Implementing Telestroke in the Inpatient Setting: Identifying Factors for Success.

BACKGROUND: Inpatient telestroke programs have emerged as a solution to provide timely stroke care in underserved areas, but their successful implementation and factors influencing their effectiveness remain underexplored. This study aimed to qualitatively evaluate the perspectives of inpatient clinicians located at spoke hospitals participating in a newly established inpatient telestroke program to identify implementation barriers and facilitators. METHODS: This was a formative evaluation relying on semistructured qualitative interviews with 16 inpatient providers (physicians and nurse practitioners) at 5 spoke sites of a hub-and-spoke inpatient telestroke program. The Integrated-Promoting Action on Research Implementation in Health Services framework guided data analysis, focusing on the innovation, recipients, context, and facilitation aspects of implementation. Interviews were transcribed and coded using thematic analysis. RESULTS: Fifteen themes were identified in the data and mapped to the Integrated-Promoting Action on Research Implementation in Health Services framework. Themes related to the innovation (the telestroke program) included easy access to stroke specialists, the benefits of limiting patient transfers, concerns about duplicating tests, and challenges of timing inpatient telestroke visits and notes to align with discharge workflow. Themes pertaining to recipients (care team members and patients) were communication gaps between teams, concern about the supervision of inpatient telestroke advanced practice providers and challenges with nurse empowerment. With regard to the context (hospital and system factors), providers highlighted familiarity with telehealth technologies as a facilitator to implementing inpatient telestroke, yet highlighted resource limitations in smaller facilities. Facilitation (program implementation) was recognized as crucial for education, standardization, and buy-in. CONCLUSIONS: Understanding barriers and facilitators to implementation is crucial to determining where programmatic changes may need to be made to ensure the success and sustainment of inpatient telestroke services.

Impact of different cover letter content and incentives on non-response bias in a sample of Veterans applying for Department of Veterans Affairs disability benefits: a randomized, 3X2X2 factorial trial.

BACKGROUND: Non-random non-response bias in surveys requires time-consuming, complicated, post-survey analyses. Our goal was to see if modifying cover letter information would prevent non-random non-response bias altogether. Our secondary goal tested whether larger incentives would reduce non-response bias. METHODS: A mailed, survey of 480 male and 480 female, nationally representative, Operations Enduring Freedom, Iraqi Freedom, or New Dawn (OEF/OIF/OND) Veterans applying for Department of Veterans Affairs (VA) disability benefits for posttraumatic stress disorder (PTSD). Cover letters conveyed different information about the survey's topics (combat, unwanted sexual attention, or lifetime and military experiences), how Veterans' names had been selected (list of OEF/OIF/OND Veterans or list of Veterans applying for disability benefits), and what incentive Veterans would receive ($20 or $40). The main outcome, non-response bias, measured differences between survey respondents' and sampling frame's characteristics on 8 administrative variables, including Veterans' receipt of VA disability benefits and exposure to combat or military sexual trauma. Analysis was intention to treat. We used ANOVA for factorial block-design, logistic, mixed-models to assess bias and multiple imputation and expectation-maximization algorithms to assess potential missing mechanisms (missing completely at random, missing at random, or not random) of two self-reported variables: combat and military sexual assault. RESULTS: Regardless of intervention, men with any VA disability benefits, women with PTSD disability benefits, and women with combat exposure were over-represented among respondents. Interventions explained 0.0 to 31.2% of men's variance and 0.6 to 30.5% of women's variance in combat non-response bias and 10.2 to 43.0% of men's variance and 0.4 to 31.9% of women's variance in military sexual trauma non-response bias. Non-random assumptions showed that men's self-reported combat exposure was overestimated by 19.0 to 28.8 percentage points and their self-reported military sexual assault exposure was underestimated by 14.2 to 28.4 percentage points compared to random missingness assumptions. Women's self-reported combat exposure was overestimated by 8.6 to 10.6 percentage points and military sexual assault exposure, by 1.2 to 6.9 percentage points. CONCLUSIONS: Our interventions reduced bias in some characteristics, leaving others unaffected or exacerbated. Regardless of topic, researchers are urged to present estimates that include all three assumptions of missingness.

Effects of patient-reported outcome assessment order.

