1
|
Lee-Riddle GS, Schmidt HJ, Reese PP, Nelson MN, Neergaard R, Barg FK, Serper M. Transplant recipient, care partner, and clinician perceptions of medication adherence monitoring technology: A mixed methods study. Am J Transplant 2024; 24:669-680. [PMID: 37923085 DOI: 10.1016/j.ajt.2023.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/28/2023] [Accepted: 10/30/2023] [Indexed: 11/07/2023]
Abstract
Medication nonadherence is a leading cause of graft loss. Adherence monitoring technologies-reminder texts, smart bottles, video-observed ingestion, and digestion-activated signaling pills-may support adherence. However, patient, care partner, and clinician perceptions of these tools are not well studied. We conducted qualitative individual semistructured interviews and focus groups among 97 participants at a single center: kidney and liver transplant recipients 2 weeks to 18 months posttransplant, their care partners, and transplant clinicians. We assessed adherence practices, reactions to monitoring technologies, and opportunities for care integration. One-size-fits-all approaches were deemed infeasible. Interviewees considered text messages the most acceptable approach; live video checks were the least acceptable and raised the most concerns for inconvenience and invasiveness. Digestion-activated signaling technology produced both excitement and apprehension. Patients and care partners generally aligned in perceptions of adherence monitoring integration into clinical care. Key themes were importance of routine, ease of use, leveraging technology for actionable medication changes, and aversion to surveillance. Transplant clinicians similarly considered text messages most acceptable and video checks least acceptable. Clinicians reported that early posttransplant use and real-time adherence tracking with patient feedback may facilitate successful implementation. The study provides initial insights that may inform future adherence technology implementation.
Collapse
Affiliation(s)
- Grace S Lee-Riddle
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Harald J Schmidt
- Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maria N Nelson
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rebecca Neergaard
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Frances K Barg
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
2
|
Shields A, Barg FK, Begolka WS, Sage K, Druby K, Gondo GC, Margolis DJ, Pusic AL, Barbieri JS. Identifying Core Outcome Domains in Chronic Skin Disease Using the Best-Worst Scaling Method. JAMA Dermatol 2024; 160:441-446. [PMID: 38381409 PMCID: PMC10882501 DOI: 10.1001/jamadermatol.2023.6245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 12/14/2023] [Indexed: 02/22/2024]
Abstract
Importance The use of patient-reported outcome measures (PROMs) potentially holds promise as an opportunity to improve outcomes and quality of care for patients with skin disease, but the routine use of PROMs remains limited. While the Patient-Reported Outcomes Measurement Information System (PROMIS) has several strengths and domains relevant to those with chronic skin disease, it is not clear which are most useful. Objective To determine which PROMIS domains are most meaningful to those with chronic skin disease to develop a PROMIS profile that effectively captures the experience of living with these skin diseases. Design, Setting, and Participants This cross-sectional study was based on data gathered from an internet survey that was administered to a sample of adult respondents in the US on the Prolific Platform and ResearchMatch and through the National Psoriasis Foundation. A list of PROMIS domains relevant to chronic skin disease was developed through literature review. These domains were included in a best-worst scaling exercise, in which participants were shown 12 sets of 4 domains and asked to choose which domain in each set was the most important and least important to their experience. Participants completed the survey between December 2022 and June 2023. Data were analyzed in June 2023. Main Outcomes and Measures Ratio-scaled preference score for each of the domains. Results Of 939 total participants, 559 (59.5%) were female, 20 (2.1%) gender nonconforming, 7 (0.7%) transgender men, and 1 (0.1%) transgender women; there were 4 American Indian/Alaska Native (0.4%), 50 Asian (5.3%), 63 Black (6.7%), 66 Hispanic or Latino/a/x (7.0%), 2 Native Hawaiian/Pacific Islander (0.2%), 749 White (79.8%), and 42 multiracial individuals (4.5%). The survey was completed by 200 participants with acne, 316 with psoriasis, 199 with atopic dermatitis, and 224 with various chronic skin diseases. For those with acne, the highest-scored domains were body image (15.66), appearance (14.96), life satisfaction (11.29), depression (9.25), and anxiety (9.18). For those with psoriasis, the highest-scored domains were life satisfaction (11.31), appearance (11.05), itch (10.98), pain (9.97), and body image (8.75). For those with atopic dermatitis, the highest-scored domains were itch (12.60), life satisfaction (11.65), appearance (11.40), body image (11.25), and pain (10.03). Conclusion and Relevance The results of this study suggest that body image, appearance, life satisfaction, itch, pain, anxiety, and depression were highly rated across the surveys. By identifying the PROMIS domains most important to individuals with chronic skin disease, clinicians can choose the domains that are most relevant to patients. In addition, this may guide the construction of a PROMIS profile that effectively captures the experience of living with these skin diseases and can serve as a patient-reported measure of disease severity and treatment effectiveness.
Collapse
Affiliation(s)
- Ali Shields
- Drexel University College of Medicine, Philadelphia, Pennsylvania
- Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Frances K. Barg
- Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Kathy Sage
- National Eczema Association, Novato, California
| | - Kelly Druby
- Penn State Health Hampden Medical Center, Enola, Pennsylvania
| | | | - David J. Margolis
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Andrea L. Pusic
- Department of Plastic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - John S. Barbieri
- Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts
- Associate Editor, JAMA Dermatology
| |
Collapse
|
3
|
Auriemma CL, Butt MI, Bahti M, Silvestri JA, Solomon E, Harhay MO, Klaiman T, Schapira MM, Barg FK, Halpern SD. Measuring Quality-weighted Hospital-Free-Days in Acute Respiratory Failure: A Modified Delphi Study. Ann Am Thorac Soc 2024. [PMID: 38507646 DOI: 10.1513/annalsats.202311-962oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/24/2024] [Indexed: 03/22/2024] Open
Abstract
RATIONALE Hospital-free days (HFDs), a measure of the number of days alive spent outside the hospital, is increasingly used as an endpoint in studies of patients with acute respiratory failure (ARF) or other critical and serious illnesses. Current approaches to measuring HFDs do not account for decrements in functional status or quality of life that ARF survivors and family members value. OBJECTIVES To develop an acceptable approach to measure quality-weighted HFDs using patient-reported outcomes. METHODS We conducted a 4-round modified Delphi among ARF experts - those with lived or professional experience. Experts rated survivorship domains, instrument and data collection characteristics, and methods to translate responses into quality-weighted HFDs. The consensus threshold was that >70% of respondents rated an item "Totally Acceptable" or "Acceptable" and <15% of respondents rated the item "Totally Unacceptable", "Unacceptable", or "Slightly Unacceptable." RESULTS Fifty-seven experts participated in Round 1. Response rates were 82-93% for subsequent rounds. Priority survivorship domains were physical function and health-related quality of life. Participants reached consensus that data collection during ARF recovery should take fewer than 15 minutes per assessment, allow for surrogate completion when patients are unable, and continue for at least 24 months of follow-up. Using the EuroQol-5 Dimensions (EQ-5D) to quality-weight HFDs met consensus criteria for acceptability. A majority of panelists preferred quality-weighted HFDs to unweighted HFDs or survival for use in future ARF studies. CONCLUSIONS Quality-weighting HFDs using patient and/or surrogate responses to the EQ-5D captured stakeholder priorities and was acceptable to this Delphi panel.
Collapse
Affiliation(s)
- Catherine L Auriemma
- University of Pennsylvania, 6572, Medicine, Philadelphia, Pennsylvania, United States;
| | - Maayra I Butt
- University of Pennsylvania, 6572, Medicine, Philadelphia, Pennsylvania, United States
| | - Melanie Bahti
- University of Pennsylvania, 6572, Medicine, Philadelphia, Pennsylvania, United States
| | - Jasmine A Silvestri
- University of Pennsylvania, 6572, Medicine, Philadelphia, Pennsylvania, United States
| | - Ellen Solomon
- University of Pennsylvania, 6572, Medicine, Philadelphia, Pennsylvania, United States
| | - Michael O Harhay
- University of Pennsylvania, 6572, Palliative and Advanced Illness Research Center, Philadelphia, Pennsylvania, United States
- University of Pennsylvania, 6572, Department of Biostatistics, Epidemiology, and Informatics, Philadelphia, Pennsylvania, United States
| | - Tamar Klaiman
- University of Pennsylvania Perelman School of Medicine, 14640, Philadelphia, Pennsylvania, United States
| | - Marilyn M Schapira
- University of Pennsylvania, 6572, Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Frances K Barg
- University of Pennsylvania Perelman School of Medicine, 14640, Family Medicine and Community Health, Philadelphia, Pennsylvania, United States
- University of Pennsylvania School of Arts and Sciences, 142839, Anthropology, Philadelphia, Pennsylvania, United States
| | - Scott D Halpern
- University of Pennsylvania Perelman School of Medicine, 14640, Philadelphia, Pennsylvania, United States
| |
Collapse
|
4
|
Marks-Anglin AK, Barg FK, Ross M, Wiebe DJ, Hwang WT. Survival analysis under imperfect record linkage using historic census data. BMC Med Res Methodol 2024; 24:67. [PMID: 38481152 PMCID: PMC10935812 DOI: 10.1186/s12874-024-02194-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 03/01/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Advancements in linking publicly available census records with vital and administrative records have enabled novel investigations in epidemiology and social history. However, in the absence of unique identifiers, the linkage of the records may be uncertain or only be successful for a subset of the census cohort, resulting in missing data. For survival analysis, differential ascertainment of event times can impact inference on risk associations and median survival. METHODS We modify some existing approaches that are commonly used to handle missing survival times to accommodate this imperfect linkage situation including complete case analysis, censoring, weighting, and several multiple imputation methods. We then conduct simulation studies to compare the performance of the proposed approaches in estimating the associations of a risk factor or exposure in terms of hazard ratio (HR) and median survival times in the presence of missing survival times. The effects of different missing data mechanisms and exposure-survival associations on their performance are also explored. The approaches are applied to a historic cohort of residents in Ambler, PA, established using the 1930 US census, from which only 2,440 out of 4,514 individuals (54%) had death records retrievable from publicly available data sources and death certificates. Using this cohort, we examine the effects of occupational and paraoccupational asbestos exposure on survival and disparities in mortality by race and gender. RESULTS We show that imputation based on conditional survival results in less bias and greater efficiency relative to a complete case analysis when estimating log-hazard ratios and median survival times. When the approaches are applied to the Ambler cohort, we find a significant association between occupational exposure and mortality, particularly among black individuals and males, but not between paraoccupational exposure and mortality. DISCUSSION This investigation illustrates the strengths and weaknesses of different imputation methods for missing survival times due to imperfect linkage of the administrative or registry data. The performance of the methods may depend on the missingness process as well as the parameter being estimated and models of interest, and such factors should be considered when choosing the methods to address the missing event times.
Collapse
Affiliation(s)
- Arielle K Marks-Anglin
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Frances K Barg
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michelle Ross
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas J Wiebe
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Wei-Ting Hwang
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- , 423 Guardian Drive, Blockley Hall Room 610, Philadelphia, PA, 19064, USA.
| |
Collapse
|
5
|
Martei YM, Obasohan M, Mokokwe L, Ralefala T, Mosepele M, Gross R, Barg FK. Stigma and Social Determinants of Health Associated With Fidelity to Guideline-Concordant Therapy in Patients With Breast Cancer Living With and Without HIV in Botswana. Oncologist 2023; 28:e1230-e1238. [PMID: 37405697 PMCID: PMC10712728 DOI: 10.1093/oncolo/oyad183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 06/01/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Patients with breast cancer in sub-Saharan Africa (SSA) experience a disproportionate burden of mortality. Fidelity to treatment guidelines, defined as receiving optimal dose and frequency of prescribed treatments, improves survival. We sought to identify patient factors associated with treatment fidelity and how this may differ for people with HIV (PWH) and breast cancer. METHODS We conducted a qualitative study of women who initiated outpatient treatment for stages I-III breast cancer in Botswana, with deviance sampling of high- and low-fidelity patients. One-on-one interviews were conducted using semi-structured guides informed by the Theory of Planned Behavior. The sample size was determined by thematic saturation. Transcribed interviews were double coded with an integrated analytic approach. RESULTS We enrolled 15 high- and 15 low-fidelity participants from August 25, 2020 to December 15, 2020, including 10 PWH (4 high, 6 low fidelity). Ninety-three percent had stage III disease. Barriers to treatment fidelity included stigma, social determinants of health (SDOH), and health system barriers. Acceptance and de-stigmatization, peer and other social support, increased knowledge and self-efficacy were identified as facilitators. The COVID-19 pandemic amplified existing socioeconomic stressors. Unique barriers and facilitators identified by PWH included intersectional stigma, and HIV and cancer care integration, respectively. CONCLUSION We identified multilevel modifiable patient and health system factors associated with fidelity. The facilitators provide opportunities for leveraging existing strengths within the Botswana context to design implementation strategies to increase treatment fidelity to guideline-concordant breast cancer therapy. However, PWH experienced unique barriers, suggesting that interventions to address fidelity may need to be tailored to specific comorbidities.
Collapse
Affiliation(s)
- Yehoda M Martei
- Department of Medicine (Hematology-Oncology), University of Pennsylvania, Philadelphia, PA, USA
| | - Modesty Obasohan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lebogang Mokokwe
- Botswana University of Pennsylvania Partnership, Gaborone, Botswana
- Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | | | | | - Robert Gross
- Department of Medicine (Infectious Diseases), University of Pennsylvania, Philadelphia, PA, USA
| | - Frances K Barg
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
6
|
Bilger A, Plenn E, Barg FK, Rendle KA, Carter WB, Lamour-Harrington A, Jones N, Peterson B, Sauceda JA, Tebas P, Mounzer K, Metzger D, Montaner LJ, Dubé K. Participant experiences in HIV cure-directed trial with an extended analytical treatment interruption in Philadelphia, United States. HIV Res Clin Pract 2023; 24:2267825. [PMID: 37837376 PMCID: PMC10634456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
BACKGROUND A feature of HIV cure trials is the need to interrupt treatment to test the efficacy of experimental interventions-a process known as analytical treatment interruptions (ATIs). OBJECTIVES We report the experiences of participants after they completed an extended ATI. METHODS From April to November 2022, we conducted post-ATI in-depth interviews with BEAT2 clinical trial (NCT03588715) participants who stopped ART while receiving an immunotherapy regimen. We used conventional content analysis to code the data. RESULTS We conducted interviews with 11 Black/African American and three White/Caucasian participants (11 males, two females, and one transgender woman). The mean ATI was 38 weeks. Participants noted several significant experiences surrounding the interventions' side effects, ATI, and returning to medication. Some participants had positive experiences with their ATI. Other participants were nervous during the ATI. Rising viral loads led some to feel a sense of failure. Although trial experiences were heterogeneous, participants unanimously had positive interactions with the clinical trial staff which facilitated their retention in the trial. Participants shared their experiences with the trial, including changes in expectations, experiences with experimental interventions and procedures, compensation as a measure of respect, effort, transportation, and effects of COVID-19 during the trial. Based on these results, we provide considerations for the conduct of future HIV cure-directed clinical trials involving ATIs. CONCLUSIONS Managing expectations, focusing on participants' contributions, and providing support to reduce feelings of having failed the research team and/or the HIV community following viral rebound should be part of HIV cure trial design. Discussing the mental health impact of rebound during consent, distinct from risk, is needed. Continued efforts to understand how people with HIV experience ATIs will improve future designs of HIV cure clinical trials.
