COVID-19 vaccination perspectives among patients with Long COVID: A qualitative study

Individuals who have Long COVID may have unique perspectives about COVID-19 vaccination due to the significant impact that COVID-19 has had on their lives. However, little is known about the specific vaccination perspectives among this patient population. The goal of our study was to improve our understanding of perspectives about COVID-19 vaccines among individuals with Long COVID. Interviews were conducted with patients receiving care at a post-COVID recovery clinic. Deductive thematic analysis was used to characterize participant perspectives according to the vaccine acceptance continuum framework, which recognizes a spectrum from vaccine acceptance to refusal. From interviews with 21 patients, we identified perspectives across the continuum of vaccine acceptance. These perspectives included acceptance of vaccines to prevent future illness, concerns about vaccine side effects on Long COVID symptoms, and refusal of vaccines due to perceived natural immunity. A limitation of our study is that these perspectives are specific to individuals receiving care at one post-COVID recovery clinic. In conclusion, our study demonstrates that some patients with Long COVID are uncertain about COVID-19 vaccines and boosters but may also be amenable to conversations that impact future vaccination acceptance. Patient perspectives should be considered when communicating recommendations for COVID-19 vaccinations to this population.

Negative lipid membranes enhance the adsorption of TAT-decorated elastin-like polypeptide micelles

A cell-penetrating peptide (CPP) is a short amino-acid sequence capable of efficiently translocating across the cellular membrane of mammalian cells. However, the potential of CPPs as a delivery vector is hampered by the strong reduction of its translocation efficiency when it bears an attached molecular cargo. To overcome this problem, we used previously developed diblock copolymers of elastin-like polypeptides (ELPBCs), which we end functionalized with TAT (transactivator of transcription), an archetypal CPP built from a positively charged amino acid sequence of the HIV-1 virus. These ELPBCs self-assemble into micelles at a specific temperature and present the TAT peptide on their corona. These micelles can recover the lost membrane affinity of TAT and can trigger interactions with the membrane despite the presence of a molecular cargo. Herein, we study the influence of membrane surface charge on the adsorption of TAT-functionalized ELP micelles onto giant unilamellar vesicles (GUVs). We show that the TAT-ELPBC micelles show an increased binding constant toward negatively charged membranes compared to neutral membranes, but no translocation is observed. The affinity of the TAT-ELPBC micelles for the GUVs displays a stepwise dependence on the lipid charge of the GUV, which, to our knowledge, has not been reported previously for interactions between peptides and lipid membranes. By unveiling the key steps controlling the interaction of an archetypal CPP with lipid membranes, through regulation of the charge of the lipid bilayer, our results pave the way for a better design of delivery vectors based on CPPs.

Differences by Race in Outcomes of an In-Person Training Intervention on Use of an Inpatient Portal: A Secondary Analysis of a Randomized Clinical Trial

Importance

Differences in patient use of health information technologies by race can adversely impact equitable access to health care services. While this digital divide is well documented, there is limited evidence of how health care systems have used interventions to narrow the gap.

Objective

To compare differences in the effectiveness of patient training and portal functionality interventions implemented to increase portal use among racial groups.

Design, Setting, and Participants

This secondary analysis used data from a randomized clinical trial conducted from December 15, 2016, to August 31, 2019. Data were from a single health care system and included 6 noncancer hospitals. Participants were patients who were at least 18 years of age, identified English as their preferred language, were not involuntarily confined or detained, and agreed to be provided a tablet to access the inpatient portal during their stay. Data were analyzed from September 1, 2022, to October 31, 2023.

Interventions

A 2 × 2 factorial design was used to compare the inpatient portal training intervention (touch, in-person [high] vs built-in video tutorial [low]) and the portal functionality intervention (technology, full functionality [full] vs a limited subset of functions [lite]).

Main Outcomes and Measures

Primary outcomes were inpatient portal use, measured by frequency and comprehensiveness of use, and use of specific portal functions. A logistic regression model was used to test the association of the estimators with the comprehensiveness use measure. Outcomes are reported as incidence rate ratios (IRRs) for the frequency outcomes or odds ratios (ORs) for the comprehensiveness outcomes with corresponding 95% CIs.

Results

Of 2892 participants, 550 (19.0%) were Black individuals, 2221 (76.8%) were White individuals, and 121 (4.2%) were categorized as other race (including African, American Indian or Alaska Native, Asian or Asian American, multiple races or ethnicities, and unknown race or ethnicity). Black participants had a significantly lower frequency (IRR, 0.80 [95% CI, 0.72-0.89]) of inpatient portal use compared with White participants. Interaction effects were not observed between technology, touch, and race. Among participants who received the full technology intervention, Black participants had lower odds of being comprehensive users (OR, 0.76 [95% CI, 0.62-0.91), but interaction effects were not observed between touch and race.

Conclusions and Relevance

In this study, providing in-person training or robust portal functionality did not narrow the divide between Black participants and White participants with respect to their inpatient portal use. Health systems looking to narrow the digital divide may need to consider intentional interventions that address underlying issues contributing to this inequity.

Trial Registration

ClinicalTrials.gov Identifier: NCT02943109.

Patient Experiences Navigating Care Coordination For Long COVID: A Qualitative Study

BACKGROUND

Little is known about how to best evaluate, diagnose, and treat long COVID, which presents challenges for patients as they seek care.

OBJECTIVE

Understand experiences of patients as they navigate care for long COVID.

DESIGN

Qualitative study involving interviews with patients about topics related to seeking and receiving care for long COVID.

PARTICIPANTS

Eligible patients were at least 18 years of age, spoke English, self-identified as functioning well prior to COVID infection, and reported long COVID symptoms continued to impact their lives at 3 months or more after a COVID infection.

APPROACH

Patients were recruited from a post-COVID recovery clinic at an academic medical center from August to September 2022. Interviews were audio-recorded, transcribed, and analyzed using thematic analysis.

KEY RESULTS

Participants (n=21) reported experiences related to elements of care coordination: access to care, evaluation, treatment, and ongoing care concerns. Some patients noted access to care was facilitated by having providers that listened to and validated their symptoms; other patients reported feeling their access to care was hindered by providers who did not believe or understand their symptoms. Patients reported confusion around how to communicate their symptoms when being evaluated for long COVID, and they expressed frustration with receiving test results that were normal or diagnoses that were not directly attributed to long COVID. Patients acknowledged that clinicians are still learning how to treat long COVID, and they voiced appreciation for providers who are willing to try new treatment approaches. Patients expressed ongoing care concerns, including feeling there is nothing more that can be done, and questioned long-term impacts on their aging and life expectancy.

CONCLUSIONS

Our findings shed light on challenges faced by patients with long COVID as they seek care. Healthcare systems and providers should consider these challenges when developing strategies to improve care coordination for patients with long COVID.

Comparing super-utilizers and lower-utilizers among commercial- and Medicare-insured adults with sickle cell disease

ABSTRACT

Sickle cell disease (SCD) is a rare but costly condition in the United States. Super-utilizers have been defined as a subset of the population with high health care encounters or expenditures. Although super-utilizers have been described in other disease states, little is known about super-utilizers among adults with SCD. This study aimed to characterize the differences in expenditures, overall health care encounters, and pain episode encounters between super-utilizers (top 10% expenditures) and lower-utilizers with SCD (high, top 10%-24.9%; moderate, 25%-49.9%; and low, bottom 50% expenditures). A retrospective longitudinal cohort of adults with SCD were identified using validated algorithms in MarketScan and Medicare claim databases from 2016 to 2020. Encounters and expenditures were analyzed from inpatient, outpatient, and emergency department settings. Differences in encounters and expenditures between lower-utilizers and super-utilizers were compared using logistic regression. Among super-utilizers, differences in encounters and expenditures were compared according to incidences of pain episode encounters. The study population included 5666 patients with commercial insurance and 8600 with Medicare. Adjusted total annual health care expenditure was 43.46 times higher for super-utilizers than for low-utilizers among commercial-insured and 13.37 times higher in Medicare-insured patients. Among super-utilizers, there were patients with few pain episode encounters who had higher outpatient expenditures than patients with a high number of pain episode encounters. Our findings demonstrate the contribution of expensive outpatient care among SCD super-utilizers, in which analyses of high expenditure have largely focused on short-term care. Future studies are needed to better understand super-utilizers in the SCD population to inform the effective use of preventive interventions and/or curative therapies.

