Vancouver Coastal health region, British Columbia; Southwestern Ontario; the province of Nova Scotia; and Eastern Health region, Newfoundland and Labrador). We analyzed interview data using a structured applied thematic approach.

RESULTS

We interviewed 68 family physicians and identified four distinct themes during our analysis related to experiences with and perspectives on virtual care: (1) changes in access to primary care; (2) quality and efficacy of care provided virtually; (3) patient and provider comfort with virtual modalities; and (4) necessary supports for virtual care moving forward.

CONCLUSIONS

The move to virtual care enhanced access to care for select patients and was helpful for family physicians to better manage their panels. However, virtual care also created access challenges for some patients (e.g., people who are underhoused or living in areas without good phone or internet access) and for some types of care (e.g., care that required access to medical devices). Family physicians are optimistic about the ongoing integration of virtual care into broader primary care delivery, but guidance, regulations, and infrastructure investments are needed to ensure equitable access and to maximize quality of care.

An integrated primary care service to reduce cardiovascular disease risk in people with severe mental illness: Primrose-A - thematic analysis of its acceptability, feasibility, and implementation

BACKGROUND

Cardiovascular disease among patients with severe mental illness in England is a major preventable contributor to premature mortality. To address this, a nurse and peer-coach delivered service (Primrose-A) was implemented in three London general practices from 2019 (implementation continued during COVID-19). This study aimed to conduct interviews with patient and staff to determine the acceptability of, and experiences with, Primrose-A.

METHODS

Semi-structured audio-recorded interviews with eight patients who had received Primrose-A, and 3 nurses, 1 GP, and 1 peer-coach who had delivered Primrose-A in three London-based GP surgeries were conducted. Reflexive thematic analysis was used to identify themes from the transcribed interviews.

FINDINGS

Overall, Primrose-A was viewed positively by patients and staff, with participants describing success in improving patients' mental health, isolation, motivation, and physical health. Therapeutic relationships between staff and patients, and long regular appointments were important facilitators of patient engagement and acceptance of the intervention. Several barriers to the implementation of Primrose-A were identified, including training, administrative and communication issues, burden of time and resources, and COVID-19.

CONCLUSIONS

Intervention acceptability could be enhanced by providing longer-term continuity of care paired with more peer-coaching sessions to build positive relationships and facilitate sustained health behaviour change. Future implementation of Primrose-A or similar interventions should consider: (1) training sufficiency (covering physical and mental health, including addiction), (2) adequate staffing to deliver the intervention, (3) facilitation of clear communication pathways between staff, and (4) supporting administrative processes.

A qualitative interview study of patients' attitudes towards and intention to use digital interventions for depressive disorders on prescription

Background

Depressive disorders are an emerging public health topic. Due to their increasing prevalence, patients with depressive disorders suffer from the lack of therapeutic treatment. Digital health interventions may offer an opportunity to bridge waiting times, supplement, or even substitute in-person treatment. Among others, the Unified Theory of Acceptance and Use of Technology (UTAUT) explains that actual technology use is affected by users' behavioural intention. However, patients' perspectives on digital interventions are rarely discussed within the specific context of primary care provided by general practitioners (GP) and need further exploration.

Method

A qualitative study design with semi-structured interviews was used to explore DTx-acceptance of patients with mild or moderate depression (n = 17). The audio-recorded interviews were transcribed verbatim, coded, and thematically analysed by qualitative content analysis.

Results

Patients' performance expectancies reveal that DTx are not perceived as a substitute for face-to-face treatment. Effort expectancies include potential advantages and efforts concerning technical, motivational, and skill-based aspects. Moreover, we identified health status and experience with depressive disorders as other determinants and potential barriers to patients' DTx acceptance: Difficult stages of depression or long-time experience are perceived hurdles for DTx use. GPs' recommendations were just partly relevant for patients and varied according to patients' consultancy preferences. But still, GPs have a crucial role for access due to prescription. GPs' influence on patients' DTx acceptance varies between three situations: (1) pre-use for consultation, (2) pre-use for access and (3) during DTx-use. Further, GPs' guidance could be especially relevant for patients during DTx-use in routine care.

Discussion

The UTAUT-based exploration suggests that acceptance determinants should be considered independently and embedded in personal and situational aspects. DTx require a healthcare professional to prescribe or diagnose the disease, unlike other digital offerings. We identified prescription- and depression-related determinants, exceeding existing theoretical constructs. GPs' guidance can compensate for some barriers to DTx use e.g., by increasing commitment and motivational support to strengthen patients' acceptance.

Conclusion

We argue for a multidimensional integration of acceptance determinants for further development of health technology acceptance research. Future research should specify how DTx can be integrated into routine care to strengthen user acceptance.

Navigating the doctor-patient-AI relationship - a mixed-methods study of physician attitudes toward artificial intelligence in primary care

BACKGROUND

Artificial intelligence (AI) is a rapidly advancing field that is beginning to enter the practice of medicine. Primary care is a cornerstone of medicine and deals with challenges such as physician shortage and burnout which impact patient care. AI and its application via digital health is increasingly presented as a possible solution. However, there is a scarcity of research focusing on primary care physician (PCP) attitudes toward AI. This study examines PCP views on AI in primary care. We explore its potential impact on topics pertinent to primary care such as the doctor-patient relationship and clinical workflow. By doing so, we aim to inform primary care stakeholders to encourage successful, equitable uptake of future AI tools. Our study is the first to our knowledge to explore PCP attitudes using specific primary care AI use cases rather than discussing AI in medicine in general terms.

METHODS

From June to August 2023, we conducted a survey among 47 primary care physicians affiliated with a large academic health system in Southern California. The survey quantified attitudes toward AI in general as well as concerning two specific AI use cases. Additionally, we conducted interviews with 15 survey respondents.

RESULTS

Our findings suggest that PCPs have largely positive views of AI. However, attitudes often hinged on the context of adoption. While some concerns reported by PCPs regarding AI in primary care focused on technology (accuracy, safety, bias), many focused on people-and-process factors (workflow, equity, reimbursement, doctor-patient relationship).

CONCLUSION

Our study offers nuanced insights into PCP attitudes towards AI in primary care and highlights the need for primary care stakeholder alignment on key issues raised by PCPs. AI initiatives that fail to address both the technological and people-and-process concerns raised by PCPs may struggle to make an impact.