BACKGROUND: In clinical trials and clinical practice, patient-reported outcomes are almost always assessed using multiple patient-reported outcome measures at the same time. This raises concerns about whether patient responses are affected by the order in which the patient-reported outcome measures are administered. METHODS: This questionnaire-based study of order effects included adult cancer patients from five cancer centers. Patients were randomly assigned to complete questionnaires via paper booklets, interactive voice response system, or tablet web survey. Linear Analogue Self-Assessment, Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events, and Patient-Reported Outcomes Measurement Information System assessment tools were each used to measure general health, physical function, social function, emotional distress/anxiety, emotional distress/depression, fatigue, sleep, and pain. The order in which the three tools, and domains within tools, were presented to patients was randomized. Rates of missing data, scale scores, and Cronbach's alpha coefficients were compared by the order in which they were assessed. Analyses included Cochran-Armitage trend tests and mixed models adjusted for performance score, age, sex, cancer type, and curative intent. RESULTS: A total of 1830 patients provided baseline patient-reported outcome assessments. There were no significant trends in rates of missing values by whether a scale was assessed earlier or later. The largest order effect for scale scores was due to a large mean score at one assessment time point. The largest difference in Cronbach's alpha between the versions for the Patient-Reported Outcomes Measurement Information System scales was 0.106. CONCLUSION: The well-being of a cancer patient has many different aspects such as pain, fatigue, depression, and anxiety. These are assessed using a variety of surveys often collected at the same time. This study shows that the order in which the different aspects are collected from the patient is not important.

The impact of survey mode on the response rate in a survey of the factors that influence Minnesota physicians' disclosure practices.

BACKGROUND: There is evidence that the physician response rate is declining. In response to this, methods for increasing the physician response rate are currently being explored. This paper examines the response rate and extent of non-response bias in a mixed-mode study of Minnesota physicians. METHODS: This mode experiment was embedded in a survey study on the factors that influence physicians' willingness to disclose medical errors and adverse events to patients and their families. Physicians were randomly selected from a list of licensed physicians obtained from the Minnesota Board of Medical Practice. Afterwards, they were randomly assigned to either a single-mode (mail-only or web-only) or mixed-mode (web-mail or mail-web) design. Differences in response rate and nonresponse bias were assessed using Fischer's Exact Test. RESULTS: The overall response rate was 18.60%. There were no statistically significant differences in the response rate across modes (p - value = 0.410). The non-response analysis indicates that responders and non-responders did not differ with respect to speciality or practice location. CONCLUSIONS: The mode of administration did not affect the physician response rate.

Barriers to Care and Health Care Utilization Among the Publicly Insured.

BACKGROUND: Although the Affordable Care Act has been successful in expanding Medicaid to >17 million people, insurance alone may not translate into access to health care. Even among the insured, substantial barriers to accessing services inhibit health care utilization. OBJECTIVES: We examined the effect of selected barriers to health care access and the magnitude of those barriers on health care utilization. RESEARCH DESIGN: Data come from a 2008 survey of adult enrollees in Minnesota's public health care programs. We used multivariate logistic regression to estimate the effects of perceived patient, provider, and system-level barriers on past year delayed, foregone, and lack of preventive care. SUBJECTS: A total of 2194 adults enrolled in Minnesota Health Care Programs who were mostly female (66%), high school graduates (76%), unemployed (62%), and living in metro areas (67%) were included in the analysis. RESULTS: Reporting problems across all barriers increased the odds of delayed care from 2 times for provider-related barriers (OR=2.0; 95% CI, 1.2-3.3) to >6 times for access barriers (OR=6.2; 95% CI, 3.8-10.2) and foregone care from 2.6 times for family/work barriers (OR=2.6; 95% CI, 1.3-5.1) to >7 times for access barriers (OR=7.1; 95% CI, 3.9-13.1). Perceived discrimination was the only barrier consistently associated with all 3 utilization outcomes. CONCLUSIONS: Multiple types of barriers are associated with delayed and foregone care. System-level barriers and discrimination have the greatest effect on health care seeking behavior.

Incentive and Reminder Strategies to Improve Response Rate for Internet-Based Physician Surveys: A Randomized Experiment.