Identifying beliefs driving COVID-19 vaccination: Lessons for effective messaging

Increasing vaccination acceptance has been essential during the COVID-19 pandemic and in preparation for future public health emergencies. This study aimed to identify messaging strategies to encourage vaccine uptake by measuring the drivers of COVID-19 vaccination among the general public. A survey to assess COVID-19 vaccination acceptance and hesitancy was advertised on Facebook in February-April 2022. The survey included items asking about COVID-19 vaccination status and participant demographics, and three scales assessing medical mistrust, perceived COVID-19 risk, and COVID-19 vaccine confidence (adapted from the Oxford COVID-19 vaccine confidence and complacency scale). The main outcome was vaccination, predicted by patient demographics and survey scale scores. Of 1,915 survey responses, 1,450 (75.7%) were included, with 1,048 (72.3%) respondents reporting they had been vaccinated. In a multivariable regression model, the COVID-19 vaccine confidence scale was the strongest predictor of vaccination, along with education level and perceived COVID-19 risk. Among the items on this scale, not all were equally important in predicting COVID-19 vaccination. The items that best predicted vaccination, at a given score on the COVID-19 vaccine confidence scale, included confidence that vaccine side effects are minimal, that the vaccine will work, that the vaccine will help the community, and that the vaccine provides freedom to move on with life. This study improved our understanding of perceptions most strongly associated with vaccine acceptance, allowing us to consider how to develop messages that may be particularly effective in encouraging vaccination among the general public for both the COVID-19 pandemic and future public health emergencies.

The Role of Palliative Care in Heart Failure, Part 3: Facilitators and Barriers to Cardiac Palliative Care Clinic Development

Background: Patients with heart failure frequently have significant disease burden and complex psychosocial needs. The integration of palliative care into the management of these patients can decrease symptom burden throughout their course of illness. Therefore, in 2009, we established a cardiac palliative care clinic colocated with heart failure providers in a large academic heart hospital. Objective: To better understand the facilitators and barriers to integrating palliative care into our heart failure management service. Design: Qualitative study using a semistructured interview guide. Setting, Subjects: Between October 2020 and January 2021, we invited all 25 primary cardiac providers at our academic medical center in the midwestern United States to participate in semistructured qualitative interviews to discuss their experiences with the cardiac palliative care clinic. Measurements: Interview transcripts were analyzed using a deductive-dominant thematic analysis approach to reveal emerging themes. Results: Providers noted that the integration of palliative care into the treatment of patients with heart failure was helped and hindered primarily by issues related to operations and communications. Operational themes about clinic proximity and the use of telehealth as well as communication themes around provider-provider communication and the understanding of palliative care were particularly salient. Conclusions: The facilitators and barriers identified have broad applicability that are independent of the etiological nature (e.g., cancer, pulmonary, neurological) of any specialty or palliative care clinic. Moreover, the strategies we used to implement improvements in our clinic may be of benefit to other practice models such as independent and embedded clinics.

The Role of Palliative Care in Heart Failure, Part 4: A Framework for Collaboration in Advance Care Planning

Background: Palliative care integration into cardiology is growing, allowing primary cardiology care teams increasing opportunities to utilize palliative care to support processes such as advance care planning (ACP). Objective: The aim of the study is to understand perspectives of cardiac care team members about the involvement and impact of palliative care on ACP in heart failure. Design: A qualitative study using a semistructured interview guide was performed. Settings/Subjects: Interviews were conducted with cardiac care team members, including cardiologists, cardiac surgeons, and nurse practitioners, at a large academic medical center in the United States with an integrated cardiac palliative care team. Measurements: Deductive and inductive thematic analysis of interview transcripts enabled characterization of themes around the role of palliative care in ACP. Results: Two themes were identified with regard to providers' perspectives about ACP: (1) different levels of comfort with initiating and conducting ACP conversations and (2) different opinions about the desired role of palliative care in the ACP process. In exploring these themes, we characterized four distinct approaches to ACP with palliative care as a novel framework for planning consultation. Conclusions: The different approaches to ACP and the implications for how cardiac providers interact with the palliative care team present an important opportunity to guide ACP consultation in practice. Adoption of this framework may help cardiac providers enhance the process of care delivery and ACP in important ways that improve care for their patients.

The Role of Palliative Care in Heart Failure, Part 2: Characteristics of Patients Undergoing Outpatient Palliative Care Evaluation for Advanced Cardiac Therapies

Background: Characteristics of patients undergoing outpatient evaluation for advanced cardiac therapies are largely unknown. Objective: To describe demographics, baseline quality of life, and frailty of patients undergoing evaluation for advanced therapies at the time of presentation for evaluation in an outpatient cardiac palliative care clinic and examine key quality of life differences across patients. Design: Retrospective chart review to report baseline demographics and quality of life. Settings/Subjects: Patients at a large academic medical center in the United States referred for advanced cardiac therapies in 2021. Measurements: Depression and anxiety were measured using the Hospital Anxiety and Depression Scale; quality of life was measured using the Functional Assessment of Chronic Illness Therapy-Palliative care (FACIT-Pal) tool; and frailty was measured using the Fried Frailty Phenotype. Differences in quality of life by disease etiology, demographic characteristics, and frailty were assessed. Results: Fifty-four patients were seen in the outpatient cardiac palliative care clinic for advanced therapy evaluation. Most were Caucasian (80%) and male (74%). Patients traveled an average of 61 minutes to the clinic. All but five lived in a rural, medically underserved, or health professional shortage area. Forty percent scored abnormal or borderline abnormal for anxiety; 22% scored abnormal or borderline abnormal for depression. The FACIT-Pal mean score was 129 (standard deviation 23), with emotional and functional well-being domains contributing most to poor quality of life. Seventy-one percent were frail. Patients with a nonischemic etiology had a 3.32 times higher rate of anxiety than nonischemic patients (95% confidence interval = 1.05-10.54, p = 0.041). Conclusion: As patients undergoing transplant evaluation have high levels of depression, anxiety, and frailty, interdisciplinary care teams will be needed to properly manage the needs of this complex population. These results can inform efforts to integrate palliative care into advanced cardiac therapy and improve patients' experiences.

The Role of Palliative Care in Heart Failure, Part 1: Referring Provider Perspectives About Opportunities in Advanced Cardiac Therapies

Background: There are many ways that palliative care can support patients with heart failure, but the role of palliative care in supporting patients who are considering or are already using advanced cardiac therapies is less clear. Objective: To understand referring providers' perspectives about the role of palliative care in the treatment of patients with heart failure considering or using advanced cardiac therapies. Design: Qualitative study using a semistructured interview guide. Setting/Subjects: This study was conducted at an academic medical center in the United States with an integrated cardiac palliative care program. Interviews were conducted with cardiology providers, including cardiologists, cardiac surgeons, and nurse practitioners who care for patients with heart failure and who are considering or receiving advanced cardiac therapies. Measurements: Interview transcripts were analyzed deductively and inductively to reveal themes in providers' perspectives. Results: Five themes were identified about the role of palliative care when advanced therapies were considered or being used: (1) educating patients; (2) supporting goal-concordant care; (3) managing symptoms; (4) addressing psychosocial needs; and (5) managing end-of-life care. Providers suggested palliative care could be a facilitator of advanced therapies, rather than merely something to add to end-of-life care. Conclusions: Cardiology providers recognize the value of integrating palliative care across the heart failure disease trajectory to provide therapy options, support decision-making processes, and provide goal-concordant care for patients considering or receiving advanced therapies. Increasing awareness of opportunities to integrate palliative care throughout the treatment of these patients may help cardiology providers better coordinate with palliative care specialists to improve patient care.

