Optimizing evidence-based practice implementation: a case study on simulated patient protocols in long-term opioid therapy

BACKGROUND

Substantial work has been done to update or create evidence-based practices (EBPs) in the changing health care landscape. However, the success of these EBPs is limited by low levels of clinician implementation.

OBJECTIVE

The goal of this study is to describe the use of standardized/simulated patient/person (SP) methodology as a framework to develop implementation bundles to increase the effectiveness, sustainability, and reproducibility of EBPs across health care clinicians.

DESIGN

We observed 12 clinicians' first-time experiences with six unique decision-making algorithms, developed previously using rigorous Delphi methods, for use with patients exhibiting concerning behaviors associated with long-term opioid therapy (LTOT) for chronic pain. Clinicians were paired with two SPs trained to portray individuals with one of the concerning behaviors addressed by the algorithms in a telehealth environment. The SP evaluations were followed by individual interviews, guided by the Consolidated Framework for Implementation Research (CFIR), with each of the clinician participants.

PARTICIPANTS

Twelve primary care clinicians and 24 SPs in Western Pennsylvania.

MAIN MEASUREMENT

The primary outcome was identifying likely facilitators for the successful implementation of the EBP using the SP methodology. Our secondary outcome was to assess the feasibility of using SPs to illuminate likely implementation barriers and facilitators.

RESULTS

The SP portrayal illuminated factors that were pertinent to address in the implementation bundle. SPs were realistic in their portrayal of patients with concerning behaviors associated with LTOT for chronic pain, but clinicians also noted that their patients in practice may have been more aggressive about their treatment plan.

CONCLUSIONS

SP simulation provides unique opportunities for obtaining crucial feedback to identify best practices in the adoption of new EBPs for high-risk patients.

SETTING

Zoom simulated patient evaluations.

"To prescribe or not to prescribe, that is the question": Perspectives on opioid prescribing for chronic, cancer-related pain from clinicians who treat pain in survivorship

BACKGROUND

Opioid pain management in cancer survivorship is a complex and understudied topic.

METHODS

The authors conducted in-depth, qualitative interviews to understand clinician approaches to opioid pain management in chronic cancer pain and to generate ideas for improvement. They used a rigorous, inductive, qualitative, descriptive approach to examine clinician (n = 20) perspectives about opioid pain management in survivorship, including oncologists (n = 5), palliative care clinicians (n = 8), primary care clinicians (n = 5), and pain management specialists (n = 2).

RESULTS

The findings indicated that no consistent medical home exists for chronic pain management in cancer survivors and that there are fundamental differences in how each subspecialty approaches chronic pain management in survivorship (e.g., "Do we think of this as noncancer pain or cancer pain?… This is in this limbo zone-this gray zone-because it's cancer-related pain, right?"). Simultaneously, clinicians are influenced by their peers' perceptions of their opioid prescribing decisions, sparking intraprofessional tension when disagreement occurs. In these instances, clinicians described overthinking and doubting their clinical decision-making as well as a sense of judgment, pressure, and/or shame. Finally, clinicians acknowledged a fear of consequences for opioid prescribing decisions. Specifically, participants cited conflict with patients, sometimes escalating to aggression and threats of violence, as well as potential disciplinary actions and/or legal consequences.

CONCLUSIONS

Participants suggested that opportunities to improve chronic cancer pain care include developing clear, systematic guidance for chronic cancer pain management, facilitating clinician communication and consultation, creating tailored survivorship care plans in partnership with patients, and developing accessible, evidence-based, complementary pain treatments.

Benefits, Harms, and Stakeholder Perspectives Regarding Opioid Therapy for Pain in Individuals With Metastatic Cancer: Protocol for a Descriptive Cohort Study

BACKGROUND

Opioids are a key component of pain management among patients with metastatic cancer pain. However, the evidence base available to guide opioid-related decision-making in individuals with advanced cancer is limited. Patients with advanced cancer or cancer that is unlikely to be cured frequently experience pain. Opioids are a key component of pain management among patients with metastatic cancer pain. Many individuals with advanced cancer are now living long enough to experience opioid-related harm. Emerging evidence from chronic noncancer pain literature suggests that longer-term opioid therapy may have limited benefits for pain and function, and opioid-related harms are also a major concern. However, whether these benefits and harms of opioids apply to patients with cancer-related pain is unknown.

OBJECTIVE

This manuscript outlines the protocol for the "Opioid Therapy for Pain in Individuals With Metastatic Cancer: The Benefits, Harms, and Stakeholder Perspectives (BEST) Study." The study aims to better understand opioid decision-making in patients with advanced cancer, along with opioid benefits and harms, through prospective examination of patients' pain experiences and opioid side effects and understanding the decision-making by patients, care partners, and clinicians.

METHODS

This is a multicenter, prospective cohort study that aims to enroll 630 patients with advanced cancer, 20 care partners, and 20 clinicians (670 total participants). Patient participants must have an advanced solid cancer diagnosis, defined by the American Cancer Society as cancer that is unlikely to be cured. We will recruit patient participants within 12 weeks after diagnosis so that we can understand opioid benefits, harms, and perspectives on opioid decision-making throughout the course of their advanced cancer (up to 2 years). We will also specifically elicit information regarding long-term opioid use (ie, opioids for ≥90 consecutive days) and exclude patients on long-term opioid therapy before an advanced cancer diagnosis. Lived-experience perspectives related to opioid use in those with advanced cancer will be captured by qualitative interviews with a subset of patients, clinicians, and care partners. Our data collection will be grounded in a behavioral decision research approach that will allow us to develop future interventions to inform opioid-related decision-making for patients with metastatic cancer.

RESULTS

Data collection began in October 2022 and is anticipated to end by November 2024.

CONCLUSIONS

Upon successful execution of our study protocol, we anticipate the development of a comprehensive evidence base on opioid therapy in individuals with advanced cancer guided by the behavioral decision research framework. The information gained from this study will be used to guide interventions to facilitate opioid decisions among patients, clinicians, and care partners. Given the limited evidence base about opioid therapy in people with cancer, we envision this study will have significant real-world implications for cancer-related pain management and opioid-related clinical decision-making.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54953.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Stakeholder-Driven Intervention Development for Dialysis Trials Using a Design Sprint Methodology

Rationale & Objective

Stigma contributes to ineffective treatment for pain among individuals with kidney failure on dialysis, particularly with buprenorphine pain treatment. To address stigma, we adapted a Design Sprint, an industry-developed structured exercise where an interdisciplinary group works over 5 days to clarify the problem, identify and choose a solution, and build and test a prototype.

Study Design

Adapted Design Sprint which clarified the problem to be solved, proposed solutions, and created a blueprint for the selected solution.

Settings & Participants

Five individuals with pain and kidney disease receiving dialysis, 5 physicians (nephrology, palliative care, and addiction medicine) and 4 large dialysis organization leaders recruited for specific expertise or experience. Conducted through online platform (Zoom) and virtual white board (Miro board).

Analytical Approach

Descriptions of the Design Sprint adaptations and processes.