Collapse
Affiliation(s)
- Andrea Bilger
- Department of Family Medicine and Community Health, University of Pennsylvania, Pennsylvania, PA, USA
| | - Eion Plenn
- Department of Family Medicine and Community Health, University of Pennsylvania, Pennsylvania, PA, USA
| | - Frances K. Barg
- Department of Family Medicine and Community Health, University of Pennsylvania, Pennsylvania, PA, USA
| | - Katharine A. Rendle
- Department of Family Medicine and Community Health, University of Pennsylvania, Pennsylvania, PA, USA
| | - William B. Carter
- BEAT-HIV Delaney Collaboratory Community Advisory Board, Philadelphia, PA, USA
| | | | - Nora Jones
- BEAT-HIV Delaney Collaboratory Community Advisory Board, Philadelphia, PA, USA
| | | | - John A. Sauceda
- Division of Prevention Sciences, Department of Medicine, Center for AIDS Prevention Studies (CAPS), University of California, San Francisco, CA, USA
| | - Pablo Tebas
- Hospital of the University of Philadelphia, University of Pennsylvania, Pennsylvania, PA, USA
| | - Karam Mounzer
- Philadelphia FIGHT Community Health Centers, Philadelphia, PA, USA
| | - David Metzger
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA, USA
| | | | - Karine Dubé
- University of California San Diego School of Medicine, Division of Infectious Diseases and Global Public Health, Chapel Hill, NC, USA
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
7
|
Lane-Fall MB, Koilor CB, Givan K, Klaiman T, Barg FK. Patient- and Team-Level Characteristics Associated with Handoff Protocol Fidelity in a Hybrid Implementation Study: Results from a Qualitative Comparative Analysis. Jt Comm J Qual Patient Saf 2023; 49:356-364. [PMID: 37208240 PMCID: PMC10524533 DOI: 10.1016/j.jcjq.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Standardization is an evidence-based approach to improve handoffs. The factors underpinning fidelity (that is, adherence) to standardized handoff protocols are not well specified, which hampers implementation and sustainability efforts. METHODS The Handoffs and Transitions in Critical Care (HATRICC) study (2014-2017) involved the creation and implementation of a standardized protocol for operating room (OR)-to-ICU handoffs in two mixed surgical ICUs. The present study used fuzzy-set qualitative comparative analysis (fsQCA) to characterize combinations of conditions associated with fidelity to the HATRICC protocol. Conditions were derived from postintervention handoff observations yielding quantitative and qualitative data. RESULTS Sixty handoffs had complete fidelity data. Four conditions from the SEIPS 2.0 model were used to explain fidelity: (1) whether the patient was newly admitted to the ICU; (2) presence of an ICU provider; (3) observer ratings of attention-paying by the handoff team; and (4) whether the handoff took place in a quiet environment. None of the conditions were singly necessary or sufficient for high fidelity. Three combinations of conditions were sufficient for fidelity: (1) presence of the ICU provider and high attention ratings; (2) a newly admitted patient, presence of the ICU provider, and quiet environment; and (3) a newly admitted patient, high attention ratings, and quiet environment. These three combinations explained 93.5% of the cases demonstrating high fidelity. CONCLUSION In a study of OR-to-ICU handoff standardization, multiple combinations of contextual factors were associated with handoff protocol fidelity. Handoff implementation efforts should consider multiple fidelity-promoting strategies that support these combinations of conditions.
Collapse
|
8
|
Wietlisbach LE, Asch DA, Eriksen W, Barg FK, Bellini LM, Desai SV, Yakubu AR, Shea JA. Using poetry to elicit internal medicine residents' perspectives on wellness. Postgrad Med J 2023; 99:428-432. [PMID: 37294722 PMCID: PMC9530064 DOI: 10.1136/postgradmedj-2021-141493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/19/2022] [Indexed: 11/04/2022]
Abstract
PURPOSE To elicit internal medicine residents' perspectives on wellness through poetry writing, examining (1) response rates, (2) the tone/sentiment of their submissions and (3) the primary thematic content. STUDY DESIGN In academic year 2019-2020, a random sample of 88 residents from four internal medicine residency programmes was invited to participate in a year-long study of wellness. In December 2019, an open-ended prompt asked residents to write a poem reflecting on their well-being. Responses were inductively coded using content analysis techniques. RESULTS The response rate for the poetry prompt was 94%. The tone of the entries was most often neutral or contradictory (42%), followed by negative (33%) and positive (25%). There were three main themes: (1) Mindsets: most residents simply wanted to make it through their programme; (2) wellness influencers: the main wellness supporters were external to the programme such as vacationing and exercise; within hospitals, friendships with colleagues and boosted wellness and (3) scheduling/repetition: difficult schedules drained energy as did the monotony of administrative tasks. CONCLUSIONS Poetry appears to be an innovative and effective vehicle to elicit residents' perspectives without compromising response rate. Poetry survey techniques allow medical trainees to provide powerful messaging to leadership. Most of what is known about trainee wellness is derived from quantitative surveys. This study showed medicine trainees' willingness to engage in poetry and add richness and personal detail to highlight key drivers of wellness. Such information provides context and brings attention in a compelling manner to an important topic.
Collapse
Affiliation(s)
- Larissa E Wietlisbach
- Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David A Asch
- Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Whitney Eriksen
- Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Frances K Barg
- Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lisa M Bellini
- Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sanjay V Desai
- Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Abdul-Rakeem Yakubu
- Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Judy A Shea
- Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
9
|
Nelson MN, Akpek E, Margolis DJ, Barg FK, Vittorio CC. A mixed methods study on factors that promote and ameliorate burnout in academic dermatologists. Arch Dermatol Res 2023; 315:859-868. [PMID: 36352151 PMCID: PMC9645749 DOI: 10.1007/s00403-022-02441-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 10/20/2022] [Indexed: 11/10/2022]
Abstract
The burnout literature is replete with burnout score results from quantitative surveys. There is a paucity of qualitative research that seeks to understand the impact of physician stressors on work-life balance and burnout. This study aimed to identify factors that support and disrupt work-life balance, drivers of burnout, and potential solutions among academic dermatologists. The objective was to better understand factors that promote wellness and ameliorate burnout. Concurrent explanatory mixed methods consisted of scores on the Abbreviated Maslach Burnout Inventory and open-ended semi-structured telephone interviews. The results were that positive factors, such as supportive home life and satisfaction derived from academic endeavors, compete with ongoing feelings of exhaustion, frustration, and apathy. Negative stressors include the electronic medical record, insufficient staffing, administrative and clinical task burden, and perceived lack of interest from mid-level and senior health system leadership in addressing clinicians' needs. This was a single-center academic study. As with all qualitative studies, these results may not be generalizable to all dermatologists. In addition, some participants were concerned about their anonymity. Modifiable root causes of burnout require institutional commitment to sustain the pace required by academic dermatologists.
Collapse
Affiliation(s)
- Maria N Nelson
- Mixed Methods Research Lab, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Eda Akpek
- Mixed Methods Research Lab, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - David J Margolis
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
- Division of Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Frances K Barg
- Division of Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, 3600 Spruce Street, 2 Maloney, Philadelphia, PA, 19104, USA
| | - Carmela C Vittorio
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA.
| |
Collapse
|
10
|
Xanthopoulos MS, Nelson MN, Eriksen W, Barg FK, Byars KC, Ishman SL, Esbensen AJ, Meinzen-Derr J, Heubi CH, Gurbani NS, Bradford R, Hicks S, Tapia IE. Caregiver experiences helping children with Down syndrome use positive airway pressure to treat obstructive sleep apnea. Sleep Med 2023; 107:179-186. [PMID: 37196396 DOI: 10.1016/j.sleep.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 04/12/2023] [Accepted: 04/23/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND/OBJECTIVE While positive airway pressure (PAP) is an efficacious intervention for the treatment of obstructive sleep apnea syndrome (OSAS) in children with Down syndrome (DS), implementation and consistent use can be difficult. Caregiver perspectives and experiences using PAP are described with the aim of informing clinical practice. METHODS Qualitative semi-structured phone interviews were conducted with 40 caregivers (i.e., mothers) of children with DS and OSAS treated with PAP for at least 6 months. Content analysis was used to identify themes associated with adherence and non-adherence. RESULTS Respondents indicated variability in caregiver experience with the adoption of PAP and observed benefits of PAP. Varied experiences were attributed to several themes including accessing supplies, interactions with the medical team and equipment company, and patients' unique needs and behaviors, including the child's willingness and ability to adapt to PAP, sensory sensitivities, keeping the mask on all night, and differences in daytime behavior. Many families reported that desensitization with a reward system and trust within the caregiver-patient relationship were helpful. Caregiver suggestions for improving PAP adherence for families of children with DS included improving communication with the medical team and medical equipment company, emphasizing patience, using visual supports, and social support and education for extended family. CONCLUSIONS Although family experiences varied, several actionable strategies by both the medical team and families emerged for improving the experience of and adherence to PAP in children with DS.
Collapse
Affiliation(s)
- Melissa S Xanthopoulos
- Sleep Center, Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Maria N Nelson
- Mixed Methods Research Lab, Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Whitney Eriksen
- Mixed Methods Research Lab, Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Frances K Barg
- Mixed Methods Research Lab, Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kelly C Byars
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Behavioral Medicine and Clinical Psychology/Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Stacey L Ishman
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Anna J Esbensen
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jareen Meinzen-Derr
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Christine H Heubi
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Neepa S Gurbani
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ruth Bradford
- Sleep Center, Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Suzanna Hicks
- Division of Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ignacio E Tapia
- Sleep Center, Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
11
|
Clason C, Sterner-Stein K, Hirschman KB, Barg FK, Riegel B. Developing effective health coaches: Experience gained in a clinical trial of a health coach intervention. Patient Educ Couns 2023; 108:107592. [PMID: 36516655 PMCID: PMC9877172 DOI: 10.1016/j.pec.2022.107592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 11/22/2022] [Accepted: 12/07/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE To identify the characteristics of an effective health coach and describe how these characteristics can be developed. METHODS A qualitative descriptive design was used to obtain insights from a convenience, homogenous sample of health coaches, social workers, and research staff members collaborating as members of a team providing a health coaching telehealth intervention for lay caregivers. Individual interviews were analyzed using thematic analysis. RESULTS The 11 study participants interviewed were predominately married (75 %), female (92 %) and Caucasian (83 %). Ages ranged from 27 to 66 with an average age of 42 years. The sample was highly educated, with five having attained a terminal degree (PhD or DNP). The participants described three themes of characteristics that contributed to the success of health coaches: personal characteristics, professional characteristics, and program characteristics. CONCLUSIONS These characteristics expand what is known about attributes that contribute to successful health coaching. Most can be trained or used in developing programs and interventions. PRACTICE IMPLICATIONS Our findings suggest that many of the core skills of an effective health coach can be developed through individual training, program design, and peer support. Innate personal characteristics such as trustworthiness, integrity, and compassion are hard to influence but can be identified in the hiring process.
Collapse
Affiliation(s)
- Caitlin Clason
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Kimberly Sterner-Stein
- Bridges to Wealth, Netter Center for Community Partnerships, University of Pennsylvania, Philadelphia, PA, USA
| | - Karen B Hirschman
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Frances K Barg
- Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Barbara Riegel
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA; Center for Home Care Policy & Research at VNS Health, New York, NY, USA; Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, AU.
| |
Collapse
|
12
|
Naik A, Syvyk S, Tong J, Wirtalla C, Barg FK, Guerra CE, Mehta SJ, Wender R, Merchant RM, Kelz RR. Factors Associated With Primary Care Physician Decision-making When Making Medication Recommendations vs Surgical Referrals. JAMA Netw Open 2023; 6:e2256086. [PMID: 36790807 PMCID: PMC9932841 DOI: 10.1001/jamanetworkopen.2022.56086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
IMPORTANCE Although objective data are used routinely in prescription drug recommendations, it is unclear how referring physicians apply evidence when making surgeon or hospital recommendations for surgery. OBJECTIVE To compare the factors associated with the hospital or surgeon referral decision-making process with that used for prescription medication recommendations. DESIGN, SETTING, AND PARTICIPANTS This qualitative study comprised interviews conducted between April 26 and May 18, 2021, of a purposive sample of 21 primary care physicians from a large primary care network in the Northeast US. MAIN OUTCOMES AND MEASURES Main outcomes were the factors considered when making prescription medication recommendations vs referral recommendations to specific surgeons or hospitals for surgery. RESULTS All 21 participant primary care physicians (14 women [66.7%]) reported use of evidence-based decision support tools and patient attributes for prescription medication recommendations. In contrast, for surgeon and hospital referral recommendations, primary care physicians relied on professional experience and training, personal beliefs about surgical quality, and perceived convenience. Primary care physicians cited perceived limitations of existing data on surgical quality as a barrier to the use of such data in the process of making surgical referrals. CONCLUSIONS AND RELEVANCE As opposed to the widespread use of objective decision support tools for guidance on medication recommendations, primary care physicians relied on subjective factors when making referrals to specific surgeons and hospitals. The findings of this study highlight the potential to improve surgical outcomes by introducing accessible, reliable data as an imperative step in the surgical referral process.