The impact of county-level factors on meaningful use of electronic health records (EHRs) among primary care providers

This study examines the impact of county-level factors on "meaningful use" (MU) of electronic health records (EHRs) for 8415 primary care providers (PCPs) that enrolled in the Florida Medicaid EHR Incentive Program through adopting, improving, or upgrading (AIU) a certified EHR technology. PCPs received incentive payments at enrollment and if they used their EHRs in meaningful ways; ways that benefit patients and providers alike they received additional payments. We conducted a retrospective cohort study of these providers over the 2011-2018 period while linking their records to other state data. We used the core constructs of the resource dependence theory (RDT), a well-established organization theory in business management, to operationalize the county-level variables. These variables were rurality, poverty, educational attainment, managed care penetration, changes in population, and number of PCPs per capita. The unit of analysis was provider-years. For practical and computational purposes, all the county variables were dichotomized. We used analysis of variance (ANOVA) to test for differences in MU attestation rates across each county variable. Odds ratios and corresponding 95% confidence intervals were derived from pooled logistic regressions using generalized estimated equations (GEE) with the binomial family and logit link functions. Clustered standard errors were used. Approximately 42% of these providers attested to MU after receiving first-year incentives. Rurality and poverty were significantly associated with MU. To some degree, managed care penetration, change in population size, and number of PCPs per capita were also associated with MU. Policy makers and healthcare managers should not ignore the contribution of county-level factors in the diffusion of EHRs among physician practices. These county-level findings provide important insights about EHR diffusion in places where traditionally underserved populations live. This county-perspective is particularly important because of the potential for health IT to enable public health monitoring and population health management that might benefit individuals beyond the patients treated by the Medicaid providers.

Designing Implementation Strategies for a Digital Suicide Safety Planning Intervention in a Psychiatric Emergency Department: Protocol for a Multimethod Research Project

BACKGROUND

Suicide prevention is currently a national health priority in Canada. Emergency departments (EDs) are critical settings for suicide prevention, and in our local psychiatric ED at the Centre for Addiction and Mental Health, we plan to embed an app-based tool called the Hope app to support suicide safety planning intervention. The app is free and available on app stores, and usability tests have been completed. As a next step to embed this new tool into the routine clinical workflow, research is needed to assess determinants of and design strategies for implementation with the end goal of routinization.

OBJECTIVE

The purpose of this 2-phased research is to implement the app in the routine clinical workflow in our local psychiatric ED. The specific objectives are as follows: (1) understanding ED clinicians' perceptions and experience of implementing the app in routine practice and identifying barriers to and facilitators of implementation (phase 1) and (2) using findings and outputs from phase 1 and collaborating with service users, families, and ED clinicians to co-design implementation strategies for the app (phase 2).

METHODS

We will use an integrated knowledge translation approach throughout this project. In phase 1, we will conduct interviews with ED clinicians to identify implementation determinants using a behavior change framework. In phase 2, a co-design team comprising clinicians, ED service users, and families will design implementation strategies that align with the determinants identified in phase 1.

RESULTS

This protocol presents detailed information about the entire structure of the 2-phased research project. Ethics approval for conducting the qualitative descriptive study (phase 1) has been obtained, and the recruitment and data collection processes will be completed no later than December 2023. Ethics approval for phase 2 is underway.

CONCLUSIONS

Involving multiple knowledge user groups early in the research and decision-making process is crucial for successful implementation. Although co-designing is commonly practiced during innovation development, there is often a misconception that the responsibility for implementing what has been designed falls on others. This research aims to fill this methodological gap in the health informatics literature. By the end of this project, we will have developed theory-informed implementation strategies to support Centre for Addiction and Mental Health ED clinicians in adopting the Hope app to complete safety planning intervention. These strategies, guided by a behavior change framework, will target clinicians' behavior change and seamlessly integrate the app into the routine clinical workflow. In addition, this research project will provide recommendations on how to involve multiple knowledge user groups and offer insights into how the methodology used can be adapted to other areas within the health informatics literature.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/50643.

Bed flow priorities and the spatial and temporal dimensions of rural older adult care

Despite prior research that examines the spatial and temporal dimensions of older adult care, there is disparate research on the influence of patient flow priorities on older adult care over time and place. Drawing on a qualitative case study of rural older adult transitions in care in the Canadian context we examine how patient flow prioritization undervalues older patients' needs and the local contexts in which care is provided. Certainly, accounting for the spatial and temporal dimensions of older adult care has broader implications that will enhance future research, policy and practice. Policy makers, researchers and clinicians may then use these recommendations as a stepping stone to align the health care system with the older populations that they serve.

Characteristics Associated With Telemonitoring Use Among Patients With Chronic Heart Failure: Retrospective Cohort Study

BACKGROUND

Chronic heart failure (HF) is a chronic disease affecting more than 64 million people worldwide, with an increasing prevalence and a high burden on individual patients and society. Telemonitoring may be able to mitigate some of this burden by increasing self-management and preventing use of the health care system. However, it is unknown to what degree telemonitoring has been adopted by hospitals and if the use of telemonitoring is associated with certain patient characteristics. Insight into the dissemination of this technology among hospitals and patients may inform strategies for further adoption.

OBJECTIVE

We aimed to explore the use of telemonitoring among hospitals in the Netherlands and to identify patient characteristics associated with the use of telemonitoring for HF.

METHODS

We performed a retrospective cohort study based on routinely collected health care claim data in the Netherlands. Descriptive analyses were used to gain insight in the adoption of telemonitoring for HF among hospitals in 2019. We used logistic multiple regression analyses to explore the associations between patient characteristics and telemonitoring use.

RESULTS

Less than half (31/84, 37%) of all included hospitals had claims for telemonitoring, and 20% (17/84) of hospitals had more than 10 patients with telemonitoring claims. Within these 17 hospitals, a total of 7040 patients were treated for HF in 2019, of whom 5.8% (409/7040) incurred a telemonitoring claim. Odds ratios (ORs) for using telemonitoring were higher for male patients (adjusted OR 1.90, 95% CI 1.50-2.41) and patients with previous hospital treatment for HF (adjusted OR 1.76, 95% CI 1.39-2.24). ORs were lower for higher age categories and were lowest for the highest age category, that is, patients older than 80 years (OR 0.30, 95% CI 0.21-0.44) compared to the reference age category (18-59 years). Socioeconomic status, degree of multimorbidity, and excessive polypharmacy were not associated with the use of telemonitoring.