Results

To facilitate patient comfort, a patient-only phase included four 90-minute sessions over 2-weeks, during which patient participants used a mapping process to define the critical problem and sketch out solutions. In a physician-only phase, consisting of two 120-minute sessions, participants accomplished the same tasks. During a combined phase of two 120-minute sessions, patients, physicians, and large dialysis organization representatives vetted and developed solutions from earlier phases, leading to an intervention blueprint. Videoconferencing technology allowed for geographically diverse representation and facilitated participation from patients experiencing medical illness. The electronic whiteboard permitted interactive written contributions and voting on priorities instead of only verbal discussion, which may privilege physician participants. A skilled qualitative researcher facilitated the sessions.

Limitations

Challenges included the time commitment of the sessions, absences owing to illness or emergencies, and technical difficulties.

Conclusions

An adapted Design Sprint is a novel method of efficiently and rapidly incorporating multiple stakeholders to develop solutions for clinical challenges in kidney disease.

Plain Language Summary

Stigma contributes to ineffective treatment for pain among individuals with kidney failure on dialysis, particularly when using buprenorphine, an opioid pain medicine with a lower risk of sedation used to treat addiction. To develop a stigma intervention, we adapted a Design Sprint, an industry-developed structured exercise where an interdisciplinary group works over 5 days to clarify the problem, identify and choose a solution, and build and test a prototype. We conducted 3 sprints with (1) patients alone, (2) physicians alone, and (3) combined patients, physicians, and dialysis organization representatives. This paper describes the adaptations and products of sprints as a method for gathering diverse stakeholder voices to create an intervention blueprint efficiently and rapidly.

A Simulated Patient Protocol for Implementing Evidence-Based Practices in Health Care Delivery

Background

Substantial work has been done to update or create evidence-based practices (EBPs) in the changing health care landscape. However, the success of these EBPs is limited by low levels of clinician implementation. The goal of this study is to describe the use of simulated patient (SP) methodology as a framework to develop implementation bundles to increase the effectiveness, sustainability, and reproducibility of EBPs across health care clinicians. The primary outcome was identifying likely facilitators for the successful implementation of EBP. Our secondary outcome was the assess the feasibility of using SPs to illuminate likely implementation barriers and facilitators.

Methods

We observed 12 primary care clinicians' first-time experiences with six unique decision-making algorithms for use with patients exhibiting concerning behaviors associated with long-term opioid therapy (LTOT) for chronic pain over Zoom. Each clinician was paired with two simulated patients trained to portray individuals with one of the concerning behaviors addressed by the algorithms. The Standardized Patient-evaluations were followed by CFIR guided one-on-one interviews with the clinicians.

Results

The SP portrayal illuminated factors that were pertinent to address in the implementation bundle. SPs were realistic in their portrayal of patients with concerning behaviors associated with LTOT for chronic pain, but clinicians also noted that their patients in practice may have been more aggressive about their treatment plan.

Conclusions

SP simulation provides unique opportunities for obtaining crucial feedback to identify best practices in the adoption of new EBPs for high-risk patients.

The Global Task Force for Chronic Pain in People with HIV (PWH): Developing a research agenda in an emerging field

Chronic pain is a common comorbidity in people with HIV (PWH), with prevalence estimates of 25-85%. Research in this area is growing, but significant gaps remain. A Global Task Force of HIV experts was organized to brainstorm a scientific agenda and identify measurement domains critical to advancing research in this field. Experts were identified through literature searches and snowball sampling. Two online questionnaires were developed by Task Force members. Questionnaire 1 asked participants to identify knowledge gaps in the field of HIV and chronic pain and identify measurement domains in studies of chronic pain in PWH. Responses were ranked in order of importance in Questionnaire 2, which was followed by a group discussion. 29 experts completed Questionnaire 1, 25 completed Questionnaire 2, and 21 participated in the group. Many important clinical and research priorities emerged, including the need to examine etiologies of chronic pain in PWH. Pain-related measurement domains were discussed, with a primary focus on domains that could be assessed in a standardized manner across various cohorts that include PWH in different countries. We collaboratively identified clinical and research priorities, as well as gaps in standardization of measurement domains, that can be used to move the field forward.

Barriers to rural health care from the provider perspective

INTRODUCTION

Rural populations routinely rank poorly on common health indicators. While it is understood that rural residents face barriers to health care, the exact nature of these barriers remains unclear. To further define these barriers, a qualitative study of primary care physicians practicing in rural communities was performed.

METHODS

Semistructured interviews were conducted with primary care physicians practicing in rural areas within western Pennsylvania, the third largest rural population within the USA, using purposively sampling. Data were then transcribed, coded, and analyzed by thematic analysis.

RESULTS

Three key themes emerged from the analysis addressing barriers to rural health care: (1) cost and insurance, (2) geographic dispersion, and (3) provider shortage and burnout. Providers mentioned strategies that they either employed or thought would be beneficial for their rural communities: (1) subsidize services, (2) establish mobile and satellite clinics (particularly for specialty care), (3) increase utilization of telehealth, (4) improve infrastructure for ancillary patient support (ie social work services), and (5) increase utilization of advanced practice providers.

CONCLUSION

There are numerous barriers to providing rural communities with quality health care. Barriers that are encountered are multidimensional. Patients are unable to obtain the care they need because of cost-related barriers. More providers need to be recruited to rural areas to combat the shortage and burnout. Advanced care-delivery methods such as telehealth, satellite clinics, or advanced practice providers can help bridge the gaps caused by geographic dispersion. Policy efforts should target all these aspects in order to appropriately address rural healthcare needs.

U.S. physicians' perspectives on the complexities and challenges of permanent contraception provision

OBJECTIVES

Evidence shows many misconceptions exist around permanent contraception, and there are numerous barriers to accessing the procedure. This qualitative study explored physician perspectives regarding patients' informational and decision-support needs, the complexities and challenges of counseling and access, and how these factors may differ for people living on lower incomes.

STUDY DESIGN

We conducted 15 semistructured, telephone interviews with obstetrician-gynecologists in three geographic regions of the United States to explore their perspectives on providing permanent contraception counseling and care. We analyzed the interviews using content analysis.

RESULTS

Physicians discussed a tension between respecting individual reproductive autonomy and concern for future regret; they wanted to support patients' desire for permanent contraception but were frequently concerned patients did not have the information they needed or the foresight to make high-quality decisions. Physicians also identified barriers to counseling including lack of time, lack of continuity over the course of prenatal care, and baseline misinformation among patients. Physicians identified additional barriers in providing a postpartum procedure even after thedecision was made including lack of personnel and operating room availability. Finally, physicians felt that people living on lower incomes faced more challenges in access primarily due to the sterilization consent regulations required by Medicaid.

CONCLUSIONS

Physicians report numerous challenges surrounding permanent contraception provision and access. Strategies are needed to support physicians and patients to enhance high-quality, patient-centered sterilization decision making and ensure that patients are able to access a permanent contraceptive procedure when desired.

IMPLICATIONS

This qualitative study demonstrates the various challenges faced by physicians to support permanent contraception decision making. These challenges may limit patients' access to the care they desire. This study supports the need to transform care delivery models and improve the federal sterilization policy to ensure equitable patient-centered access to desired permanent contraception.

