Perspectives from patients with chronic lung disease on a telehealth-facilitated integrated palliative care model: a qualitative content analysis study

BACKGROUND

Chronic lung disease affects nearly 37 million Americans and often results in significant quality of life impairment and healthcare burden. Despite guidelines calling for palliative care (PC) integration into pulmonary care as a vital part of chronic lung disease management, existing PC models have limited access and lack scalability. Use of telehealth to provide PC offers a potential solution to these barriers. This study explored perceptions of patients with chronic lung disease regarding a telehealth integrated palliative care (TIPC) model, with plans to use findings to inform development of an intervention protocol for future testing.

METHODS

For this qualitative study, we conducted semi-structured interviews between June 2021- December 2021 with patients with advanced chronic lung disease. Interviews explored experiences with chronic lung disease, understanding of PC, and perceived acceptability of the proposed model along with anticipated facilitators and barriers of the TIPC model. We analyzed findings with a content analysis approach.

RESULTS

We completed 20 interviews, with two that included both a patient and caregiver together due to patient preference. Perceptions were primarily related to three categories: burden of chronic lung disease, pre-conceived understanding of PC, and perspective on the proposed TIPC model. Analysis revealed a high level of disease burden related to chronic lung disease and its impact on day-to-day functioning. Although PC was not well understood, the TIPC model using a shared care planning approach via telehealth was seen by most as an acceptable addition to their chronic lung disease care.

CONCLUSIONS

These findings emphasize the need for a patient-centered, shared care planning approach in chronic lung disease. The TIPC model may be one option that may be acceptable to individuals with chronic lung disease. Future work includes using findings to refine our TIPC model and conducting pilot testing to assess acceptability and utility of the model.

Patient and caregiver perceptions of the possibility of home blood transfusions

BACKGROUND

Patients with hematologic malignancies (HM) often develop transfusion dependence. The patient and caregiver burdens associated with the need for frequent transfusions are high. Home blood transfusions has the potential to reduce these burdens, but is not widely practiced in the United States. We designed a qualitative study to evaluate the patient and caregiver perceptions of the potential for a home blood transfusion program.

STUDY DESIGN AND METHODS

Eligible patients included Adult (≥18 years) patients who were English speaking and met the definition for transfusion dependence within 3 months of study enrollment. We identified and interviewed eligible participants (patients and caregivers), using a semi-structured interview guide to elicit patient perceptions of the acceptability, barriers, and benefits related to home blood product transfusions. Interviews were audio recorded and transcribed. Results were imported into NVivo 12 (version 12; QSR International, Burlington, VT) for coding and analysis.

RESULTS

We recruited participants until we reached thematic saturation, which occurred at 29 participants (20 patients, 9 caregivers). Among the 20 patient participants, nine had MDS (45%) and 11 had acute leukemia (55%). Most of the patients (60%) reported getting one transfusion per week. Four themes emerged when the participants discussed their perception regarding the potential of a home blood transfusion program: (1) current in-person experience, (2) caregiver burden, (3) perceptions of home blood transfusions, and (4) interest in participating in a home blood transfusion program.

CONCLUSION

The concept of home blood transfusions was well received and further research to study its implementation is warranted.

Patient-reported outcome measure use among older adults after emergency department care: A systematic review

BACKGROUND

Patient-reported outcome measures (PROMs) are gaining favor in clinical and research settings given their ability to capture a patient's symptom burden, functional status, and quality of life. Our objective in this systematic review was to summarize studies including PROMs assessed among older adults (age ≥ 65 years) after seeking emergency care.

METHODS

With the assistance of a medical librarian, we searched Ovid MEDLINE, PubMed, Embase, CINAHL, Web of Science-Core Collection, and Cochrane CENTRAL from inception through June 2023 for studies in which older adult ED patients had PROMs assessed in the post-emergency care time period. Independent reviewers performed title/abstract review, full-text screening, data extraction, study characteristic summarization, and risk-of-bias (RoB) assessments.

RESULTS

Our search strategy yielded 5153 studies of which 56 met study inclusion criteria. Within included studies, 304 unique PROM assessments were performed at varying time points after the ED visit, including 61 unique PROMs. The most commonly measured domain was physical function, assessed within the majority of studies (47/56; 84%), with measures including PROMs such as Katz activities of daily living (ADLs), instrumental ADLs, and the Barthel Index. PROMs were most frequently assessed at 1-3 months after an ED visit (113/304; 37%), greater than 6 months (91/304; 30%), and 4-6 months (88/304; 29%), with very few PROMs assessed within 1 month of the ED visit (12/304; 4%). Of the 16 interventional studies, two were determined to have a low RoB, four had moderate RoB, nine had high RoB, and one had insufficient information. Of the 40 observational studies, 10 were determined to be of good quality, 20 of moderate quality, and 10 of poor quality.

CONCLUSIONS

PROM assessments among older adults following an ED visit frequently measured physical function, with very few assessments occurring within the first 1 month after an ED visit.

Recommendations from people who use drugs in Philadelphia, PA about structuring point-of-care drug checking

BACKGROUND

Adulterants, such as fentanyl and xylazine, among others, are present in a high percentage of the illicit drug supply, increasing the risk for overdose and other adverse health events among people who use drugs (PWUD). Point-of-care drug checking identifies components of a drug sample and delivers results consumers. To successfully meet the diverse needs of PWUD, more information is needed about the utility of drug checking, motivations for using services contextualized in broader comments on the drug supply, hypothesized actions to be taken after receiving drug checking results, and the ideal structure of a program.

METHODS

In December 2021, semi-structured interviews were conducted with 40 PWUD who were accessing harm reduction services in Philadelphia, PA. Participants were asked about opinions and preferences for a future drug checking program. Interviews were audio recorded, transcribed and coded using content analysis to identify themes.

RESULTS

Participants were primarily White (52.5%) and male (60%). Heroin/fentanyl was the most frequently reported drug used (72.5%, n = 29), followed by crack cocaine (60.0%, n = 24) and powder cocaine (47.5%, n = 19). Emerging themes from potential drug checking consumers included universal interest in using a drug checking program, intentions to change drug use actions based on drug checking results, deep concern about the unpredictability of the drug supply, engaging in multiple harm reduction practices, and concerns about privacy while accessing a service.

CONCLUSIONS

We offer recommendations for sites considering point-of-care drug checking regarding staffing, safety, logistics, and cultural competency. Programs should leverage pre-existing relationships with organizations serving PWUD and hire people with lived experiences of drug use. They should work with local or state government to issue protections to people accessing drug checking programs and ensure the service is anonymous and that data collection is minimized to keep the program low-threshold. Programs will ideally operate in multiple locations and span "atmosphere" (e.g., from clinical to a drop-in culture), offer in-depth education to participants about results, engage with a community advisory board, and not partner with law enforcement.

Ethnic and racial differences in self-reported symptoms, health status, activity level, and missed work at 3 and 6 months following SARS-CoV-2 infection

Introduction

Data on ethnic and racial differences in symptoms and health-related impacts following SARS-CoV-2 infection are limited. We aimed to estimate the ethnic and racial differences in symptoms and health-related impacts 3 and 6 months after the first SARS-CoV-2 infection.

Methods

Participants included adults with SARS-CoV-2 infection enrolled in a prospective multicenter US study between 12/11/2020 and 7/4/2022 as the primary cohort of interest, as well as a SARS-CoV-2-negative cohort to account for non-SARS-CoV-2-infection impacts, who completed enrollment and 3-month surveys (N = 3,161; 2,402 SARS-CoV-2-positive, 759 SARS-CoV-2-negative). Marginal odds ratios were estimated using GEE logistic regression for individual symptoms, health status, activity level, and missed work 3 and 6 months after COVID-19 illness, comparing each ethnicity or race to the referent group (non-Hispanic or white), adjusting for demographic factors, social determinants of health, substance use, pre-existing health conditions, SARS-CoV-2 infection status, COVID-19 vaccination status, and survey time point, with interactions between ethnicity or race and time point, ethnicity or race and SARS-CoV-2 infection status, and SARS-CoV-2 infection status and time point.

Results

Following SARS-CoV-2 infection, the majority of symptoms were similar over time between ethnic and racial groups. At 3 months, Hispanic participants were more likely than non-Hispanic participants to report fair/poor health (OR: 1.94; 95%CI: 1.36-2.78) and reduced activity (somewhat less, OR: 1.47; 95%CI: 1.06-2.02; much less, OR: 2.23; 95%CI: 1.38-3.61). At 6 months, differences by ethnicity were not present. At 3 months, Other/Multiple race participants were more likely than white participants to report fair/poor health (OR: 1.90; 95% CI: 1.25-2.88), reduced activity (somewhat less, OR: 1.72; 95%CI: 1.21-2.46; much less, OR: 2.08; 95%CI: 1.18-3.65). At 6 months, Asian participants were more likely than white participants to report fair/poor health (OR: 1.88; 95%CI: 1.13-3.12); Black participants reported more missed work (OR, 2.83; 95%CI: 1.60-5.00); and Other/Multiple race participants reported more fair/poor health (OR: 1.83; 95%CI: 1.10-3.05), reduced activity (somewhat less, OR: 1.60; 95%CI: 1.02-2.51; much less, OR: 2.49; 95%CI: 1.40-4.44), and more missed work (OR: 2.25; 95%CI: 1.27-3.98).