CONCLUSIONS

The use of reimbursed telemonitoring for HF was limited up to 2019, and our results suggest that large variation exists among hospitals. A lack of adoption is therefore not only due to a lack of diffusion among hospitals but also due to a lack of scaling up within hospitals that already deploy telemonitoring. Future studies should therefore focus on both kinds of adoption and how to facilitate these processes. Older patients, female patients, and patients with no previous hospital treatment for HF were less likely to use telemonitoring for HF. This shows that some patient groups are not served as much by telemonitoring as other patient groups. The underlying mechanism of the reported associations should be identified in order to gain a deeper understanding of telemonitoring use among different patient groups.

Expectations of new technologies in nursing care among hospital patients in Germany - an interview study

Introduction

New technologies will be increasingly available for nursing care, including robots, patient mobilisation devices, digital event detection or prevention equipment. Technologies are expected to support nurses, increase patients' safety and reduce costs. Yet, although these technologies will significantly shape patients' experience, we need to learn more about patients' perspectives regarding new technology in care. This study aims to investigate attitudes, expectations, worries and anticipated implementation effects of new assistive technology in nursing care by patients.

Methods

Qualitative, guided, semi-open interviews were conducted. The recruitment was carried out in a trauma surgery ward of a university hospital in Germany. Eight different technologies were presented via video clips and additional information to the patients, followed by in-depth discussions. The interviews were analysed using qualitative evaluative content analysis. The Consolidated Criteria for Reporting Qualitative Research (COREQ) Checklist was used to ensure study quality.

Results

Study participants anticipate different outcomes for the implementation of new nursing technology: (1) For patients, they consider the potential for improvement in health and well-being as well as for their hospital stay experience, but also fear possible health risks or social or emotional factors like loss of autonomy or loneliness. (2) For professional nurses, participants expect relief from physically stressful work routines; however, they might be replaced by machines and lose their employment (3) For the nursing process, safety and quality improvements for care delivery may encounter a negative quantification of human life and risks of constant surveillance.

Conclusion

Patients identify opportunities, challenges and shortcomings of nursing technology implementation. They describe nuanced and mixed accounts of patients' perspectives that are structured in a 'continuum of anticipated effects' of implementing technology in our article. The results can inform future implementation strategies.

Fixing the Leaky Pipe: How to Improve the Uptake of Patient-Reported Outcomes-Based Prognostic and Predictive Models in Cancer Clinical Practice

PURPOSE

This discussion paper outlines challenges and proposes solutions for successfully implementing prediction models that incorporate patient-reported outcomes (PROs) in cancer practice.

METHODS

We organized a full-day multidisciplinary meeting of people with expertise in cancer care delivery, PRO collection, PRO use in prediction modeling, computing, implementation, and decision science. The discussions presented here focused on identifying challenges to the development, implementation and use of prediction models incorporating PROs, and suggesting possible solutions.

RESULTS

Specific challenges and solutions were identified across three broad areas. (1) Understanding decision making and implementation: necessitating multidisciplinary collaboration in the early stages and throughout; early stakeholder engagement to define the decision problem and ensure acceptability of PROs in prediction; understanding patient/clinician interpretation of PRO predictions and uncertainty to optimize prediction impact; striving for model integration into existing electronic health records; and early regulatory alignment. (2) Recognizing the limitations to PRO collection and their impact on prediction: incorporating validated, clinically important PROs to maximize model generalizability and clinical engagement; and minimizing missing PRO data (resulting from both structural digital exclusion and time-varying factors) to avoid exacerbating existing inequalities. (3) Statistical and modeling challenges: incorporating statistical methods to address missing data; ensuring predictive modeling recognizes complex causal relationships; and considering temporal and geographic recalibration so that model predictions reflect the relevant population.

CONCLUSION

Developing and implementing PRO-based prediction models in cancer care requires extensive multidisciplinary working from the earliest stages, recognition of implementation challenges because of PRO collection and model presentation, and robust statistical methods to manage missing data, causality, and calibration. Prediction models incorporating PROs should be viewed as complex interventions, with their development and impact assessment carried out to reflect this.

Building Diversity, Equity, and Inclusion Within Radiology Artificial Intelligence: Representation Matters, From Data to the Workforce

Diversity, equity, and inclusion (DEI) is both a critical ingredient and moral imperative in shaping the future of radiology artificial intelligence (AI) for improved patient care, from design to deployment. At the design level: Potential biases and discrimination within data sets results in inaccurate radiology AI models, and there is an urgent need to purposefully embed DEI principles throughout the AI development and implementation process. At the deployment level: Diverse representation in radiology AI leadership, research, and career development is necessary to avoid worsening structural and historical health inequities. To create an inclusive and equitable AI-enabled future in healthcare, a DEI radiology AI leadership training program may be needed to cultivate a diverse and sustainable pipeline of leaders in the field.

Genetic Testing and Other Healthcare Use by Black and White Individuals in a Genomic Sequencing Study

INTRODUCTION

Early adopters play a critical role in the diffusion of medical innovations by spreading awareness, increasing acceptability, and driving demand. Understanding the role of race in the context of other characteristics of potential early adopters can shed light on disparities seen in the early implementation of genomic medicine. We aimed to understand the association between self-identified race and individual experience with genetic testing outside of the research context.

METHODS

We assessed factors associated with the odds of having ever received genetic testing prior to enrollment in a genomic sequencing study among 674 self-identified white and 407 self-identified African, African American, or Afro-Caribbean ("Black") individuals.

RESULTS

Controlling for individual determinants of healthcare use (demographics, personality traits, knowledge and attitudes, and health status), identifying as Black was associated with lower odds of prior genetic testing (OR = 0.43, 95% CI [0.27-0.68], p < 0.001). In contrast, self-identified race was not associated with the use of non-genetic clinical screening tests (e.g., echocardiogram, colonoscopy). Black and white individuals were similar on self-reported personality traits tied to early adoption but differed by sociodemographic and resource facilitators of early adoption.

CONCLUSION

Persistent racial disparities among early adopters may represent especially-entrenched disparities in access to and knowledge of genomic technologies in clinical settings.