DISCLAIMER

Although the term permanent contraception has increasingly replaced the word sterilization in clinical settings, we use sterilization in some places throughout this paper as that was the standard terminology at the time the interviews were conducted and the language the interviewed physicians used.

A qualitative crossroads of rhythm and race: Black patients' experiences living with atrial fibrillation

Importance

Race-based disparities in atrial fibrillation (AF) outcomes are well-documented, but few studies have investigated individuals' experiences of living with the condition, particularly among Black individuals.

Objective

We aimed to identify common themes and challenges experienced by individuals of Black race with AF.

Design

A tailored, qualitative script was developed to assess the perspectives of participants in focus groups.

Setting

Virtual focus groups.

Participants

Three focus groups of 4-6 participants (16 participants total) were recruited from the racial/ethnic minority participants in the Mobile Relational Agent to Enhance Atrial Fibrillation Self-care Trial.

Main outcomes and measures

Focus group transcripts were inductively coded to identify common themes.

Results

Nearly all participants self-identified as Black race (n = 15, 93.8 %). Participants were mostly male (62.5 %) with mean age of 67 (range 40-78) years. Three themes were identified. First, participants described physical and mental burdens associated with having AF. Second, participants described AF as being a condition that is difficult to manage. Lastly, participants identified key tenets to support self-management of AF (self-education, community support, and patient-provider relationships).

Conclusions and relevance

Participants reported AF is unpredictable and challenging to manage, and that social and community supports are essential. The social and behavioral themes identified in this qualitative research highlight the need for tailored clinical strategies for AF self-management which incorporate individuals' social contexts.

Trial registration

National Clinical Trial number 04075994.

Comparing survey data to qualitative themes in patient stories to help researchers better identify pressing community healthcare needs

BACKGROUND

Narrative medicine is a powerful approach for strengthening clinicians' therapeutic alliances with patients and helping them understand others' perspectives by giving patients a voice. MyPaTH Story Booth is a cross-sectional observational study that uses narrative medicine concepts to allow community participants to share their health and healthcare-related experiences through relatively unstructured interviews (i.e., stories). The archive forms a qualitative research 'commons' where researchers can learn about patient and caregiver perspectives and tailor research goals to better address community needs. Brief surveys allow storytellers to classify their stories so that the archive is searchable.

METHODS

This study assessed sensitivity, specificity, positive predictive and negative predictive values of self-reported surveys for categorizing 83 stories, compared with a 'gold standard' (most commonly accepted method for interpreting narratives) of qualitative coding. Stories were classified as either having or not having each of 38 different classifications based on US National Library of Medicine (NLM) Health Topics (Type of disorder or condition and Part of the body discussed) or developed with stakeholder input (Type of health/healthcare experience).

RESULTS

Survey data assessing 'Part of the body discussed' and 'Type of disorder or condition' typically was highly sensitive (64%-95%) and specific (73%-99%) suggesting high adequacy of surveys in identifying stories. Questions focused on 'Type of health/healthcare experience' showed inconsistent and relatively lower sensitivities (48%-93%) and specificities (30%-79%) suggesting lower adequacy of surveys in identifying stories.

CONCLUSION

Survey items based on NLM Health Topics allowed people to categorize their health narratives into relevant, searchable topics making the database more accessible.

How to Provide Sexual and Reproductive Health Care to Patients: Focus Groups With Rheumatologists and Rheumatology Advanced Practice Providers

OBJECTIVE

Rheumatologists have identified challenges to providing sexual and reproductive health (SRH) care to patients with gestational capacity. We conducted focus groups with rheumatologists and rheumatology advanced practice providers (APPs) to elicit their solutions to overcoming barriers to SRH care.

METHODS

Qualitative focus groups were conducted with rheumatologists (3 groups) and APPs (2 groups) using videoconferencing. Discussions were transcribed and 2 trained research coordinators developed a content-based codebook. The coordinators applied the codebook to transcripts, and discrepancies were adjudicated to full agreement. The codes were synthesized and used to conduct a thematic analysis. Differences in codes were also identified between the clinician groups by provider type.

RESULTS

A total of 22 clinicians were included in the sample, including 12 rheumatologists and 10 APPs. Four themes emerged: (1) clinicians recommended preparing patients to engage in SRH conversations before and during clinic visits; (2) consultation systems are needed to facilitate rapid SRH care with women's health providers; (3) clinicians advised development of training opportunities and easy-to-access resources to address SRH knowledge gaps; and (4) clinicians recommended that educational materials about SRH in the rheumatology context are provided for patients. Although similar ideas were generated between the APP and rheumatologist groups, the rheumatologists were generally more interested in additional training and education, whereas APPs were more interested in electronic health record prompts and tools.

CONCLUSION

Providers identified many potential solutions and facilitators to enhancing SRH care in rheumatology that might serve as a foundation for intervention development.

"I Refused to Get Addicted to Opioids": Exploring Attitudes About Opioid Use Disorder in Patients With Advanced Cancer Pain and Their Support People

Patients with advanced cancer are commonly prescribed opioids, yet patient attitudes about opioid risks (eg, opioid use disorder, or OUD) are understudied. Our objective was to use in-depth qualitative interviews to understand perceptions of opioid prescribing and OUD in patients with advanced, solid-tumor cancers and their support people. We conducted a qualitative study using a rigorous inductive, qualitative descriptive approach to examine attitudes about OUD in patients with advanced cancer (n = 20) and support providers (n = 11). Patients with cancer hold 2 seemingly distinct views: prescription opioids are addictive, yet OUD cannot happen to me or my loved one. Participants described general concerns about the addictive nature of prescription opioids ("My biggest concern… would just be the risk of getting addicted to the medication or even like, overdosing it"), while separating cancer pain management from OUD when considering prescription opioid risks and benefits ("They need to make sure they get the right ones, when they're taking it away from you."). Finally, participants identified personal characteristics and behaviors that they felt were protective against developing OUD (commonly control, willpower, and responsibility). This rigorous qualitative study demonstrates that patients with advanced cancer and their support people simultaneously hold concerns about the addictive nature of prescription opioids, while distancing from perceptions of OUD risks when using opioids for cancer pain management. Given high rates of opioid exposure during advanced cancer treatment, it is important to explore opportunities to promote a balanced understanding of prescription opioid use and OUD risks in this population. PERSPECTIVE: Though prescription opioids carry risk of OUD, there is little data to help guide patients with advanced cancer. Findings suggest that there is a need to develop new, innovative strategies to promote effective pain management and minimize opioid risks in this complex population.

Manifestations of Opioid Stigma in Patients With Advanced Cancer: Perspectives From Patients and Their Support Providers

PURPOSE

Stigma surrounding prescription opioids, or opioid stigma, is increasingly recognized as a barrier to effective and guideline-concordant cancer pain management. Patients with advanced cancer report high rates of pain and prescription opioid exposure, yet little is known about how opioid stigma may manifest in this population.

METHODS

We conducted in-depth qualitative interviews with 20 patients with advanced cancer and 11 support providers between March 2020, and May 2021. We took a rigorous inductive, qualitative descriptive approach to characterize how opioid stigma manifests in the lives of patients with advanced cancer.