Discussion

Awareness of ethnic and racial differences in outcomes following SARS-CoV-2 infection may inform clinical and public health efforts to advance health equity in long-term outcomes.

Making Harm Reduction More Accessible: Fentanyl Test Strip Awareness and Attitudes among Emergency Department Patients Who Use Drugs

BACKGROUND

Fentanyl test strips (FTS) are a harm reduction method for people to test their drugs for fentanyl. Ideal points for FTS distribution have not been identified. Many people who use drugs have frequent contact with the Emergency Department (ED). We piloted FTS distribution in two urban hospital EDs.

METHODS

Between June-December 2021 in Philadelphia, PA, patients with past 30-day drug use completed a survey about drug use, fentanyl attitudes, and FTS; then offered FTS and a brief training. Survey data were analyzed using SPSS for bivariate statistics.

RESULTS

Patients (n = 135) were primarily White (68.1%) and male (72.6%). Participants regularly interacted with substance use (57.8%) and benefits coordination (49.6%) services. The most common drugs used were heroin/fentanyl (68.9%), crack cocaine (45.2%) and cannabis (40.0%). Most (98.5%) had heard of fentanyl though few (18.5%) had ever used FTS. Across most drug types, participants were concerned about fentanyl. All accepted FTS training and distribution. Few (9.6%) were somewhat or very concerned about having FTS if stopped by police and this number varied by race (7.6% of White people were somewhat or very concerned, compared to 12.8% of Black people). Most participants were already engaged in risk reduction practices.

DISCUSSION

FTS are a widely desired harm reduction tool to facilitate informed decision-making, and non-harm reduction locations are potentially feasible and acceptable distribution sites. Given regular contact with EDs and social services across the sample, FTS should be offered at non-harm reduction locations that come into frequent contact with people who use drugs.

"Once I take that one bite": the consideration of harm reduction as a strategy to support dietary change for patients with diabetes

BACKGROUND

Despite well-established guidelines to treat diabetes, many people with diabetes struggle to manage their disease. For many, this struggle is related to challenges achieving nutrition-related lifestyle changes. We examined how people with diabetes describe barriers to maintaining a healthy diet and considered the benefits of using a harm reduction approach to assist patients to achieve nutrition-related goals.

METHODS

This is a secondary analysis of 89 interviews conducted with adults who had type 1 or type 2 diabetes. Interviews were analyzed using a content analysis approach. Themes regarding food or diet were initially captured in a "food" node. Data in the food node were then sub-coded for this analysis, again using a content analysis approach.

RESULTS

Participants frequently used addiction language to talk about their relationship with food, at times referring to themselves as "an addict" and describing food as "their drug." Participants perceived their unhealthy food choices either as a sign of weakness or as "cheating." They also identified food's ability to comfort them and an unwillingness to change as particular challenges to sustaining a healthier diet.

CONCLUSION

Participants often described their relationship with food through an addiction lens. A harm reduction approach has been associated with positive outcomes among those with substance abuse disorder. Patient-centered communication incorporating the harm reduction model may improve the patient-clinician relationship and thus improve patient outcomes and quality-of-life while reducing health-related stigma in diabetes care. Future work should explore the effectiveness of this approach in patients with diabetes.

TRIAL REGISTRATION

Registered on ClinicalTrials.gov, NCT02792777. Registration information submitted 02/06/2016, with the registration first posted on the ClinicalTrials.gov website 08/06/2016. Data collection began on 29/04/2016.

A Prioritized Patient-Centered Research Agenda to Reduce Disparities in Telehealth Uptake: Results from a National Consensus Conference

Introduction

We hosted a national consensus conference with a diverse group of stakeholders to develop a patient-centered research agenda focused on reducing disparities in telehealth use.

Methods

Attendees were purposively invited to participate in a 2-day virtual conference. The group developed a prioritized research agenda focused on reducing disparities in telehealth uptake, with discussion informed by findings from a scoping review. All work was conducted in partnership with a Steering Committee of national experts in telehealth and patient-centered care (n = 5) and a community-based Telehealth Advisory Board with experience with telehealth use and barriers (n = 8).

Results

Sixty individuals participated in the conference and discussion resulted in a final list of 20 questions. Fifty-two attendees voted on the final prioritization of these questions. Results were aggregated for all voters (n = 52) and patient-only voters (n = 8). The top question identified by both groups focused on patient and family perspectives on important barriers to telehealth use. The entire group voting identified telehealth's impact on patient outcomes as the next most important questions, while the patient-only group identified trust-related considerations and cultural factors impacting telehealth use as next priorities.

Conclusions

This project involved extensive patient and stakeholder engagement. While voting varied between patients only and the entire group of conference attendees, top identified priorities included patient and family perspectives on important barriers to telehealth, trust and cultural barriers and facilitators to telehealth, and assessment of telehealth's impact on patient outcomes. This research agenda can inform design of future research focused on addressing disparities in telehealth use.

Long COVID Clinical Phenotypes up to 6 Months After Infection Identified by Latent Class Analysis of Self-Reported Symptoms

Background

The prevalence, incidence, and interrelationships of persistent symptoms after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection vary. There are limited data on specific phenotypes of persistent symptoms. Using latent class analysis (LCA) modeling, we sought to identify whether specific phenotypes of COVID-19 were present 3 months and 6 months post-infection.

Methods

This was a multicenter study of symptomatic adults tested for SARS-CoV-2 with prospectively collected data on general symptoms and fatigue-related symptoms up to 6 months postdiagnosis. Using LCA, we identified symptomatically homogenous groups among COVID-positive and COVID-negative participants at each time period for both general and fatigue-related symptoms.

Results

Among 5963 baseline participants (4504 COVID-positive and 1459 COVID-negative), 4056 had 3-month and 2856 had 6-month data at the time of analysis. We identified 4 distinct phenotypes of post-COVID conditions (PCCs) at 3 and 6 months for both general and fatigue-related symptoms; minimal-symptom groups represented 70% of participants at 3 and 6 months. When compared with the COVID-negative cohort, COVID-positive participants had higher occurrence of loss of taste/smell and cognition problems. There was substantial class-switching over time; those in 1 symptom class at 3 months were equally likely to remain or enter a new phenotype at 6 months.

Conclusions

We identified distinct classes of PCC phenotypes for general and fatigue-related symptoms. Most participants had minimal or no symptoms at 3 and 6 months of follow-up. Significant proportions of participants changed symptom groups over time, suggesting that symptoms present during the acute illness may differ from prolonged symptoms and that PCCs may have a more dynamic nature than previously recognized. Clinical Trials Registration. NCT04610515.

Patient-Important Needs and Goals Related to Nutrition Interventions during Cancer Treatment

Patients with cancer often experience nutrition-related challenges for which they are subsequently connected with nutritional support. Yet to date there are no validated tools to assess whether nutrition interventions sufficiently address patients' needs. A vital step toward developing a tool is to identify primary patient-important goals related to receiving nutrition support during cancer care. To that end, we interviewed patients and clinicians to identify nutrition-related needs and goals of patients undergoing cancer treatment. We interviewed 31 patients undergoing cancer treatment and 17 clinicians at the Sidney Kimmel Cancer Center at Thomas Jefferson University in Philadelphia, PA. Two coders analyzed transcripts using a conventional qualitative content analysis approach. Patients and clinicians both identified weight maintenance, improved food satisfaction and intake, and improved quality of life metrics - such as reduced emotional and financial stress - as top nutrition-related goals. Participants also highlighted the importance of patients receiving food they like and having control over what they eat when designing optimal nutrition interventions. These findings will be used in future work to create a patient-centered assessment tool designed to capture a range of patient goals related to nutrition interventions.