EXPERTS II - How are patient and caregiver participation in health and social care shaped by experienced burden of treatment and social inequalities? Protocol for a qualitative synthesis

Background

The workload health and social care service users and caregivers take on, and their capacity to do this work is important. It may play a key part in shaping the implementation of innovations in health service delivery and organisation; the utilisation and satisfaction with services; and the outcomes of care. Previous research has often focused on experiences of a narrow range of long-term conditions, and on factors that shape adherence to self-care regimes.

Aims

With the aim of deriving policy and practice implications for service redesign, this evidence synthesis will extend our understanding of service user and caregiver workload and capacity by comparing how they are revealed in qualitative studies of lived experience of three kinds of illness trajectories: long-term conditions associated with significant disability (Parkinson's disease, schizophrenia); serious relapsing remitting disease (Inflammatory Bowel Disease, bipolar disorder); and rapidly progressing acute disease (brain cancer, early onset dementia).

Methods

We will review and synthesise qualitative studies of lived experience of participation in health and social care that are shaped by interactions between experienced treatment burdens, social inequalities and illness trajectories. The review will involve:   1.  Construction of a theory-informed coding manual; systematic search of bibliographic databases to identify, screen and quality assess full-text papers.   2.  Analysis of papers using manual coding techniques, and text mining software; construction of taxonomies of service user and caregiver work and capacity.   3.  Designing a model of core components and identifying common factors across conditions, trajectories, and contexts.   4.  Work with practitioners, and a Patient and Public Involvement (PPI) group, to explore the validity of the models produced; to develop workload reduction strategies; and to consider person-centred service design.

Dissemination

We will promote workload reduction models to support service users and caregivers and produce policy briefs and peer-reviewed publications for practitioners, policy-makers, and researchers.

Digital behaviour change interventions to increase vegetable intake in adults: a systematic review

BACKGROUND

Digital interventions may help address low vegetable intake in adults, however there is limited understanding of the features that make them effective. We systematically reviewed digital interventions to increase vegetable intake to 1) describe the effectiveness of the interventions; 2) examine links between effectiveness and use of co-design, personalisation, behavioural theories, and/or a policy framework; and 3) identify other features that contribute to effectiveness.

METHODS

A systematic search strategy was used to identify eligible studies from MEDLINE, Embase, PsycINFO, Scopus, CINAHL, Cochrane Library, INFORMIT, IEEE Xplore and Clinical Trial Registries, published between January 2000 and August 2022. Digital interventions to increase vegetable intake were included, with effective interventions identified based on statistically significant improvement in vegetable intake. To identify policy-action gaps, studies were mapped across the three domains of the NOURISHING framework (i.e., behaviour change communication, food environment, and food system). Risk of bias was assessed using Cochrane tools for randomized, cluster randomized and non-randomized trials.

RESULTS

Of the 1,347 records identified, 30 studies were included. Risk of bias was high or serious in most studies (n = 25/30; 83%). Approximately one quarter of the included interventions (n = 8) were effective at improving vegetable intake. While the features of effective and ineffective interventions were similar, embedding of behaviour change theories (89% vs 61%) and inclusion of stakeholders in the design of the intervention (50% vs 38%) were more common among effective interventions. Only one (ineffective) intervention used true co-design. Although fewer effective interventions included personalisation (67% vs 81%), the degree of personalisation varied considerably between studies. All interventions mapped across the NOURISHING framework behaviour change communication domain, with one ineffective intervention also mapping across the food environment domain.

CONCLUSION

Few digital interventions identified in this review were effective for increasing vegetable intake. Embedding behaviour change theories and involving stakeholders in intervention design may increase the likelihood of success. The under-utilisation of comprehensive co-design methods presents an opportunity to ensure that personalisation approaches better meet the needs of target populations. Moreover, future digital interventions should address both behaviour change and food environment influences on vegetable intake.

Information and communication technology-based interventions for suicide prevention implemented in clinical settings: a scoping review

BACKGROUND

A large number of information and communication technology (ICT) based interventions exist for suicide prevention. However, not much is known about which of these ICTs are implemented in clinical settings and their implementation characteristics. In response, this scoping review aimed to systematically explore the breadth of evidence on ICT-based interventions for suicide prevention implemented in clinical settings and then to identify and characterize implementation barriers and facilitators, as well as evaluation outcomes, and measures.

METHODS

We conducted this review following the Joanna Briggs Institute methodology for scoping reviews. A search strategy was applied to the following six databases between August 17-20, 2021: MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Library, Information Science and Technology Abstracts. We also supplemented our search with Google searches and hand-searching reference lists of relevant reviews. To be included in this review, studies must include ICT-based interventions for any spectrum of suicide-related thoughts and behaviours including non-suicidal self-injury. Additionally, these ICTs must be implemented in clinical settings, such as emergency department and in-patient units. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist to prepare this full report.

RESULTS

This review included a total of 75 citations, describing 70 studies and 66 ICT-based interventions for suicide prevention implemented in clinical settings. The majority of ICTs were computerized interventions and/or applications (n = 55). These ICTs were commonly used as indicated strategies (n = 49) targeting patients who were actively presenting with suicide risk. The three most common suicide prevention intervention categories identified were post-discharge follow-up (n = 27), screening and/or assessment (n = 22), and safety planning (n = 20). A paucity of reported information was identified related to implementation strategies, barriers and facilitators. The most reported implementation strategies included training, education, and collaborative initiatives. Barriers and facilitators of implementation included the need for resource supports, knowledge, skills, motivation as well as engagement with clinicians with research teams. Studies included outcomes at patient, clinician, and health system levels, and implementation outcomes included acceptability, feasibility, fidelity, and penetration.

CONCLUSION

This review presents several trends of the ICT-based interventions for suicide prevention implemented in clinical settings and identifies a need for future research to strengthen the evidence base for improving implementation. More effort is required to better understand and support the implementation and sustainability of ICTs in clinical settings. The findings can also serve as a future resource for researchers seeking to evaluate the impact and implementation of ICTs.

Health equity related challenges and experiences during the rapid implementation of virtual care during COVID-19: a multiple case study

BACKGROUND

Virtual care quickly became of crucial importance to health systems around the world during the COVID-19 pandemic. Despite the potential of virtual care to enhance access for some communities, the scale and pace at which services were virtualized did not leave many organizations with sufficient time and resources to ensure optimal and equitable delivery of care for everyone. The objective of this paper is to outline the experiences of health care organizations rapidly implementing virtual care during the first wave of the COVID-19 pandemic and examine whether and how health equity was considered.