Perspectives of patients undergoing neoadjuvant chemotherapy for breast cancer during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic resulted in a lapse in routine health care and cancer screenings for many individuals. This study sought to improve our understanding of the impact of the COVID-19 pandemic on women being treated for breast cancer, both in general, and specifically related to their diagnosis.

METHODS

Semi-structured interviews were conducted between August 2021 and February 2022 with women who were receiving neoadjuvant chemotherapy for early-stage breast cancer at the Stefanie Spielman Comprehensive Breast Center in Columbus, Ohio. Interviews were recorded and transcribed verbatim. Transcripts were coded using deductive dominant thematic analysis and inductive coding that allowed for categorization of data as well as identification of emergent themes.

RESULTS

Data collected from our 19 interviews revealed that the COVID-19 pandemic posed important challenges for breast cancer patients including fear of COVID-19 infection and feelings of isolation. Most interviewees noted they had been vaccinated against COVID-19 because of a desire to protect themselves and others from getting sick. Some women also expressed concerns about having delayed their screening mammograms due to the pandemic. Several patients described unexpected positive aspects of the pandemic such as being able to spend more time with family and having the ability to continue working because of the option to work from home during their cancer treatment.

CONCLUSIONS

Our findings provide important insight about the impact of COVID-19 on breast cancer patients. We highlight the positives that have been reported because of the pandemic, as well as the need to address delayed breast cancer screening.

Understanding Concerns about COVID-19 and Vaccination: Perspectives from Kidney Transplant Recipients

The COVID-19 pandemic poses a significant risk for immunosuppressed groups such as transplant patients. The purpose of this study was to improve our understanding of the impact of the COVID-19 pandemic on kidney transplant recipients, including their views on COVID-19 vaccination. Semi-structured interviews were conducted from December 2021 to August 2022 with 38 kidney transplant recipients who had an appointment with their transplant care team within the previous 6 months. We used qualitative thematic analysis to characterize the perspectives of interviewees. Regardless of COVID-19 vaccination status, most interviewees reported utilizing public health measures such as masking, hand washing, and avoiding crowds to protect themselves against COVID-19. Vaccinated interviewees (n = 31) noted that they chose to receive a COVID-19 vaccine because of their increased risk due to their immunocompromised state. For unvaccinated interviewees (n = 7), reasons for not receiving a COVID-19 vaccine included concerns about the safety and efficacy of the vaccine. Both vaccinated and unvaccinated interviewees expressed concerns about the lack of adequate testing of the vaccine in transplant patients and questioned if the vaccine might have unknown side effects for transplant recipients. Regardless of the vaccination status, most interviewees noted having trust in their healthcare team. Interviewees also described interpersonal tensions that arose during the pandemic, many of which surrounded vaccination and other preventive measures that were important to participants to protect their health. Together, these data demonstrate differing concerns and experiences related to the COVID-19 pandemic for vaccinated and unvaccinated transplant recipients. These findings highlight the unique needs of transplant recipients and reveal opportunities to support this vulnerable patient population in efforts to protect their health as the COVID-19 pandemic evolves.

Patient and provider perspectives on the use of patient portals during pregnancy and the postpartum period

INTRODUCTION

Interest in the use of patient portals to support prenatal and postpartum care is growing. This study was conducted to understand patient and provider perspectives about the impact of portal use during pregnancy and the postpartum period.

METHODS

Interviews were conducted with 30 pregnant or postpartum patients and 15 obstetric care providers at an academic medical center that offers its patients access to an outpatient portal. Interview transcripts were analyzed deductively and inductively to categorize findings and identify emergent themes.

RESULTS

Patients and providers described how use of a patient portal during pregnancy and postpartum impacted communication (by supporting convenient communication and access to information), care processes (by aiding appointment attendance and helping with medication management), and care experience (by reducing anxiety and promoting patient involvement). Interviewees provided suggestions to improve patient portal use in obstetric care including using portals to increase access to educational materials and supportive resources, to collect patient-generated data, and to increase patient involvement in postpartum care.

DISCUSSION

Patient portals have particular value for patients' use during pregnancy and the postpartum period due to the frequency of healthcare visits and the heightened attention to one's health during this time. There are opportunities to tailor portal content and functions to patients' needs to improve communication, care processes, and care experiences for this patient population. Further improving the functionality of patient portals for patients' use during pregnancy and the postpartum period has the potential to positively impact patient experiences and health outcomes.

A Qualitative Examination of Interprofessional Teamwork for Infection Prevention: Development of a Model and Solutions

Health care-associated infections (HAIs), such as central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs), are associated with patient mortality and high costs to the health care system. These are largely preventable by practices such as prompt removal of central lines and Foley catheters. While seemingly straightforward, these practices require effective teamwork between physicians and nurses to be enacted successfully. Understanding the dynamics of interprofessional teamwork in the HAI prevention context requires further examination. We interviewed 420 participants (physicians, nursing, others) across 18 hospitals about interprofessional collaboration in this context. We propose an Input-Mediator-Output-Input (IMOI) model of interprofessional teamwork in the context of HAI prevention, suggesting that various organizational processes and structures facilitate specific teamwork attitudes, behaviors, and cognitions, which subsequently lead to HAI prevention outcomes including timeliness of line and Foley removal, ensuring sterile technique, and hand hygiene. We then propose strategies to improve interprofessional teamwork around HAI prevention.

Perspectives of Volunteer Firefighters during the COVID-19 Pandemic: Stumbling Blocks and Silver Linings

The COVID-19 pandemic has profoundly affected the lives of almost every individual in every nation, with numbers of infections continuing to grow. Across these nations, first responders are essential in their roles addressing emergencies, despite their risk of exposure to COVID-19 in the course of their work. We sought to understand the impacts of the COVID-19 pandemic on the lives of volunteer firefighters in the United States, an understudied group of these first responders. Interviews were conducted with volunteer firefighters between September and November 2021. Interviews were analyzed using deductive dominant thematic analysis. Thirty-three firefighters were interviewed who had an average of 22 years of service and a mean age of 52 years. Interviewees described pandemic-related challenges including the fear of COVID exposure and frustrations with work and personal relationships. They also identified unexpected work-related benefits including a deepened commitment to serve and improvements to training and safety. Further, some volunteers noted personal benefits such as developing stronger connections with others, having a new outlook on life, and observing goodwill. Our findings provide insight into the multifaceted and complex impact of the COVID-19 pandemic on volunteer firefighters.

The COVID-19 vaccine concerns scale: Development and validation of a new measure

Reasons for COVID-19 hesitancy are multi-faceted and tend to differ from those for general vaccine hesitancy. We developed the COVID-19 Vaccine Concerns Scale (CVCS), a self-report measure intended to better understand individuals’ concerns about COVID-19 vaccines. We validated the scale using data from a convenience sample of 2,281 emergency medical services providers, a group of professionals with high occupational COVID-19 risk. Measures included the CVCS items, an adapted Oxford COVID-19 vaccine hesitancy scale, a general vaccine hesitancy scale, demographics, and self-reported COVID-19 vaccination status. The CVCS had high internal consistency reliability (α = .89). A one-factor structure was determined by exploratory and confirmatory factor analyses (EFA and CFA), resulting in a seven-item scale. The model had good fit (X2[14] = 189.26, p < .001; CFI = .95, RMSEA = .11 [.09, .12], NNFI = .93, SRMR = .03). Moderate Pearson correlations with validated scales of general vaccine hesitancy (r = .71 , p < .001; n = 2144) and COVID-19 vaccine hesitancy (r = .82; p < .001; n = 2279) indicated construct validity. The CVCS predicted COVID-19 vaccination status (B =  −2.21, Exp(B) = .11 [95% CI = .09, .13], Nagelkerke R² = .55), indicating criterion-related validity. In sum, the 7-item CVCS is a reliable and valid self-report measure to examine fears and concerns about COVID-19 vaccines. The scale predicts COVID-19 vaccination status and can be used to inform efforts to reduce COVID-19 vaccine hesitancy.