A Qualitative Analysis of Hospitalist Perceptions of Self-Directed Discharge Among Inpatients with Opioid Use Disorder

Background: People with opioid use disorder (OUD) have high rates of hospital admissions and high rates of patient-directed discharge, leading to significant morbidity and mortality. In this study, we aimed to understand hospitalist attitudes toward patients with OUD leaving before treatment completion and their willingness to collaborate with patients in future initiatives focused on improving the experience of hospital-based care for patients with OUD. Methods: We conducted semi-structured interviews with hospitalists at two hospitals in Philadelphia, PA to explore their perspectives on social and structural factors that contribute to patients with OUD leaving the hospital before treatment completion. Interviews were recorded, transcribed, and coded with NVivo using conventional content analysis. Results: Twenty-two hospitalists (64% female, 72.7% White, mean age 37) were interviewed between February and April 2021. Hospitalists listed the following as reasons for patients with OUD leaving before treatment completion: untimely and inadequate pain/withdrawal treatment, limited prescribing options in medications for OUD, restrictive visitor and smoking policies, and patient social and other obligations. Twenty out of 22 hospitalists were willing to engage in collaborative patient-centered care but noted institutional barriers. Conclusion: Hospitalists stated willingness to collaborate with patients on identifying and developing systems-level solutions that would allow for patient-centered care. In-hospital access to addiction consult service, staff with lived experience, and other culturally competent resources are key to reducing self-directed discharge, as is training to address stigma and reframe perceptions of appropriate dosing for pain and withdrawal. Hospitalists note a need for transitions to outpatient care after hospital discharge.

Communicating Diagnostic Uncertainty at Emergency Department Discharge: A Simulation-Based Mastery Learning Randomized Trial

PURPOSE

There are no standardized approaches for communicating with patients discharged from the emergency department with diagnostic uncertainty. This trial tested efficacy of the Uncertainty Communication Education Module, a simulation-based mastery learning curriculum designed to establish competency in communicating diagnostic uncertainty.

METHOD

Resident physicians at 2 sites participated in a 2-arm waitlist randomized controlled trial from September 2019 to June 2020. After baseline (T1) assessment of all participants via a standardized patient encounter using the Uncertainty Communication Checklist (UCC), immediate access physicians received training in the Uncertainty Communication Education Module, which included immediate feedback, online educational modules, a smartphone-based application, and telehealth deliberate practice with standardized patients. All physicians were retested 16-19 weeks later (T2) via in-person standardized patient encounters; delayed access physicians then received the intervention. A final test of all physicians occurred 11-15 weeks after T2 (T3). The primary outcome measured the percentage of physicians in the immediate versus delayed access groups meeting or exceeding the UCC minimum passing standard at T2.

RESULTS

Overall, 109 physicians were randomized, with mean age 29 years (range 25-46). The majority were male (n = 69, 63%), non-Hispanic/Latino (n = 99, 91%), and White (n = 78, 72%). At T2, when only immediate access participants had received the curriculum, immediate access physicians demonstrated increased mastery (n = 29, 52.7%) compared with delayed access physicians (n = 2, 3.7%, P < .001; estimated adjusted odds ratio of mastery for the immediate access participants, 31.1 [95% CI, 6.8-143.1]). There were no significant differences when adjusting for training site or stage of training.

CONCLUSIONS

The Uncertainty Communication Education Module significantly increased mastery in communicating diagnostic uncertainty at the first postintervention test among emergency physicians in standardized patient encounters. Further work should assess the impact of clinical implementation of these communication skills.

Effect of COVID-19 Vaccine Messaging Platforms in Emergency Departments on Vaccine Acceptance and Uptake: A Cluster Randomized Clinical Trial

IMPORTANCE

Large segments of the US population's primary health care access occurs in emergency departments (EDs). These groups have disproportionately high COVID-19 vaccine hesitancy and lower vaccine uptake.

OBJECTIVE

To determine whether provision of COVID-19 vaccine messaging platforms in EDs increases COVID-19 vaccine acceptance and uptake in unvaccinated patients.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cluster randomized clinical trial was conducted at 7 hospital EDs in 4 US cities from December 6, 2021, to July 28, 2022. Noncritically ill adult patients who had not previously received COVID-19 vaccines were enrolled.

INTERVENTIONS

A 3-pronged COVID-19 vaccine messaging platform (an English- or Spanish-language 4-minute video; a 1-page informational flyer; and a brief, scripted message from an ED physician or nurse) was delivered during patient waiting times.

MAIN OUTCOMES AND MEASURES

The 2 primary outcomes were (1) COVID-19 vaccine acceptance, assessed by survey responses in the ED, and (2) receipt of a COVID-19 vaccine within 30 days, ascertained by ED confirmation of vaccination, electronic health record review, and telephone follow-up.

RESULTS

Of the 496 participants enrolled (221 during intervention weeks and 275 during control weeks), the median (IQR) age was 39 (30-54) years, 205 (41.3%) were female, 193 (38.9%) were African American, 97 (19.6%) were Latinx, and 218 (44.0%) lacked primary care physicians. More intervention group participants, compared with control participants, stated that they would accept the vaccine in the ED (57 [25.8%] vs 33 [12.0%]; adjusted difference, 11.9 [95% CI, 4.5-19.3] percentage points; number needed to treat [NNT], 8 [95% CI, 5-22]). More intervention group participants than control participants received a COVID-19 vaccine within 30 days of their ED visit (44 [20.0%] vs 24 [8.7%]; adjusted difference, 7.9 [95% CI, 1.7-14.1] percentage points; NNT, 13 [95% CI, 7-60]). The intervention group had greater outcome effect sizes than the control group in participants who lacked a primary care physician (acceptance, 38 of 101 [37.6%] vs 16 of 117 [13.7%] [P for interaction = .004]; uptake, 31 of 101 [30.7%] vs 11 of 117 [9.4%] [P for interaction = .006]), as well as in Latinx persons (acceptance, 23 of 52 [44.2%] vs 5 of 48 [10.4%] [P for interaction = .004]; uptake, 22 of 52 [42.3%] vs 4 of 48 [8.3%] [P for interaction < .001]).

CONCLUSIONS AND RELEVANCE

Results of this cluster randomized clinical trial showed that with low NNT, implementation of COVID-19 vaccine messaging platforms in EDs leads to greater vaccine acceptance and uptake in unvaccinated ED patients. Broad implementation in EDs could lead to greater COVID-19 vaccine delivery to underserved populations whose primary health care access occurs in EDs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05142332.

Feasibility and Cost of Telehealth Head and Neck Cancer Survivorship Care: A Systematic Review

OBJECTIVE

Evaluate the feasibility and cost-effectiveness of telehealth head and neck cancer (HNC) survivorship care.

DATA SOURCES

Ovid MEDLINE, Embase, Scopus, CINAHL.

REVIEW METHODS

A systematic search for peer-reviewed feasibility studies on telehealth models for HNC survivorship care published between 2005 and 2021 was conducted using the terms "head and neck cancer" and "telehealth" and their synonyms. Inclusion criteria were studies on telehealth survivorship program interventions for HNC patients with quantitative feasibility outcome measures (eg, enrollment, retention, attrition/dropout rate, adherence/task completion rate, patient satisfaction, cost).

RESULTS

Thirty-eight studies out of 1557 identified met inclusion criteria and were included for analysis. Feasibility outcomes evaluated were enrollment and attrition rates, adherence/task completion rates, patient satisfaction, and user feedback surveys in different survivorship domains. Patient enrollment ranged from 20.8% to 85.7%, while attrition ranged from 7% to 47.7%. Overall, adherence was 30.2% higher in the intervention group than in the control group (46.8% vs 16.6%). Studies with cost analysis found telehealth models of care to be statistically significantly less expensive and more cost-efficient than the standard model of care, with a $642.30 saving per patient (n = 3). Telehealth models also substantially reduced work time saving per visit (on average, 7 days per visit).

CONCLUSION

While telehealth survivorship programs are feasible and cost-effective and are associated with improved patient outcomes, they might not be ideal for every patient. Further investigations are needed to understand the role of telehealth in survivorship care, given the variability in study design, reporting, measures, and methodological quality.

Perspectives of COVID-19 vaccine-hesitant emergency department patients to inform messaging platforms to promote vaccine uptake

OBJECTIVES

Efforts to promote COVID-19 vaccine acceptance must consider the critical role of the emergency department (ED) in providing health care to underserved patients. Focusing on patients who lacked primary care, we sought to elicit the perspectives of unvaccinated ED patients regarding COVID-19 vaccination concerns and potential approaches that might increase their vaccine acceptance.

METHODS

We conducted this qualitative interview study from August to November 2021 at four urban EDs in San Francisco, California; Seattle, Washington; Durham, North Carolina; and Philadelphia, Pennsylvania. We included ED patients who were ≥18 years old, fluent in English or Spanish, had not received a COVID-19 vaccine, and did not have primary care physicians or clinics. We excluded patients who were unable to complete an interview, in police custody, under suspicion of active COVID-19 illness, or presented with a psychiatric chief complaint. We enrolled until we reached thematic saturation in relevant domains. We analyzed interview transcripts with a content analysis approach focused on identifying concerns about COVID-19 vaccines and ideas regarding the promotion of vaccine acceptance and potential trusted messengers.