METHODS

We used an exploratory, multiple case study approach involving four health and social service organizations providing virtual care services to structurally marginalized communities in the province of Ontario, Canada. We conducted semi-structured qualitative interviews with providers, managers, and patients to understand the challenges experienced by organizations and the strategies put in place to support health equity during the rapid virtualization of care. Thirty-eight interviews were thematically analyzed using rapid analytic techniques.

RESULTS

Organizations experienced challenges related to infrastructure availability, digital health literacy, culturally appropriate approaches, capacity for health equity, and virtual care suitability. Strategies to support health equity included the provision of blended models of care, creation of volunteer and staff support teams, participation in community engagement and outreach, and securement of infrastructure for clients. We put our findings into the context of an existing framework conceptualizing access to health care and expand on what this means for equitable access to virtual care for structurally marginalized communities.

CONCLUSION

This paper highlights the need to pay greater attention to the role of health equity in virtual care delivery and situate that conversation around existing inequitable structures in the health care system that are perpetuated when delivering care virtually. An equitable and sustainable approach to virtual care delivery will require applying an intersectionality lens on the strategies and solutions needed to address existing inequities in the system.

Social inequalities in the self-management of type 1 diabetes: A serial multiple mediation analysis

AIMS

Diabetes requires complex self-management. Due to this complexity, social disparities exist in the self-management of type 1 diabetes. Various pathways to describe associations between socio-economic factors and health outcomes have been suggested. We sought to elucidate the potential of health literacy and social support to reduce social disparities in diabetes self-management.

METHODS

Questionnaire responses were linked to data from electronic medical records, yielding a study population of 1186 people with type 1 diabetes. Mediation analyses using adjusted linear regressions were used to establish pathways between self-reported educational attainment, social support, functional health literacy and clinically obtained measures of glycaemic control.

RESULTS

We found evidence of an association between education and glycated haemoglobin, partially mediated by functional health literacy and social support. However, the direct association between social support and glycaemic control was not statistically significant.

CONCLUSIONS

Whilst both functional health literacy and social support play a role in glycaemic control, our findings did not explain the main impact of social disparities on glycaemic control. Interventions to reduce disparities in glycaemic control related to educational attainment should focus beyond functional health literacy and social support.

Targeting Patients' Cognitive Load for Telehealth Video Visits Through Student-Delivered Helping Sessions at a United States Federally Qualified Health Center: Equity-Focused, Mixed Methods Pilot Intervention Study

BACKGROUND

The task complexity involved in connecting to telehealth video visits may disproportionately impact health care access in populations already experiencing inequities. Human intermediaries can be a strategy for addressing health care access disparities by acting as technology helpers to reduce the cognitive load demands required to learn and use patient-facing telehealth technologies.

OBJECTIVE

We conducted a cognitive load theory-informed pilot intervention involving warm accompaniment telehealth helping sessions with patients at a Federally Qualified Health Center (FQHC). We demonstrate how to design and report recruitment methods, reach, delivery process, and the preliminary impact of a novel equity-focused intervention.

METHODS

Early into the COVID-19 pandemic a telehealth helping session was offered to patients at FQHC via phone. Graduate students led the sessions on conducting a telehealth video test run or helping with patient portal log-in. They systematically recorded their recruitment efforts, intervention observations, and daily reflection notes. Following the intervention, we asked the intervention participants to participate in an interview and all patients who had telehealth visits during and 4 weeks before and after the intervention period to complete a survey. Electronic health records were reviewed to assess telehealth visit format changes. Descriptive and inferential statistical analyses of the recruitment records, electronic health record data, and surveys were performed. Through integrative analysis, we developed process-related themes and recommendations for future equity-focused telehealth interventions.

RESULTS

Of the 239 eligible patients, 34 (14.2%) completed the intervention and 3 (1.2%) completed subsequent interviews. The intervention participants who completed the survey (n=15) had lower education and less technological experience than the nonintervention survey participants (n=113). We identified 3 helping strategies for cognitive load reduction: providing step-by-step guidance for configuring and learning, building rapport to create confidence while problem-solving, and being on the same page to counter informational distractions. Intervention participants reported increased understanding but found that learning the video visit software was more difficult than nonintervention participants. A comparison of visit experiences did not find differences in difficulty (cognitive load measure) using telehealth-related technologies, changes to visit modality, or reported technical problems during the visit. However, the intervention participants were significantly less satisfied with the video visits.

CONCLUSIONS

Although a limited number of people participated in the intervention, it may have reached individuals more likely to need technology assistance. We postulate that significant differences between intervention and nonintervention participants were rooted in baseline differences between the groups' education level, technology experience, and technology use frequency; however, small sample sizes limit conclusions. The barriers encountered during the intervention suggest that patients at FQHC may require both improved access to web-based technologies and human intermediary support to make telehealth video visits feasible. Future large, randomized, equity-focused studies should investigate blended strategies to facilitate video visit access.

Exploring perceptions, knowledge, and attitudes regarding pharmacogenetic testing in the medically underserved

Introduction: Pharmacogenetic testing may hold promise in addressing health disparities, as medically underserved patients appear to be prescribed medications with pharmacogenetic guidelines at higher rates. While routine clinical implementation of testing in medically underserved populations has not yet been achieved, using patient perspectives to inform implementation should increase the likelihood of success. The aim of this study was to assess the perceptions, knowledge, and attitudes regarding pharmacogenetic testing in medically underserved patients. Methods: We developed a survey instrument to assess respondent views on pharmacogenetic testing. The survey instrument was developed through a process of literature review, expert input, iterative pilot testing, and final refinement. The survey instrument was fielded to US adults with an estimated household income of $42,000 per year or less. Results: During the survey instrument development, 59 pilot testers provided 133 comments which lead to 38 revisions to the survey instrument. The nationwide survey resulted in 1,060 respondents, of which half (49.8%) reported having no health insurance or being on Medicaid. Most patients (78.9%) had not previously heard of pharmacogenetic testing. After being provided an explanation of pharmacogenetic testing, 60.5% were very or moderately interested in receiving testing if there were no cost and 75.8% of respondents agreed or strongly agreed that pharmacogenetic testing should be available to help with medication selection regardless of cost. Respondents shared that their greatest concern with pharmacogenetic testing was that the test would cost them money, which was expressed by over half (52.7%). This was followed by concerns that the results could reveal a risk for a disease, could affect health insurance, and would not improve care. Discussion: Our results indicate a strong interest in pharmacogenetic testing and identify key perceptions, attitudes, concerns, and potential barriers that can be addressed as pharmacogenetic testing is clinically implemented in medically underserved patient populations.