RESULTS

Patients and their support providers described three primary manifestations of opioid stigma: (1) direct experiences with opioid stigma and discrimination in health care settings (eg, negative, stigmatizing interactions in pharmacies or a pain clinic); (2) concerns about opioid stigma affecting patient care in the future, or anticipated stigma; and (3) opioid-restricting attitudes and behaviors that may reflect internalized stigma and fear of addiction (eg, feelings of guilt).

CONCLUSION

This qualitative study advances our understanding of opioid stigma manifestations in patients with advanced cancer, as well as coping strategies that patients may use to alleviate their unease (eg, minimizing prescription opioid use, changing clinicians, and distancing from perceptions of addiction). In recognition of the costs of undermanaged cancer pain, it is important to consider innovative treatment strategies to address opioid stigma and improve pain management for patients with advanced cancer. Future research should examine opportunities to build an effective, multilevel opioid stigma intervention targeting patients, clinicians, and health care systems.

"How much desire should I have?": a qualitative study of low libido in postmenopausal women

We conducted 15 interviews and 3 focus groups (total N = 36) among women 60 and older with low libido to better understand the role that it plays in their lives. Interviews and focus groups were led by facilitators using open-ended questions. A codebook was developed, then codes were assigned to all data. We identified three themes. First, women reported that sex was an important aspect of their lives. Second, women desired to know what was "normal" with regards to sexuality and aging. Third, women were distressed by low libido, concerned that it could have negative effects on romantic relationships and self-image.

Use of Chart-Stimulated Recall to Explore Uncertainty in Medical Decision-Making Among Senior Internal Medicine Residents

BACKGROUND

Uncertainty is common and impacts both patients and clinicians. The approach to uncertainty in medical trainees may be distinct from that of practicing clinicians and has important implications for medical education.

OBJECTIVE

Describe trainee approach to uncertainty with the use of chart-stimulated recall (CSR)-based interviews, as well as the utility of such interviews in promoting reflection about decision-making among senior internal medicine (IM) residents.

DESIGN

Qualitative analysis of CSR-based interviews with IM residents.

PARTICIPANTS

Senior IM residents rotating on inpatient night float at the University of Pittsburgh Medical Center from February to September 2019.

INTERVENTION

Each participant completed one, 20-min CSR session based on a self-selected case in which there was uncertainty in decision-making. Interviews explored the sources of, approaches to, and feelings about uncertainty.

APPROACH

Two independent coders developed a codebook and independently coded all transcripts. Transcripts were then analyzed using thematic analysis.

KEY RESULTS

The perceived acuity of the patient presentation was the main driver of the approach to and stress related to uncertainty. Perceived level of responsibility in resolving uncertainty during the overnight shift also varied among individual participants. Attending expression of uncertainty provided comfort to residents and alleviated stress related to uncertainty. Residents felt comfortable discussing their uncertainty and felt that the opportunity to think aloud during the exercise was valuable.

CONCLUSIONS

Our study demonstrated a novel approach to the exploration of uncertainty in medical decision-making, with the use of CSR. Variations in resident perceived level of responsibility in resolving uncertainty during the overnight shift suggest a need for curriculum development in approach to uncertainty during night shifts. Though residents often experienced stress related to uncertainty, attending expression of uncertainty was an important mitigator of that stress, emphasizing the important role that the trainee-attending interaction plays in the diagnostic process.

Staff Perceptions of Barriers and Facilitators to Implementation of Behavioral Health Homes at Community Mental Health Provider Settings

Individuals living with a serious mental illness are disproportionately affected by preventable and/or manageable chronic conditions. Integrated care and support for behavioral and physical health within community mental health provider (CMHP) settings, also known as behavioral health homes (BHH), can lead to improvements in care and cost outcomes. This study explored staff perceptions of barriers and facilitators to BHH implementation. We conducted semi-structured interviews with CMHP staff at baseline, 1, and 2 years after the start of implementation. We analyzed interviews to identify major themes. We conducted 65 total interviews with 30 unique staff members. Common barriers included staff turnover, hesitation to change care processes, and acute service user needs. Facilitators included agency-wide culture change, intervention champions, and integration of intervention processes into daily workflows. Despite common barriers, CMHP staff identified several elements related to successful BHH implementation, including the CMHP-wide cultural shift to comprehensively address health/wellness that benefitted service users and staff alike.

Effect of Different Interventions to Help Primary Care Clinicians Avoid Unsafe Opioid Prescribing in Opioid-Naive Patients With Acute Noncancer Pain: A Cluster Randomized Clinical Trial

Importance

Prescription opioids can treat acute pain in primary care but have potential for unsafe use and progression to prolonged opioid prescribing.

Objective

To compare clinician-facing interventions to prevent unsafe opioid prescribing in opioid-naive primary care patients with acute noncancer pain.

Design Setting and Participants

We conducted a multisite, cluster-randomized, 2 × 2 factorial, clinical trial in 3 health care systems that comprised 48 primary care practices and 525 participating clinicians from September 2018 through January 2021. Patient participants were opioid-naive outpatients, 18 years or older, who presented for a qualifying clinic visit with acute noncancer musculoskeletal pain or nonmigraine headache.

Interventions

Practices randomized to: (1) control; (2) opioid justification; (3) monthly clinician comparison emails; or (4) opioid justification and clinician comparison. All groups received opioid prescribing guidelines via the electronic health record at the time of a new opioid prescription.

Main Outcomes and Measures

Primary outcome measures were receipt of an initial opioid prescription at the qualifying clinic visit. Other outcomes were opioid prescribing for more than 3 months and a concurrent opioid/benzodiazepine prescription over 12-month follow-up.

Results

Among 22 616 enrolled patient participants (9740 women [43.1%]; 64 American Indian/Alaska Native [0.3%]; 590 Asian [2.6%], 1120 Black/African American [5.0%], 1777 Hispanic [7.9%], 225 Native Hawaiian/Pacific Islander [1.0%], and 18 981 White [83.9%] individuals), the initial opioid prescribing rates at the qualifying clinic visit were 3.1% in the total sample, 4.2% in control, 3.6% in opioid justification, 2.6% in clinician comparison, and 1.9% in opioid justification and clinician comparison. Compared with control, the adjusted odds ratio (aOR) for a new opioid prescription was 0.74 (95% CI, 0.46-1.18; P = .20) for opioid justification and 0.60 (95% CI, 0.38-0.96; P = .03) for clinician comparison. Compared with control, clinician comparison was associated with decreased odds of opioid therapy of more than 3 months (aOR, 0.79; 95% CI, 0.69-0.91; P = .001) and concurrent opioid/benzodiazepine prescription (aOR, 0.85; 95% CI, 0.72-1.00; P = .04), whereas opioid justification did not have a significant effect.

Conclusions and Relevance

In this cluster randomized clinical trial, comparison emails decreased the proportion of opioid-naive patients with acute noncancer pain who received an opioid prescription, progressed to treatment with long-term opioid therapy, or were exposed to concurrent opioid and benzodiazepine therapy. Health care systems can consider adding clinician-targeted nudges to other initiatives as an efficient, scalable approach to further decrease potentially unsafe opioid prescribing.

Trial Registration

ClinicalTrials.gov Identifier: NCT03537573.