RESULTS

Of 65 patients enrolled, 28 (43%) identified as female, their median age was 36 years (interquartile range 29-49), and 12 (18%) interviews were conducted in Spanish. Primary concerns about COVID-19 vaccines included risk of complications, known and unknown side effects, and fear of contracting COVID-19 from vaccines. Trust played a major role for patients in deciding which sources to use for vaccine information and in engendering vaccine acceptance. Health care providers and family or friends were commonly cited as trusted messengers of information.

CONCLUSIONS

We characterized concerns about COVID-19 vaccines, uncovered themes that may promote vaccine acceptance, and identified trusted messengers-primarily health care professionals. These data may inform the development of nuanced COVID-19 vaccine messaging platforms to address COVID-19 vaccine hesitancy among underserved ED populations.

Quality Frameworks for Virtual Care: Expert Panel Recommendations

Given the significant advance of virtual care in the past year and half, it seems timely to focus on quality frameworks and how they have evolved collaboratively across health care organizations. Massachusetts General Hospital's (MGH) Center for TeleHealth and Mass General Brigham's (MGB) Virtual Care Program are committed to hosting annual symposia on key topics related to virtual care. Subject matter experts across the country, health care organizations, and academic medical centers are invited to participate. The inaugural MGH/MGB Virtual Care Symposium, which focused on rethinking curriculum, competency, and culture in the virtual care era, was held on September 2, 2020. The second MGH/MGB Virtual Care Symposium was held on November 2, 2021, and focused on virtual care quality frameworks. Resultant topics were (1) guiding principles necessary for the future of virtual care measurement; (2) best practices deployed to measure quality of virtual care and how they compare and align with in-person frameworks; (3) evolution of quality frameworks over time; (4) how increased adoption of virtual care has impacted patient access and experience and how it has been measured; (5) the pitfalls and barriers which have been encountered by organizations in developing virtual care quality frameworks; and (6) examples of how quality frameworks have been applied in various use cases. Common elements of a quality framework for virtual care programs among symposium participants included improving the patient and provider experience, a focus on achieving health equity, monitoring success rates and uptime of the technical elements of virtual care, financial stewardship, and clinical outcomes. Virtual care represents an evolution in the access to care paradigm that helps keep health care aligned with other modern industries in digital technology and systems adoption. With advances in health care delivery models, it is vitally important that the quality measurement systems be adapted to include virtual care encounters. New methods may be necessary for asynchronous transactions, but synchronous virtual visits and consults can likely be accommodated in traditional quality frameworks with minimal adjustments. Ultimately, quality frameworks for health care will adapt to hybrid in-person and virtual care practices.

Pilot testing fentanyl test strip distribution in an emergency department setting: Experiences, lessons learned, and suggestions from staff

OBJECTIVES

Fentanyl test strips (FTSs) are increasingly used to address fentanyl contamination of the illicit drug supply by testing a drug for the presence of fentanyl, allowing people who use drugs (PWUD) to engage in overdose prevention. While emergency departments (EDs) have implemented various harm reduction strategies for PWUD, to date distribution of FTSs in EDs is limited and not evaluated. Thus, we sought to explore ED staff experiences distributing FTSs.

METHODS

Twenty-one staff serving different roles (e.g., physician, nurse, technician, social worker, certified recovery specialist) within two urban EDs in a major metropolitan area were enrolled in a pilot study to distribute FTS to patients who use drugs. Participants were interviewed about their experience at 3 weeks and again at 3 months. Interviews were recorded, transcribed verbatim, and coded using a conventional content analysis approach.

RESULTS

All participants endorsed the utility of FTS distribution in the ED. Across 42 interviews, participants discussed evolving strategies to approach patients about FTS, primarily favorable patient reactions to FTSs, improved dynamics between participants and patients, mixed intervention support from other staff, and named challenges of FTS distribution and recommendations to make FTS distribution in the ED widespread. Recommendations included medical records prompts to offer FTS, offering via different types of staff, and offering FTS during triage.

CONCLUSIONS

Implementing FTS distribution may improve patient rapport while providing patients with tools to avoid a fentanyl overdose. Participants generally reported positive experiences distributing FTSs within the ED but the barriers they identified limited opportunities to make distribution more integrated into their workflow. EDs considering this intervention should train staff on FTSs and how to identify and train patients and explore mechanisms to routinize distribution in the ED environment.

Emergency department-to-community care transition barriers: A qualitative study of older adults

BACKGROUND

Over one-half of older adults are discharged to the community after emergency department (ED) visits, and studies have shown there is increased risk of adverse health outcomes in the immediate post-discharge period. Understanding the experiences of older adults during ED-to-community care transitions has the potential to improve geriatric emergency clinical care and inform intervention development. We therefore sought to assess barriers experienced by older adults during ED-to-community care transitions.

METHODS

We conducted a qualitative analysis of community-dwelling cognitively intact patients aged 65 years and older receiving care in four diverse EDs from a single U.S. healthcare system. We constructed a conceptual framework a priori to guide the development and iterative revision of a codebook, used purposive sampling, and conducted recorded, semi-structured interviews using a standardized guide. Two researchers coded the professionally transcribed data using a combined deductive and inductive approach and analyzed transcripts to identify dominant themes and representative quotations.

RESULTS

Among 25 participants, 20 (80%) were women and 17 (68%) were white. We identified four barriers during the ED-to-community care transition: (1) ED discharge process was abrupt with missing information regarding symptom explanation and performed testing, (2) navigating follow-up outpatient clinical care was challenging, (3) new physical limitations and fears hinder performance of baseline activities, and (4) major and minor ramifications for caregivers impact an older adult's willingness to request or accept assistance.

CONCLUSIONS

Older adults identified barriers to successful ED-to-community care transitions that can inform the development of novel and effective interventions.

Increasing equitable access to telehealth oncology care in the COVID-19 National Emergency: Creation of a telehealth task force

INTRODUCTION

Telehealth (TH) utilization in cancer care prior to COVID-19 was variable. Research highlights disparities in access determined by socioeconomic factors including education, income, race, and age. In response to COVID-19 and these disparities, we assessed the impact of a personalized digital support structure, the Telehealth Task Force (TTF), to reduce disparities in TH.

METHODS

We performed a retrospective review of cohorts between January 1, 2020 and August 30, 2020: Pre (TH use with basic telephone support), Intervention (TH access with TTF), and Post (TH access after TTF initiation and educational material dissemination). Data collected included successful TH access, health literacy (HL), and Area Deprivation Index, a ranking of neighborhoods by socioeconomic disadvantage (ADI). The data were analyzed in univariate ordinary least squares model and adjacent categories ratio model using statistical software R to understand the relationship between TTF, HL, ADI, and TH access.

RESULTS

We included 555 patients from January 1, 2020 to August 30, 2020 (90 preintervention, 194 intervention, and 271 postintervention), excluding patients without ADI/HL. TTF support successfully engaged older, racially, and socioeconomically diverse patients in TH; ADI is significantly higher in the postintervention group vs. preintervention (mean difference = 7.66, 95% CI 1.00-4.32, p = 0.024) and more patients had low HL during intervention compared with preintervention (adjacent categories ratio = 0.62, 95% CI 0.41-0.93, p = 0.021).

DISCUSSION

COVID-19 created an immediate need for TH. Implementation of the TTF helped close the digital divide, increasing TH access for vulnerable patients. Attention to digital readiness can mitigate disparities in access to care. Future research should explore the implementation of widespread routine digital support initiatives.

Hospitalist perspectives on buprenorphine treatment for inpatients with opioid use disorder

Background

Patients with opioid use disorder (OUD) have high hospital admission rates. Hospitalists, clinicians that work in inpatient medical settings, may have a unique opportunity to intervene on behalf of these patients, yet their experience with and attitudes towards treating patients with OUD need further exploration.

Methods

We conducted qualitative analysis of 22 semi-structured interviews with hospitalists between January and April 2021 in Philadelphia, PA. Participants were hospitalists in one major metropolitan university hospital and one urban community hospital in a city with a high prevalence of OUD and overdose deaths. Participants were asked about their experiences, successes, and difficulties in treating hospitalized patients with OUD.

Results

Twenty-two hospitalists were interviewed. Participants were majority female (14, 64%) and White (16, 73%). We identified the following common themes: lack of training/experience with OUD, a lack of community OUD treatment infrastructure, a lack of inpatient OUD/withdrawal treatment resources, the "X-waiver" as a barrier to prescribing buprenorphine, the "ideal" patient to start on buprenorphine, and the hospital as an ideal intervention setting.

Conclusions

Hospitalization due to acute illness or complication of drug use represents a potential intervention point to initiate treatment for patients with OUD. While hospitalists exhibit willingness to prescribe medications, provide harm reduction education, and link patients to outpatient addiction treatment, they identify training and infrastructure barriers that must first be addressed.

