Reducing Firearm Access for Suicide Prevention: Implementation Evaluation of the Web-Based "Lock to Live" Decision Aid in Routine Health Care Encounters

Background

"Lock to Live" (L2L) is a novel web-based decision aid for helping people at risk of suicide reduce access to firearms. Researchers have demonstrated that L2L is feasible to use and acceptable to patients, but little is known about how to implement L2L during web-based mental health care and in-person contact with clinicians.

Objective

The goal of this project was to support the implementation and evaluation of L2L during routine primary care and mental health specialty web-based and in-person encounters.

Methods

The L2L implementation and evaluation took place at Kaiser Permanente Washington (KPWA)-a large, regional, nonprofit health care system. Three dimensions from the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) model-Reach, Adoption, and Implementation-were selected to inform and evaluate the implementation of L2L at KPWA (January 1, 2020, to December 31, 2021). Electronic health record (EHR) data were used to purposefully recruit adult patients, including firearm owners and patients reporting suicidality, to participate in semistructured interviews. Interview themes were used to facilitate L2L implementation and inform subsequent semistructured interviews with clinicians responsible for suicide risk mitigation. Audio-recorded interviews were conducted via the web, transcribed, and coded, using a rapid qualitative inquiry approach. A descriptive analysis of EHR data was performed to summarize L2L reach and adoption among patients identified at high risk of suicide.

Results

The initial implementation consisted of updates for clinicians to add a URL and QR code referencing L2L to the safety planning EHR templates. Recommendations about introducing L2L were subsequently derived from the thematic analysis of semistructured interviews with patients (n=36), which included (1) "have an open conversation," (2) "validate their situation," (3) "share what to expect," (4) "make it accessible and memorable," and (5) "walk through the tool." Clinicians' interviews (n=30) showed a strong preference to have L2L included by default in the EHR-based safety planning template (in contrast to adding it manually). During the 2-year observation period, 2739 patients reported prior-month suicide attempt planning or intent and had a documented safety plan during the study period, including 745 (27.2%) who also received L2L. Over four 6-month subperiods of the observation period, L2L adoption rates increased substantially from 2% to 29% among primary care clinicians and from <1% to 48% among mental health clinicians.

Conclusions

Understanding the value of L2L from users' perspectives was essential for facilitating implementation and increasing patient reach and clinician adoption. Incorporating L2L into the existing system-level, EHR-based safety plan template reduced the effort to use L2L and was likely the most impactful implementation strategy. As rising suicide rates galvanize the urgency of prevention, the findings from this project, including L2L implementation tools and strategies, will support efforts to promote safety for suicide prevention in health care nationwide.

SV-VATS exhibits dual intraoperative and postoperative advantages

Background

The merits of spontaneous ventilation video-assisted thoracic surgery (SV-VATS) are still controversial. Our team retrospectively evaluated the intraoperative and postoperative advantages of this surgical approach, comparing with mechanical ventilation video-assisted thoracic surgery (MV-VATS).

Methods

We did a single center retrospective study at the First Affiliated Hospital of Yunnan Province. 244 patients were eventually assigned to the SV-group and MV-group, and their intraoperative indicators and thoracic surgery postoperative data were included in the comparison.

Results

The SV-group exhibited markedly less intraoperative bleeding and postoperative thoracic drainage, and the bleeding volume was correlated with the volume and duration of drainage. Further analysis showed that, patients undergoing SV-VATS had less activation of white blood cells and neutrophils after surgery, but they also had lower serum albumin concentrations. Risks of short-term postoperative complications, including inflammatory reactions, malignant arrhythmias, constipation, and moderate or more pleural effusions, were also significantly reduced in the SV-group. Additionally, hospitalization cost was lower in the SV-group than that in the MV-group.

Conclusions

SV-VATS is suitable for various types of thoracic surgery, and effectively reduce intraoperative bleeding and postoperative thoracic drainage. With less postoperative inflammatory response, it reduces the risk of short-term postoperative complications. It is also able to help to reduce the financial burden of patients.

Using Multiple Mini-Interviews for Students' Admissions in Pakistan: A Pilot Study

BACKGROUND

A significant challenge continuing to face medical educators is the development of an effective method for student admissions into medical school. Conventional interviews have been commonly used for assessment of non-cognitive skills; however, they are subject to different biases and lack of standardization. The present study aims to determine the validity, reliability, feasibility, and acceptability of implementing Multiple Mini-Interviews (MMI) as a selection method for undergraduate medical students.