Collapse
Affiliation(s)
- Anusha Naik
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Solomiya Syvyk
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Jason Tong
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Chris Wirtalla
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Frances K. Barg
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Carmen E. Guerra
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Shivan J. Mehta
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Richard Wender
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Raina M. Merchant
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rachel R. Kelz
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| |
Collapse
|
13
|
Cronholm PF, Kellum WE, MacCombie A, Nelson M, Neergaard R, Haywood O, Parido ME, Melochick J, Tarka DK, Barg FK. Engaging Stakeholders to Improve Care for Adults with Complex Health and Social Needs during a Public Health Emergency. J Health Care Poor Underserved 2023. [DOI: 10.1353/hpu.2023.0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
|
14
|
Klusaritz H, Bilger A, Paterson E, Summers C, Barg FK, Cronholm PF, Saine ME, Sochalski J, Doubeni CA. Impact of Stigma on Clinician Training for Opioid Use Disorder Care: A Qualitative Study in a Primary Care Learning Collaborative. Ann Fam Med 2023; 21:S31-S38. [PMID: 36849482 PMCID: PMC9970664 DOI: 10.1370/afm.2920] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/03/2022] [Accepted: 10/12/2022] [Indexed: 03/01/2023] Open
Abstract
PURPOSE We undertook a study to examine how stigma influences the uptake of training on medication for opioid use disorder (MOUD) in primary care academic programs. METHODS We conducted a qualitative study of 23 key stakeholders responsible for implementing MOUD training in their academic primary care training programs that were participants in a learning collaborative in 2018. We assessed barriers to and facilitators of successful program implementation and used an integrated approach to develop a codebook and analyze the data. RESULTS Participants represented the family medicine, internal medicine, and physician assistant fields, and they included trainees. Most participants described clinician and institutional attitudes, misperceptions, and biases that enabled or hindered MOUD training. Perceptions included concerns that patients with OUD are "manipulative" or "drug seeking." Elements of stigma in the origin domain (ie, beliefs by primary care clinicians or the community that OUD is a choice and not a disease), the enacted domain (eg, hospital bylaws banning MOUD and clinicians declining to obtain an X-Waiver to prescribe MOUD), and the intersectional domain (eg, inadequate attention to patient needs) were perceived as major barriers to MOUD training by most respondents. Participants described strategies that improved the uptake of training, including giving attention to clinician concerns, clarifying the biology of OUD, and ameliorating clinician fears of being ill equipped to provide care for patients. CONCLUSIONS OUD-related stigma was commonly reported in training programs and impeded the uptake of MOUD training. Potential strategies to address stigma in the training context, beyond providing content on effective evidence-based treatments, include addressing the concerns of primary care clinicians and incorporating the chronic care framework into OUD treatment.
Collapse
Affiliation(s)
- Heather Klusaritz
- The National Center for Integrated Behavioral Health in Primary Care, Rochester, Minnesota and Philadelphia, Pennsylvania.,Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrea Bilger
- The National Center for Integrated Behavioral Health in Primary Care, Rochester, Minnesota and Philadelphia, Pennsylvania.,Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily Paterson
- The National Center for Integrated Behavioral Health in Primary Care, Rochester, Minnesota and Philadelphia, Pennsylvania.,Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Courtney Summers
- The National Center for Integrated Behavioral Health in Primary Care, Rochester, Minnesota and Philadelphia, Pennsylvania.,Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Frances K Barg
- The National Center for Integrated Behavioral Health in Primary Care, Rochester, Minnesota and Philadelphia, Pennsylvania.,Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter F Cronholm
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - M Elle Saine
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julie Sochalski
- The National Center for Integrated Behavioral Health in Primary Care, Rochester, Minnesota and Philadelphia, Pennsylvania.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chyke A Doubeni
- The National Center for Integrated Behavioral Health in Primary Care, Rochester, Minnesota and Philadelphia, Pennsylvania .,Department of Family and Community Medicine, The Ohio State University, Columbus, Ohio
| |
Collapse
|
15
|
Largent EA, Eriksen W, Barg FK, Greysen SR, Halpern SD. Participants' Perspectives on Payment for Research Participation: A Qualitative Study. Ethics Hum Res 2022; 44:14-22. [PMID: 36316972 PMCID: PMC9631331 DOI: 10.1002/eahr.500147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Investigators commonly offer payments to research participants to promote recruitment and retention. Yet the ethics of offering monetary incentives to research participants continues to be debated. Prior conceptual work has addressed some of these concerns; there is, however, also a need for empirical evidence to understand the effects of payment on participants. Here, we report the results of a qualitative study comprising (1) discourse analysis of recruitment conversations between study coordinators and potential participants for an actual clinical trial and (2) semistructured interviews with participants addressing the effects of an incentive on their decision-making. Many participants reported that money had been a motivation for enrolling in the clinical trial but did not use reasoning that suggested undue influence or unjust inducement. These findings add to a growing body of literature suggesting that payment is an ethically acceptable tool for promoting recruitment and retention in clinical trials.
Collapse
Affiliation(s)
- Emily A Largent
- Bioethicist in the Department of Medical Ethics and Health Policy at the University of Pennsylvania Perelman School of Medicine
| | - Whitney Eriksen
- Qualitative researcher in the Department of Family Medicine and Community Health at the University of Pennsylvania Perelman School of Medicine
| | - Frances K Barg
- Medical anthropologist in the Department of Family Medicine and Community Health at the University of Pennsylvania Perelman School of Medicine
| | - S Ryan Greysen
- Hospitalist and health services researcher in the Section of Hospital Medicine at the Center for Evidence-Based Practice at the University of Pennsylvania Perelman School of Medicine
| | - Scott D Halpern
- Intensivist and health services researcher in the Department of Medicine and the Department of Medical Ethics and Health Policy at the University of Pennsylvania Perelman School of Medicine
| |
Collapse
|
16
|
Galligan MM, Goldstein L, Garcia SM, Kellom K, Wolfe HA, Haggerty M, DeBrocco D, Barg FK, Friedlaender E. A Qualitative Study of Resident Experiences With Clinical Event Debriefing. Hosp Pediatr 2022; 12:977-989. [PMID: 36222096 DOI: 10.1542/hpeds.2022-006606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The facilitated discussion of events through clinical event debriefing (CED) can promote learning and wellbeing, but resident involvement is often limited. Although the graduate medical education field supports CED, interventions to promote resident involvement are limited by poor insight into how residents experience CED. The objective of this study was to characterize pediatric resident experiences with CED, with a specific focus on practice barriers and facilitators. METHODS We conducted this qualitative study between November and December 2020 at a large, free-standing children's hospital. We recruited pediatric residents from postgraduate years 1 to 4 to participate in virtual focus groups. Focus groups were digitally recorded, deidentified, and transcribed. Transcripts were entered into coding software for analysis. We analyzed the data using a modified grounded theory approach to identify major themes. RESULTS We conducted 4 mixed-level focus groups with 26 residents. Our analysis identified multiple barriers and facilitators of resident involvement in CED. Several barriers were logistical in nature, but the most salient barriers were derived from unique features of the resident role. For example, residents described the transience of their role as a barrier to both participating and engaging in CED. However, they described advancing professional experience and the desire for reflective learning as facilitators. CONCLUSIONS Residents in this study highlighted many factors affecting their participation and engagement in CED, including barriers related to the unique features of their role. On the basis of resident experiences, we propose several recommendations for CED practice that graduate medical education programs and hospitals should consider for supporting resident involvement in CED.
Collapse
Affiliation(s)
- Meghan M Galligan
- Department of Pediatrics.,Center for Pediatric Clinical Effectiveness
| | | | | | | | | | | | - Dawn DeBrocco
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Frances K Barg
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | |
Collapse
|
17
|
Neergaard R, Jones NL, Roebuck C, Rendle KA, Barbati Z, Peterson B, Tebas P, Mounzer K, Metzger D, Montaner LJ, Dube K, Barg FK. "I know that I was a part of making a difference": Participant motivations for joining a cure-directed HIV trial with an analytical treatment interruption. AIDS Res Hum Retroviruses 2022. [PMID: 35979886 PMCID: PMC10389247 DOI: 10.1089/aid.2022.0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Analytical treatment interruption (ATI), defined as a closely monitored clinical pause in antiretroviral therapy, is a core component of many HIV cure-directed clinical studies. ATIs may cause significant physical and psychosocial risks for people living with HIV and, as a result, integrating participant and community perspectives into clinical trial designs that include an ATI is crucial to ensuring a successful and person-centered trial. We conducted semi-structured interviews with participants enrolling in the BEAT-2 cure-directed trial (NCT03588715). Interviews elicited participant motivations and decision-making processes for trial participation as well as participants' perceptions of the ATI. Interviews were recorded, transcribed, and analyzed using a directed content analysis. Fourteen of 15 trial participants completed interviews. The majority were Black (79%) cisgender male (79%). Participants noted several significant motivating factors contributing to their desire to enroll in the HIV cure-directed clinical trial, the most prominent being a desire to find a cure for HIV and help others in the HIV community. HIV care teams were the most commonly identified resource for patients when making the decision to enroll in the trial, and family, friends, and romantic partners also played a significant role. Altruism was a primary motivation for participation, although participants also shared interest in learning about HIV science and research. Participants had a strong understanding of trial procedures and displayed significant trust in the study team to keep them informed and healthy during their participation. The ATI was a significant source of anxiety for participants. Their primary worry was that their prior antiretroviral treatment (ART) regimen would no longer be effective once they resumed ART. Despite these concerns, participants shared considerable excitement for continued participation in the trial and being a part of the search towards an HIV cure.
Collapse
Affiliation(s)
- Rebecca Neergaard
- University of Pennsylvania Perelman School of Medicine, Family Medicine and Community Health, Philadelphia, Pennsylvania, United States;
| | - Nora L Jones
- Temple University, Center for Urban Bioethics, Philadelphia, Pennsylvania, United States.,Wistar Institute, BEAT-HIV Collaboratory Community Advisory Board (CAB), Philadelphia, Pennsylvania, United States;
| | - Christopher Roebuck
- University of California Berkeley, Anthropology, Berkeley, California, United States.,Wistar Institute, BEAT-HIV Collaboratory Community Advisory Board (CAB), Philadelphia, Pennsylvania, United States;
| | - Katharine A Rendle
- University of Pennsylvania Perelman School of Medicine, Family Medicine and Community Health, Philadelphia, Pennsylvania, United States;
| | - Zoe Barbati
- University of Pennsylvania Perelman School of Medicine, Family Medicine and Community Health, Philadelphia, Pennsylvania, United States;
| | - Beth Peterson
- Wistar Institute, Martin Delaney BEAT-HIV Collaboratory, Philadelphia, Pennsylvania, United States;
| | - Pablo Tebas
- University of Pennsylvania, Philadelphia, Pennsylvania, United States;
| | - Karam Mounzer
- University of Pennsylvania Health System, Philadelphia, Pennsylvania, United States;
| | - David Metzger
- University of Pennsylvania Perelman School of Medicine, Psychiatry, 3535 Market Street, Suite 4000, Philadelphia, Pennsylvania, United States, 19104;
| | - Luis J Montaner
- The Wistar Institute, 3601 Spruce Street, Philadelphia, Pennsylvania, United States, 19104;
| | - Karine Dube
- UNC Gillings School of Global Health Health, Public Health Leadership Program, 4108 McGavran-Greenberg Hall, Chapel Hill, North Carolina, United States, 27516;
| | - Frances K Barg
- University of Pennsylvania Perelman School of Medicine, Family Medicine and Community Health, Philadelphia, Pennsylvania, United States.,University of Pennsylvania Perelman School of Medicine, Department of Biostatistics, Epidemiology and Informatics, Philadelphia, Pennsylvania, United States;
| |
Collapse
|
18
|
Cronholm PF, Kellum WE, Lawer JAR, Farris AM, Jacobs LM, Wood JC, Barg FK. Developing a Research Agenda for Adults with Complex Health and Social Needs. J Health Care Poor Underserved 2022; 33:1597-1611. [DOI: 10.1353/hpu.2022.0087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
19
|
Barbieri JS, Barg FK. More Than Skin Deep-Understanding the Lived Experience of Acne. JAMA Dermatol 2022; 158:991-992. [PMID: 35857284 DOI: 10.1001/jamadermatol.2022.2741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- John S Barbieri
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts.,Associate Editor, JAMA Dermatology
| | - Frances K Barg
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| |
Collapse
|
20
|
Wietlisbach LE, Asch DA, Eriksen W, Barg FK, Bellini LM, Desai SV, Yakubu AR, Shea JA. Using poetry to elicit internal medicine residents' perspectives on wellness. Postgrad Med J 2022:7130726. [PMID: 37084142 DOI: 10.1136/postmj/postgradmedj-2021-141493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/19/2022] [Indexed: 04/22/2023]
Abstract
PURPOSE To elicit internal medicine residents' perspectives on wellness through poetry writing, examining (1) response rates, (2) the tone/sentiment of their submissions and (3) the primary thematic content. STUDY DESIGN In academic year 2019-2020, a random sample of 88 residents from four internal medicine residency programmes was invited to participate in a year-long study of wellness. In December 2019, an open-ended prompt asked residents to write a poem reflecting on their well-being. Responses were inductively coded using content analysis techniques. RESULTS The response rate for the poetry prompt was 94%. The tone of the entries was most often neutral or contradictory (42%), followed by negative (33%) and positive (25%). There were three main themes: (1) Mindsets: most residents simply wanted to make it through their programme; (2) wellness influencers: the main wellness supporters were external to the programme such as vacationing and exercise; within hospitals, friendships with colleagues and boosted wellness and (3) scheduling/repetition: difficult schedules drained energy as did the monotony of administrative tasks. CONCLUSIONS Poetry appears to be an innovative and effective vehicle to elicit residents' perspectives without compromising response rate. Poetry survey techniques allow medical trainees to provide powerful messaging to leadership. Most of what is known about trainee wellness is derived from quantitative surveys. This study showed medicine trainees' willingness to engage in poetry and add richness and personal detail to highlight key drivers of wellness. Such information provides context and brings attention in a compelling manner to an important topic.
Collapse
Affiliation(s)
- Larissa E Wietlisbach
- Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David A Asch
- Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Whitney Eriksen
- Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Frances K Barg
- Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lisa M Bellini
- Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sanjay V Desai
- Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Abdul-Rakeem Yakubu
- Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Judy A Shea
- Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
21
|
Levoy K, Wool J, Ashare RL, Rosa WE, Barg FK, Meghani SH. "It's Rougher on Me Than It Is on Him": Family Caregiver-Generated and Prioritized Illness Concerns While Patients Undergo Cancer Treatments. JCO Oncol Pract 2022; 18:e525-e536. [PMID: 34735272 PMCID: PMC9014424 DOI: 10.1200/op.21.00164] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Research eliciting patients' illness concerns has typically focused later in the cancer continuum, rather than during cancer treatments. Family caregiver concerns are overlooked during this time. Less is known about how patients and caregivers prioritize concerns during cancer treatments, which holds potential for improving supportive oncology care (ie, primary palliative care). The purpose of this study was to elicit and compare which domains of supportive oncology are of highest importance to patients and caregivers during cancer treatments. METHODS Freelisting, a cognitive anthropology method, was used to elicit concerns in order of importance. Freelist data were analyzed using Smith's salience index. Qualitative interviews were conducted with a caregiver subsample to add explanatory insights. RESULTS In descending order, pain, death, fear, family, and awful were salient Freelist items for patients (n = 65), whereas sadness, time-consuming, support, anger, tired, death, and frustration were salient for caregivers (n = 24). When integrated with supportive oncology domains, patients' concerns reflected a prioritization of the physical (pain) and emotional (death, fear, and awful) domains, with less emphasis on social (family) aspects. Caregivers' prioritized the emotional (sadness, anger, death, and frustration) and social (time-consuming and support) domains, with less emphasis on the physical (tired) aspects. CONCLUSION Our findings suggest that enhancing primary palliative care delivery by oncology teams requires systems thinking to support both the patient and caregiver as the primary unit of care. Primary palliative care may be improved by prioritizing interventions that address physical concerns among patients as well as key social concerns among caregivers to support the complex caregiving role while patients undergo cancer treatments.