Geographic Location Impacts Patient Portal Use via Desktop and Mobile Devices

Disparities in patient portal use are impacted by individuals' access to technology and the internet as well as their skills and health behaviors. An individual's geographic location may impact these factors as well as contribute to their decision to use a portal, their choice of device to access the portal, and their use of portal functions. This study evaluated patient portal use by geographic location according to three comparators: proximity to the medical center offering the portal, urban/rural classification, and degree of digital distress. Patients residing farther from the medical center, in rural areas, or in areas of higher digital distress were less likely to be active portal users. Patients in areas of higher digital distress were more likely to use the mobile portal application instead of the desktop portal website alone. Users of the mobile portal application used portal functions more frequently, and being a mobile user had a greater impact on the use of some portal functions by patients residing in areas of higher digital distress. Mobile patient portal applications have the potential to increase portal use, but work is needed to ensure equitable internet access, to promote mobile patient portal applications, and to cultivate individuals' skills to use portals.

Perspectives of hospital leaders and staff on patient education for the prevention of healthcare-associated infections

OBJECTIVE

Device-related healthcare-associated infections (HAIs), such as catheter-associated urinary tract infections (CAUTIs) and central-line-associated bloodstream infections (CLABSIs), are largely preventable. However, there is little evidence of standardized approaches to educate patients about how they can help prevent these infections. We examined the perspectives of hospital leaders and staff about patient education for CAUTI and CLABSI prevention to understand the challenges to patient education and the opportunities for improvement.

METHODS

In total, 471 interviews were conducted with key informants across 18 hospitals. Interviews were analyzed deductively and inductively to identify themes around the topic of patient education for infection prevention.

RESULTS

Participants identified patient education topics specific to CAUTI and CLABSI prevention, including the risks of indwelling urinary catheters and central lines, the necessity of hand hygiene, the importance of maintenance care, and the support to speak up. Challenges, such as lack of standardized education, and opportunities, such as involvement of patient and family advisory groups, were also identified regarding patient education for CAUTI and CLABSI prevention.

CONCLUSIONS

Hospital leaders and staff identified patient education topics, and ways to deliver this information, that were important in the prevention of CAUTIs and CLABSIs. By identifying both challenges and opportunities related to patient education, our results provide guidance on how patient education for infection prevention can be further improved. Future work should evaluate the implementation of standardized approaches to patient education to better understand the potential impact of these strategies on the reduction of HAIs.

Effect of In-Person vs Video Training and Access to All Functions vs a Limited Subset of Functions on Portal Use Among Inpatients: A Randomized Clinical Trial

Importance

Inpatient portals provide patients with clinical data and information about their care and have the potential to influence patient engagement and experience. Although significant resources have been devoted to implementing these portals, evaluation of their effects has been limited.

Objective

To assess the effects of patient training and portal functionality on use of an inpatient portal and on patient satisfaction and involvement with care.

Design, Setting, and Participants

This randomized clinical trial was conducted from December 15, 2016, to August 31, 2019, at 6 noncancer hospitals that were part of a single health care system. Patients who were at least 18 years of age, identified English as their preferred language, were not involuntarily confined or detained, and agreed to be provided a tablet to access the inpatient portal during their stay were eligible for participation. Data were analyzed from May 1, 2019, to March 15, 2021.

Interventions

A 2 × 2 factorial intervention design was used to compare 2 levels of a training intervention (touch intervention, consisting of in-person training vs built-in video tutorial) and 2 levels of portal function availability (tech intervention) within an inpatient portal (all functions operational vs a limited subset of functions).

Main Outcomes and Measures

The primary outcomes were inpatient portal use, measured by frequency and comprehensiveness of use, and patients' satisfaction and involvement with their care.

Results

Of 2892 participants, 1641 were women (56.7%) with a median age of 47.0 (95% CI, 46.0-48.0) years. Most patients were White (2221 [76.8%]). The median Charlson Comorbidity Index was 1 (95% CI, 1-1) and the median length of stay was 6 (95% CI, 6-7) days. Notably, the in-person training intervention was found to significantly increase inpatient portal use (incidence rate ratio, 1.34 [95% CI, 1.25-1.44]) compared with the video tutorial. Patients who received in-person training had significantly higher odds of being comprehensive portal users than those who received the video tutorial (odds ratio, 20.75 [95% CI, 16.49-26.10]). Among patients who received the full-tech intervention, those who also received the in-person intervention used the portal more frequently (incidence rate ratio, 1.36 [95% CI, 1.25-1.48]) and more comprehensively (odds ratio, 22.52; [95% CI, 17.13-29.62]) than those who received the video tutorial. Patients who received in-person training had higher odds (OR, 2.01 [95% CI, 1.16-3.50]) of reporting being satisfied in the 6-month postdischarge survey. Similarly, patients who received the full-tech intervention had higher odds (OR, 2.06 [95%CI, 1.42-2.99]) of reporting being satisfied in the 6-month postdischarge survey.

Conclusions and Relevance

Providing in-person training or robust portal functionality increased inpatient engagement with the portal during the hospital stay. The effects of the training intervention suggest that providing personalized training to support use of this health information technology can be a powerful approach to increase patient engagement via portals.

Trial Registration

ClinicalTrials.gov Identifier: NCT02943109.

Concerns and frustrations about the public reporting of device-related healthcare-associated infections: Perspectives of hospital leaders and staff

BACKGROUND

Public reporting of healthcare-associated infections (HAIs) aims to incentivize improvement in infection prevention. The motivation and mechanisms of public reporting have raised concerns about the reliability of this data, but little is known about the specific concerns of hospital leaders and staff. This study sought to better understand perspectives of individuals in these roles regarding the identification and public reporting of HAIs.

METHODS

We conducted interviews with 471 participants including hospitals leaders (e.g., administrative and clinical leaders) and hospital staff (e.g., physicians and nurses) between 2017 and 2019 across 18 U.S. hospitals. A semi-structured interview guide was used to explore perspectives about the use of HAI data within the context of management strategies used to support infection prevention.

RESULTS

Interviewees described concerns about public reporting of HAI data, including a lack of trust in the data and inadvertent consequences of its public reporting, as well as specific frustrations related to the identification and accountability for publicly-reported HAIs.

CONCLUSION

Concerns and frustrations related to public reporting of HAI data highlight the need for improved guidelines, transparency, and incentives. Efforts to build trust in publicly-reported HAI data can help ensure this information is used effectively to improve infection prevention practices.

Identifying management practices for promoting infection prevention: Perspectives on strategic communication

BACKGROUND

Engaging leaders to share information about infections and infection prevention across their organizations is known to be important in initiatives designed to reduce healthcare-associated infections (HAIs). Yet the topics and communication strategies used by leaders that focus on HAI prevention are not well understood. This study aimed to identify and describe practices around information sharing used to support HAI prevention.

METHODS

We visited 18 U.S. hospitals between 2017 and 2019 and interviewed 188 administrative and clinical leaders to ask about management practices they used to facilitate HAI prevention. Interview transcripts were analyzed to characterize practices involving strategic communications.

RESULTS

Sharing information to support infection prevention involved strategic communications around two main topics: (1) facilitators of success and best practices, and (2) barriers to success and lessons learned. In addition, the practice of storytelling reportedly allowed leaders to highlight impact and elicit emotion, provide education, and acknowledge success in infection prevention by providing examples of real events.