Pediatric Return Visits to the Emergency Department: The Time to Return Curve

OBJECTIVE

Although 72-hour return visits are a frequently reported metric for pediatric patients discharged from the emergency department (ED), the basis for this metric is not established. Our objective was to statistically derive a cutoff time point for the characterization of pediatric return visits.

METHODS

We performed a retrospective cohort study using data of patients discharged from any of 44 pediatric EDs. We selected the first encounter per patient from January 1 to December 31, 2019, as the index encounter and included the first return visit within 30 days. We constructed a cumulative hazard curve to characterize the timing of return visits and constructed a multivariable adaptive regression spline model to identify a hinge point in return visit presentations. We identified the association between admission for early return visits and admission for late return visits using generalized linear mixed modeling.

RESULTS

Of 1,986,778 index ED discharges, 193,605 (9.7%) ED return visits were included. A double-exponential decay model demonstrated superior fit compared with a single exponential model ( P < 0.0001). Multivariable adaptive regression spline modeling identified a hinge at 7 days. When comparing proportions of return visits leading to hospitalization between early (23.8%) and late (15.1%) return visits, early visits (≤7 days) had higher adjusted odds of hospital admission (adjusted odds ratio, 1.73; 95% confidence interval, 1.69-1.77) relative to late return visits (>7 days). Findings were similar in sensitivity analyses within age subgroups, Census region, and in which the diagnosis (using the Diagnosis and Grouping System) was the same between the index and return visit. Among return visits that occurred within 7 days of the index visit, 46.3% had the same diagnosis grouping in both visits.

CONCLUSIONS

An empirically derived 7-day cutoff may be more appropriate for characterization of pediatric return visits to the ED. Encounters after this period had lower adjusted odds of admission.

Emergency Department Communication in Persons Living With Dementia and Care Partners: A Scoping Review

OBJECTIVES

To synthesize published research exploring emergency department (ED) communication strategies and decision-making with persons living with dementia (PLWD) and their care partners as the basis for a multistakeholder consensus conference to prioritize future research.

DESIGN

Systematic scoping review.

SETTINGS AND PARTICIPANTS

PLWD and their care partners in the ED setting.

METHODS

Informed by 2 Patient-Intervention-Comparison-Outcome (PICO) questions, we conducted systematic electronic searches of medical research databases for relevant publications following standardized methodological guidelines. The results were presented to interdisciplinary stakeholders, including dementia researchers, clinicians, PLWD, care partners, and advocacy organizations. The PICO questions included: How does communication differ for PLWD compared with persons without dementia? Are there specific communication strategies that improve the outcomes of ED care? Future research areas were prioritized.

RESULTS

From 5451 studies identified for PICO-1, 21 were abstracted. From 2687 studies identified for PICO-2, 3 were abstracted. None of the included studies directly evaluated communication differences between PLWD and other populations, nor the effectiveness of specific communication strategies. General themes emerging from the scoping review included perceptions by PLWD/care partners of rushed ED communication, often exacerbated by inconsistent messages between providers. Care partners consistently reported limited engagement in medical decision-making. In order, the research priorities identified included: (1) Barriers/facilitators of effective communication; (2) valid outcome measures of effective communication; (3) best practices for care partner engagement; (4) defining how individual-, provider-, and system-level factors influence communication; and (5) understanding how each member of ED team can ensure high-quality communication.

CONCLUSIONS AND IMPLICATIONS

Research exploring ED communication with PLWD is sparse and does not directly evaluate specific communication strategies. Defining barriers and facilitators of effective communication was the highest-ranked research priority, followed by validating outcome measures associated with improved information exchange.

"Unfortunately, I don't have an answer for you": How resident physicians communicate diagnostic uncertainty to patients during emergency department discharge

OBJECTIVE

To describe how emergency medicine resident physicians discuss diagnostic uncertainty during a simulated ED discharge discussion.

METHODS

A secondary content analysis of simulated clinical encounter audiotapes completed by emergency medicine residents across two sites.

RESULTS

When discussing lack of diagnosis, residents explained the evaluation revealed no cause for symptoms, noted concerning diagnoses that were excluded, and acknowledged both symptoms and patients' feelings. Residents used explicit and implicit language to discuss diagnostic uncertainty with similar frequency. Almost half of the residents discussed the ED role as focused on emergent illness to give patients context for their uncertain diagnoses. However, 28% of residents in this study did not discuss diagnostic uncertainty in any form. All residents provided reassurance.

CONCLUSION

Residents use a range of approaches to discuss diagnostic uncertainty with patients at the time of a simulated ED discharge, with some residents omitting discussion of uncertainty entirely.

PRACTICE IMPLICATIONS

These findings represent the current state of communication, which needs improvement. These findings do not immediately transfer to clinical practice recommendations, but rather support a need for both further study and development of formal communication training on this topic.

Perspectives of people in Philadelphia who use fentanyl/heroin adulterated with the animal tranquilizer xylazine; Making a case for xylazine test strips

Background

Xylazine is an animal tranquilizer increasingly detected in those who have died of an opioid overdose in Philadelphia, PA and elsewhere. Despite an increasing presence of xylazine in the local fentanyl/heroin drug market and its association with ulcers, there are few perspectives about xylazine from people who use drugs and no data about the utility of a hypothetical xylazine test strip.

Methods

Between January to May 2021 in Philadelphia, PA, people who used fentanyl/heroin and had previously used fentanyl test strips were queried about xylazine and hypothetical xylazine test strips. Interviews were transcribed and analysis was conducted via conventional content analysis.

Results

Participants (7 spontaneously, 6 after probing, n = 13) discussed "tranq" (i.e., xylazine) in the fentanyl/heroin supply. None enjoyed tranq or wanted it in their fentanyl/heroin. Participants suspected xylazine saturation of the fentanyl/heroin market, disliked the sensation of the drug, and had safety concerns about xylazine exposure. Participants did not indicate concerns about overdose. All were interested in hypothetical xylazine test strips. While previous literature indicates that some people enjoy tranq in their fentanyl/heroin, our findings differed, with participants expressing concern about the consequences of undesired exposure. The interest expressed for xylazine test strips by people who use fentanyl/heroin is an important opportunity to center their voices in the development of innovations designed to mitigate the harms of unwanted adulterant exposure.

Conclusions

In the present study, people who use fentanyl/heroin indicated an interest to test their drug for the presence of xylazine prior to use.

There's an app for that: Teaching residents to communicate diagnostic uncertainty through a mobile gaming application

BACKGROUND

Clear communication is integral to good clinical care; however, communication training is cost and time intensive. Mobile applications (apps) may provide a useful adjunct to traditional simulation skills training.

OBJECTIVE

To evaluate (1) use of an app for teaching communication skills about diagnostic uncertainty, (2) feedback on app use, and (3) the association between use and skill mastery.

PATIENT INVOLVEMENT

The app under study is designed to improve doctor-patient communication.

METHODS

The study was a planned sub-analysis of a randomized controlled waitlist trial with emergency medicine resident physicians randomized to receive immediate or delayed access to an educational curriculum focused on diagnostic uncertainty. The curriculum included a web-based interactive module and the app. Metrics describing participants' use of the app, feedback on use, and association of use and achieving mastery in communicating diagnostic uncertainty are reported. Differences between groups utilizing the app were analyzed using Chi-squared test; logistic regression assessed the association between app use and achieving mastery of the communication skill.

RESULTS

Among 109 participants completing the trial, only 34 (31.2%) used the app. Most participants engaged with the app on one occasion for a median of 50 min (IQR 31, 87). Senior residents were more likely to use the app than junior residents (41.3% vs 23.8%, p=0.05). Overall reviews were positive; 76% reported the app helped them learn. There was no significant association between app use and achieving mastery of the communication skill in the trial [OR 2.1, 95% CI (0.91-4.84)].

DISCUSSION

Despite positive reviews of app use, overall use was low and there was no association with achieving mastery.

PRACTICAL VALUE

Offering an app as an auxiliary training opportunity may be beneficial to some residents, but shouldn't be planned for use as a primary didactic modality unless there is evidence for effectiveness and use is mandated.

AVAILABILITY OF DATA AND MATERIALS

The datasets generated and/or analyzed during the current study are not publicly available since some data may be identifiable but are available from the corresponding author on reasonable request.

PROmotion of COvid-19 VA(X)ccination in the Emergency Department-PROCOVAXED: study protocol for a cluster randomized controlled trial

Background

We conducted in-depth interviews to characterize reasons for COVID-19 vaccine hesitancy in emergency department (ED) patients and developed messaging platforms that may address their concerns. In this trial, we seek to determine whether provision of these COVID-19 vaccine messaging platforms in EDs will be associated with greater COVID-19 vaccine acceptance and uptake in unvaccinated ED patients.