Collapse
Affiliation(s)
- Kristin Levoy
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, IN,Center for Aging Research, Regenstrief Institute, Indianapolis, IN,Kristin Levoy, PhD, MSN, RN, Department of Community and Health Systems, Indiana University School of Nursing, 600 Barnhill Dr, Indianapolis, IN 46202; e-mail:
| | - Jesse Wool
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA,NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA,Nursing Operations Department, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - William E. Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Frances K. Barg
- Department of Family and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Salimah H. Meghani
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA,NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
22
|
Abstract
This cross-sectional study aims to describe the self-care of adult African immigrants in the US with chronic illness and explore the relationship between acculturation and self-care. A total of 88 African immigrants with chronic illness were enrolled. Self-care was measured with the Self Care of Chronic Illness Inventory v3 and the Self-Care Self-Efficacy scale. Scores are standardized 0 to 100 with scores >70 considered adequate. Acculturation was measured using a modified standardized acculturation instrument and predefined acculturation proxies. The self-care scores showed adequate self-care, with the mean scores of 78.6, 77.9, and 75.6 for self-care maintenance, monitoring, and management. Self-care self-efficacy mean score was 81.3. Acculturation was not significantly associated with self-care. Self-care self-efficacy was a strong determinant of self-care maintenance (p < .0001), monitoring (p < .0001), and management (p < .0001). The perception of inadequate income was a significant determinant of poor self-care management (p = .03). Self-care self-efficacy and perceived income adequacy were better determinants of self-care than acculturation.
Collapse
Affiliation(s)
- Onome H. Osokpo
- University of Pennsylvania School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, USA
| | - Lisa M. Lewis
- University of Pennsylvania School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, USA
| | - Uchechukwu Ikeaba
- West Chester University of Pennsylvania, 25 University Avenue, West Chester, PA 19383
| | - Jesse Chittams
- University of Pennsylvania School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, USA
| | - Frances K. Barg
- University of Pennsylvania Perelman School of Medicine, 915 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Barbara J. Riegel
- University of Pennsylvania School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, USA
| |
Collapse
|
23
|
Shea JA, Bellini LM, Desai SV, Barg FK, Eriksen W, Wietlisbach LE, Yakubu AR, Asch DA. Exploring Residents' Well-Being and Burnout via Qualitative Ecological Momentary Assessment. Acad Med 2022; 97:414-419. [PMID: 34753860 PMCID: PMC8881344 DOI: 10.1097/acm.0000000000004508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
PURPOSE Most of what is known about resident burnout and wellness comes from cross-sectional snapshot surveys. The purpose of this study was to elicit qualitative perspectives on wellness from a cohort of internal residents over time using ecological momentary assessment. METHOD Drawing on principles of ecological momentary assessment, 13 different open-ended survey prompts were delivered between October and March during the 2019-2020 academic year. Participants were 88 randomly selected internal medicine residents from 4 internal medicine training programs in the Northeast. RESULTS The response rate was 95%. Three main themes regarding wellness were self, program/education environment, and medical/structural system. A fourth theme, the desire to provide quality patient care, cut across all other themes. The patient care theme repeatedly stressed residents' desire to spend more time with patients. The self theme primarily reflected messages about personal emotions and the need for work-life balance and wellness. The program/education environment theme reflected the value of learning, teamwork and community, and program culture. The medical/structural system theme showed that residents' experiences were shaped by the efficiency of their days and largely a product of their schedules and administrative support. Closing advice to future trainees was optimistic and reassuring. CONCLUSIONS While findings support much of what has been learned via single-occasion survey snapshots, an ecological momentary assessment design allowed a deeper dive into contextual associations. The results affirm the primacy of patient care and also highlight the value of teamwork and culture. Peers and program leaders are heavily influential in setting the tone for the learning experience, whether for the day or with a more enduring message of respect and support. There is opportunity to maximize high- or higher-value learning experiences for residents and find solutions to reduce and reframe the perceived "low-value administrative work" that is part of care coordination.
Collapse
Affiliation(s)
- Judy A Shea
- J.A. Shea is the Leon Hess Professor of Internal Medicine, Department of Medicine, and associate dean of medical education research, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; ORCID: https://orcid.org/0000-0002-7334-4192
| | - Lisa M Bellini
- L.M. Bellini is professor, Department of Medicine, and senior vice dean for academic affairs, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; ORCID: https://orcid.org/0000-0003-0985-2384
| | - Sanjay V Desai
- S.V. Desai is director, Osler Medical Residency, and vice-chair for education, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; ORCID: https://orcid.org/0000-0002-9759-7696
| | - Frances K Barg
- F.K. Barg is director, University of Pennsylvania Mixed Methods Research Lab, and professor, Department of Family Medicine and Community Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; ORCID: https://orcid.org/0000-0003-3328-1980
| | - Whitney Eriksen
- W. Eriksen is a senior researcher, University of Pennsylvania Mixed Methods Research Lab, Philadelphia, Pennsylvania; ORCID: https://orcid.org/0000-0003-2196-1815
| | - Larissa E Wietlisbach
- L.E. Wietlisbach is a medical student and research assistant, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; ORCID: https://orcid.org/0000-0002-8375-3264
| | - Abdul-Rakeem Yakubu
- A.-R. Yakubu is a research assistant, University of Pennsylvania Mixed Methods Research Lab, Philadelphia, Pennsylvania
| | - David A Asch
- D.A. Asch is a professor, Perelman School of Medicine and Wharton School at the University of Pennsylvania, and physician, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; ORCID: https://orcid.org/0000-0002-7970-286X
| |
Collapse
|
24
|
Schrauben SJ, Rivera E, Bocage C, Eriksen W, Amaral S, Dember LM, Feldman HI, Barg FK. A Qualitative Study of Facilitators and Barriers to Self-Management of CKD. Kidney Int Rep 2022; 7:46-55. [PMID: 35005313 PMCID: PMC8720654 DOI: 10.1016/j.ekir.2021.10.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/21/2021] [Accepted: 10/25/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Self-management is an integral component of CKD treatment. Nevertheless, many patients with CKD do not adequately engage in self-management behaviors, and little is known on the underlying reasons. We aimed to identify and describe the factors that influence self-management behaviors from the perspective of adults with CKD. Methods We conducted 30 semistructured interviews with adults with CKD stage 3 or 4 from an academic nephrology clinic in the United States. Interviews were analyzed thematically. Results The following are the 3 key phases of CKD self-management behavior engagement identified: (i) prioritization, (ii) performance, and (iii) maintenance. Prioritization was favorably influenced by optimism, stress management, and patient-provider communication and hampered by fatalism and competing priorities. Behavior performance was facilitated by motivating factors, self-efficacy, and support resources and impeded by comorbid conditions that caused treatment burden and adverse symptoms. Behavior maintenance relied on effective routines, influenced by similar factors as behavior performance, and reinforced by memory aids, goal setting, self-monitoring, and proactive preparation. Conclusion We identified modifiable facilitators and barriers that influence the incorporation of CKD self-management into daily life. Our findings have important implications for the care of patients with CKD by providing a framework for providers to develop effective, tailored approaches to promote self-management engagement.
Collapse
Affiliation(s)
- Sarah J Schrauben
- Renal, Electrolyte-Hypertension Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eleanor Rivera
- College of Nursing, University of Illinois Chicago, Chicago, Illinois, USA
| | - Claire Bocage
- Claire M. Fagin School of Nursing at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Whitney Eriksen
- Department of Family Medicine and Community Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sandra Amaral
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Laura M Dember
- Renal, Electrolyte-Hypertension Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Harold I Feldman
- Renal, Electrolyte-Hypertension Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Frances K Barg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Family Medicine and Community Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
25
|
Kearney MD, Barg FK, Alexis D, Higginbotham E, Aysola J. Employee Health and Wellness Outcomes Associated With Perceived Discrimination in Academic Medicine: A Qualitative Analysis. JAMA Netw Open 2022; 5:e2145243. [PMID: 35089355 PMCID: PMC8800072 DOI: 10.1001/jamanetworkopen.2021.45243] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Organizational culture and workplace interactions may enhance or adversely impact the wellness of all members of learning and work environments, yet a nuanced understanding of how such experiences within health care organizations impact the health and wellness of their membership is lacking. OBJECTIVE To identify and characterize the reported health and wellness outcomes associated with perceived discrimination among academic medicine faculty, staff, and students. DESIGN, SETTING, AND PARTICIPANTS This qualitative study analyzed anonymously submitted written narratives from 2016 that described experiences related to inclusion in the workplace or lack thereof. Narratives that described health outcomes associated with work- or school-based discrimination were purposively sampled. Participants were faculty, staff, and students at health-related schools or hospitals affiliated with the University of Pennsylvania. Data analysis was performed from March 2019 to January 2020. EXPOSURES Self-reported experiences, both witnessed and personal, of discrimination in the workplace. RESULTS A total of 315 narratives were collected, and 115 narratives from 115 participants were analyzed. Most respondents identified as female (70 respondents [60.9%]), non-Hispanic White (68 respondents [59.1%]), and heterosexual (89 respondents [77.4%]) and had worked at the institution for at least 1 year (99 respondents [86.0%]). The outcomes associated with adverse workplace experiences were broad and ranged in nature from emotional to mental and physical. Most reported outcomes were emotional (101 respondents [87.8%]), and more than 1 in 10 narratives (14 respondents [12.2%]) described a mental or physical health outcome. Many of the participants felt devaluated, overexerted, and hopeless, resulting in clinically relevant manifestations, such as increased stress and anxiety levels and even elevated blood pressure. CONCLUSIONS AND RELEVANCE This qualitative study identified a continuum of negative outcomes on employee health and well-being associated with perceived discrimination and chronic exclusion in the workplace. These findings suggest the need for organizations to promote inclusion as a component of workplace wellness interventions.
Collapse
Affiliation(s)
- Matthew D. Kearney
- Department of Family Medicine and Community Health and Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Equity Advancement, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Frances K. Barg
- Department of Family Medicine and Community Health and Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Dominique Alexis
- Office of Inclusion and Diversity, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Eve Higginbotham
- Office of Inclusion and Diversity, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Jaya Aysola
- Office of Inclusion and Diversity, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Penn Medicine Center for Health Advancement, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| |
Collapse
|
26
|
Schriger S, Binagwaho A, Keetile M, Kerry V, Mubiligi JM, Ramogola-Masire D, Roland M, Barg FK, Cancedda C. Hierarchy of qualities in global health partnerships: a path towards equity and sustainability. BMJ Glob Health 2022; 6:bmjgh-2021-007132. [PMID: 34969686 PMCID: PMC8718486 DOI: 10.1136/bmjgh-2021-007132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/03/2021] [Indexed: 11/03/2022] Open
Abstract
Despite the exponential growth of global health partnerships (GHPs) over the past 20 years, evidence for their effectiveness remains limited. Furthermore, many partnerships are dysfunctional as a result of inequitable partnership benefits, low trust and accountability and poor evaluation and quality improvement practices. In this article, we describe a theoretical model for partnerships developed by seven global health experts. Through semistructured interviews and an open-coding approach to data analysis, we identify 12 GHP pillars spanning across three interconnected partnership levels and inspired by Maslow's hierarchy of needs. The transactional pillars are governance, resources and expertise, power management, transparency and accountability, data and evidence and respect and curiosity. The collaborative pillars (which build on the transactional pillars) are shared vision, relationship building, deep understanding and trust. The transformational pillars (which build on the collaborative pillars and allow partnerships to achieve their full potential) are equity and sustainability. The theoretical model described in this article is complemented by real-life examples, which outline both the cost incurred when GHPs fail to live up to these pillars and the benefits gained when GHPs uphold them. We also provide lessons learnt and best practices that GHPs should adopt to further increase their strength and improve their effectiveness in the future. To continue improving health outcomes and reducing health inequities globally, we need GHPs that are transformational, not just rhetorically but de facto. These actualised partnerships should serve as a catalyst for the greater societal good and not simply as a platform to accrue and exchange organisational benefits.
Collapse
Affiliation(s)
- Simone Schriger
- Department of Psychology, School of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | - Vanessa Kerry
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Doreen Ramogola-Masire
- University of Botswana, Gaborone, Botswana.,For Frances Barg: Department of Family Medicine and Community Health; For Corrado Cancedda and Doreen Ramogola Masire: Center for Global Health; For Corrado Cancedda only: Division of Infectious Diseases/Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michelle Roland
- Sutter Medical Group, An Affiliate of Sutter Medical Foundation, Jackson, California, USA
| | - Frances K Barg
- For Frances Barg: Department of Family Medicine and Community Health; For Corrado Cancedda and Doreen Ramogola Masire: Center for Global Health; For Corrado Cancedda only: Division of Infectious Diseases/Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Corrado Cancedda
- For Frances Barg: Department of Family Medicine and Community Health; For Corrado Cancedda and Doreen Ramogola Masire: Center for Global Health; For Corrado Cancedda only: Division of Infectious Diseases/Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
27
|
Galligan MM, Haggerty M, Wolfe HA, Debrocco D, Kellom K, Garcia SM, Neergaard R, Akpek E, Barg FK, Friedlaender E. From the Frontlines: A Qualitative Study of Staff Experiences With Clinical Event Debriefing. Hosp Pediatr 2021; 11:hpeds.2021-006088. [PMID: 34808664 DOI: 10.1542/hpeds.2021-006088] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Clinical event debriefing (CED) can improve patient care and outcomes, but little is known about CED across inpatient settings, and participant experiences have not been well described. In this qualitative study, we sought to characterize and compare staff experiences with CED in 2 hospital units, with a goal of generating recommendations for a hospital-wide debriefing program. METHODS We conducted 32 semistructured interviews with clinical staff who attended a CED in the previous week. We explored experiences with CED, with a focus on barriers and facilitators. We used content analysis with constant comparative coding to understand priorities identified by participants. We used inductive reasoning to develop a set of CED practice recommendations to match participant priorities. RESULTS Three primary themes emerged related to CED barriers and facilitators. (1) Factors affecting attendance: most respondents voiced a need for frontline staff inclusion in CED, but they also cited competing clinical duties and scheduling conflicts as barriers. (2) Factors affecting participant engagement: respondents described factors that influence participant engagement in reflective discussion. They described that the CED leader must cultivate a psychologically safe environment in which participants feel empowered to speak up, free from judgment. (3) Factors affecting learning and systems improvement: respondents emphasized that the CED group should generate a plan for improvement with accountable stakeholders. Collectively, these priorities propose several recommendations for CED practice, including frontline staff inclusion. CONCLUSIONS In this study, we propose recommendations for CED that are derived from first-hand participant experiences. Future study will explore implementation of CED practice recommendations.