CONCLUSIONS

Our findings provide insight about how strategic communication of information around HAIs and HAI prevention can be used to support improvement. Organizations and leaders should consider the different opportunities to incorporate the practice of strategic communication, including using storytelling, to advance their infection prevention efforts.

Examining the Relationship between Health Literacy, Health Numeracy, and Patient Portal Use

OBJECTIVES

The objective of this study is to investigate the relationships between health literacy and numeracy (HLN) and patient portal use, measured in inpatient and outpatient settings.

METHODS

Using data collected as part of a pragmatic randomized controlled trial conducted across the inpatient population of a U.S.-based academic medical center, the present study evaluated the relationships between patients' perceptions of health literacy and their skills, interpreting medical information with metrics of engagement with patient portals.

RESULTS

Self-reported levels of HLN for patients in the study sample (n = 654) were not significantly associated with inpatient portal use as measured by frequency of use or the number of different inpatient portal functions used. Use of the outpatient version of the portal over the course of 6 months following hospital discharge was also not associated with HLN. A subsequent assessment of patients after 6 months of portal use postdischarge (response rate 40%) did not reveal any differences with respect to portal use and health numeracy; however, a significant increase in self-reported levels of health literacy was found at this point.

CONCLUSION

While previous studies have suggested that low HLN might represent a barrier to inpatient portal adoption and might limit engagement with outpatient portals, we did not find these associations to hold. Our findings, however, suggest that the inpatient setting may be effective in facilitating technology acceptance. Specifically, the introduction of an inpatient portal made available on hospital-provided tablets may have practical implications and contribute to increased adoption of patient-facing health information technology tools.

An Opportunity to Understand Concerns about COVID-19 Vaccination: Perspectives from EMS Professionals

Some healthcare professionals, including emergency medical service (EMS) professionals, remain hesitant about receiving COVID-19 vaccines. This study sought to understand EMS professionals’ perspectives regarding COVID-19 vaccination. Using open-ended comments from a national survey deployed electronically to over 19,000 EMS professionals in April of 2021, we examined perspectives about acceptance of and hesitancy toward COVID-19 vaccines. Survey comments revealed differences in perspectives between vaccinated and unvaccinated EMS professionals regarding their personal role in improving public health through COVID-19 vaccination as well as vaccine benefits and the protection conferred by vaccination. Unvaccinated individuals also expressed concerns over the research and development of the COVID-19 vaccines that led to their decision not to get vaccinated. Individuals who were vaccinated suggested ways to increase uptake of the vaccine including having healthcare professionals serve as leaders for vaccination and educating individuals about COVID-19 vaccination through credible resources. Vaccine hesitancy remains a challenge to achieving herd immunity to COVID-19 through vaccination, even among healthcare professionals. Understanding the perspectives of those who have chosen not to be vaccinated can help direct strategies to reduce confusion and concerns. The perspectives of vaccinated individuals may also be valuable in identifying opportunities to promote vaccination in the professional setting.

Closing the Gap on COVID-19 Vaccinations in First Responders and Beyond: Increasing Trust

Although COVID-19 vaccines are widely available in the U.S. and much of the world, many have chosen to forgo this vaccination. Emergency medical services (EMS) professionals, despite their role on the frontlines and interactions with COVID-positive patients, are not immune to vaccine hesitancy. Via a survey conducted in April 2021, we investigated the extent to which first responders in the U.S. trusted various information sources to provide reliable information about COVID-19 vaccines. Those vaccinated generally trusted healthcare providers as a source of information, but unvaccinated first responders had fairly low trust in this information source-a group to which they, themselves, belong. Additionally, regardless of vaccination status, trust in all levels of government, employers, and their community as sources of information was low. Free-response explanations provided some context to these findings, such as preference for other COVID-19 management options, including drugs proven ineffective. A trusted source of COVID-19 vaccination information is not readily apparent. Individuals expressed a strong desire for the autonomy to make vaccination decisions for themselves, as opposed to mandates. Potential reasons for low trust, possible solutions to address them, generalizability to the broader public, and implications of low trust in official institutions are discussed.

Relationships between patient portal activation and patient satisfaction scores among CG-CAHPS and HCAHPS respondents

OBJECTIVES

Patient portals are health information technology tools that offer patients access to their personal health information and a means to communicate with health care providers, but little is known about their impact on patient satisfaction. Identifying factors that increase patient satisfaction may improve patient care and can protect health care providers from financial penalties. Our study sought to investigate how patient portals are associated with patient satisfaction in both inpatient and outpatient settings.

STUDY DESIGN

Retrospective, pooled cross-sectional study.

METHODS

Data from the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) and Hospital CAHPS (HCAHPS) patient satisfaction surveys were linked to inpatient and outpatient portal account status at a large academic medical center. Using fractional logistic regression, we investigated the relationship between patient satisfaction survey scores and patient portal activation.

RESULTS

Patients with an activated outpatient portal account reported higher patient satisfaction across a subset of the CG-CAHPS dimensions, and patients with an activated inpatient portal account reported higher patient satisfaction across a subset of the HCAHPS dimensions, compared with patients without the respective portal accounts.

CONCLUSIONS

Our study suggests the potential for patient portals to enhance patient satisfaction, especially in areas such as care coordination and care transitions. In both inpatient and outpatient settings, portal use may improve the patient-centeredness of care. Our findings indicate important considerations for both health care organizations and their patients to promote patient portal use as a means of improving patient satisfaction, especially in the context of potential impacts on reimbursement and reputation.

Examining Patients' Capacity to Use Patient Portals: Insights for Telehealth

BACKGROUND

The increase in telehealth in response to the coronavirus disease 2019 pandemic highlights the need to understand patients' capacity to utilize this care modality. Patient portals are a tool whose use requires similar resources and skills as those required for telehealth. Patients' capacity to use patient portals may therefore provide insight regarding patients' readiness and capacity to use telehealth.

OBJECTIVE

The aim of this study was to examine factors related to patients' capacity to use a patient portal and test the impact of these factors on patients' portal use.

RESEARCH DESIGN AND SUBJECTS

Using data from a large-scale pragmatic randomized controlled trial of patient portal use, 1081 hospitalized patients responded to survey items that were then mapped onto the 4 dimensions of the Engagement Capacity Framework: self-efficacy, resources, willingness, and capabilities.

MEASURES

The outcome variable was frequency of outpatient portal use. We evaluated associations between Engagement Capacity Framework dimensions and patient portal use, using regression analyses.

RESULTS

Patients with fewer resources, fewer capabilities, lower willingness, and lower overall capacity to use patient portals used the portal less; in contrast, those with lower perceived self-efficacy used the portal more.

CONCLUSIONS

Our findings highlight differences in patients' capacity to use patient portals, which provide an initial understanding of factors that may influence the use of telehealth and offer important guidance in efforts to support patients' telehealth use. Offering patients training tailored to the use of telehealth tools may be particularly beneficial.

COVID-19 Vaccinations in EMS Professionals: Prevalence and Predictors

Background:

Immunizations for emergency medical services (EMS) professionals during pandemics are an important tool to increase the safety of the workforce as well as their patients. The purpose of this study was to better understand EMS professionals’ decisions to receive or decline a COVID-19 vaccine.

Methods:

We conducted a cross-sectional analysis of nationally certified EMS professionals (18–85 years) in April 2021. Participants received an electronic survey asking whether they received a vaccine, why or why not, and their associated beliefs using three validated scales: perceived risk of COVID-19, medical mistrust, and confidence in the COVID-19 vaccine. Data were merged with National Registry dataset demographics. Analyses included descriptive analysis and multivariable logistic regression (OR, 95% CI). Multivariate imputation by chained equations was used for missingness.