BACKGROUND: Most research on how to enhance response rates in physician surveys has been done using paper surveys. Uncertainties remain regarding how to enhance response rates in Internet-based surveys. OBJECTIVE: To evaluate the impact of a low-cost nonmonetary incentive and paper mail reminders (formal letter and postcard) on response rates in Internet-based physician surveys. METHODS: We executed a factorial-design randomized experiment while conducting a nationally representative Internet-based physician survey. We invited 3966 physicians (randomly selected from a commercial database of all licensed US physicians) via email to complete an Internet-based survey. We used 2 randomly assigned email messages: one message offered a book upon survey completion, whereas the other did not mention the book but was otherwise identical. All nonrespondents received several email reminders. Some physicians were further assigned at random to receive 1 reminder via paper mail (either a postcard or a letter) or no paper reminder. The primary outcome of this study was the survey response rate. RESULTS: Of the 3966 physicians who were invited, 451 (11.4%) responded to at least one survey question and 336 (8.5%) completed the entire survey. Of those who were offered a book, 345/2973 (11.6%) responded compared with 106/993 (10.7%) who were not offered a book (odds ratio 1.10, 95% CI 0.87-1.38, P=.42). Regarding the paper mail reminder, 168/1572 (10.7%) letter recipients, 148/1561 (9.5%) postcard recipients, and 69/767 (9.0%) email-only recipients responded (P=.35). The response rate for those receiving letters or postcards was similar (odds ratio 1.14, 95% CI 0.91-1.44, P=.26). CONCLUSIONS: Offering a modest nonmonetary incentive and sending a paper reminder did not improve survey response rate. Further research on how to enhance response rates in Internet-based physician surveys is needed.

The Perception of Female Smokers with Fibromyalgia on the Effects of Smoking on Fibromyalgia Symptoms.

OBJECTIVE: Smokers with fibromyalgia have greater pain intensity and function impairment compared to nonsmokers. Patients' perceptions of interactions between smoking and fibromyalgia symptoms have not been described. The primary aim of this study was to report the perceptions of female smokers with fibromyalgia on how smoking affects symptoms. METHODS: Forty-eight daily smokers with fibromyalgia enrolled in the Mayo Clinic Fibromyalgia Treatment Center completed the Fibromyalgia Impact Questionnaire, Fagerstrom Test for Nicotine Dependence, Patient Health Questionnaire-9, General Anxiety Disorder-7 and a Fibromyalgia Symptoms and Smoking Survey which queried how smoking directly affected fibromyalgia symptoms (eg, pain, tiredness/fatigue, stiffness, nervousness/anxiety, depression/blueness, irritability, concentration, and overall) or indirectly as a coping mechanism. RESULTS: The majority of subjects reported smoking had no direct effect on fibromyalgia physical symptoms (pain [60% reported no effect], fatigue [56%], stiffness [81%]) but direct improvement of emotional symptoms (anxiety [62% reported improvement], irritability [64%]). The majority of subjects used smoking to cope with pain (69%) via distraction (83%) and relaxation (77%), lessening emotional distress by reducing a sense of frustration (83%) or sadness (54%) because of pain, and as a justification for resting vis-à-vis "smoke breaks" (69%). Thirty-one smokers were mildly and 17 moderately/severely dependent on tobacco, and no difference in fibromyalgia impact score (P = 0.70), pain (P = 0.39), depression (P = 0.20), and anxiety (P = 0.64) scores were detected, but more moderately/severely dependent subjects reported smoking improved pain (50% vs. 17%, P = 0.04). DISCUSSION: Smokers with fibromyalgia reported smoking helped to cope with fibromyalgia pain but generally did not directly ameliorate fibromyalgia physical symptoms.

Propensity score matching to measure the effect of survey mode on reports of racial and ethnic discrimination in health care.

OBJECTIVE: To examine the effect of survey mode (mail vs. telephone) on the likelihood of reporting health care-related discrimination based on race, ethnicity, or nationality. METHODS: We use data from a mixed-mode, mail and telephone survey of public health care program enrollees (N=2807), including Somali, Hmong, African American, American Indian, and Latino populations. Self-reported discrimination was measured as the experience of unfair treatment by health care providers due to race, ethnicity, or nationality. We use propensity score matching to create exchangeable groups of phone and mail respondents based on the probability of completing the survey by phone. RESULTS: Overall, 33.1% of respondents reported having experienced discrimination in health care, but only 23.6% of telephone respondents reported discrimination compared with 36.8% of mail respondents. After matching phone and mail respondents based on probability of responding by telephone, all observable significant differences between respondents that were brought about by differential self-selection into mode were erased, allowing us to estimate the effect of survey mode on report of discrimination. Even after matching, the mode effect remains, where report of health care discrimination for telephone respondents would have been 12.6 percentage points higher had they responded by mail (22.6% vs. 35.2%). CONCLUSIONS: Survey mode has a significant effect on report of discrimination. Respondents may be more willing to disclose experiences of discrimination in a mail survey than to a telephone interviewer. Findings have substantial policy and clinical significance as variation in report of discrimination based on mode may lead to underestimation of the extent of the problem.