Methods

This is a cluster-randomized controlled trial (RCT) evaluating our COVID-19 vaccine messaging platforms in seven hospital EDs (mix of academic, community, and safety-net EDs) in four US cities. Within each study site, we randomized 30 1-week periods to the intervention and 30 1-week periods to the control. Adult patients who have not received a COVID-19 vaccine are eligible with these exclusions: (1) major trauma, intoxication, altered mental status, or critical illness; (2) incarceration; (3) psychiatric chief complaint; and (4) suspicion of acute COVID-19 illness. Participants receive an orally administered Intake survey. During intervention weeks, participants then receive three COVID-19 vaccine messaging platforms (4-min video, one-page informational flyer and a brief, scripted face-to-face message delivered by an ED physician or nurse); patients enrolled during non-intervention weeks do not receive these platforms. Approximately, an hour after intake surveys, participants receive a Vaccine Acceptance survey during which the primary outcome of acceptance of the COVID-19 vaccine in the ED is ascertained. The other primary outcome of receipt of a COVID-19 vaccine within 32 days is ascertained by electronic health record review and phone follow-up. To determine whether provision of vaccine messaging platforms is associated with a 7% increase in vaccine acceptance and uptake, we will need to enroll 1290 patients.

Discussion

Highlighting the difficulties of trial implementation during the COVID-19 pandemic in acute care settings, our novel trial will lay the groundwork for delivery of public health interventions to vulnerable populations whose only health care access occurs in EDs.

Conclusions

Toward addressing vaccine hesitancy in vulnerable populations who seek care in EDs, our cluster-RCT will determine whether implementation of vaccine messaging platforms is associated with greater COVID-19 vaccine acceptance and uptake in unvaccinated ED patients.

Trial status

We began enrollment in December 2021 and expect to continue through 2022.

Trial registration

ClinicalTrials.govNCT05142332. Registered 02 December 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06285-x.

COVID-19 Pandemic Influence on Medical Oncology Provider Perceptions of Telehealth Video Visits

PURPOSE

The COVID-19 pandemic necessitated a rapid expansion of telehealth use in oncology, a specialty in which prior utilization was low in part because of barriers perceived by providers. Understanding the changing perceptions of medical oncology providers during the pandemic is critical for continued expansion and improvement of telehealth in cancer care. This study was designed to identify medical oncology providers' perceptions of telehealth video visits as influenced by the COVID-19 pandemic.

METHODS

We conducted semi-structured interviews with medical oncology providers from November 20, 2020, to January 27, 2021, at the Sidney Kimmel Cancer Center at Thomas Jefferson University, a National Cancer Institute-designated cancer center in an urban, academic health system in Philadelphia, PA. We assessed provider perceptions of the impact of the COVID-19 pandemic on (1) provider-level comfort and willingness for telehealth, (2) provider-perceived patient comfort and willingness to engage in telehealth, and (3) continued barriers to successful telehealth use.

RESULTS

Volunteer and convenience sampling resulted in the participation of 25 medical oncology providers, including 18 physicians and seven advanced practice providers, in semi-structured interviews. Of the 25 participants, 13 (52%) were female and 19 (76%) were White, with an average age of 48.5 years (standard deviation = 12.6). Respondents largely stated an increased comfort level and willingness for use of video visits. In addition, respondents perceived a positive change in patient comfort and willingness, mostly driven by convenience, accessibility, and reduced risk of COVID-19 exposure. However, several reported technologic issues and limited physical examination capability as remaining barriers to telehealth adoption.

CONCLUSION

The rapid adoption of telehealth necessitated by the COVID-19 pandemic has increased provider-level and provider-perceived patient comfort and willingness to engage in video visits for cancer care. As both providers and patients increasingly accept telehealth across many use cases, future work should focus on further addressing technology and physical examination barriers and ensuring continued reimbursement for telehealth as a routine part of covered care.

Transitioning to Telehealth? A Guide to Evaluating Outcomes

Objectives

Methods

Results

Conclusions

Public Interest Summary

"I'm Going to Be Good to Me": Exploring the Role of Shame and Guilt in Patients With Type 2 Diabetes

OBJECTIVE

People with type 2 diabetes are likely to experience shame or guilt as they navigate through their disease. Previous research has shown that feelings of shame and guilt often exist within the clinician-patient relationship, often as a result of the complex care regimen required to achieve treatment goals. The purpose of this qualitative study was to explore patients' experiences of shame and guilt in type 2 diabetes management and the impact their clinicians have on these experiences.

METHODS

Semistructured interviews were used to explore patients' experiences with shame and guilt. Interviews were audio-recorded, transcribed, and coded using directed content analysis. Demographic data were also obtained.

RESULTS

We completed 20 interviews with people with type 2 diabetes (65% Black, 70% female). Participants exhibited feelings more consistent with guilt than with shame. All participants discussed how their clinicians affected these feelings. Patients who expressed feelings of guilt were able to recognize opportunities for behavior change without experiencing global devaluation, in which they linked their actions to an unchangeable aspect of their identity or personality, often describing their guilt as motivating of change. Unlike guilt, when patients experienced shame, they often exhibited global devaluation, in which they blamed their personality, experienced hopelessness, and increased maladaptive behaviors.

CONCLUSION

Our findings highlight a notable difference between shame and guilt in the context of type 2 diabetes management. We believe that incorporation of an understanding of these nuances, along with ideal responses to both shame and guilt, will enhance clinicians' ability to provide high-quality patient-centered care to people with diabetes.

Emergency Medicine Clinician Experiences Addressing Uncertainty in First-Trimester Bleeding

The purpose of this work is to understand Emergency Department (ED) clinicians’ experiences in communicating uncertainty about first-trimester bleeding (FTB) and their need for training on this topic. This cross-sectional study surveyed a national sample of attending physicians and advanced practice providers (APPs). The survey included quantitative and qualitative questions about communicating with patients presenting with FTB. These questions assessed clinicians’ frequency encountering challenges, comfort, training, prior experience, and interest in training on the topic. Of 402 respondents, 54% reported that they encountered challenges at least sometimes when discussing FTB with patients where the pregnancy outcome is uncertain. While the majority (84%) were at least somewhat prepared for these conversations from their training, which commonly addressed the diagnostic approach to this scenario, 39% strongly or moderately agreed that they could benefit from training on the topic. Because the majority of ED clinicians identified at least sometimes encountering challenges communicating with pregnant patients about FTB, our study indicates a need exists for more training in this skill.

Development of the Oncology Opportunity Cost Assessment Tool: Item Generation and Content Validity Testing

PURPOSE

The purpose of this study was to develop the Oncology Opportunity Cost Assessment Tool (OOCAT), a survey instrument to evaluate the opportunity costs patients experience when seeking medical oncology care.

METHODS

Development of the OOCAT involved extensive patient engagement through both focus groups and interviews. First, the study team developed a list of opportunity cost concepts, which included patients' logistical and financial considerations related to seeking care. We conducted focus groups with patients to expand upon this list of concepts, and then developed a set of questions that incorporated all the concepts generated during the focus groups. To refine these questions, we next performed cognitive interviews with another set of patients to ensure content validity and clarity of instrument items, refining the OOCAT iteratively on the basis of feedback.

RESULTS

We engaged 23 participants (17 patients and six caregivers) across four focus groups and 17 participants in cognitive interviews. Focus group participants generated 112 concepts, which resulted in an initial OOCAT with 16 questions. Cognitive interviews resulted in modification of 12 questions and addition of two questions (related to coordination of transportation and impact on home responsibilities). The final OOCAT consisted of 18 items examining time requirements for appointments, financial implications of traveling to appointments for the patient and the caregiver, and logistical and quality-of-life challenges associated with traveling for appointments.

CONCLUSION

We developed the OOCAT, an instrument designed to evaluate patient-level opportunity costs of seeking medical oncology care. Further studies to validate the OOCAT are underway.

Patient-important outcomes to inform shared decision making and goal setting for diabetes treatment

OBJECTIVE

Despite well-established treatment guidelines, diabetes is difficult to manage for many individuals. The importance of using shared decision making to optimize diabetes treatment is recognized, yet what matters most to individuals with diabetes is not well established. Our goal was to identify patients' goals and priorities for diabetes management.

METHODS

We engaged 141 participants through interviews and group concept mapping to identify patient-important outcomes (PIOs) for diabetes care. We generated a master list of PIOs by aggregating interview data coded to "goals" and ideas brainstormed during concept mapping, and then a patient advisory board sorted the PIOs into higher-level domains.

RESULTS

We identified 41 PIOs sorted into 7 broad domains: optimize daily self-care, optimize long term health, learn about diabetes, achieve measurable goals, manage medications, manage diet and best utilize medical / professional services.