Results:

A total of 2,584 respondents satisfied inclusion criteria (response rate = 14%). Overall, 70% of EMS professionals were vaccinated. Common reasons for vaccination among vaccinated respondents were to protect oneself (76%) and others (73%). Common reasons for non-vaccination among non-vaccinated respondents included concerns about vaccine safety (53%) and beliefs that vaccination was not necessary (39%). Most who had not received the vaccine did not plan to get it in the future (84%). Hesitation was most frequently related to wanting to see how the vaccine was working for others (55%). Odds of COVID-19 vaccination were associated with demographics including age (referent <28 years; 39–50 years: 1.56, 1.17–2.08; >51 years: 2.22, 1.64–3.01), male sex (1.26, 1.01–1.58), residing in an urban/suburban area (referent rural; 1.36, 1.08–1.70), advanced education (referent GED/high school and below; bachelor’s and above: 1.72, 1.19–2.47), and working at a hospital (referent fire-based agency; 1.53, 1.04–2.24). Additionally, vaccination odds were significantly higher with greater perceived risk of COVID-19 (2.05, 1.68–2.50), and higher vaccine confidence (2.84, 2.40–3.36). Odds of vaccination were significantly lower with higher medical mistrust (0.54, 0.46–0.63).

Conclusion:

Despite vaccine availability, not all EMS professionals had been vaccinated. The decision to receive a COVID-19 vaccine was associated with demographics, beliefs regarding COVID-19 and the vaccine, and medical mistrust. Efforts to increase COVID-19 vaccination rates should emphasize the safety and efficacy of vaccines.

Management practices for leaders to promote infection prevention: Lessons from a qualitative study

BACKGROUND

Prevention of healthcare-associated infections (HAIs) is critical to reduce preventable deaths and healthcare costs. Variable success with HAI prevention efforts has suggested that management practices are critical to support clinical infection prevention practices. This study examined hospital leaders' management practices around the prevention of catheter-associated urinary tract infections (CAUTIs) and central line-associated bloodstream infections (CLABSIs) to identify actions that leaders can take to promote HAI prevention efforts.

METHODS

We conducted interviews with 420 key informants, including managers and frontline staff, in 18 hospitals across the United States. Interviewees were asked about management practices supporting HAI prevention. We analyzed interview transcripts using rigorous qualitative methods to understand how management practices were operationalized in infection prevention efforts.

RESULTS

Across hospitals and interviewees, three management practices were characterized as important facilitators of HAI prevention: (1) engagement of executive leadership; (2) information sharing; and (3) manager coaching. We found that visible executive leadership, efficient communication, and frequent opportunities to provide and promote learning from feedback were perceived to promote and sustain HAI prevention efforts.

CONCLUSIONS

Our findings provide insight into management practices for leaders that support successful HAI prevention. In practice, these tactics may need to be adjusted to accommodate the current restrictions caused by the COVID-19 pandemic, in order to maintain HAI prevention efforts as a priority.

Differential Effects of Outpatient Portal User Status on Inpatient Portal Use: Observational Study

Background

The decision to use patient portals can be influenced by multiple factors, including individuals’ perceptions of the tool, which are based on both their personal skills and experiences. Prior experience with one type of portal may make individuals more comfortable with using newer portal technologies. Experienced outpatient portal users in particular may have confidence in their ability to use inpatient portals that have similar functionality. In practice, the use of both outpatient and inpatient portal technologies can provide patients with continuity of access to their health information across care settings, but the influence of one type of portal use on the use of other portals has not been studied.

Objective

This study aims to understand how patients’ use of an inpatient portal is influenced by outpatient portal use.

Methods

This study included patients from an academic medical center who were provided access to an inpatient portal during their hospital stays between 2016 and 2018 (N=1571). We analyzed inpatient portal log files to investigate how inpatient portal use varied by using 3 categories of outpatient portal users: prior users, new users, and nonusers.

Results

Compared with prior users (695/1571, 44.24%) of an outpatient portal, new users (214/1571, 13.62%) had higher use of a select set of inpatient portal functions (messaging function: incidence rate ratio [IRR] 1.33, 95% CI 1.06-1.67; function that provides access to the outpatient portal through the inpatient portal: IRR 1.34, 95% CI 1.13-1.58). Nonusers (662/1571, 42.14%), compared with prior users, had lower overall inpatient portal use (all active functions: IRR 0.68, 95% CI 0.60-0.78) and lower use of specific functions, which included the function to review vitals and laboratory results (IRR 0.51, 95% CI 0.36-0.73) and the function to access the outpatient portal (IRR 0.53, 95% CI 0.45-0.62). In comparison with prior users, nonusers also had lower odds of being comprehensive users (defined as using 8 or more unique portal functions; odds ratio [OR] 0.57, 95% CI 0.45-0.73) or composite users (defined as comprehensive users who initiated a 75th or greater percentile of portal sessions) of the inpatient portal (OR 0.42, 95% CI 0.29-0.60).

Conclusions

Patients’ use of an inpatient portal during their hospital stay appeared to be influenced by a combination of factors, including prior outpatient portal use. For new users, hospitalization itself, a major event that can motivate behavioral changes, may have influenced portal use. In contrast, nonusers might have lower self-efficacy in their ability to use technology to manage their health, contributing to their lower portal use. Understanding the relationship between the use of outpatient and inpatient portals can help direct targeted implementation strategies that encourage individuals to use these tools to better manage their health across care settings.

Identifying the role of inpatient portals to support health literacy: Perspectives from patients and care team members

OBJECTIVE

Health literacy is a fundamental contributor to an individual's ability to self-manage their health and appropriately use health care services. Tools that positively impact health literacy therefore have potential to improve health outcomes. Inpatient portals are a tool that provides patients an opportunity to cultivate health literacy skills during hospitalization. Our study investigated how inpatient portal use could impact attributes of health literacy.

METHODS

We conducted semi-structured interviews with 132 patients and 440 care team members to learn about patients' inpatient portal use. Interview transcripts were analyzed deductively and inductively to categorize data and understand emergent themes around health literacy.

RESULTS

Patients and care team members identified inpatient portal functions that they perceived to positively impact health literacy. These functions included providing patients access to health information, care plans, and educational materials, as well as enabling patient communication with their care team.

CONCLUSION

Recognizing the potential of inpatient portals to improve health literacy is critical to ensure they are implemented in ways that leverage this benefit for patients.

PRACTICE IMPLICATIONS

Health care organizations should implement inpatient portals that include features that support health literacy and encourage patients to use these portals in ways that improve their health literacy skills.

Rewarding and recognizing frontline staff for success in infection prevention

Management practices help support efforts to prevent healthcare-associated infections (HAIs). Providing rewards and recognition to frontline staff is one management practice found to be in use by hospitals that are higher-performers in HAI prevention. Using data from interviews with hospital managers and frontline staff at 18 US hospitals, our study identifies how managers can use reward and recognition programs as motivational tools to sustain frontline HAI prevention efforts.

Care Team Perspectives About an Inpatient Portal: Benefits and Challenges of Patients' Portal Use During Hospitalization

While current research about inpatient portals has focused largely on the patient perspective, it is also critical to consider the care team point of view, as support from these individuals is essential to successful portal implementation and use. We held brief in-person interviews with 433 care team members across a six-hospital health system to explore opinions about patients' use of an inpatient portal as perceived by care team members. Using the Inpatient Portal Evaluation Framework, we characterized benefits and challenges of portal use that care team members reported affected patients, themselves, and the collaborative work of these care teams with their patients. Interviewees noted inpatient portals can improve patient care and experience and also indicated room for improvement in portal use for hospitalized patients. Further understanding of the care team perspective is critical to inform approaches to inpatient portal implementation that best benefit both patients and providers.