Barriers and facilitators to resuming meaningful daily activities among critical illness survivors in the UK: a qualitative content analysis

OBJECTIVE

To identify critical illness survivors' perceived barriers and facilitators to resuming performance of meaningful activities when transitioning from hospital to home.

DESIGN

Secondary content analysis of semistructured interviews about patients' experiences of intensive care (primary analysis disseminated on the patient-facing website www.healthtalk.org). Two coders characterised patient-perceived barriers and facilitators to resuming meaningful activities. To facilitate clinical application, we mapped the codes onto the Person-Task-Environment model of performance, a patient-centred rehabilitation model that characterises complex interactions among the person, task and environment when performing activities.

SETTING

United Kingdom, 2005-2006.

PARTICIPANTS

39 adult critical illness survivors, sampled for variation among demographics and illness experiences.

RESULTS

Person-related barriers included negative mood or affect, perceived setbacks; weakness or limited endurance; pain or discomfort; inadequate nutrition or hydration; poor concentration/confusion; disordered sleep/hallucinations/nightmares; mistrust of people or information; and altered appearance. Task-related barriers included miscommunication and managing conflicting priorities. Environment-related barriers included non-supportive health services and policies; challenging social attitudes; incompatible patient-family coping (emotional trauma and physical disability); equipment problems; overstimulation; understimulation; and environmental inaccessibility. Person-related facilitators included motivation or attitude; experiencing progress; and religion or spirituality. Task-related facilitators included communication. Environment-related facilitators included support from family, friends or healthcare providers; supportive health services and policies; equipment; community resources; medications; and accessible housing. Barriers decreased and facilitators increased over time. Six barrier-facilitator domains dominated based on frequency and emphasis across all performance goals: mood/motivation, setbacks/progress, fatiguability/strength; mis/communication; lack/community support; lack/health services and policies.

CONCLUSIONS

Critical illness survivors described a comprehensive inventory of 18 barriers and 11 facilitators that align with the Person-Task-Environment model of performance. Six dominant barrier-facilitator domains seem strong targets for impactful interventions. These results verify previous knowledge and offer novel opportunities for optimising patient-centred care and reducing disability after critical illness.

Perceived Facilitators of and Barriers to Implementation of a Decision Support Tool for Adolescent Depression and Suicidality Screening: Focus Group and Interview Study

BACKGROUND

Screening Wizard (SW) is a technology-based decision support tool aimed at guiding primary care providers (PCPs) to respond to depression and suicidality screens in adolescents. Separate screens assess adolescents' and parents' reports on mental health symptoms, treatment preferences, and potential treatment barriers. A detailed summary is provided to PCPs, also identifying adolescent-parent discrepancies. The goal of SW is to enhance decision-making to increase the utilization of evidence-based treatments.

OBJECTIVE

This qualitative study aims to describe multi-stakeholder perspectives of adolescents, parents, and providers to understand the potential barriers to the implementation of SW.

METHODS

We interviewed 11 parents and 11 adolescents and conducted two focus groups with 18 health care providers (PCPs, nurses, therapists, and staff) across 2 pediatric practices. Participants described previous experiences with screening for depression and were shown a mock-up of SW and asked for feedback. Interviews and focus groups were transcribed verbatim, and codebooks were inductively developed based on content. Transcripts were double coded, and disagreements were adjudicated to full agreement. Completed coding was used to produce thematic analyses of the interviews and focus groups.

RESULTS

We identified five main themes across the interviews and focus groups: parents, adolescents, and pediatric PCPs agree that depression screening should occur in pediatric primary care; there is concern that accurate self-disclosure does not always occur during depression screening; SW is viewed as a tool that could facilitate depression screening and that might encourage more honesty in screening responses; parents, adolescents, and providers do not want SW to replace mental health discussions with providers; and providers want to maintain autonomy in treatment decisions.

CONCLUSIONS

We identified that providers, parents, and adolescents are all concerned with current screening practices, mainly regarding inaccurate self-disclosure. They recognized value in SW as a computerized tool that may elicit more honest responses and identify adolescent-parent discrepancies. Surprisingly, providers did not want the SW report to include treatment recommendations, and all groups did not want the SW report to replace conversations with the PCP about depression. Although SW was originally developed as a treatment decision algorithm, this qualitative study has led us to remove this component, and instead, SW focuses on aspects identified as most useful by all groups. We hope that this initial qualitative work will improve the future implementation of SW.

This Is a Different Patient Population: Opioid Prescribing Challenges for Patients With Cancer-Related Pain

PURPOSE

Responses to the opioid epidemic in the United States, including efforts to monitor and limit prescriptions for noncancer pain, may be affecting patients with cancer. Oncologists' views on how the opioid epidemic may be influencing treatment of cancer-related pain are not well understood.

METHODS

We conducted a multisite qualitative interview study with 26 oncologists from a mix of urban and rural practices in Western Pennsylvania. The interview guide asked about oncologists' views of and experiences in treating cancer-related pain in the context of the opioid epidemic. A multidisciplinary team conducted thematic analysis of interview transcripts to identify and refine themes related to challenges to safe and effective opioid prescribing for cancer-related pain and recommendations for improvement.

RESULTS

Oncologists described three main challenges: (1) patients who receive opioids for cancer-related pain feel stigmatized by clinicians, pharmacists, and society; (2) patients with cancer-related pain fear becoming addicted, which affects their willingness to accept prescription opioids; and (3) guidelines for safe and effective opioid prescribing are often misinterpreted, leading to access issues. Suggested improvements included educational materials for patients and families, efforts to better inform prescribers and the public about safe and appropriate uses of opioids for cancer-related pain, and additional support from pain and/or palliative care specialists.

CONCLUSION

Challenges to safe and effective opioid prescribing for cancer-related pain include opioid stigma and access barriers. Interventions that address opioid stigma and provide additional resources for clinicians navigating complex opioid prescribing guidelines may help to optimize cancer pain treatment.

Outpatient Exam Room Presentations in Resident Continuity Clinics: a Qualitative Report

INTRODUCTION

Outpatient exam room presentations (OERPs) in resident continuity clinics could address several current challenges in graduate medical education including increasing patient satisfaction, enhancing patient-centered care, and operationalizing competency-based education through direct observation. The authors' aim of this study was to explore the positive and negative aspects of OERPs as a precepting model in resident continuity clinics and to develop a list of best practices for medical educators to utilize when conducting OERPs.

MATERIALS AND METHODS

The authors defined an OERP as a case presentation and subsequent discussion taking place inside the exam room with the attending physician, resident physician, and patient present. Following a 1-month pilot period of conducting OERPs in internal medicine resident continuity clinics, the authors conducted individual phone interviews and focus groups with internal medicine attendings and residents, respectively. The authors analyzed transcripts using thematic analysis and the constant comparative method. Sixteen attendings participated in individual phone interviews and four resident focus groups averaged five participants per group.

RESULTS

Four main topics emerged: (1) effect of OERPs on patient care, (2) effect of OERPs on medical education, (3) barriers to OERPs, and (4) OERP best practices.