CONCLUSIONS

Most (4/7) of PIO domains focused on personal and life goals, not medically-oriented goals. Use of these PIOs and domains may facilitate more effective SDM discussions for patients with diabetes.

PRACTICE IMPLICATIONS

Use of PIOs from this work can enable the empowerment of patients to voice their priorities during SDM conversations, thus facilitating development of truly individualized diabetes treatment plans.

Polypharmacy and Potentially Inappropriate Medication Use in Older Blacks with Diabetes Mellitus Presenting to the Emergency Department

Background: Medication-related problems in older Blacks with diabetes mellitus (DM) are not well established. Objectives: To describe the frequency of medication-related problems in older Blacks with DM presenting to the emergency department (ED). Methods: The study was a cross-sectional analysis of baseline data from a randomized controlled trial evaluating Blacks aged ≥60 years of age presenting to the ED. Polypharmacy, potentially inappropriate medication (PIM) use, and anticholinergic score were evaluated. Results: Of 168 patients (median age = 68, range 60-92), most (n = 164, 98%) were taking ≥5 medications, and 67 (39.9%) were taking a PIM. A majority (n = 124, 74%) were taking a medication with an anticholinergic score ≥1. Number of medications was correlated with number of PIMs (r = .22, p = .004) and anticholinergic score (r = .50, p < .001). Conclusion: Polypharmacy and PIM use was common in older Blacks with DM.

Assessing the impact of medically tailored meals and medical nutrition therapy on type 2 diabetes: Protocol for Project MiNT

BACKGROUND

Research has shown that among people with type 2 diabetes mellitus, reduction in hemoglobin A1c (HbA1c) prevents long term complications. Medically tailored meals (MTM) and telehealth-delivered medical nutrition therapy (tele-MNT) are promising strategies for patient-centered diabetes care.

OBJECTIVES

Project MiNT will determine whether provision of MTM with and without the addition of telehealth-delivered medical nutrition therapy improves HbA1c and is cost effective for patients with type 2 diabetes mellitus.

METHODS

Patients with poorly controlled type 2 diabetes mellitus (HbA1c >8%) will be recruited from Jefferson Health. Eligible patients will be randomized to one of three arms: 1) usual care, 2) 12 weeks of home-delivered MTM, or 3) MTM + 12 months of tele-MNT. All participants (n = 600) will complete three follow-up assessments at 3, 6, and 12 months. The primary outcome is change in HbA1c at 6 months. Secondary outcomes include change in HbA1c at 3 and 12 months and cost-effectiveness of the intervention at 6 and 12 months. Conclusion Findings from Project MiNT will inform MTM coverage and financing decisions, how to structure services for scalability and system-wide integration, and the role of these services in reducing health disparities.

The impact of COVID-19 on healthcare delivery for people who use opioids: a scoping review

Research objective

The COVID-19 pandemic disrupted healthcare delivery worldwide with likely negative effects on people who use opioids (PWUO). This scoping review of the original research literature describes the impact of the COVID-19 pandemic on healthcare delivery for PWUO and identifies gaps in the literature.

Methods

This scoping review of the original research literature maps the available knowledge regarding the impact of the COVID-19 pandemic on healthcare delivery for PWUO. We utilized the methodology developed by the Joanna Briggs Institute for scoping reviews, and content analyses methodology to characterize the current state of the literature.

Results

Of the 14 included studies, administrative database (n = 11), cross-sectional (n = 1) or qualitative (n = 2) studies demonstrated service gaps (n = 7), patient/provider experiences (n = 3), and patient outcomes for PWUO (n = 4). In March 2020, healthcare utilization dropped quickly, sharply increasing only for reasons of opioid overdose by May 2020. Service gaps existed in accessing treatment for new patients during the pandemic due to capacity and infrastructure limits. Physicians reported difficulty referring patients to begin an outpatient opioid treatment program due to increased restrictions in capacity and infrastructure. Patients also reported uncertainty about accessing outpatient treatment, but that telehealth initiation of buprenorphine increased access to treatment from home. Disproportionate increases in overdose rates among African Americans were reported in two studies, with differences by race and gender not examined in most studies. Fatal overdoses increased 60% in African Americans during the pandemic, while fatal overdoses in Non-Hispanic White individuals decreased.

Conclusions

In summary, this beginning evidence demonstrates that despite early reluctance to use the healthcare system, opioid overdose-related use of healthcare increased throughout the pandemic. Service delivery for medications to treat OUD remained at or above pre-pandemic levels, indicating the ability of telehealth to meet demand. Yet, racial disparities that existed pre-pandemic for PWUO are intensifying, and targeted intervention for high-risk groups is warranted to prevent further mortality. As the pandemic progresses, future research must focus on identifying and supporting subgroups of PWUO who are at heightened risk for experiencing negative outcomes and lack of access to care.

Living Through the Pandemic: The Voices of Persons With Dementia and Their Caregivers

Social-distancing guidelines from the COVID-19 pandemic have potential to compound morbidity in persons with dementia (PwD) and increase caregiver burden. This qualitative study utilized semi-structured interviews between August-November 2020 to explore the impact of COVID-19 on PwD and caregivers. Conventional qualitative content analysis was used. Inter-coder reliability was confirmed using the kappa coefficient. Twenty-five interviews were completed with four themes emerging: disruption of socialization, fear and risk mitigation, coping strategies, and caregiver burden. Participants described how lack of socialization and confinement led to feelings of loneliness, depression, and worsening memory problems. Caregivers reported increased burden and heightened feelings of responsibility for their loved one. Increased isolation imposed by the pandemic has a detrimental impact on PwD. Further work is needed to develop interventions to support PwD and other cognitive impairments and caregivers during the pandemic and when in-person socialization is not possible.

Digital Literacy at an Urban Cancer Center: Implications for Technology Use and Vulnerable Patients

PURPOSE

eHealth literacy, or the ability to seek, find, understand, and appraise health information from electronic sources, has become increasingly relevant in the era of COVID-19, when so many aspects of patient care became dependent on technology. We aimed to understand eHealth literacy among a diverse sample of patients with cancer and discuss ways for health systems and cancer centers to ensure that all patients have access to high-quality care.

METHODS

A cross-sectional survey of patients with cancer and caregivers was conducted at an NCI-designated cancer center to assess access to the Internet, smartphone ownership, use of mobile apps, willingness to engage remotely with the health care team, and use of the patient portal. Descriptive statistics and bivariate analyses were used to assess frequencies and significant differences between variables.

RESULTS

Of 363 participants, 55% (n = 201) were female, 71% (n = 241) identified as non-Hispanic White, and 29% (n = 85) reported that their highest level of education was a high school diploma. Most (90%, n = 323) reported having access to the Internet and most (82%, n = 283) reported owning a smartphone. Younger patients or those with a college degree were significantly more likely to own a smartphone, access health information online, know how to download an app on their own, have an interest in communicating with their health care team remotely, or have an account on the electronic patient portal.

CONCLUSION

As cancer centers increasingly engage patients through electronic and mobile applications, patients with low or limited digital literacy may be excluded, exacerbating current cancer health disparities. Patient-, provider- and system-level technology barriers must be understood and mitigated.

Patient Markers of Successful Diabetes Management

PURPOSE

For individuals with diabetes, diabetes health status may not align with A1C targets. Patients may use nonclinical targets when assessing their diabetes management success. Identifying these targets is important in developing patient-centered management plans. The purpose of this study was to identify patient markers of successful diabetes management among patients in an urban academic health system.

METHODS

A secondary analysis of semistructured interviews was completed with 89 adults with type 1 or type 2 diabetes. Participants had a recent diabetes-related emergency department (ED) visits or hospitalization or were primary care patients with an A1C >7.5%. Interviews were conducted to saturation. Demographic data were collected via self-report and electronic medical records. Interviews were analyzed using conventional content analysis. This analysis focused on patient perceptions of successful management coded to "measuring management success."

RESULTS

Although most participants cited A1C or blood glucose as a marker of successful diabetes management, they had varied understanding of these metrics. Most used a combination of targets from the following categories: 1) A1C, blood glucose, and numbers; 2) engagement in medical care; 3) taking medication and medication types; 4) symptoms; 5) diet, exercise, and weight; and 6) stress management and social support.

CONCLUSION

Individuals not meeting glycemic goals and/or with recent diabetes-related ED visits or hospitalizations had varied understanding of A1C and blood glucose targets. They use multiple additional markers of successful management and had a desire for management discussions that incorporate these markers. These measures should be incorporated into their care plans along with clinical targets.