An Exploration of the Association between Inpatient Access to Tablets and Patient Satisfaction with Hospital Care

Patient-centered care seeks to improve healthcare quality by engaging patients in their health management. Hospitals are employing strategies to enhance patient engagement to improve care quality, as measured by patient satisfaction through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Tablets are one tool hospitals use to increase patient engagement during hospitalization, as tablets can provide patients with access to both entertainment options and personal health information through patient portals. To explore the association between tablet access and patient satisfaction, data on tablet provisioning were linked to patient HCAHPS scores. Patients who were provided a tablet had higher HCAHPS scores in a subset of satisfaction measures, as compared with patients who were not provided a tablet, suggesting that tablets could positively influence patients' satisfaction with their hospital stay. Future studies are warranted to understand the specific ways in which tablet use improves the patient experience during hospitalization.

Improving Acceptance of Inpatient Portals: Patients' and Care Team Members' Perspectives

Background: Inpatient portals are gaining interest as a means to increase patient-centered care during hospitalization. However, acceptance of a new technology such as the inpatient portal relies on perceptions of both its usefulness and ease of use. These factors have not been studied in the context of inpatient portal implementation. Methods: We interviewed patients (n = 123) and care team members (n = 447) about their experiences using an inpatient portal that had been implemented across a large, academic medical center. Interviews lasted 5-15 min, were audio-recorded, transcribed verbatim, and then analyzed using a combination of deductive and inductive methods. Results: Collectively, interviewees reported that the inpatient portal was a useful tool as it improved patients' access to information, enhanced communication, facilitated education, and appeared to promote patients' sense of control while in the hospital. Most interviewees also found the technology easy to use. However, there were concerns that the portal was not easy to use for those less experienced with technology. Interviewees identified the need to emphasize the value of the technology to both patients and care team members and the need to provide additional training to support portal use, as ways to promote acceptance of the tool. Discussion and Conclusions: Inpatient portals can improve patient-centered care, but such improvements require acceptance of the tool by both patients and care team members. Our findings about the usefulness and ease of use of an inpatient portal can inform future efforts to improve the implementation and acceptance of this new technology.

Patient portal messaging for care coordination: a qualitative study of perspectives of experienced users with chronic conditions

BACKGROUND

Patient portal secure messaging (asynchronous electronic communication between physicians and their established patients) allows patients to manage their care through asynchronous, direct communication with their providers. This type of engagement with health information technology could have important benefits for patients with chronic conditions, and a more thorough understanding of the use and barriers of secure messaging among this population is needed. The objective of this study was to explore how experienced portal users engage with secure messaging to manage their chronic conditions.

METHODS

Three focus groups were conducted with 17 total patients who self-reported a cardiopulmonary condition. Participants were asked questions about their experience with patient portal secure messaging. Focus group transcripts were coded through inductive and deductive methods to reveal common themes.

RESULTS

Patients' motivation for using messaging included the speed and ease of such communication and direct access to a physician. Messaging was used by patients as an extension of the office visit and supported coordination of care among providers as well as patient collaboration with family members or caretakers. Patients identified challenges to using messaging, including technological barriers, worry about uncompensated physician time spent responding to messages, and confusion about what constitutes an appropriate 'non-urgent' message.

CONCLUSIONS

This study highlights the potential of patient portal messaging as a tool for care coordination to enhance chronic disease self-management. However, uncertainty about the appropriate use of portal messaging persists even among experienced users. Additional patient training in the proper use of secure messaging and its benefits for disease self-management may help to resolve these concerns.

Empowering Patients during Hospitalization: Perspectives on Inpatient Portal Use

BACKGROUND

Patients have demonstrated an eagerness to use portals to access their health information and connect with care providers. While outpatient portals have been extensively studied, there is a recognized need for research that examines inpatient portals.

OBJECTIVE

We conducted this study to improve our understanding about the role of a portal in the context of inpatient care. Our study focused on a large sample of the general adult inpatient population and obtained perspectives from both patients and care team members about inpatient portal use.

METHODS

We interviewed patients (n = 120) who used an inpatient portal during their hospitalization at 15 days or 6 months after discharge to learn about their portal use. We also interviewed care team members (n = 331) 4 weeks, 6 months, and 12 months after inpatient portal implementation to collect information about their ongoing perspectives about patients' use of the portal.

RESULTS

The perspectives of patients and care team members generally converged on their views of the inpatient portal. Three features-(1) ordering meals, (2) looking up health information, and (3) viewing the care team-were most commonly used; the secure messaging feature was less commonly used and of some concern to care team members. The inpatient portal benefited patients in four main ways: (1) promoted independence, (2) reduced anxiety, (3) informed families, and (4) increased empowerment.

CONCLUSION

Inpatient portals are recognized as a tool that can enhance the delivery of patient-centered care. In addition to empowering patients by increasing their sense of control, inpatient portals can support family members and caregivers throughout the hospital stay. Given the consistency of perspectives about portal use across patients and care team members, our findings suggest that inpatient portals may facilitate shifts in organizational culture that increase the patient centeredness of care and improve patient experience in the hospital context.

From Composition to Cure: A Systems Engineering Approach to Anticancer Drug Carriers

The molecular complexity and heterogeneity of cancer has led to a persistent, and as yet unsolved, challenge to develop cures for this disease. The pharmaceutical industry focuses the bulk of its efforts on the development of new drugs, but an alternative approach is to improve the delivery of existing drugs with drug carriers that can manipulate when, where, and how a drug exerts its therapeutic effect. For the treatment of solid tumors, systemically delivered drug carriers face significant challenges that are imposed by the pathophysiological barriers that lie between their site of administration and their site of therapeutic action in the tumor. Furthermore, drug carriers face additional challenges in their translation from preclinical validation to clinical approval and adoption. Addressing this diverse network of challenges requires a systems engineering approach for the rational design of optimized carriers that have a realistic prospect for translation from the laboratory to the patient.

Characterisation of hydration and nanophase separation during the temperature response in hydrophobic/hydrophilic elastin-like polypeptide (ELP) diblock copolymers

To understand the complex nanoscale dehydration process during the lower critical solution temperature (LCST) based inverse phase transition of a class of thermoresponsive biopolymers, diblock elastin-like polypeptides (ELPs) were investigated by spin probing continuous wave electron paramagnetic resonance (CW EPR) spectroscopy. The diblock copolymers composed of a hydrophobic block and a hydrophilic block showed different mechanisms of a temperature-driven phase transition. While the phase transition temperature is a function of the hydrophobic mass fraction of the diblock ELPs, the hydrophilic block length determines the molecular structure of the polymer aggregates formed above the transition temperature. When the weight ratio of hydrophilic block length to hydrophobic block length is greater than or equal to 0.3, the polymer aggregates consist of a hydrophobic core and a hydrophilic corona. The interface of these two regions become permeable at temperatures above the transition temperature. In case of smaller ratios, the aggregating hydrophobic parts of the polymer enclose the hydrated hydrophilic blocks, that are too small to form a hydrophilic corona, leading to bigger and less dense aggregates of higher polarity.

Phase Behavior and Self-Assembly of Perfectly Sequence-Defined and Monodisperse Multiblock Copolypeptides

This paper investigates how the properties of multiblock copolypeptides can be tuned by their block architecture, defined by the size and distribution of blocks along the polymer chain. These parameters were explored by the precise, genetically encoded synthesis of recombinant elastin-like polypeptides (ELPs). A family of ELPs was synthesized in which the composition and length were conserved while the block length and distribution were varied, thus creating 11 ELPs with unique block architectures. To our knowledge, these polymers are unprecedented in their intricately and precisely varied architectures. ELPs exhibit lower critical solution temperature (LCST) behavior and micellar self-assembly, both of which impart easily measured physicochemical properties to the copolymers, providing insight into polymer hydrophobicity and self-assembly into higher order structures, as a function of solution temperature. Even subtle variation in block architecture changed the LCST phase behavior and morphology of these ELPs, measured by their temperature-triggered phase transition and nanoscale self-assembly. Size and morphology of polypeptide micelles could be tuned solely by controlling the block architecture, thus demonstrating that when sequence can be precisely controlled, nanoscale self-assembly of polypeptides can be modulated by block architecture.