CONCLUSION

Participants noted both positive and negative effects of OERPs on patient care and medical education. Best practices suggested to maximize these benefits and minimize drawbacks included targeting OERPs to certain types of clinical encounters and employing strategies to preserve the resident physician-patient relationship and resident autonomy.

Perspectives of Adult Rheumatologists Regarding Family Planning Counseling and Care: A Qualitative Study

OBJECTIVE

Little is known about whether and how rheumatologists provide family planning counseling and reproductive health care (FPCC) to reproductive-age women with rheumatic diseases. This qualitative study sought to assess rheumatologists' perspectives, attitudes, and practices regarding FPCC.

METHODS

Semistructured interviews were conducted with a geographically diverse US sample of rheumatologists (n = 12). Interviews were transcribed verbatim, and a code book was inductively developed based on transcript content. Two coders applied the code book to all transcripts, and coding differences were adjudicated to full agreement. The finalized coding was used to conduct a thematic analysis.

RESULTS

Six themes were identified across interviews. Rheumatologists said that they 1) feel responsible for providing some FPCC to patients, 2) experience tension between respecting patients' autonomy and their own anxieties about managing high-risk pregnancies, 3) view patient-initiated conversations as FPCC facilitators, and they regard lack of guidelines and the presence of competing clinical priorities as barriers to FPCC, 4) are reluctant to prescribe contraception, 5) desire greater access to resources to help guide FPCC, and 6) recognize the benefits of multidisciplinary collaboration with gynecologists.

CONCLUSION

Rheumatologists feel a sense of responsibility to provide some aspects of FPCC to reproductive-age female patients. However, their own apprehensions about managing complicated pregnancies may negatively influence how they advise patients about pregnancy planning or avoidance. Rheumatologists do not prescribe contraception but rarely refer patients to gynecologists for contraceptive care. Future work should focus on eliminating barriers and identifying solutions that support rheumatologists' efforts to provide high-quality FPCC to patients.

Internal Medicine Resident Perceptions of Patients with Substance Use Disorder After Attending a Mutual Support Group Meeting

BACKGROUND

Mutual support groups (MSGs) are support systems for patients with substance use disorders (SUDs), yet medical residents lack awareness in the role MSGs play in addiction treatment.

AIM

We developed an educational intervention to expose residents to MSGs and improve attitudes toward patients with SUD.

SETTING

The study took place from October 2017 to March 2018 within a large academic medical center.

PARTICIPANTS

First- to third-year internal medicine residents participated.

PROGRAM DESCRIPTION

Residents attended a MSG meeting. They completed surveys pre- and post-meeting and attended a focus group debrief session. Focus group transcripts were coded and thematically analyzed.

PROGRAM EVALUATION

Sixty-eight residents participated in the curriculum, 54 attended the focus group and 47 completed the pre- and post-survey. Qualitative themes included (1) appreciation for the sense of community at meetings, (2) improved perspective taking of patients with SUDs, (3) concern regarding religion, and (4) improved confidence in MSG referrals. Post-intervention, residents had more positive attitudes toward patients with SUD (p < 0.05 for 9 of 14 questions) and toward MSGs (p < 0.05 for 2 of 4 questions).

DISCUSSION

Implementing an educational intervention on MSGs gives residents an experience that impacts attitudes toward patients with SUD and confidence with MSG referrals.

"I Don't Feel Like the Odd One": Utilizing Content Analysis to Compare the Effects of Social Media Use on Well-Being Among Sexual Minority and Nonminority US Young Adults

PURPOSE

Although there is evidence of associations between social media (SM) use and mental well-being among the general population, these associations among lesbian, gay, and bisexual (LGB) persons are poorly understood. This study compared the influence of SM experiences on mental well-being between LGB and non-LGB persons.

DESIGN AND SETTING

Online cross-sectional survey.

PARTICIPANTS

National sample of 2408 US adults aged 18 to 30 years.

METHOD

We asked participants to provide examples of when SM affected their well-being separately in good and bad ways. We coded, summed, and used rate ratios (RRs) to compare responses of LGB and non-LGB individuals. Thematically similar codes were described and grouped into categories.

RESULTS

Most responses described positive SM effects. However, of 6 codes that were significantly more frequent among LGB respondents, only social capital (RR = 1.58, 95% confidence interval [CI], 1.17-2.12) described a positive effect. Five codes described negative effects of SM for LGB users: negative emotional contagion (RR = 1.28, 95% CI, 1.04-1.58), comparison with others (RR = 1.28, 95% CI, 1.01-1.62), real-life repercussions (RR = 1.86, 95% CI, 1.18-2.94), envy (RR = 2.49, 95% CI, 1.48-4.19), and need for profile management (RR = 2.32, 95% CI, 1.07-5.03).

CONCLUSION

These findings suggest that, for LGB persons, gaining social capital from SM is valuable for establishing and maintaining connections. Increased negative SM experiences may pose a risk for the mental well-being of LGB individuals.

Experiences with Menses and Menstrual Suppression of Young Women with a History of Cancer

Background: Adolescent and young adult (AYA) women undergoing multiagent chemotherapy are at risk for heavy menstrual bleeding (HMB). There is a paucity of data on the experiences with menses of AYA women with cancer, their risk for HMB, and how they perceive menstrual suppression. Objective: This study aimed to (1) describe the attitudes and experiences of AYA women with a history of cancer regarding their menses and menstrual suppression and to (2) investigate facilitators and barriers to improve this aspect of oncologic care. Design/Methods: AYA women with a history of cancer completed individual semistructured interviews regarding their experiences, attitudes, and preferences around menstrual health. Two independent reviewers conducted a thematic analysis of transcribed interviews to elicit major themes. Results: We interviewed 20 young women with a history of cancer (mean age 19.9 years) who were treated with chemotherapy within the past 5 years. Themes included the following: (1) negative feelings and worry about menstrual bleeding; (2) positive attitudes toward menstrual suppression; (3) misconceptions about menstrual health; and (4) desire for tailored discussions about menstrual suppression. Conclusions: AYA women with a cancer history elucidate clear opinions regarding menstruation during chemotherapy, and many hold misconceptions regarding menses and menstrual suppression. Enhanced patient-provider communication and patient educational resources around menstrual health and menstrual suppression are needed to improve comprehensive oncologic care during chemotherapy.

A Diabetes Education Model in Primary Care: Provider and Staff Perspectives

Purpose

The purpose of this qualitative study was to explore the effectiveness of Glucose to Goal (G2G), a diabetes self-management education and support (DSMES) model for primary care (PC).

Methods

PC providers and staff were recruited from 5 PC practices participating in the 18-month intervention to participate in focus groups and interviews, which were used to gain insights about their perspectives on DSMES and how G2G was implemented across the intervention. Data were collected by qualitative researchers at baseline, midpoint, and study completion.

Results

At baseline, PC participants held a favorable view of DSMES and welcomed having a diabetes educator (DE) in their practice. Most participants suggested DEs would be helpful in meeting patients’ nutrition needs but should give therapeutic advice only with a doctor’s oversight. Participants anticipated that having a DE onsite would mitigate transportation, scheduling, communication, and cost barriers. Participant viewpoints about G2G remained unchanged from midpoint to study end, while barriers regarding location and transportation were perceived as being reduced by having a DE in the practice. Despite referral rates remaining low in some practices, many concerns stated at earlier timepoints appeared to have been attenuated by G2G components (eg, bringing the DE onsite, preidentifying patients, and DE ability to communicate and make diabetes management recommendations).