Collapse
Affiliation(s)
- Meghan M Galligan
- Departments of Pediatrics
- The Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Heather A Wolfe
- Anesthesiology and Critical Care Medicine
- The Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Katherine Kellom
- Policy Laboratory, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Stephanie M Garcia
- Policy Laboratory, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rebecca Neergaard
- Family Medicine and Community Health, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eda Akpek
- Family Medicine and Community Health, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Frances K Barg
- Family Medicine and Community Health, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | |
Collapse
|
28
|
Halpern SD, Chowdhury M, Bayes B, Cooney E, Hitsman BL, Schnoll RA, Lubitz SF, Reyes C, Patel MS, Greysen SR, Mercede A, Reale C, Barg FK, Volpp KG, Karlawish J, Stephens-Shields AJ. Effectiveness and Ethics of Incentives for Research Participation: 2 Randomized Clinical Trials. JAMA Intern Med 2021; 181:1479-1488. [PMID: 34542553 PMCID: PMC8453363 DOI: 10.1001/jamainternmed.2021.5450] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Incentivizing research participation is controversial and variably regulated because of uncertainty regarding whether financial incentives serve as undue inducements by diminishing peoples' sensitivity to research risks or unjust inducements by preferentially increasing enrollment among underserved individuals. OBJECTIVE To determine whether incentives improve enrollment in real randomized clinical trials (RCTs) or serve as undue or unjust inducements. DESIGN, SETTING, AND PARTICIPANTS Two RCTs of incentives that were embedded in 2 parent RCTs, 1 comparing smoking cessation interventions (conducted at smoking cessation clinics in 2 health systems) and 1 evaluating an ambulation intervention (conducted across wards of the Hospital of the University of Pennsylvania) included all persons eligible for the parent trials who did not have prior knowledge of the incentives trials. Recruitment occurred from September 2017 to August 2019 for the smoking trial and January 2018 through May 2019 for the ambulation trial; data were analyzed from January 2020 to July 2020. INTERVENTIONS Patients were randomly assigned to incentives of $0, $200, or $500 for participating in the smoking cessation trial and $0, $100, or $300 for the ambulation trial. MAIN OUTCOMES AND MEASURES The primary outcome of each incentive trial was the proportion of people assigned to each recruitment strategy that consented to participate. Each trial was powered to test the hypotheses that incentives served neither as undue inducements (based on the interaction between incentive size and perceived research risk, as measured using a 10-point scale, on the primary outcome), nor unjust inducements (based on the interaction between incentive size and participants' self-reported income). Noninferiority methods were used to test whether the data were compatible with these 2 effects of incentives and superiority methods to compare the primary and other secondary outcomes. RESULTS There were a total of 654 participants (327 women [50.0%]; mean [SD] age, 50.6 [12.1] years; 394 Black/African American [60.2%], 214 White [32.7%], and 24 multiracial individuals [3.7%]) in the smoking trial, and 642 participants (364 women [56.7%]; mean [SD] age, 46.7 [15.6] years; 224 Black/African American [34.9%], 335 White [52.2%], and 5 multiracial individuals [0.8%]) in the ambulation trial. Incentives significantly increased consent rates among those in the smoking trial in 47 of 216 (21.8%), 78 of 217 (35.9%), and 104 of 221 (47.1%) in the $0, $200, and $500 groups, respectively (adjusted odds ratio [aOR] for each increase in incentive, 1.70; 95% CI, 1.34-2.17; P < .001). Incentives did not increase consent among those in the ambulation trial: 98 of 216 (45.4%), 102 of 212 (48.1%), and 92 of 214 (43.0%) in the $0, $100, and $300 groups, respectively (aOR, 0.88; 95% CI, 0.64-1.22; P = .45). In neither trial was there evidence of undue or unjust inducement (upper confidence limits of ORs for undue inducement, 1.15 and 0.99; P < .001 showing noninferiority; upper confidence limits of ORs for unjust inducement, 1.21 and 1.26; P = .01 and P < .001, respectively). There were no significant effects of incentive size on the secondary outcomes in either trial, including time spent reviewing the risk sections of consent forms, perceived research risks, trial understanding, perceived coercion, or therapeutic misconceptions. CONCLUSIONS AND RELEVANCE In these 2 randomized clinical trials, financial incentives increased trial enrollment in 1 of 2 trials and did not produce undue or unjust inducement or other unintended consequences in either trial. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02697799.
Collapse
Affiliation(s)
- Scott D Halpern
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Marzana Chowdhury
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brian Bayes
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Elizabeth Cooney
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brian L Hitsman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Robert A Schnoll
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Su Fen Lubitz
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Celine Reyes
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mitesh S Patel
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - S Ryan Greysen
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ashley Mercede
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Catherine Reale
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Frances K Barg
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Anthropology, University of Pennsylvania School of Arts and Sciences, Philadelphia
| | - Kevin G Volpp
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Jason Karlawish
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Penn Memory Center at the Penn Neuroscience Center, Philadelphia, Pennsylvania
| | - Alisa J Stephens-Shields
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| |
Collapse
|
29
|
Saine ME, Szymczak JE, Moore TM, Bamford LP, Barg FK, Forde KA, Schnittker J, Holmes JH, Mitra N, Lo Re V. The impact of disease-related knowledge on perceptions of stigma among patients with Hepatitis C Virus (HCV) infection. PLoS One 2021; 16:e0258143. [PMID: 34610030 PMCID: PMC8491913 DOI: 10.1371/journal.pone.0258143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/19/2021] [Indexed: 12/12/2022] Open
Abstract
Most patients with hepatitis C virus (HCV) infection perceive some degree of disease-related stigma. Misunderstandings about diseases may contribute to disease-related stigma. The objective of this study was to evaluate patient-level knowledge about HCV infection transmission and natural history and its association with HCV-related stigma among HCV-infected patients. We conducted a cross-sectional survey study among 265 patients with HCV in Philadelphia using the HCV Stigma Scale and the National Health and Nutrition Examination Survey (NHANES) Hepatitis C Follow-up Survey (2001-2008). The association between HCV knowledge and HCV-related stigma was evaluated via linear regression. Overall knowledge about HCV transmission and natural history was high, with >80% of participants answering ≥9 of 11 items correctly (median number of correct responses, 9 [82%]), HCV-related knowledge was similar between HIV/HCV-coinfected and HCV-monoinfected participants (p = 0.30). A higher level of HCV-related knowledge was associated with greater perceived HCV-related stigma (β, 2.34 ([95% CI, 0.51-4.17]; p = 0.013). Results were similar after adjusting for age, race, ethnicity, HIV status, education level, stage of HCV management, time since diagnosis, and history of injection drug use. In this study, increased HCV-related knowledge was associated with greater perceptions of HCV stigma. Clinicians may consider allotting time to address common misconceptions about HCV when educating patients about HCV infection, which may counterbalance the stigmatizing impact of greater HCV-related knowledge.
Collapse
Affiliation(s)
- M. Elle Saine
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Julia E. Szymczak
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Tyler M. Moore
- Department of Psychiatry, Brain Behavior Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Laura P. Bamford
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego School of Medicine, San Diego, California, United States of America
| | - Frances K. Barg
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Kimberly A. Forde
- Section of Hepatology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States of America
| | - Jason Schnittker
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America
- Department of Sociology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - John H. Holmes
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Vincent Lo Re
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| |
Collapse
|
30
|
Mancheno C, Asch DA, Klinger EV, Goldshear JL, Mitra N, Buttenheim AM, Barg FK, Ungar LH, Yang L, Merchant RM. Effect of Posting on Social Media on Systolic Blood Pressure and Management of Hypertension: A Randomized Controlled Trial. J Am Heart Assoc 2021; 10:e020596. [PMID: 34558301 PMCID: PMC8649152 DOI: 10.1161/jaha.120.020596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Online platforms are used to manage aspects of our lives including health outside clinical settings. Little is known about the effectiveness of using online platforms to manage hypertension. We assessed effects of tweeting/retweeting cardiovascular health content by individuals with poorly controlled hypertension on systolic blood pressure (SBP) and patient activation. Methods and Results We conducted this 2‐arm randomized controlled trial. Eligibility included diagnosis of hypertension; SBP >140 mm Hg; and an existing Twitter account or willingness to create one to follow study Twitter account. Intervention arm was asked to tweet/retweet health content 2×/week using a specific hashtag for study duration (6 months). The main measures include primary outcome change in SBP; secondary outcome point change in Patient Activation Measure (PAM). We remotely recruited and enrolled 611 participants, mean age 52 (SD, 11.7). Mean baseline SBP for the intervention group was 155.8 and for control was 155.6. At 6 months, mean SBP for intervention group was 137.6 and for control was 135.7. Mean change in SBP from baseline to 6 months for the intervention group was −18.5 and for control was −19.8 (P=0.48). Mean PAM at baseline for the intervention group was 70.3 for control was 72.7. At 6 months, mean PAM scores were 71.1 (intervention) and 75.6 (control). Mean change in PAM score for the intervention group was 0.0 and for control was 3.3 (P=0.12). Conclusions Recruiting and engaging patients and collecting outcome measures remotely are feasible using Twitter. Encouraging patients with poorly controlled hypertension to tweet or retweet health content on Twitter did not improve SBP or PAM score at 6 months. Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02622256.
Collapse
Affiliation(s)
- Christina Mancheno
- Penn Medicine Center for Digital Health University of Pennsylvania Philadelphia PA
| | - David A Asch
- Penn Medicine Center for Digital Health University of Pennsylvania Philadelphia PA.,Center for Health Equity Research and Promotion - Philadelphia Veterans Affairs Medical Center Philadelphia PA.,The Wharton School University of Pennsylvania Philadelphia PA
| | - Elissa V Klinger
- Penn Medicine Center for Digital Health University of Pennsylvania Philadelphia PA
| | - Jesse L Goldshear
- Penn Medicine Center for Digital Health University of Pennsylvania Philadelphia PA
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology and Informatics University of Pennsylvania Philadelphia PA
| | - Alison M Buttenheim
- Department of Family and Community Health University of Pennsylvania School of Nursing Philadelphia PA.,Center for Health Incentives and Behavioral Economics Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Frances K Barg
- Department of Family and Community Health University of Pennsylvania School of Nursing Philadelphia PA
| | - Lyle H Ungar
- Penn Medicine Center for Digital Health University of Pennsylvania Philadelphia PA.,The Wharton School University of Pennsylvania Philadelphia PA.,Department of Computer and Information Science University of Pennsylvania Philadelphia PA
| | - Lin Yang
- Department of Biostatistics, Epidemiology and Informatics University of Pennsylvania Philadelphia PA
| | - Raina M Merchant
- Penn Medicine Center for Digital Health University of Pennsylvania Philadelphia PA.,Department of Emergency Medicine Perelman School of Medicine University of Pennsylvania Philadelphia PA.,Center for Health Incentives and Behavioral Economics Perelman School of Medicine University of Pennsylvania Philadelphia PA
| |
Collapse
|
31
|
Ralefala TB, Mokokwe L, Jammalamadugu S, Legobere D, Motlhwa WS, Oyekunle AA, Grover S, Barg FK, Shulman LN, Martei YM. Provider Barriers and Facilitators of Breast Cancer Guideline-Concordant Therapy Delivery in Botswana: A Consolidated Framework for Implementation Research Analysis. Oncologist 2021; 26:e2200-e2208. [PMID: 34390287 PMCID: PMC8649035 DOI: 10.1002/onco.13935] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 08/02/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction Systemic treatment for breast cancer in sub‐Saharan Africa (SSA) is cost effective. However, there are limited real‐world data on the translation of breast cancer treatment guidelines into clinical practice in SSA. The study aimed to identify provider factors associated with adherence to breast cancer guideline‐concordant care at Princess Marina Hospital (PMH) in Botswana. Materials and Methods The Consolidated Framework for Implementation Research was used to conduct one‐on‐one semistructured interviews with breast cancer providers at PMH. Purposive sampling was used, and sample size was determined by thematic saturation. Transcribed interviews were double‐coded and analyzed in NVivo using an integrated analysis approach. Results Forty‐one providers across eight departments were interviewed. There were variations in breast cancer guidelines used. Facilitators included a strong tension for change and a government‐funded comprehensive cancer care plan. Common provider and health system barriers were lack of available resources, staff shortages and poor skills retention, lack of relative priority compared with HIV/AIDS, suboptimal interdepartmental communication, and lack of a clearly defined national cancer control policy. Community‐level barriers included accessibility and associated transportation costs. Participants recommended the formal implementation of future guidelines that involved key stakeholders in all phases of planning and implementation, strategic government buy‐in, expansion of multidisciplinary tumor boards, leveraging nongovernmental and academic partnerships, and setting up monitoring, evaluation, and feedback processes. Discussion The study identified complex, multilevel factors affecting breast cancer treatment delivery in Botswana. These results and recommendations will inform strategies to overcome specific barriers in order to promote standardized breast cancer care delivery and improve survival outcomes. Implications for Practice To address the increasing cancer burden in low‐ and middle‐income countries, resource‐stratified guidelines have been developed by multiple international organizations to promote high‐quality guideline‐concordant care. However, these guidelines still require adaptation in order to be successfully translated into clinical practice in the countries where they are intended to be used. This study highlights a systematic approach of evaluating important contextual factors associated with the successful adaptation and implementation of resource‐stratified guidelines in sub‐Saharan Africa. In Botswana, there is a critical need for local stakeholder input to inform country‐level and facility‐level resources, cancer care accessibility, and community‐level barriers and facilitators. To address an increasing mortality burden, resource‐stratified guidelines have been developed to ensure that breast cancer care is matched to specific resources in low‐ and middle‐income countries. This article identifies facilitators and barriers to the use of breast cancer guidelines by oncology providers at Princess Marina Hospital in Botswana using the Consolidated Framework for Implementation Research (CFIR).