Continuous glucose monitors and virtual care in high-risk, racial and ethnic minority populations: Toward promoting health equity

Continuous glucose monitors (CGMs) have become an important tool to aid self-management of blood glucose for many patients with diabetes in the U.S., and the benefits of CGM use are well-documented. However, disparities in CGM use exist, with lower use in certain marginalized racial and ethnic groups. CGM may be an important and underutilized tool to help reduce inequities. Evidence supporting the use of CGMs as a part of virtual care is discussed, with an emphasis on designing virtual diabetes care programs to promote health equity. Recommendations for clinical practice and research are presented. In clinical practice, CGM should be an option for all people with diabetes who qualify based on clinical practice guidelines, regardless of race, ethnicity, or other individual characteristics. Future research should characterize the use of, benefit from, and preferences for CGM among individuals from racial and ethnic groups to guide interventions at the health system, clinic, provider, and patient levels to promote equitable, evidence-based, and guideline-directed CGM use in marginalized racial and ethnic groups with diabetes.

Emerging Health Disparities during the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has underscored social and racial discrimination in global health, showing that health equity is still a goal to be achieved. Understanding the impact of COVID-19 on public health potential is vital to present a fair opportunity for people of different backgrounds to be as healthy as possible. As such, this communication discusses the emerging health disparities in light of the COVID-19 pandemic and analyzes their implications. Original research, effective health communication, and promotion strategies ought to be leveraged to step closer toward national and international health equity.

Explaining psychosocial care among unaccompanied minor refugees: a realist review

Research on the psychosocial care (PSC) of unaccompanied minor refugees (UMRs) has mainly taken a socioepidemiological approach and has focused on the perspectives of experts in the field. In contrast, the knowledge concerning the differing context factors and the underlying mechanisms of current PSC which could inform policy recommendations is scant. The study aims at unravelling the contexts, mechanisms and outcomes of PSC for UMRs. For a realist review (RR), scientific evidence and gray literature were synthesised consistent with the RAMESES publication standards for realist synthesis. Based on an iterative keyword search in electronic databases (e.g., PubMed) and screening, 34 works from 2005 to 2019 were included in a realist synthesis. Theory-informed context-mechanism-outcome configurations (CMOs) were extracted, to explain underlying processes and mechanisms. Characterised by their interrelatedness, the dominant CMOs included the UMRs' intersections of transitions (e.g., adolescence and migration), their needs for culture-, and gender-sensitive PSC, and the undersupply of PSC. These contexts and outcomes are mediated by pre-, peri- and post-migratory stressors as well as care structures and are moreover influenced by overarching discourses and concepts. They comprise adverse and beneficial mechanisms in the PSC of UMRs. The existing literature grasps the PSC of UMRs by different disciplines and approaches but does not offer a comprehensive overview on micro-macro intersections and included discourses. The inclusion of lay perspectives and an intersectional approach could inform health service research. The reflection of UMR-related categorical constructs of resilience and vulnerability, discourses of othering, as well as restrictive health policies may guide policy recommendations.

Priorities for successful use of artificial intelligence by public health organizations: a literature review

Artificial intelligence (AI) has the potential to improve public health's ability to promote the health of all people in all communities. To successfully realize this potential and use AI for public health functions it is important for public health organizations to thoughtfully develop strategies for AI implementation. Six key priorities for successful use of AI technologies by public health organizations are discussed: 1) Contemporary data governance; 2) Investment in modernized data and analytic infrastructure and procedures; 3) Addressing the skills gap in the workforce; 4) Development of strategic collaborative partnerships; 5) Use of good AI practices for transparency and reproducibility, and; 6) Explicit consideration of equity and bias.

Community stakeholder-driven technology solutions towards rural health equity: A concept mapping study in Western Canada

BACKGROUND

Technology holds great potential for promoting health equity for rural populations, who have more chronic illnesses than their urban counterparts but less access to services. Yet, more participatory research approaches are needed to gather community-driven health technology solutions. The purpose was to collaboratively identify and prioritize action strategies for using technology to promote rural health equity through community stakeholder engagement.

METHODS

Concept mapping, a quantitative statistical technique, embedded within a qualitative approach, was used to identify and integrate technological solutions towards rural health equity from community stakeholders in three steps: (1) idea generation; (2) sorting and rating feasibility/importance and (3) group interpretation. Purposeful recruitment strategies were used to recruit key stakeholders and organizational representatives from targeted rural communities.

RESULTS

Overall, 34 rural community stakeholders from western Canada (76% female, mean age = 55.4 years) participated in the concept mapping process. In Step 1, 84 ideas were generated that were reduced to a pool of 30. Multidimensional scaling and cluster analysis resulted in a six-cluster map representing how technological solutions can contribute toward rural health equity. The clusters of ideas included technological solutions and applications, but also ideas to make health care more accessible regardless of location, training and support in the use of technology, ensuring digital tools are simplified for ease of use, technologies to support collaboration among healthcare professionals and ideas for overcoming challenges to data sharing across health systems/networks. Each cluster included ideas that were rated as equally important and feasible. Key themes included organizational and individual-level solutions and connecting patients to newly developed technologies.

CONCLUSIONS

Overall, the grouping of solutions revealed that technological applications require not only access but also support and collaboration. Concept mapping is a tool that can engage rural community stakeholders in the identification of technological solutions for promoting rural health equity.

PATIENT OR PUBLIC CONTRIBUTION

Rural community stakeholders were involved in the generation and interpretation of technological solutions towards rural health equity in a three-step process: (1) individual brainstorming of ideas, (2) sorting and rating all ideas generated and (3) collective interpretation and group consensus on final results.