Conclusions

This study demonstrates that G2G, providing DSMES in PC, appeared to be a welcome service where acceptance of and enthusiasm for the model grew over the course of the intervention.

A Qualitative Analysis of Resident Adverse Event Reporting: What's Holding Us Back

This study utilized focus groups of residents, who report adverse events at differing rates depending on their hospital site, to better understand barriers to residents' reporting and identify modifiable aspects of an institution's culture that could encourage resident event reporting. Focus groups included residents who rotated at 3 hospitals and represented 4 training programs. Focus groups were audio recorded and analyzed using qualitative methods. A total of 64 residents participated in 8 focus groups. Reporting behavior varied by hospital culture. Residents worried about damage to their professional relationships and lacked insight into the benefits of multiple reports of the same event or how human factors engineering can prevent errors. Residents did not understand how reporting affects litigation. Residents at other academic institutions likely experience similar barriers. This study illustrates that resident reporting is modifiable by changing hospital culture, but hospitals have only a few opportunities to mishandle reporting before resident reporting attitudes solidify.

Encouraging Resident Adverse Event Reporting: A Qualitative Study of Suggestions from the Front Lines

INTRODUCTION

Little is known about what motivates residents to report adverse events. The goals of the qualitative study were to: (1) better understand facilitators to residents' event reporting and (2) identify effective interventions that encourage residents to report.

METHODS

The authors conducted focus groups of upper-level residents from 4 training programs (2 internal medicine, a pediatric, and a combined medicine-pediatric) who rotated at 3 institutions within a large healthcare system in 2016. Quantitative data on reporting experience were gathered. Focus groups were audio recorded and transcribed. Two coders reviewed transcripts using the editing approach and organized codes into themes.

RESULTS

Sixty-four residents participated in 8 focus groups. Residents were universally exposed to reportable events and knew how to report. Residents' reporting behavior varied by site according to local culture, with residents filing more reports at the pediatric hospital compared to other sites, but all groups expressed similar general views about facilitators to reporting. Facilitators included familiarity with the investigation process, reporting via telephone, and routine safety educational sessions with safety administrators. Residents identified specific interventions that encouraged reporting at the pediatric hospital, including incorporating an attending physician review of events into sign-out and training on error disclosure.

CONCLUSIONS

This study provides insight into what motivates resident event reporting and describes concrete interventions to increase reporting. Our findings are consistent with the Theoretical Domains Framework of behavioral change. These strategies could prove successful at other pediatric hospitals to build a culture that values reporting and prepares residents as patient safety champions.

Mindfulness for Chronic Low Back Pain: A Qualitative Analysis

Objective

Mindfulness is a nonpharmacologic mind-body therapy that has been shown to be effective in older adults with chronic low back pain (cLBP). There are few first-person accounts in the literature that describe the older adult experience and perspective while learning mindfulness and meditation to treat pain. The objective of this study was to investigate dominant themes present in the experiences of older adults applying mindfulness and meditation to cope with cLBP.

Design

Qualitative analysis of four focus groups.

Subject

Twenty-five adults age 65 years or older who had completed an eight-week mindfulness program.

Methods

The focus groups met for a comprehensive discussion session about their experience with mindfulness and meditation. The audio for each session was recorded, and the discussions were transcribed. Codebook development, qualitative coding, and thematic analysis were performed. The coders each coded all four transcripts, following which they met to adjudicate all coding differences until they were in complete agreement on coding.

Results

Several key themes were brought up by older adults utilizing mindfulness as a means of coping with pain, which included overcoming fear of pain ("Before [learning mindfulness], I used to dread pain"), pain awareness ("You're focusing more on being aware than the pain; now that's what helps me"), and pain significance ("It becomes insignificant").

Conclusions

The themes identify several ways mindfulness impacts older adults with cLBP, including decreased negative emotions related to chronic pain such as fear of pain, a different perspective or change in awareness about pain, and reducing the significance of pain.

"It's her body": low-income men's perceptions of limited reproductive agency

OBJECTIVES

While some attention has been paid to men's contraceptive use and attitudes in international contexts, relatively little is known about the attitudes towards contraception and pregnancy of low-income, urban men in the U.S.

STUDY DESIGN

We conducted semi-structured interviews with 58 low-income men in Pittsburgh, PA, to explore their perspectives on contraception, pregnancy, fatherhood, and relationships. We analyzed the interviews using a combination of content analysis, the constant comparison method, and thematic analysis.

RESULTS

Men who we interviewed frequently described feeling that they lacked agency regarding when pregnancies occurred and whether or not they became fathers. Several factors contributed to their sense of low agency, including the belief that women should control contraception and reproduction, a reluctance to have conversations about contraception in some contexts, a lack of acceptable male-controlled contraceptive methods, experiences with pregnancy-promoting behaviors by women, and fatalistic attitudes towards pregnancy occurrence.

CONCLUSIONS

Many men in our study described perceptions of limited reproductive agency. In describing their lack of agency, men reinforced contemporary gender norms in which the "work" of pregnancy prevention is a woman's responsibility. Responses to men's perceived limited reproductive agency should work towards deconstructing gendered norms in the work of pregnancy prevention and promote shared and mutual gender responsibility over reproduction while also supporting women's reproductive autonomy.

IMPLICATIONS

This study identifies several factors that contribute to low-income men's sense of low reproductive agency and highlights the complexity of acknowledging men's feelings and perceptions about reproductive control in the broader context of gender and power.

Body Image, Attractiveness, and Sexual Satisfaction Among Midlife Women: A Qualitative Study

BACKGROUND

Women often undergo physical changes during the menopause transition, but the relationship between body image and sexual function in midlife is unclear. We used a qualitative approach to explore how body image relates to sexual function and satisfaction in midlife women.

MATERIALS AND METHODS

We conducted 19 individual interviews and 3 focus groups (total N = 39) among sexually active women 45-60 years of age using a semistructured guide. Sessions were audiorecorded and transcribed. Two investigators developed a codebook using an iterative process; the primary investigator then coded all data. Codes relating to body image were examined to identify key themes.

RESULTS

The mean age was 58 (range 46-59); 54% were White, 36% Black, and 10% were of another race. Most (72%) were peri- or postmenopausal. All but two women identified as heterosexual. Feeling attractive was an important reason for sexual activity. Changes in appearance, especially weight gain and breast changes, were common among these women. Women's body image impacted their sexual satisfaction; women who felt self-conscious about their bodies reported that these concerns had a negative impact on their sexual satisfaction, whereas women who felt confident discussed better sexual satisfaction, even in the face of bodily changes. Black women were more likely to discuss feeling confident than White women.

CONCLUSIONS

Feeling attractive is important to sexual satisfaction in midlife women. Bodily changes, especially weight gain, are common during midlife. While many women are self-conscious about their appearance, some women develop increased self-acceptance. Supporting positive body image may help midlife women maintain sexual satisfaction with aging.