Collapse
Affiliation(s)
- Tlotlo B Ralefala
- Princess Marina Hospital, Gaborone, Botswana; Ministry of Health and Wellness, Gaborone, Botswana
| | - Lebogang Mokokwe
- Botswana University of Pennsylvania Partnership, Gaborone, Botswana.,University of Botswana, Gaborone, Botswana
| | - Swetha Jammalamadugu
- Princess Marina Hospital, Gaborone, Botswana; Ministry of Health and Wellness, Gaborone, Botswana.,University of Botswana, Gaborone, Botswana
| | | | | | | | - Surbhi Grover
- Botswana University of Pennsylvania Partnership, Gaborone, Botswana.,University of Botswana, Gaborone, Botswana.,Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Frances K Barg
- Department of Family Medicine and Community Health; Department of Anthropology, University of Pennsylvania, Philadelphia, PA
| | - Lawrence N Shulman
- Department of Medicine (Hematology - Oncology), University of Pennsylvania, Philadelphia, PA
| | - Yehoda M Martei
- Botswana University of Pennsylvania Partnership, Gaborone, Botswana.,University of Botswana, Gaborone, Botswana.,Department of Medicine (Hematology - Oncology), University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
32
|
Wietlisbach LE, Asch DA, Eriksen W, Barg FK, Bellini LM, Desai SV, Yakubu AR, Shea JA. Dark Clouds With Silver Linings: Resident Anxieties About COVID-19 Coupled With Program Innovations and Increased Resident Well-Being. J Grad Med Educ 2021; 13:515-525. [PMID: 34434512 PMCID: PMC8370362 DOI: 10.4300/jgme-d-20-01497.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 03/05/2021] [Accepted: 05/04/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic forced numerous unprecedented systemic changes within residency programs and hospital systems. OBJECTIVE We explored how the COVID-19 pandemic, and associated changes in clinical and educational experiences, were related to internal medicine residents' well-being in the early months of the pandemic. METHODS Across 4 internal medicine residency programs in the Northeast United States that have previously participated in the iCOMPARE study, all 394 residents were invited to participate in a study with open-ended survey prompts about well-being approximately every 2 weeks in academic year 2019-2020. In March and April 2020, survey prompts were refocused to COVID-19. Content analysis revealed themes in residents' open-ended responses to 4 prompts. RESULTS One hundred and eighty-six residents expressed interest, and 88 were randomly selected (47%). There were 4 main themes: (1) in early days of the pandemic, internal medicine residents reported fear and anxiety about uncertainty and lack of personal protective equipment; (2) residents adapted and soon were able to reflect, rest, and pursue personal wellness; (3) communication from programs and health systems was inconsistent early in the pandemic but improved in clarity and frequency; (4) residents appreciated the changes programs had made, including shorter shifts, removal of pre-rounding, and telemedicine. CONCLUSIONS COVID-19 introduced many challenges to internal medicine residency programs and to resident well-being. Programs made structural changes to clinical schedules, educational/conference options, and communication that boosted resident well-being. Many residents hoped these changes would continue regardless of the pandemic's course.
Collapse
Affiliation(s)
- Larissa E. Wietlisbach
- Larissa E. Wietlisbach, BSA, is a Medical Student and Research Assistant, Perelman School of Medicine, University of Pennsylvania
| | - David A. Asch
- David A. Asch, MD, MBA, is Professor, Perelman School of Medicine and The Wharton School, and an Internal Medicine Physician, Department of Medicine, University of Pennsylvania
| | - Whitney Eriksen
- Whitney Eriksen, PhD, RN, is a Senior Researcher, University of Pennsylvania Mixed Methods Research Lab
| | - Frances K. Barg
- Frances K. Barg, PhD, MEd, is Director, University of Pennsylvania Mixed Methods Research Lab, and Professor, Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania
| | - Lisa M. Bellini
- Lisa M. Bellini, MD, is Senior Vice Dean for Academic Affairs, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, and University of Pennsylvania
| | - Sanjay V. Desai
- Sanjay V. Desai, MD, is Director, Osler Medical Residency, and Vice-Chair for Education, Department of Medicine, Johns Hopkins University
| | - Abdul-Rakeem Yakubu
- Abdul-Rakeem Yakubu is a Research Assistant, University of Pennsylvania Mixed Methods Research Lab
| | - Judy A. Shea
- Judy A. Shea, PhD, is Associate Dean of Medical Education Research, Perelman School of Medicine, and Professor, Department of Medicine, University of Pennsylvania
| |
Collapse
|
33
|
Barbieri JS, Fulton R, Neergaard R, Nelson MN, Barg FK, Margolis DJ. Patient Perspectives on the Lived Experience of Acne and Its Treatment Among Adult Women With Acne: A Qualitative Study. JAMA Dermatol 2021; 157:1040-1046. [PMID: 34319378 DOI: 10.1001/jamadermatol.2021.2185] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction Acne often persists into adulthood in women. However, few studies have specifically explored the lived experience of acne in adult populations. Objective To examine the lived experience of acne and its treatment among a cohort of adult women. Design, Setting, and Participants A qualitative analysis was conducted from free listing and open-ended, semistructured interviews of patients at a large academic health care system (University of Pennsylvania Health System) and a private practice (Dermatologists of Southwest Ohio). Fifty women 18 to 40 years of age with moderate to severe acne participated in interviews conducted between August 30, 2019, and December 31, 2020. Main Outcomes and Measures Free-listing data from interviews were used to calculate the Smith S, a measure of saliency for each list item. Semistructured interviews were examined to detect themes about patient perspectives regarding their acne and its treatment. Results Fifty participants (mean [SD] age, 28 [5.38] years; 24 [48%] White) described acne-related concerns about their appearance that affected their social, professional, and personal lives, with many altering their behavior because of their acne. Depression, anxiety, and social isolation were commonly reported. Participants described successful treatment as having completely clear skin over time or a manageable number of blemishes. Many participants described frustration with finding a dermatologist with whom they were comfortable and with identifying effective treatments for their acne. Conclusions and Relevance The results of this qualitative study suggest that women with acne have strong concerns about appearance and experience mental and emotional health consequences and disruption of their personal and professional lives. In addition, many patients describe challenges finding effective treatments and accessing care. Future trials to understand the optimal treatment approaches for women with acne are needed to improve outcomes in this population.
Collapse
Affiliation(s)
- John S Barbieri
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Rachel Fulton
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Rebecca Neergaard
- Mixed Methods Research Lab, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Maria N Nelson
- Mixed Methods Research Lab, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Frances K Barg
- Mixed Methods Research Lab, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - David J Margolis
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| |
Collapse
|
34
|
Meghani SH, Levoy K, Magan KC, Starr LT, Yocavitch L, Barg FK. "I'm Dealing With That": Illness Concerns of African American and White Cancer Patients While Undergoing Active Cancer Treatments. Am J Hosp Palliat Care 2021; 38:830-841. [PMID: 33107324 PMCID: PMC8424597 DOI: 10.1177/1049909120969121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND National oncology guidelines recommend early integration of palliative care for patients with cancer. However, drivers for this integration remain understudied. Understanding illness concerns at the time of cancer treatment may help facilitate integration earlier in the cancer illness trajectory. OBJECTIVE To describe cancer patients' concerns while undergoing cancer treatment, and determine if concerns differ among African Americans and Whites. METHODS A 1-time, semi-structured qualitative interview was conducted with a purposive subsample of cancer patients participating in a larger study of illness concerns. Eligible patients were undergoing cancer treatments and had self-reported moderate-to-severe pain in the last week. Analysis encompassed a qualitative descriptive approach with inductive thematic analysis. RESULTS Participants (16 African American, 16 White) had a median age of 53 and were predominantly females (72%) with stage III/IV cancer (53%). Illness concerns were largely consistent across participants and converged on 3 themes: symptom experience (pain, options to manage pain), cancer care delivery (communication, care coordination and care transitions), and practical concerns (access to community and health system resources, financial toxicity). CONCLUSIONS The findings extend the scope of factors that could be utilized to integrate palliative care earlier in the cancer illness trajectory, moving beyond the symptoms- and prognosis-based triggers that typify current referrals to also consider diverse logistical concerns. Using this larger set of concerns aids anticipatory risk mitigation and planning (e.g. care transitions, financial toxicity), helps patients receive a larger complement of support services, and builds cancer patients' capacity toward a more patient-centered treatment and care experience.
Collapse
Affiliation(s)
- Salimah H. Meghani
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing; Philadelphia, Pennsylvania
| | - Kristin Levoy
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing; Philadelphia, Pennsylvania
| | | | - Lauren T. Starr
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing; Philadelphia, Pennsylvania
| | | | - Frances K. Barg
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania
| |
Collapse
|
35
|
Kirschen MP, Smith KA, Snyder M, Zhang B, Flibotte J, Heimall L, Budzynski K, DeLeo R, Cona J, Bocage C, Hur L, Winters M, Hanna R, Mensinger JL, Huh J, Lang SS, Barg FK, Shea JA, Ichord R, Berg RA, Levine JM, Nadkarni V, Topjian A. Serial Neurologic Assessment in Pediatrics (SNAP): A New Tool for Bedside Neurologic Assessment of Critically Ill Children. Pediatr Crit Care Med 2021; 22:483-495. [PMID: 33729729 DOI: 10.1097/pcc.0000000000002675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We developed a tool, Serial Neurologic Assessment in Pediatrics, to screen for neurologic changes in patients, including those who are intubated, are sedated, and/or have developmental disabilities. Our aims were to: 1) determine protocol adherence when performing Serial Neurologic Assessment in Pediatrics, 2) determine the interrater reliability between nurses, and 3) assess the feasibility and acceptability of using Serial Neurologic Assessment in Pediatrics compared with the Glasgow Coma Scale. DESIGN Mixed-methods, observational cohort. SETTING Pediatric and neonatal ICUs. SUBJECTS Critical care nurses and patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Serial Neurologic Assessment in Pediatrics assesses Mental Status, Cranial Nerves, Communication, and Motor Function, with scales for children less than 6 months, greater than or equal to 6 months to less than 2 years, and greater than or equal to 2 years old. We assessed protocol adherence with standardized observations. We assessed the interrater reliability of independent Serial Neurologic Assessment in Pediatrics assessments between pairs of trained nurses by percent- and bias- adjusted kappa and percent agreement. Semistructured interviews with nurses evaluated acceptability and feasibility after nurses used Serial Neurologic Assessment in Pediatrics concurrently with Glasgow Coma Scale during routine care. Ninety-eight percent of nurses (43/44) had 100% protocol adherence on the standardized checklist. Forty-three nurses performed 387 paired Serial Neurologic Assessment in Pediatrics assessments (149 < 6 mo; 91 ≥ 6 mo to < 2 yr, and 147 ≥ 2 yr) on 299 patients. Interrater reliability was substantial to near-perfect across all components for each age-based Serial Neurologic Assessment in Pediatrics scale. Percent agreement was independent of developmental disabilities for all Serial Neurologic Assessment in Pediatrics components except Mental Status and lower extremity Motor Function for patients deemed "Able to Participate" with the assessment. Nurses reported that they felt Serial Neurologic Assessment in Pediatrics, compared with Glasgow Coma Scale, was easier to use and clearer in describing the neurologic status of patients who were intubated, were sedated, and/or had developmental disabilities. About 92% of nurses preferred to use Serial Neurologic Assessment in Pediatrics over Glasgow Coma Scale. CONCLUSIONS When used by critical care nurses, Serial Neurologic Assessment in Pediatrics has excellent protocol adherence, substantial to near-perfect interrater reliability, and is feasible to implement. Further work will determine the sensitivity and specificity for detecting clinically meaningful neurologic decline.
Collapse
Affiliation(s)
- Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Nursing, Children's Hospital of Philadelphia, Philadelphia, PA
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Physical Therapy, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Occupational Therapy, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Speech-Language Pathology, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Family Medicine and Community Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA
- Division of Neurosurgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Katherine A Smith
- Department of Nursing, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Megan Snyder
- Department of Nursing, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Bingqing Zhang
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - John Flibotte
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Lauren Heimall
- Department of Nursing, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Katrina Budzynski
- Department of Physical Therapy, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ryan DeLeo
- Department of Occupational Therapy, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jackelyn Cona
- Department of Speech-Language Pathology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Claire Bocage
- Department of Family Medicine and Community Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Lynn Hur
- Department of Family Medicine and Community Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Madeline Winters
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Richard Hanna
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Janell L Mensinger
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA
| | - Jimmy Huh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Shih-Shan Lang
- Division of Neurosurgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Frances K Barg
- Department of Family Medicine and Community Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Judy A Shea
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Rebecca Ichord
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Joshua M Levine
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
36
|
Musicus AA, Hua SV, Schwartz MB, Block JP, Barg FK, Economos CD, Glanz K, Krieger JW, Roberto CA. Messages Promoting Healthy Kids' Meals: An Online RCT. Am J Prev Med 2021; 60:674-683. [PMID: 33632647 PMCID: PMC8279041 DOI: 10.1016/j.amepre.2020.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 10/06/2020] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Calorie labeling is now required on all large U.S. chain restaurant menus, but its influence on consumer behavior is mixed. This study examines whether different parent-targeted messages encourage parents to order lower-calorie meals for their children in a hypothetical online setting. METHODS An online RCT was conducted with sociodemographically diverse primary caregivers of children aged 6-12 years (data collected and analyzed in 2017-2019). Participants (N=2,373) were randomized to see 1 of 4 messages: (1) nonfood control, (2) kids' meals are the right size for children, (3) doctors recommend a 600 kcal per meal limit for kids, or (4) 600 kcal per meal is a generally recommended limit for kids. Participants ordered hypothetical meals for their children and themselves and rated meal and message perceptions. RESULTS There were no significant differences between conditions in calories ordered for children at either restaurant, although all 3 food message conditions ordered fewer calories for their children than the control (full service: 27-68 fewer kcal, fast food: 18-64 fewer kcal). The general 600 kcal/meal limit message consistently performed best across outcomes, encouraging parents to order the fewest calories for their children at both restaurants (5%-7% fewer) and significantly increasing their understanding of calorie recommendations for kids' meals. It also significantly reduced fast-food calories parents ordered for themselves compared with the control (-106 kcal, p=0.042). CONCLUSIONS Although no statistically significant differences were detected, messages with specific calorie recommendations for kids led parents to order lower-calorie restaurant meals for their children, suggesting that additional real-world studies with larger sample sizes are warranted.