Developing standardized patient-based cases for communication training: lessons learned from training residents to communicate diagnostic uncertainty

Health professions education has benefitted from standardized patient (SP) programs to develop and refine communication and interpersonal skills in trainees. Effective case design is essential to ensure an SP encounter successfully meets learning objectives that are focused on communication skills. Creative, well-designed case scenarios offer learners the opportunity to engage in complex patient encounters, while challenging them to address the personal and emotional contexts in which their patients are situated. Therefore, prior to considering the practical execution of the patient encounter, educators will first need a clear and structured strategy for writing, organizing, and developing cases. The authors reflect on lessons learned in developing standardized patient-based cases to train learners to communicate to patients during times of diagnostic uncertainty, and provide suggestions to develop a set of simulation cases that are both standardized and diverse. Key steps and workflow processes that can assist educators with case design are introduced. The authors review the need to increase awareness of and mitigate existing norms and implicit biases, while maximizing variation in patient diversity. Opportunities to leverage the breadth of emotional dispositions of the SP and the affective domain of a clinical encounter are also discussed as a means to guide future case development and maximize the value of a case for its respective learning outcomes.

Medical Oncology Patient Perceptions of Telehealth Video Visits

PURPOSE

Telehealth in medical oncology has expanded secondary to the COVID-19 pandemic. However, quantitative research on medical oncology telehealth use shows conflicting results on patient satisfaction, whereas qualitative data are sparse. Our qualitative study aimed to identify the factors influencing patient acceptability of video visits for medical oncology care before and at the onset of the expansion of telehealth because of the COVID-19 pandemic.

METHODS

Semi-structured interviews were conducted between November 2019 and April 2020 with 20 patients who participated in a telehealth visit with a medical oncology provider at Thomas Jefferson University.

RESULTS

Of the 20 participants, 13 (65%) were female and 15 (75%) were White, with a mean (standard deviation) age of 60.5 years (11.8). Patients identified convenience, anxiety, COVID-19, and provider preference as positively influencing the acceptability of video visits; however, some patients noted limitations in provider connection, physical examinations, and visit length as disadvantages. Regarding receipt of serious or bad news, some preferred video visits for privacy, immediacy of results, news processing, and family comfort. Others preferred in-person encounters for provider support and the ability to receive written information and in-person referrals.

CONCLUSION

Patient-perceived factors influencing general acceptability, appropriateness of serious and bad news delivery, and future uses of telehealth were unique to each individual, but shared common themes. Understanding each patient's perspective of telehealth acceptability and tailoring use to their preferences is critical for continued utilization. Further research is needed to understand and address reasons for lack of telehealth uptake among certain patients.

Unmet Behavioral Health and Social Needs of Home Healthcare Patients and Their Caregivers

Lack of recognition and treatment of mental health disorders in the home healthcare (HHC) population has been recognized as a national public health problem. However, there is a gap in understanding the behavioral health needs of HHC patients and caregivers from the perspectives of HHC patients, caregivers, and HHC personnel. These perspectives are critical for informing an acceptable and scalable integrated care model. We conducted semi-structured interviews with HHC patients, caregivers, and HHC personnel to assess the unmet behavioral health needs of HHC patients and their caregivers. Participants were recruited from a Medicare-certified HHC agency that is part of a large health system on the east coast. We completed a total of 31 interviews between January and May 2020. Findings suggest that HHC patients have significant unmet behavioral health and social needs and their caregivers are emotionally and physically drained. Reasons that patients may not be receiving adequate behavioral health services include denial, cost, culture, lack of awareness of available resources, lack of transportation, and homebound status. While most patients discussed the emotional toll of their illness, few were connected to services. HHC personnel offered suggestions on how to meet the behavioral health needs of patients, with the primary focus on providing in-home options. Gaps in meeting the needs of the HHC population necessitate integrated care models that can effectively address the behavioral health and social needs of HHC patients and their families. Future research should develop and test patient and caregiver-directed integrated care models in the HHC setting.

Medical Oncology Professionals' Perceptions of Telehealth Video Visits

IMPORTANCE

Telehealth has emerged as a means of improving access and reducing cost for medical oncology care; however, use by specialists prior to the coronavirus disease 2019 (COVID-19) pandemic still remained low. Medical oncology professionals' perceptions of telehealth for cancer care are largely unknown, but are critical to telehealth utilization and expansion efforts.

OBJECTIVE

To identify medical oncology health professionals' perceptions of the barriers to and benefits of telehealth video visits.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study used interviews conducted from October 30, 2019, to March 5, 2020, of medical oncology health professionals at the Thomas Jefferson University Hospital, an urban academic health system in the US with a cancer center. All medical oncology physicians, physicians assistants, and nurse practitioners at the hospital were eligible to participate. A combination of volunteer and convenience sampling was used, resulting in the participation of 29 medical oncology health professionals, including 20 physicians and 9 advanced practice professionals, in semistructured interviews.

MAIN OUTCOMES AND MEASURES

Medical oncology health professionals' perceptions of barriers to and benefits of telehealth video visits as experienced by patients receiving cancer treatment.

RESULTS

Of the 29 participants, 15 (52%) were women and 22 (76%) were White, with a mean (SD) age of 48.5 (12.0) years. Respondents' perceptions were organized using the 4 domains of the National Quality Forum framework: clinical effectiveness, patient experience, access to care, and financial impact. Respondents disagreed on the clinical effectiveness and potential limitations of the virtual physical examination, as well as on the financial impact on patients. Respondents also largely recognized the convenience and improved access to care enabled by telehealth for patients. However, many reported concern regarding the health professional-patient relationship and their limited ability to comfort patients in a virtual setting.

CONCLUSIONS AND RELEVANCE

Medical oncology health professionals shared conflicting opinions regarding the barriers to and benefits of telehealth in regard to clinical effectiveness, patient experience, access to care, and financial impact. Understanding oncologists' perceptions of telehealth elucidates potential barriers that need to be further investigated or improved for telehealth expansion and continued utilization; further research is ongoing to assess current perceptions of health professionals and patients given the rapid expansion of telehealth during the COVID-19 pandemic.

Development of the Uncertainty Communication Checklist: A Patient-Centered Approach to Patient Discharge From the Emergency Department

Clear communication with patients upon emergency department (ED) discharge is important for patient safety during the transition to outpatient care. Over one-third of patients are discharged from the ED with diagnostic uncertainty, yet there is no established approach for effective discharge communication in this scenario. From 2017 to 2019, the authors developed the Uncertainty Communication Checklist for use in simulation-based training and assessment of emergency physician communication skills when discharging patients with diagnostic uncertainty. This development process followed the established 12-step Checklist Development Checklist framework and integrated patient feedback into 6 of the 12 steps. Patient input was included as it has potential to improve patient-centeredness of checklists related to assessment of clinical performance. Focus group patient participants from 2 clinical sites were included: Thomas Jefferson University Hospital, Philadelphia, PA, and Northwestern University Hospital, Chicago, Illinois.The authors developed a preliminary instrument based on existing checklists, clinical experience, literature review, and input from an expert panel comprising health care professionals and patient advocates. They then refined the instrument based on feedback from 2 waves of patient focus groups, resulting in a final 21-item checklist. The checklist items assess if uncertainty was addressed in each step of the discharge communication, including the following major categories: introduction, test results/ED summary, no/uncertain diagnosis, next steps/follow-up, home care, reasons to return, and general communication skills. Patient input influenced both what items were included and the wording of items in the final checklist. This patient-centered, systematic approach to checklist development is built upon the rigor of the Checklist Development Checklist and provides an illustration of how to integrate patient feedback into the design of assessment tools when appropriate.

"I had no other choice but to catch it too": the roles of family history and experiences with diabetes in illness representations

BACKGROUND

A family history of diabetes and family members' experiences with diabetes may influence individuals' beliefs and expectations about their own diabetes. No qualitative studies have explored the relationship between family history and experiences and individuals' diabetes illness representations.

METHODS

Secondary data analysis of 89 exploratory, semi-structured interviews with adults with type 1 or type 2 diabetes seeking care in an urban health system. Participants had a recent diabetes-related ED visit/hospitalization or hemoglobin A1c > 7.5%. Interviews were conducted until thematic saturation was achieved. Demographic data were collected via self-report and electronic medical record review. Interviews were audio-recorded, transcribed, and coded using a conventional content analysis approach. References to family history and family members' experiences with diabetes were analyzed using selected domains of Leventhal's Common Sense Model of Self-Regulation.

RESULTS

Participants cited both genetic and behavioral family history as a major cause of their diabetes. Stories of relatives' diabetes complications and death figured prominently in their discussion of consequences; however, participants felt controllability over diabetes through diet, physical activity, and other self-care behaviors.

CONCLUSIONS

Findings supported an important role of family diabetes history and experience in development of diabetes illness representations. Further research is needed to expand our understanding of the relationships between these perceptions, self-management behaviors, and outcomes. Family practice providers, diabetes educators and other team members should consider expanding assessment of current family structure and support to also include an exploration of family history with diabetes, including which family members had diabetes, their self-care behaviors, and their outcomes, and how this history fits into the patient's illness representations.