"The Financial Is the Main Issue, It's Not Even the Child": Exploring the Role of Finances in Men's Concepts of Fatherhood and Fertility Intention

Despite demonstrable need, men’s utilization of sexual and reproductive health services remains low. This low utilization may particularly affect low-income men, given the disproportionate prevalence of unintended pregnancy in low-income populations. Bolstering men’s utilization of sexual and reproductive health services requires understanding the services that are most relevant to them. Semistructured interviews about fatherhood, fertility intention, and contraceptive use were conducted with 58 low-income Black and White men in Pittsburgh, Pennsylvania. The interviews were analyzed using content analysis to determine common themes that were most relevant to the men interviewed. The primacy of financial stability emerged as a dominant theme in men’s perceptions of fatherhood readiness, successful fathering, and fertility intentions. However, men had children despite feeling financially unprepared, and their contraceptive use was not always congruent with their stated fertility intentions. Some men described financial services as a feature of family planning services that they would find useful. Because of the salience of financial stability in preparation for fatherhood, integrating financial counseling and job skills training into the context of sexual and reproductive health services could be a useful structural intervention to increase men’s use of family planning services and to provide them with the support they say they need as fathers.

Elimination Kinetics of Prostate-Specific Antigen Serum and Urine

The serum half-life of prostate-specific antigen (PSA) was calculated in 66 patients subsequent to radical prostatectomy. Comparing serum half-life to disease outcome in 37 patients after a minimum follow-up of two years, it was found that PSA serum half-life identifies patients with residual disease earlier and more reliably than the presence or absence of detectable PSA levels postoperatively. It is suggested that residual tumor affects the half-life by contributing to the serum level of PSA. When PSA serum half-life was calculated solely in potentially cured patients, we found a half-life of 1.6 days, which is considerably shorter than in previous reports based on patient populations regardless of the outcome of disease in the follow-up.

To elucidate the route of PSA elimination, serial urine PSA levels were determined before and after radical prostatectomy, revealing strong evidence for the assumption that PSA is not eliminated by the kidneys in its unchanged form.

Patient-Centered Outcomes and Treatment Preferences Regarding Sexual Problems: A Qualitative Study Among Midlife Women

BACKGROUND

Sexual dysfunction is common in midlife women and can have a significant negative impact on quality of life. Although treatments exist, there is little research on which sexual function outcomes and treatments midlife women prefer.

AIM

To better understand the sexual function outcomes that were most important to sexually active women 45 to 60 years old and the types of treatments they would prefer from individual interviews and focus groups.

METHODS

Twenty individual interviews and three focus groups (N = 39) were led by a trained facilitator, audio recorded, and transcribed. Two investigators developed a codebook, and the primary investigator coded all data. A second investigator coded five randomly selected interviews to ensure intercoder reliability. Codes relating to outcomes and treatment preferences were examined to identify central themes.

RESULTS

The mean age was 52.8 years (range = 45-59). When asked what they would want a sexual dysfunction treatment to do, women sought solutions to specific sexual problems: low desire, vaginal pain and dryness, and decreased arousal or ability to achieve orgasm. However, when asked about the most important aspect of their sex life, most women indicated emotional outcomes, such as enhanced intimacy with their partner, were most important to them. Most women preferred behavioral over pharmaceutical treatments, citing concerns about side effects. These women felt that behavioral treatments might be better equipped to address physical and psychological aspects of sexual problems.

CLINICAL IMPLICATIONS

This study highlights the importance of considering not only physical but also emotional outcomes when evaluating and treating sexual dysfunction in midlife women. It also emphasizes the importance of developing behavioral treatments in addition to pharmaceutical treatments.

STRENGTHS AND LIMITATIONS

By using a qualitative approach, this study allowed women the time and space to speak their own words about their experiences with sexuality at midlife. In addition, different racial and ethnic groups and menopausal statuses were represented. Limitations include limited generalizability, as is true for most qualitative research. In addition, although most women did endorse sexual problems, we did not exclude women with no sexual complaints.

CONCLUSIONS

Midlife women value physical and emotional outcomes with regard to sexual function. Many midlife women in this sample expressed a preference for behavioral approaches over pharmaceutical approaches for the treatment of sexual dysfunction. Thomas HN, Hamm M, Hess R, et al. Patient-Centered Outcomes and Treatment Preferences Regarding Sexual Problems: A Qualitative Study Among Midlife Women. J Sex Med 2017;14:1011-1017.

The physical and psychological impact of neurogenic claudication: the patients' perspectives

BACKGROUND

The patient perspective regarding the impact of neurogenic claudication (NC) has not been well studied. The objectives of this study were to determine what is most bothersome among patients with NC and how it impacts their lives and expectations with surgical and non-surgical treatment.

METHODS

Semi-structured telephone interviews were conducted, audio recorded and transcribed verbatim. A thematic analysis categorized key findings based on relative importance and impact on participants.

RESULTS

Twenty-eight individuals participated in this study. Participants were most bothered by the pain of NC, which dramatically impacted their lives. Inability to walk was the dominant functional limitation and this impacted the ability to engage in recreational and social activities. The most surprising finding was how frequently participants reported significant emotional effects of NC.

CONCLUSIONS

From a patients' perspective NC has a significant multidimensional effects with pain, limited walking ability and emotional effects being most impactful to their lives.

Readiness to Implement an Evidence-Based Psychotherapy: Perspectives of Community Mental Health Clinicians and Administrators

OBJECTIVE

Using evidence-based psychotherapies in community mental health clinics could significantly improve patient functioning. This study explored perceived facilitators and barriers related to implementing interpersonal and social rhythm therapy (IPSRT), an evidence-based psychotherapy for bipolar disorder.

METHODS

The authors conducted 30-minute semistructured interviews with clinic administrators, supervisors, and clinicians from five community mental health clinics focusing on anticipated barriers and facilitators related to implementing IPSRT.

RESULTS

Seventeen participants (four administrators, three supervisors, and ten clinicians) completed the interviews. Important barriers to effective implementation included frequent client no-shows, difficulties transitioning from training to practice, and time constraints. Facilitators included support from supervisors and other clinicians, decreased productivity requirements or compensation for time spent while learning IPSRT, and reference materials.

CONCLUSIONS

Administrators and clinicians expressed similar beliefs about facilitators and barriers related to implementing IPSRT. The challenge of high no-show rates was not identified as a barrier in previous research.

COMETARY SCIENCE. The structure of the regolith on 67P/Churyumov-Gerasimenko from ROLIS descent imaging

The structure of the upper layer of a comet is a product of its surface activity. The Rosetta Lander Imaging System (ROLIS) on board Philae acquired close-range images of the Agilkia site during its descent onto comet 67P/Churyumov-Gerasimenko. These images reveal a photometrically uniform surface covered by regolith composed of debris and blocks ranging in size from centimeters to 5 meters. At the highest resolution of 1 centimeter per pixel, the surface appears granular, with no apparent deposits of unresolved sand-sized particles. The thickness of the regolith varies across the imaged field from 0 to 1 to 2 meters. The presence of aeolian-like features resembling wind tails hints at regolith mobilization and erosion processes. Modeling suggests that abrasion driven by airfall-induced particle "splashing" is responsible for the observed formations.