METHODS

MMI consisting of 8 stations was developed and implemented. A variance component analysis was computed to identify different sources of variance and estimate overall reliability. Content validity was established by seeking consensus on non-cognitive attributes desired by stakeholders. Acceptability and feasibility were determined by a post-MMI questionnaire.

RESULTS

A total of 381 out of 450 (84.66%) candidates participated in the study. The G coefficient was 0.70. Participants found MMI as an acceptable and feasible method of assessment, with 75% of candidates and 95% of assessors preferring MMI to traditional interviews.

CONCLUSION

MMI as an assessment method for students' admissions demonstrated reliable findings. Stakeholders found it feasible and acceptable. Individual institutions can tailor the stations towards selection of the characteristics that are most valued within their local context.

Organization and implementation of an oral cholera vaccination campaign in an endemic urban setting in Dhaka, Bangladesh

Bangladesh has historically been cholera endemic, with seasonal cholera outbreaks occurring each year. In collaboration with the government of Bangladesh, the Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) initiated operational research to test strategies to reach the high-risk urban population with an affordable oral cholera vaccine (OCV) “ShancholTM” and examine its effectiveness in reducing diarrhea due to cholera. Here we report a sub-analysis focusing on the organization, implementation and effectiveness of different oral cholera vaccine delivery strategies in the endemic urban setting in Bangladesh. We described how the vaccination program was planned, prepared and implemented using different strategies to deliver oral cholera vaccine to a high-risk urban population in Dhaka, Bangladesh based on administrative data and observations made during the program. The objective of this study is to evaluate the organization, implementation and effectiveness of different oral cholera vaccine delivery strategies in the endemic urban setting in Bangladesh. OCV administration by trained local volunteers through outreach sites and mop-up activities yielded high coverage of 82% and 72% of 172,754 targeted individuals for the first and second dose respectively, using national Expanded Program on Immunization (EPI) campaign mechanisms without disrupting routine immunization activities. The cost of delivery was low. Safety and cold chain requirements were adequately managed. The adopted strategies were technically and programmatically feasible. Current evidence on implementation strategies in different settings together with available OCV stockpiles should encourage at-risk countries to use OCV along with other preventive and control measures.

Implementation of a COPD Screening Questionnaire in an Outpatient HIV Clinic

Human immunodeficiency virus (HIV) is associated with increased risk for chronic obstructive pulmonary disease (COPD); yet substantial under-recognition of COPD exists. We administered a patient-completed, physician-reviewed COPD screening tool in an outpatient HIV clinic to determine whether screening is feasible or possible. Patients attending nonacute, routine HIV care visits were provided a brief COPD screening tool, which included three questions focused on age, respiratory symptoms, and smoking history. Providers were given completed forms for review and ordered spirometry at their discretion. Forms and medical records were subsequently reviewed to determine completion and results of spirometry testing. Of the 1,510 patients screened during the study period, 968 (64%) forms were completed. After excluding 79 incomplete forms, 889 (92%) unique patient forms were included in this analysis. Among these, 204 (23%) met criteria for spirometry referral, among whom physicians ordered spirometry in 64 (31%). At 6 months following study completion, 19 (30%) of the patients referred for spirometry had the test completed, with 5 (26%) demonstrating airflow obstruction. Nearly one out of four HIV patients met indication for screening spirometry and roughly one out of four undergoing spirometry had COPD. Critical drop-offs in the screening and diagnostic process occurred at questionnaire completion and spirometry ordering. Interventions tailored to these critical steps could improve the yield from COPD screening and help to optimize the identification of COPD in high-risk HIV-infected populations. COPD screening in a clinic focused on longitudinal HIV care can effectively identify COPD among those completing the screening continuum.

A note on implementation of decaying product correlation structures for quasi-least squares

This note implements an unstructured decaying product matrix via the quasi-least squares approach for estimation of the correlation parameters in the framework of generalized estimating equations. The structure we consider is fairly general without requiring the large number of parameters that are involved in a fully unstructured matrix. It is straightforward to show that the quasi-least squares estimators of the correlation parameters yield feasible values for the unstructured decaying product structure. Furthermore, subject to conditions that are easily checked, the quasi-least squares estimators are valid for longitudinal Bernoulli data. We demonstrate implementation of the structure in a longitudinal clinical trial with both a continuous and binary outcome variable.