Virtual Care and the Inverse Care Law: Implications for Policy, Practice, Research, Public and Patients

Virtual care spread rapidly at the outbreak of the COVID-19 pandemic. Restricting in-person contact contributed to reducing the spread of infection and saved lives. However, the benefits of virtual care were not evenly distributed within and across social groups, and existing inequalities became exacerbated for those unable to fully access to, or benefit from virtual services. This "perspective" paper discusses the extent to which challenges in virtual care access and use in the context of COVID-19 follow the Inverse Care Law. The latter stipulates that the availability and quality of health care is inversely proportionate to the level of population health needs. We highlight the inequalities affecting some disadvantaged populations' access to, and use of public and private virtual care, and contrast this with a utopian vision of technology as the "solution to everything". In public and universal health systems, the Inverse Care Law may manifests itself in access issues, capacity, and/or lack of perceived benefit to use digital technologies, as well as in data poverty. For commercial "Direct-To-Consumer" services, all of the above may be encouraged via a consumerist (i.e., profit-oriented) approach, limited and episodic services, or the use of low direct cost platforms. With virtual care rapidly growing, we set out ways forward for policy, practice, and research to ensure virtual care benefits for everyone, which include: (1) pay more attention to "capabilities" supporting access and use of virtual care; (2) consider digital technologies as a basic human right that should be automatically taken into account, not only in health policies, but also in social policies; (3) take more seriously the impact of the digital economy on equity, notably through a greater state involvement in co-constructing "public health value" through innovation; and (4) reconsider the dominant digital innovation research paradigm to better recognize the contexts, factors, and conditions that influence access to and use of virtual care by different groups.

Towards implementation of comprehensive breast cancer risk prediction tools in health care for personalised prevention

Advances in knowledge about breast cancer risk factors have led to the development of more comprehensive risk models. These integrate information on a variety of risk factors such as lifestyle, genetics, family history, and breast density. These risk models have the potential to deliver more personalised breast cancer prevention. This is through improving accuracy of risk estimates, enabling more effective targeting of preventive options and creating novel prevention pathways through enabling risk estimation in a wider variety of populations than currently possible. The systematic use of risk tools as part of population screening programmes is one such example. A clear understanding of how such tools can contribute to the goal of personalised prevention can aid in understanding and addressing barriers to implementation. In this paper we describe how emerging models, and their associated tools can contribute to the goal of personalised healthcare for breast cancer through health promotion, early disease detection (screening) and improved management of women at higher risk of disease. We outline how addressing specific challenges on the level of communication, evidence, evaluation, regulation, and acceptance, can facilitate implementation and uptake.

Technology-Based Interventions in Substance Use Treatment to Promote Health Equity Among People Who Identify as African American/Black, Hispanic/Latinx, and American Indian/Alaskan Native: Protocol for a Scoping Review

BACKGROUND

Technology-based interventions (TBIs; ie, web-based and mobile interventions) have the potential to promote health equity in substance use treatment (SUTx) for underrepresented groups (people who identify as African American/Black, Hispanic/Latinx, and American Indian/Alaskan Native) by removing barriers and increasing access to culturally relevant effective treatments. However, technologies (emergent and more long-standing) may have unintended consequences that could perpetuate health care disparities among people who identify as a member of one of the underrepresented groups. Health care research, and SUTx research specifically, is infrequently conducted with people who identify with these groups as the main focus. Therefore, an improved understanding of the literature at the intersection of SUTx, TBIs, and underrepresented groups is warranted to avoid exacerbating inequities and to promote health equity.

OBJECTIVE

This study aims to explore peer-reviewed literature (January 2000-March 2021) that includes people who identify as a member of one of the underrepresented groups in SUTx research using TBIs. We further seek to explore whether this subset of research is race/ethnicity conscious (does the research consider members of underrepresented groups beyond their inclusion as study participants in the introduction, methods, results, or discussion).

METHODS

Five electronic databases (MEDLINE, Scopus, Cochrane Library, CINAHL, and PsycInfo) were searched to identify SUTx research using TBIs, and studies were screened for eligibility at the title/abstract and full-text levels. Studies were included if their sample comprised of people who identify as a member of one of the underrepresented groups at 50% or more when combined.

RESULTS

Title/abstract and full-text reviews were completed in 2021. These efforts netted a sample of 185 studies that appear to meet inclusionary criteria. Due to the uniqueness of tobacco relative to other substances in the SUTx space, as well as the large number of studies netted, we plan to separately publish a scoping review on tobacco-focused studies that meet all other criteria. Filtering for tobacco-focused studies (n=31) netted a final full-text sample for a main scoping review of 154 studies. The tobacco-focused scoping review manuscript is expected to be submitted for peer review in Spring 2022. The main scoping review data extraction and data validation to confirm the accuracy and consistency of data extraction across records was completed in March 2022. We expect to publish the main scoping review findings by the end of 2022.

CONCLUSIONS

Research is needed to increase our understanding of the range and nature of TBIs being used in SUTx research studies with members of underrepresented groups. The planned scoping review will highlight research at this intersection to promote health equity.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/34508.

Has Virtual Care Arrived? A Survey of Rural Canadian Providers During the Early Stages of the COVID-19 Pandemic

We investigated the uptake and perceptions of virtual care solutions by rural Canadian primary and specialist providers during the early phase (May-June 2020) of the COVID-19 pandemic. A web-based, cross-sectional survey of rural primary and specialty care providers examined types of virtual care platforms used (eg, phone, video), appointment length, experience and satisfaction with the solution used, plans for future use of virtual care, and patients' use of virtual care services. Targeted participants were actively-practicing providers in rural Western Canada who were emailed an invitation for the study and its survey link. Fifty-nine providers (26% response rate) completed the survey. During the pandemic, 78% of providers reported using virtual care for more than 60% of their appointments, while only 3% did so frequently pre-pandemic. Most providers used phone consultations, despite believing that video provided a better virtual visit. Key barriers included workflow interruptions, unique concerns about quality of care, remuneration and sustainability, or poor internet access and bandwidth for both providers and patients. The key opportunity noted was improved access to care. While most virtual care visits were not conducted using video technologies, overall virtual care resulted in high provider satisfaction, while not increasing workload. Virtual care will continue to play an important role in future rural care practice; however, sustainability will require both provider-level and system-level changes.

Accelerating Virtual Health Implementation Following the COVID-19 Pandemic: Questionnaire Study

BACKGROUND

The COVID-19 pandemic accelerated drivers for virtual health adoption and triggered the US federal government to implement regulatory changes to reduce barriers to virtual health implementation. Consequently, virtual health solutions have been increasingly adopted, and health systems in the United States have been reorganizing their care delivery process with unprecedented speed.