Collapse
Affiliation(s)
- Aviva A Musicus
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
| | - Sophia V Hua
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Marlene B Schwartz
- UConn Rudd Center for Food Policy & Obesity, University of Connecticut, Hartford, Connecticut
| | - Jason P Block
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
| | - Frances K Barg
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christina D Economos
- Division of Nutrition Interventions, Communication, and Behavior Change, Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
| | - Karen Glanz
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James W Krieger
- Department of Health Services, School of Public Health, University of Washington, Seattle, Washington; School of Medicine, University of Washington, Seattle, Washington
| | - Christina A Roberto
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
37
|
Dowzicky PM, Shah AA, Barg FK, Eriksen WT, McHugh MD, Kelz RR. An Assessment of Patient, Caregiver, and Clinician Perspectives on the Post-discharge Phase of Care. Ann Surg 2021; 273:719-724. [PMID: 31356271 DOI: 10.1097/sla.0000000000003479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE We sought to elicit patients', caregivers', and health care providers' perceptions of home recovery to inform care personalization in the learning health system. SUMMARY BACKGROUND DATA Postsurgical care has shifted from the hospital into the home. Daily care responsibilities fall to patients and their caregivers, yet stakeholder concerns in these heterogeneous environments, especially as they relate to racial inequities, are poorly understood. METHODS Surgical oncology patients, caregivers, and clinicians participated in freelisting; an open-ended interviewing technique used to identify essential elements of a domain. Within 2 weeks after discharge, participants were queried on 5 domains: home independence, social support, pain control, immediate, and overall surgical impact. Salience indices, measures of the most important words of interest, were calculated using Anthropac by domain and group. RESULTS Forty patients [20 whites and 20 African-Americans (AAs)], 30 caregivers (17 whites and 13 AAs), and 20 providers (8 residents, 4 nurses, 4 nurse practitioners, and 4 attending surgeons) were interviewed. Patients and caregivers attended to the personal recovery experience, whereas providers described activities and individuals associated with recovery. All groups defined surgery as life-changing, with providers and caregivers discussing financial and mortality concerns. Patients shared similar thoughts about social support and self-care ability by race, whereas AA patients described heterogeneous pain management and more hopeful recovery perceptions. AA caregivers expressed more positive responses than white caregivers. CONCLUSIONS Patients live the day-to-day of recovery, whereas caregivers and clinicians also contemplate more expansive concerns. Incorporating relevant perceptions into traditional clinical outcomes and concepts could enhance the surgical experience for all stakeholders.
Collapse
Affiliation(s)
- Phillip M Dowzicky
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Arnav A Shah
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Frances K Barg
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Whitney T Eriksen
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Rachel R Kelz
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
38
|
Hua SV, Sterner-Stein K, Barg FK, Musicus AA, Glanz K, Schwartz MB, Block JP, Economos CD, Krieger JW, Roberto CA. A Qualitative Study of Parents With Children 6 to 12 Years Old: Use of Restaurant Calorie Labels to Inform the Development of a Messaging Campaign. J Acad Nutr Diet 2021; 120:1884-1892.e4. [PMID: 33099402 DOI: 10.1016/j.jand.2020.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 05/19/2020] [Accepted: 05/26/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND US law mandates that chain restaurants with 20 or more locations post calorie information on their menus to inform consumers and encourage healthy choices. Few qualitative studies have assessed how parents perceive and use this information when ordering for their children and what types of accompanying messages might increase use of calorie labels when ordering food. OBJECTIVE We aimed to better understand parents' perceptions and use of calorie labeling and the types of messages that might increase use. DESIGN We conducted 10 focus groups (n = 58) and 20 shop-along interviews (n = 20). Focus group participants discussed their hypothetical orders and restaurant experiences when dining with their children, and shop-along participants verbalized their decision processes while ordering at a restaurant. Both groups gave feedback on 4 public service messages aimed to increase healthier ordering for children. All interviews were voice-recorded and transcribed. PARTICIPANTS/SETTING Participants were primary caregivers of at least 1 child between 6 and 12 years who reported having less than a college education at the time of screening and who commonly ate at chain restaurants. Focus groups were conducted in a conference room, and shop-alongs were conducted in quick-serve and full-service chain restaurants around Philadelphia between August 2016 and May 2017. ANALYSES A modified grounded theory approach was used to extract themes from transcripts. RESULTS Thematic analysis of transcripts revealed 5 key themes: (1) parents' use of calorie labels; (2) differences across restaurant settings; (3) nonjudgmental information; (4) financial value and enjoyment of food; and (5) message preferences. These themes suggested that nonjudgmental, fact-based messages that highlight financial value, feelings of fullness, and easy meal component swaps without giving up the treatlike aspect of eating out may be particularly helpful for consumers. CONCLUSIONS These findings can inform current US Food and Drug Administration campaign efforts to support consumer use of calorie labels on menus.
Collapse
|
39
|
Wortzel JD, Wiebe DJ, Elahi S, Agawu A, Barg FK, Emmett EA. Ascertainment Bias in a Historic Cohort Study of Residents in an Asbestos Manufacturing Community. Int J Environ Res Public Health 2021; 18:2211. [PMID: 33668103 PMCID: PMC7956794 DOI: 10.3390/ijerph18052211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 02/18/2021] [Accepted: 02/20/2021] [Indexed: 11/16/2022]
Abstract
This paper describes follow-up for a cohort of 4530 residents living in the asbestos manufacturing community of Ambler, PA, U.S. in 1930. Using re-identified census data, cause and date of death data obtained from the genealogic website Ancestry.com, along with geospatial analysis, we explored relationships among demographic characteristics, occupational, paraoccupational and environmental asbestos exposures. We identified death data for 2430/4530 individuals. Exposure differed significantly according to race, gender, age, and recency of immigration to the U.S. Notably, there was a significant difference in the availability of year of death information for non-white vs. white individuals (odds ratio (OR) = 0.62 p-value < 0.001), females (OR = 0.53, p-value < 0.001), first-generation immigrants (OR = 0.67, p-value = 0.001), second-generation immigrants (OR = 0.31, p-value < 0.001) vs. non-immigrants, individuals aged less than 20 (OR = 0.31 p-value < 0.001) and individuals aged 20 to 59 (OR = 0.63, p-value < 0.001) vs. older individuals. Similarly, the cause of death was less often available for non-white individuals (OR = 0.42, p-value <0.001), first-generation immigrants and (OR = 0.71, p-value = 0.009), second-generation immigrants (OR = 0.49, p-value < 0.001), individuals aged less than 20 (OR = 0.028 p-value < 0.001), and individuals aged 20 to 59 (OR = 0.26, p-value < 0.001). These results identified ascertainment bias that is important to consider in analyses that investigate occupational, para-occupational and environmental asbestos exposure as risk factors for mortality in this historic cohort. While this study attempts to describe methods for assessing itemized asbestos exposure profiles for a community in 1930 using Ancestry.com and other publicly accessible databases, it also highlights how historic cohort studies likely underestimate the impact of asbestos exposure on vulnerable populations. Future work will aim to assess mortality patterns in this cohort.
Collapse
Affiliation(s)
- Jeremy D. Wortzel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (J.D.W.); (D.J.W.); (A.A.); (E.A.E.)
| | - Douglas J. Wiebe
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (J.D.W.); (D.J.W.); (A.A.); (E.A.E.)
| | - Shabnam Elahi
- School of Medicine, Georgetown University, Washington, DC 20007, USA;
| | - Atu Agawu
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (J.D.W.); (D.J.W.); (A.A.); (E.A.E.)
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Frances K. Barg
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (J.D.W.); (D.J.W.); (A.A.); (E.A.E.)
| | - Edward A. Emmett
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (J.D.W.); (D.J.W.); (A.A.); (E.A.E.)
| |
Collapse
|
40
|
Garland SN, Trevino K, Liou KT, Gehrman P, Spiguel E, MacLeod J, Walker DAH, Glosik B, Seluzicki C, Barg FK, Mao JJ. Multi-stakeholder perspectives on managing insomnia in cancer survivors: recommendations to reduce barriers and translate patient-centered research into practice. J Cancer Surviv 2021; 15:951-960. [PMID: 33606188 DOI: 10.1007/s11764-021-01001-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/06/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE Insomnia is a debilitating symptom experienced by nearly 60% of cancer survivors. Building on our prior research showing the clinical benefit of cognitive behavioral therapy for insomnia (CBT-I) and acupuncture, we organized a workshop of patient advocates and clinician stakeholders to understand the barriers and develop recommendations for the dissemination and implementation of these interventions. METHODS Participants completed a pre-workshop survey assessing their experiences with insomnia and barriers to insomnia treatment and participated in a workshop facilitated by professionals and patient experts. Responses from the survey were tabulated and the discussions from the workshop were content-analyzed to extract relevant factors that may influence dissemination and implementation. RESULTS Multidisciplinary and stakeholder workshop participants (N = 51) identified barriers and proposed solutions and future recommendations for dissemination and implementation of evidence-based interventions to improve sleep health in cancer survivors. Barriers were identified in four categories: patient (e.g., knowledge, time, cost), clinician (e.g., education, time, capacity), institutional (e.g., space, insurance reimbursement, referrals), and societal (e.g., lack of prioritization for sleep issues). Based on these categories, we made six recommendations for dissemination and implementation of research findings to improve clinical sleep management in oncology. CONCLUSION Dissemination and implementation efforts are necessary to translate research into clinical practice to improve patient care. IMPLICATIONS FOR CANCER SURVIVORS Sleep needs to be prioritized in cancer care, but patient, provider, and institutional/societal barriers remain. Dedicated effort and resources at each of these levels are needed to help millions of people affected by cancer manage their insomnia and improve their quality of life.
Collapse
Affiliation(s)
| | - Kelly Trevino
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kevin T Liou
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Jodi MacLeod
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Betsy Glosik
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Jun J Mao
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
41
|
Williamson AA, Milaniak I, Watson B, Cicalese O, Fiks AG, Power TJ, Barg FK, Beidas RS, Mindell JA, Rendle KA. Early Childhood Sleep Intervention in Urban Primary Care: Caregiver and Clinician Perspectives. J Pediatr Psychol 2021; 45:933-945. [PMID: 32430496 DOI: 10.1093/jpepsy/jsaa024] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/14/2020] [Accepted: 03/30/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Despite significant income-related disparities in pediatric sleep, few early childhood sleep interventions have been tailored for or tested with families of lower socio-economic status (SES). This qualitative study assessed caregiver and clinician perspectives to inform adaptation and implementation of evidence-based behavioral sleep interventions in urban primary care with families who are predominantly of lower SES. METHODS Semi-structured interviews were conducted with (a) 23 caregivers (96% mothers; 83% Black; 65% ≤125% U.S. poverty level) of toddlers and preschoolers with insomnia or insufficient sleep and (b) 22 urban primary care clinicians (physicians, nurse practitioners, social workers, and psychologists; 87% female; 73% White). Guided by the Consolidated Framework for Implementation Research, the interview guide assessed multilevel factors across five domains related to intervention implementation. Qualitative data were analyzed using an integrated approach to identify thematic patterns across participants and domains. RESULTS Patterns of convergence and divergence in stakeholder perspectives emerged across themes. Participants agreed upon the importance of child sleep and intervention barriers (family work schedules; household and neighborhood factors). Perspectives aligned on intervention (flexibility; collaborative and empowering care) and implementation (caregiver-to-caregiver support and use of technology) facilitators. Clinicians identified many family barriers to treatment engagement, but caregivers perceived few barriers. Clinicians also raised healthcare setting factors that could support (integrated care) or hinder (space and resources) implementation. CONCLUSIONS Findings point to adaptations to evidence-based early childhood sleep intervention that may be necessary for effective implementation in urban primary care. Such adaptations could potentially reduce significant pediatric sleep-related health disparities.
Collapse
Affiliation(s)
- Ariel A Williamson
- Children's Hospital of Philadelphia.,Perelman School of Medicine, University of Pennsylvania
| | - Izabela Milaniak
- Department of Psychology, University of Pennsylvania.,Nemours/Alfred I. duPont Hospital for Children
| | - Bethany Watson
- Department of Psychology, University of Pennsylvania.,Bellevue/New York University
| | | | - Alexander G Fiks
- Children's Hospital of Philadelphia.,Perelman School of Medicine, University of Pennsylvania
| | - Thomas J Power
- Children's Hospital of Philadelphia.,Perelman School of Medicine, University of Pennsylvania
| | | | - Rinad S Beidas
- Perelman School of Medicine, University of Pennsylvania.,Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania
| | - Jodi A Mindell
- Children's Hospital of Philadelphia.,Department of Psychology, Saint Joseph's University
| | | |
Collapse
|
42
|
Bazen A, Barg FK, Takeshita J. Research Techniques Made Simple: An Introduction to Qualitative Research. J Invest Dermatol 2021; 141:241-247.e1. [PMID: 33504436 DOI: 10.1016/j.jid.2020.11.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 10/29/2020] [Accepted: 11/10/2020] [Indexed: 10/22/2022]
Abstract
Qualitative research has gained increasing prominence in health-related research and is experiencing greater use in dermatology. A major strength of and reason to perform qualitative research is that it allows one to gain an understanding of the insider (e.g., patient, medical provider, other players in the healthcare system) perspectives on health and insights about their behaviors, motivations, and expectations. This is particularly important in the field of dermatology where most diseases are, fortunately, not directly fatal but have major effects on affected individuals' lives in ways that are often not readily quantifiable. As such, it is important for dermatologists, both researchers and clinicians, to understand the basic tenets of qualitative methodology to properly utilize qualitative methods, evaluate the qualitative literature, and identify relevant findings to apply to clinical practice. In this article, we provide an overview of qualitative research and some of the more commonly used qualitative methods with an aim to increase awareness and appreciation of the power of qualitative studies.
Collapse
Affiliation(s)
- Alexus Bazen
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Frances K Barg
- Department of Family Medicine and Community Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Junko Takeshita
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
43
|
Affiliation(s)
- Shimrit Keddem
- Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
- Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Frances K. Barg
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Rosemary Frasso
- Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania
| |
Collapse
|
44
|
Keddem S, Barg FK, Frasso R. Practical Guidance for Studies Using Freelisting Interviews. Prev Chronic Dis 2021; 18:E04. [PMID: 33444525 PMCID: PMC7845553 DOI: 10.5888/pcd17.200355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Freelisting is a qualitative interviewing technique that has recently grown in popularity. It is an excellent tool for rapidly exploring how groups of people think about and define a particular health-related domain and is well suited for engaging communities and identifying shared priorities. In this article, we outline 7 practical considerations for conducting freelisting studies summarized from 16 articles conducted by the authors at the University of Pennsylvania and Thomas Jefferson University in partnership with community-based organizations and students. Our recommendations can inform study design, data collection, and data analysis for investigators who are interested in using freelisting interviews in their research.