Quantitative Mapping of the Spatial Distribution of Nanoparticles in Endo-Lysosomes by Local pH

Understanding the intracellular distribution and trafficking of nanoparticle drug carriers is necessary to elucidate their mechanisms of drug delivery and is helpful in the rational design of novel nanoparticle drug delivery systems. The traditional immunofluorescence method to study intracellular distribution of nanoparticles using organelle-specific antibodies is laborious and subject to artifacts. As an alternative, we developed a new method that exploits ratiometric fluorescence imaging of a pH-sensitive Lysosensor dye to visualize and quantify the spatial distribution of nanoparticles in the endosomes and lysosomes of live cells. Using this method, we compared the endolysosomal distribution of cell-penetrating peptide (CPP)-functionalized micelles to unfunctionalized micelles and found that CPP-functionalized micelles exhibited faster endosome-to-lysosome trafficking than unfunctionalized micelles. Ratiometric fluorescence imaging of pH-sensitive Lysosensor dye allows rapid quantitative mapping of nanoparticle distribution in endolysosomes in live cells while minimizing artifacts caused by extensive sample manipulation typical of alternative approaches. This new method can thus serve as an alternative to traditional immunofluorescence approaches to study the intracellular distribution and trafficking of nanoparticles within endosomes and lysosomes.

Bio-inspired synthesis of hybrid silica nanoparticles templated from elastin-like polypeptide micelles

The programmed self-assembly of block copolymers into higher order nanoscale structures offers many attractive attributes for the development of new nanomaterials for numerous applications including drug delivery and biosensing. The incorporation of biomimetic silaffin peptides in these block copolymers enables the formation of hybrid organic-inorganic materials, which can potentially enhance the utility and stability of self-assembled nanostructures. We demonstrate the design, synthesis and characterization of amphiphilic elastin-like polypeptide (ELP) diblock copolymers that undergo temperature-triggered self-assembly into well-defined spherical micelles. Genetically encoded incorporation of the silaffin R5 peptide at the hydrophilic terminus of the diblock ELP leads to presentation of the silaffin R5 peptide on the coronae of the micelles, which results in localized condensation of silica and the formation of near-monodisperse, discrete, sub-100 nm diameter hybrid ELP-silica particles. This synthesis method, can be carried out under mild reaction conditions suitable for bioactive materials, and will serve as the basis for the development and application of functional nanomaterials. Beyond silicification, the general strategies described herein may also be adapted for the synthesis of other biohybrid nanomaterials as well.

Applications of elastin-like polypeptides in drug delivery

Elastin-like polypeptides (ELPs) are biopolymers inspired by human elastin. Their lower critical solution temperature phase transition behavior and biocompatibility make them useful materials for stimulus-responsive applications in biological environments. Due to their genetically encoded design and recombinant synthesis, the sequence and size of ELPs can be exactly defined. These design parameters control the structure and function of the ELP with a precision that is unmatched by synthetic polymers. Due to these attributes, ELPs have been used extensively for drug delivery in a variety of different embodiments-as soluble macromolecular carriers, self-assembled nanoparticles, cross-linked microparticles, or thermally coacervated depots. These ELP systems have been used to deliver biologic therapeutics, radionuclides, and small molecule drugs to a variety of anatomical sites for the treatment of diseases including cancer, type 2 diabetes, osteoarthritis, and neuroinflammation.

Non-chromatographic purification of recombinant elastin-like polypeptides and their fusions with peptides and proteins from Escherichia coli

Elastin-like polypeptides are repetitive biopolymers that exhibit a lower critical solution temperature phase transition behavior, existing as soluble unimers below a characteristic transition temperature and aggregating into micron-scale coacervates above their transition temperature. The design of elastin-like polypeptides at the genetic level permits precise control of their sequence and length, which dictates their thermal properties. Elastin-like polypeptides are used in a variety of applications including biosensing, tissue engineering, and drug delivery, where the transition temperature and biopolymer architecture of the ELP can be tuned for the specific application of interest. Furthermore, the lower critical solution temperature phase transition behavior of elastin-like polypeptides allows their purification by their thermal response, such that their selective coacervation and resolubilization allows the removal of both soluble and insoluble contaminants following expression in Escherichia coli. This approach can be used for the purification of elastin-like polypeptides alone or as a purification tool for peptide or protein fusions where recombinant peptides or proteins genetically appended to elastin-like polypeptide tags can be purified without chromatography. This protocol describes the purification of elastin-like polypeptides and their peptide or protein fusions and discusses basic characterization techniques to assess the thermal behavior of pure elastin-like polypeptide products.

Rational design of "heat seeking" drug loaded polypeptide nanoparticles that thermally target solid tumors

This paper demonstrates the first example of targeting a solid tumor that is externally heated to 42 °C by "heat seeking" drug-loaded polypeptide nanoparticles. These nanoparticles consist of a thermally responsive elastin-like polypeptide (ELP) conjugated to multiple copies of a hydrophobic cancer drug. To rationally design drug-loaded nanoparticles that exhibit thermal responsiveness in the narrow temperature range between 37 and 42 °C, an analytical model was developed that relates ELP composition and chain length to the nanoparticle phase transition temperature. Suitable candidates were designed based on the predictions of the model and tested in vivo by intravital confocal fluorescence microscopy of solid tumors, which revealed that the nanoparticles aggregate in the vasculature of tumors heated to 42 °C and that the aggregation is reversible as the temperature reverts to 37 °C. Biodistribution studies showed that the most effective strategy to target the nanoparticles to tumors is to thermally cycle the tumors between 37 and 42 °C. These nanoparticles set the stage for the targeted delivery of a range of cancer chemotherapeutics by externally applied mild hyperthermia of solid tumors.

Harnessing the power of cell-penetrating peptides: activatable carriers for targeting systemic delivery of cancer therapeutics and imaging agents

Targeted delivery of cancer therapeutics and imaging agents aims to enhance the accumulation of these molecules in a solid tumor while avoiding uptake in healthy tissues. Tumor-specific accumulation has been pursued with passive targeting by the enhanced permeability and retention effect, as well as with active targeting strategies. Active targeting is achieved by functionalization of carriers to allow specific interactions between the carrier and the tumor environment. Functionalization of carriers with ligands that specifically interact with overexpressed receptors on cancer cells represents a classic approach to active tumor targeting. Cell-penetrating peptides (CPPs) provide a non-specific and receptor-independent mechanism to enhance cellular uptake that offers an exciting alternative to traditional active targeting approaches. While the non-specificity of CPP-mediated internalization has the intriguing potential to make this approach applicable to a wide range of tumor types, their promiscuity is, however, a significant barrier to their clinical utility for systemically administered applications. Many approaches have been investigated to selectively turn on the function of systemically delivered CPP-functionalized carriers specifically in tumors to achieve targeted delivery of cancer therapeutics and imaging agents.

Digital switching of local arginine density in a genetically encoded self-assembled polypeptide nanoparticle controls cellular uptake

Cell-penetrating peptides (CPPs) are a class of molecules that enable efficient internalization of a wide variety of cargo in diverse cell types, making them desirable for delivery of anticancer drugs to solid tumors. For CPPs to be useful, it is important to be able to turn their function on in response to an external trigger that can be spatially localized in vivo. Here we describe an approach to turning on CPP function by modulation of the local density of arginine (Arg) residues by temperature-triggered micelle assembly of diblock copolymer elastin-like polypeptides (ELP(BC)s). A greater than 8-fold increase in cellular uptake occurs when Arg residues are presented on the corona of ELP(BC) micelles, as compared to the same ELP(BC) at a temperature in which it is a soluble unimer. This approach is the first to demonstrate digital 'off-on' control of CPP activity by an extrinsic thermal trigger in a clinically relevant temperature range by modulation of the interfacial density of Arg residues on the exterior of a nanoparticle.