OBJECTIVE

This study aimed to assess and make recommendations on the strategy, business model, implementation, and future considerations for scaling and sustaining virtual health solutions based on the views of executives from the largest health systems in the United States.

METHODS

In September 2020 and October 2020, the Health Management Academy conducted 29 quantitative surveys and 23 qualitative interviews involving 58 executives from 41 of the largest health systems in the United States. Participating health systems were approximately equally distributed across size categories (small, medium, and large, defined as annual total operating revenue US $2-3 billion, $3-6 billion, and >$6 billion, respectively) and US Census Bureau regions (Northeast, Midwest, South, and West).

RESULTS

Based on the Health Management Academy's assessment of approaches to governance, financing, data infrastructure, and clinical integration of virtual health, most participating health systems (13/24, 54%) had a mid-stage level of maturity in virtual health implementation. Executives reported the pandemic is forcing health systems to re-examine strategic priorities; the most commonly raised key impacts were increased access (15/21, 71%) and flexibility (10/21, 48%) as well as lower costs of care delivery (9/21, 43%). Most executives (16/28, 57%) reported their organization had a defined budget for virtual health, and many noted that virtual health is best supported through value-based payment models. Irrespective of health system maturity, reimbursement was consistently rated as a key challenge to virtual health scaling, along with patient access to and understanding of virtual health technology. The success of virtual health implementation was most commonly measured by patient satisfaction, health care provider engagement, and proportion of health care providers using virtual health solutions (reported by 7/8, 88%; 6/8, 75%; and 7/8, 75% of information technology executives, respectively). Almost all health systems (27/29, 93%) expect to continue growing their virtual health offerings for the foreseeable future, with user-friendliness and ease of integration into the electronic medical record as key factors in making go-forward decisions on virtual health solutions (each selected by 9/10, 90% executives).

CONCLUSIONS

The increased demand for virtual health solutions during the COVID-19 pandemic is expected to continue postpandemic. Consequently, health systems are re-evaluating their current platforms, processes, and strategy to develop a sustainable, long-term approach to virtual health. To ensure future success, health system leaders need to proactively build on their virtual health solutions; advocate for payment, site flexibility, and reimbursement parity for virtual health; and demonstrate continued engagement and boldness to evolve care beyond established models.

Sociodemographic differences in patient experience with primary care during COVID-19: results from a cross-sectional survey in Ontario, Canada

PURPOSE

We sought to understand patients' care-seeking behaviours early in the pandemic, their use and views of different virtual care modalities, and whether these differed by sociodemographic factors.

METHODS

We conducted a multisite cross-sectional patient experience survey at 13 academic primary care teaching practices between May and June 2020. An anonymised link to an electronic survey was sent to a subset of patients with a valid email address on file; sampling was based on birth month. For each question, the proportion of respondents who selected each response was calculated, followed by a comparison by sociodemographic characteristics using χ² tests.

RESULTS

In total, 7532 participants responded to the survey. Most received care from their primary care clinic during the pandemic (67.7%, 5068/7482), the majority via phone (82.5%, 4195/5086). Among those who received care, 30.53% (1509/4943) stated that they delayed seeking care because of the pandemic. Most participants reported a high degree of comfort with phone (92.4%, 3824/4139), video (95.2%, 238/250) and email or messaging (91.3%, 794/870). However, those reporting difficulty making ends meet, poor or fair health and arriving in Canada in the last 10 years reported lower levels of comfort with virtual care and fewer wanted their practice to continue offering virtual options after the pandemic.

CONCLUSIONS

Our study suggests that newcomers, people living with a lower income and those reporting poor or fair health have a stronger preference and comfort for in-person primary care. Further research should explore potential barriers to virtual care and how these could be addressed.

Challenges and strategies for promoting health equity in virtual care: findings and policy directions from a scoping review of reviews

OBJECTIVE

We sought to understand and synthesize review-level evidence on the challenges associated with accessibility of virtual care among underserved population groups and to identify strategies that can improve access to, uptake of, and engagement with virtual care for these populations.

MATERIALS AND METHODS

A scoping review of reviews was conducted (protocol available at doi: 10.2196/22847). A total of 14 028 records were retrieved from MEDLINE, EMBASE, CINAHL, Scopus, and Epistemonikos databases. Data were abstracted, and challenges and strategies were identified and summarized for each underserved population group and across population groups.

RESULTS

A total of 37 reviews were included. Commonly occurring challenges and strategies were grouped into 6 key thematic areas based on similarities across communities: (1) the person's orientation toward health-related needs, (2) the person's orientation toward health-related technology, (3) the person's digital literacy, (4) technology design, (5) health system structure and organization, and (6) social and structural determinants of access to technology-enabled care. We suggest 4 important directions for policy development: (1) investment in digital health literacy education and training, (2) inclusive digital health technology design, (3) incentivizing inclusive digital health care, and (4) investment in affordable and accessible infrastructure.

DISCUSSION AND CONCLUSION

Challenges associated with accessibility of virtual care among underserved population groups can occur at the individual, technological, health system, and social/structural determinant levels. Although the policy approaches suggested by our review are likely to be difficult to achieve in a given policy context, they are essential to a more equitable future for virtual care.

Caregivers of children feel confident about using the internet for health information

BACKGROUND

Caregivers of children may rely on internet sources, health care providers, peers or family for health information.

OBJECTIVE

To examine the impact of sociodemographic factors on the use of the internet for health information by caregivers of children, and the impact on self-efficacy, effort and frustration.

METHODS

Using data from the 2019 Health Information National Trends Survey, the effects of information source on self-efficacy, effort and frustration was examined using the complex samples module of SPSS.

RESULTS

The internet was the most common source of health information for caregivers of children (n = 247), with high confidence, low frustration and effort reported. Younger, higher educated and higher income caregivers were significantly more likely to use the internet for health information. Information from Health Care Providers (HCPs) was associated with greater confidence, and information from peers associated with lesser effort and frustration. No significant effects on self-efficacy, effort or frustration for online health information was noted compared to other sources.

CONCLUSIONS

Efforts to reduce barriers to online health information may be required for some groups of caregivers, and health care providers may have a role to play in this.