Collapse
Affiliation(s)
- Shimrit Keddem
- Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.,University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania.,Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Frances K Barg
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Rosemary Frasso
- Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania.,College of Population Health, Thomas Jefferson University, 901 Walnut St,10th Floor, Philadelphia, PA 19107.
| |
Collapse
|
45
|
Wolk CB, Schondelmeyer AC, Barg FK, Beidas R, Bettencourt A, Brady PW, Brent C, Eriksen W, Kinkler G, Landrigan CP, Neergaard R, Bonafide CP. Barriers and Facilitators to Guideline-Adherent Pulse Oximetry Use in Bronchiolitis. J Hosp Med 2021; 16:23-30. [PMID: 33357326 PMCID: PMC7768921 DOI: 10.12788/jhm.3535] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/09/2020] [Accepted: 09/13/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Continuous pulse oximetry monitoring (cSpO2) in children with bronchiolitis does not improve clinical outcomes and has been associated with increased resource use and alarm fatigue. It is critical to understand the factors that contribute to cSpO2 overuse in order to reduce overuse and its associated harms. METHODS This multicenter qualitative study took place in the context of the Eliminating Monitor Overuse (EMO) SpO2 study, a cross-sectional study to establish rates of cSpO2 in bronchiolitis. We conducted semistructured interviews, informed by the Consolidated Framework for Implementation Research, with a purposive sample of stakeholders at sites with high and low cSpO2 use rates to identify barriers and facilitators to addressing cSpO2 overuse. Interviews were audio recorded and transcribed. Analyses were conducted using an integrated approach. RESULTS Participants (n = 56) included EMO study site principal investigators (n = 12), hospital administrators (n = 8), physicians (n = 15), nurses (n = 12), and respiratory therapists (n = 9) from 12 hospitals. Results suggest that leadership buy-in, clear authoritative guidelines for SpO2 use incorporated into electronic order sets, regular education about cSpO2 in bronchiolitis, and visual reminders may be needed to reduce cSpO2 utilization. Parental perceptions and individual clinician comfort affect cSpO2 practice. CONCLUSION We identified barriers and facilitators to deimplementation of cSpO2 for stable patients with bronchiolitis across children's hospitals with high- and low-cSpO2 use. Based on these data, future deimplementation efforts should focus on clear protocols for cSpO2, EHR changes, and education for hospital staff on bronchiolitis features and rationale for reducing cSpO2.
Collapse
Affiliation(s)
- Courtney Benjamin Wolk
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amanda C Schondelmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Frances K Barg
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rinad Beidas
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amanda Bettencourt
- Department of Systems, Populations, and Leadership, School of Nursing, University of Michigan, Ann Arbor, Michigan
| | - Patrick W Brady
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Canita Brent
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Whitney Eriksen
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Grace Kinkler
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher P Landrigan
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Rebecca Neergaard
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher P Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
46
|
Auriemma CL, Harhay MO, Haines KJ, Barg FK, Halpern SD, Lyon SM. What Matters to Patients and Their Families During and After Critical Illness: A Qualitative Study. Am J Crit Care 2021; 30:11-20. [PMID: 33385204 DOI: 10.4037/ajcc2021398] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Despite increased emphasis on providing higher-quality patient- and family-centered care in the intensive care unit (ICU), there are no widely accepted definitions of such care in the ICU. OBJECTIVES To determine (1) aspects of care that patients and families valued during their ICU encounter, (2) outcomes that patients and families prioritized after hospital discharge, and (3) outcomes perceived as equivalent to or worse than death. METHODS Semistructured interviews (n = 49) of former patients of an urban, academic medical ICU and their family members. Two investigators reviewed all transcripts line by line to identify key concepts. Codes were created and defined in a codebook with decision rules for their application and were analyzed using qualitative content analysis. RESULTS Salient themes were identified and grouped into 2 major categories: (1) processes of care within the ICU- communication, patient comfort, and a sense that the medical team was "doing everything" (ie, providing exhaustive medical care) and (2) patient and surrogate outcomes after the ICU-survival, quality of life, physical function, and cognitive function. Several outcomes were deemed worse than death: severe cognitive/physical disability, dependence on medical machinery/equipment, and severe/constant pain. CONCLUSION Although survival was important, most participants qualified this preference. Simple measures of mortality rates may not represent patient- or family-centered outcomes in evaluations of ICU-based interventions, and new measures that incorporate functional outcomes and patients' and family members' views of life quality are necessary to promote patient-centered, evidence-based care.
Collapse
Affiliation(s)
- Catherine L. Auriemma
- Catherine L. Auriemma is a pulmonary and critical care fellow, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine; Palliative and Advanced Illness Research (PAIR) Center; and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Michael O. Harhay
- Michael O. Harhay is a biostatistician, PAIR Center; and Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania
| | - Kimberley J. Haines
- Kimberley J. Haines is an intensive care unit physiotherapist, Department of Physiotherapy, Western Health; Department of Physiotherapy, The University of Melbourne; and Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Frances K. Barg
- Frances K. Barg is a medical anthropologist, Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine; and Department of Anthropology, University of Pennsylvania School of Arts and Sciences, Philadelphia
| | - Scott D. Halpern
- Scott D. Halpern is a pulmonary and critical care physician, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine; PAIR Center; Leonard Davis Institute of Health Economics; Department of Biostatistics, Epidemiology and Informatics, and Department of Medical Ethics and Health Policy Perelman School of Medicine, University of Pennsylvania
| | - Sarah M. Lyon
- Sarah M. Lyon is a pulmonary and critical care physician, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania; and Department of Medicine, Division of Pulmonary & Critical Care Medicine, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| |
Collapse
|
47
|
Saine ME, Szymczak JE, Forde KA, Moore TM, Bamford LP, Barg FK, Schnittker J, Holmes JH, Mitra N, Re VL. 1072. The Impact of Hepatitis C-Related Knowledge on Perceptions of Stigma Among Infected Individuals. Open Forum Infect Dis 2020. [PMCID: PMC7776710 DOI: 10.1093/ofid/ofaa439.1258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Stigma is an important and understudied barrier to hepatitis C virus (HCV) infection treatment and elimination. Education to dispel disease-based myths and misinformation has been identified as a key intervention point to reduce disease-related stigma; however, the association between knowledge about HCV infection and perceptions of stigma among HCV-infected patients remains unknown. Methods To address this gap and evaluate the association between patient-level HCV knowledge and HCV-related stigma, we conducted a cross-sectional study among 270 HCV-infected patients (147 [56%] HIV-coinfected) from 5 clinics across Philadelphia. HCV-related stigma was measured using the validated 33-item HCV Stigma Scale (range, 33-132). HCV-related knowledge was measured via the National Health and Nutrition Examination Survey (NHANES) Hepatitis C Follow-up Survey (2003-2008), an eleven item True/False survey (range, 0 to 11) comprising statements about HCV-related health effects and transmission. The association between HCV knowledge and HCV-related stigma was evaluated via linear regression by HIV status. Self-reported demographic, behavioral, and clinical covariates were evaluated in adjusted analyses. Results The median overall HCV knowledge score was high at 9 out of 11 points (IQR, 9-10). Median knowledge scores did not significantly differ between HIV/HCV-coinfected and HCV-monoinfected participants (10 versus 9; p=0.29). However, higher HCV knowledge scores were associated with higher HCV-related stigma score among HCV-monoinfected participants (p=0.03) but not among HCV/HIV-coinfected participants (p=0.12). Differences by HIV status were also observed when adjusting for demographic, behavioral, and clinical covariates. Conclusion Regardless of HIV status, the majority of both HIV/HCV-coinfected and HCV-monoinfected participants in this study answered questions about HCV knowledge correctly. Surprisingly, greater HCV knowledge was associated with increased HCV-related stigma among HCV-monoinfected participants, but this association was not observed among coinfected participants. Additional studies are needed to understand why this association was observed only among monoinfected persons. Disclosures M. Elle Saine, PhD, MA, Leonard Davis Institute of Health Economics Research (Grant/Research Support)
Collapse
Affiliation(s)
- M Elle Saine
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Kimberly A Forde
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tyler M Moore
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Frances K Barg
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - John H Holmes
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nandita Mitra
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vincent Lo Re
- Department of Biostatistics, Epidemiology, and Informatics, Philadelphia, Pennsylvania
| |
Collapse
|
48
|
Saine ME, Szymczak JE, Moore TM, Bamford LP, Barg FK, Schnittker J, Holmes JH, Mitra N, Re VL. Determinants of stigma among patients with hepatitis C virus infection. J Viral Hepat 2020; 27:1179-1189. [PMID: 32500618 PMCID: PMC9390068 DOI: 10.1111/jvh.13343] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 05/21/2020] [Indexed: 12/12/2022]
Abstract
Stigma around hepatitis C virus (HCV) infection is an important and understudied barrier to HCV treatment and elimination. The determinants of HCV-related stigma, including the impacts of stage of HCV treatment (ie spontaneously cleared; diagnosed, untreated; previously treated, not cured; currently being treated; and treated, cured) and coinfection with human immunodeficiency virus (HIV), remain unknown. To address these gaps, we conducted a cross-sectional study among patients with a history of HCV infection (n = 270) at outpatient clinics in Philadelphia from July 2018 to May 2019. We evaluated stigma using the validated HCV Stigma Scale, adapted from the Berger HIV Stigma Scale. Associations among HCV-related stigma and hypothesized demographic, behavioural, and clinical risk factors were evaluated by multivariable linear regression. Most participants (95.5%) experienced HCV-related stigma. Mean stigma scores did not differ significantly between HCV-monoinfected and HIV/HCV-coinfected participants (P = .574). However, we observed significant interactions between HIV status and multiple determinants; therefore, we stratified analyses by HIV status. Among HIV/HCV-coinfected participants, previous HCV treatment without cure, female gender, Hispanic/Latinx ethnicity and some college education were significantly associated with higher HCV-stigma scores. An annual income of $10 000-$40 000 was associated with significantly lower stigma scores. No significant associations were observed among HCV-monoinfected participants. We found that most participants experienced stigma associated with HCV diagnosis. While stigma scores were similar between HCV-monoinfected and HIV/HCV-coinfected participants, the determinants associated with HCV stigma differed by HIV status. Understanding how experiences of stigma differ between HCV-monoinfected and HIV/HCV-coinfected patients may aid in the development of targeted interventions to address the HCV epidemic.
Collapse
Affiliation(s)
- M. Elle Saine
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia E. Szymczak
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tyler M. Moore
- Department of Psychiatry, Brain Behavior Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Laura P. Bamford
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Philadelphia FIGHT Community Health Centers, Philadelphia, PA, USA
| | - Frances K. Barg
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jason Schnittker
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA,Department of Sociology, University of Pennsylvania, Philadelphia, PA, USA
| | - John H. Holmes
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Vincent Lo Re
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
49
|
Holmes A, Williams C, Wang S, Barg FK, Takeshita J. Content analysis of psoriasis and eczema direct-to-consumer advertisements. Cutis 2020; 106:147-150. [PMID: 33104118 DOI: 10.12788/cutis.0070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Direct-to-consumer (DTC) advertisements have been associated with both beneficial and detrimental effects on real-world health care utilization. We aimed to evaluate advertisement placement, character representation, and disease-related content in psoriasis and eczema DTC advertisements. We conducted a content analysis of DTC advertisements televised on 4 major networks over 14 consecutive days in July 2018. In total, 13 advertisements for psoriasis and 27 advertisements for eczema were identified. Among psoriasis advertisements, 81 affected characters were shown, and among eczema advertisements, 80 affected characters were shown. Our findings suggest missed opportunities for education and patient reach among psoriasis and eczema DTC advertisements. Lack of diversity of characters among advertisements for psoriasis and eczema may reinforce existing and emerging treatment disparities.
Collapse
Affiliation(s)
- Alexis Holmes
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Cheyenne Williams
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Shiyu Wang
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Frances K Barg
- Department of Family Medicine and Community Health; Department of Biostatistics, Epidemiology and Informatics; Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Junko Takeshita
- Department of Dermatology; Department of Biostatistics, Epidemiology and Informatics; Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| |
Collapse
|
50
|
Kaufmann TL, Rendle KA, Aakhus E, Nimgaonkar V, Shah A, Bilger A, Gabriel PE, Trotta R, Braun J, Shulman LN, Bekelman JE, Barg FK. Views From Patients With Cancer in the Setting of Unplanned Acute Care: Informing Approaches to Reduce Health Care Utilization. JCO Oncol Pract 2020; 16:e1291-e1303. [PMID: 32574133 DOI: 10.1200/op.20.00013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE New oncology care delivery models that avoid preventable acute care are needed, yet it is unclear which interventions best meet the needs of patients and caregivers. Perspectives from patients who experienced unplanned acute care events may inform the successful development and implementation of care delivery models. METHODS We performed a qualitative interview study of patients with solid tumors on active treatment who experienced the following 3 types of unplanned acute care events: emergency department visits, first hospitalizations, and multiple hospitalizations. Patients were prospectively recruited within a large academic health system from August 2018 to January 2019. Interviews followed a semi-structured guide developed from the Consolidated Framework for Implementation Research. The constant comparative approach was used to identify themes. RESULTS Forty-nine patients were interviewed; 51% were men, 75% were non-Hispanic White, and the mean age was 57.4 years (standard deviation, 1.9 years). Fifty-five percent of patients had metastatic disease, and 33% had an Eastern Cooperative Oncology Group performance status of 3-4. We identified the following key themes: drivers of the decision to seek acute care, patients' emotional concerns that influence interactions with the oncology team, and strategies used to avoid acute care. Patients' recommendations for interventions included anticipatory guidance, peer support, improved triage methods, and enhanced symptom management. Patients preferred options for virtual and home-based outpatient care. CONCLUSION Patient-centered care models should focus on early delivery of supportive interventions that help patients and caregivers navigate the unexpected issues that come with cancer treatment. Patients advocate for proactive, multidisciplinary supportive interventions that enable home-based care and are led by the primary oncology team.
Collapse
Affiliation(s)
- Tara L Kaufmann
- Department of Medicine, Division of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Penn Center for Cancer Care Innovation at the Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Katharine A Rendle
- Penn Center for Cancer Care Innovation at the Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Erin Aakhus
- Department of Medicine, Division of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Penn Center for Cancer Care Innovation at the Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Vivek Nimgaonkar
- Department of Medicine, Division of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Arnav Shah
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Andrea Bilger
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Peter E Gabriel
- Department of Medicine, Division of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Penn Center for Cancer Care Innovation at the Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Rebecca Trotta
- Penn Center for Cancer Care Innovation at the Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jennifer Braun
- Penn Center for Cancer Care Innovation at the Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Lawrence N Shulman
- Penn Center for Cancer Care Innovation at the Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Justin E Bekelman
- Penn Center for Cancer Care Innovation at the Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Frances K Barg
- Penn Center for Cancer Care Innovation at the Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Hospital of the University of Pennsylvania, Philadelphia, PA
| |
Collapse
|