A national survey of radiation oncologists and urologists on recommendations of prostate-specific antigen screening for prostate cancer.

OBJECTIVE: To assess recommendations for prostate-specific antigen (PSA) screening in a national survey of radiation oncologists and urologists following the recent USA Preventive Services Task Force (USPSTF) grade D recommendation. METHODS: A random sample of 1366 radiation oncologists and urologists were identified from the American Medical Association Physician Masterfile. From November 2011 to April 2012, a mail survey was sent to query PSA screening recommendations for men at average risk of prostate cancer for the following age groups: 40-49, 50-59, 60-69, 70-74, 75-79 and ≥80 years. Multivariable logistic regression was used to test for differences in PSA-based screening recommendations by physician characteristics. RESULTS: Response rates were similar at 52% for radiation oncologists and urologists (P = 0.92). Overall, 51.5% of respondents recommended PSA-based screening for men aged 40-49 years, while nearly all endorsed it for those aged 50-74 years (96.1% for 50-59, 97.3% for 60-69, and 87.7% for 70-74 years). However, screening recommendations decreased to 43.9% and 12.8% for men aged 75-79 and ≥80 years, respectively. On multivariable analysis, urologists were more likely to recommend screening for men aged 40-49 (odds ratio [OR] 3.09; P < 0.001) and 50-59 years (OR 3.81; P = 0.01), but less likely for men aged 75-79 (OR 0.66; P = 0.01) and ≥80 years (OR 0.45; P = 0.002) compared with radiation oncologists. CONCLUSION: While radiation oncologists and urologists recommended PSA screening for men aged 50-69 years, there was less agreement about screening for younger (40-49 years old) and older (≥70 years) men at average risk for prostate cancer.

Survey mode and asking about future intentions did not impact self-reported colorectal cancer screening accuracy.

BACKGROUND: Self-reported colorectal cancer (CRC) screening behavior is often subject to over-reporting bias. We examined how the inclusion of a future intention to screen item (viz. asking about future intentions to get screened before asking about past screening) and mode of survey administration impacted the accuracy of self-reported CRC screening. METHODS: The target population was men and women between 49 and 85 years of age who lived in Olmsted County, MN, for at least 10 years at the time of the study. Eligible residents were randomized into four groups representing the presence or absence the future intention to screen item in the questionnaire and administration mode (mail vs. telephone). A total of 3,638 cases were available for analysis with 914, 838, 956, and 930 in the mail/future intention, mail/no future intention, telephone/future intention, and telephone/no future intention conditions, respectively. False positives were defined as self-reporting being screened among those with no documented history of screening in medical records and false negatives as not self-reporting screening among those with history of screening. RESULTS: Comparing false positive and false negative reporting rates for each specific screening test among the responders at the bivariate level, regardless of mode, there were no statistically significant differences by the presence or absence of a preceding future intention question. When considering all tests combined, the percentage of false negatives within the telephone mode was slightly higher for those with the future intention question (6.7% vs 4.2%, p = 0.04). Multivariate models that considered the independent impact of the future intention question and mode, affirmed the results observed at the bivariate level. However, individuals in the telephone arm (compared to mail) were slightly (though not significantly) more likely to report a false positive (36.4% vs 31.8%, OR = 1.11, p = 0.55). CONCLUSION: It may be that in the context of a questionnaire that is clearly focused on CRC and with specific descriptions of the various CRC screening tests, certain design features such as including intention to screen items or mode of administration will have very little impact on the accuracy of self-reported CRC screening.

Health-related quality of life in children and young adults with post-thrombotic syndrome: results from a cross-sectional study.

OBJECTIVE: While post-thrombotic syndrome (PTS) is increasingly recognized in children with a history of deep vein thrombosis (DVT), its impact on the health-related quality of life (HRQoL) is unknown. Our objective was to evaluate the association between the PTS and HRQoL by surveying a cohort of patients treated at our institution for DVT. MATERIALS/METHODS: All unique pediatric patients (0-18 years) treated for a DVT at the Mayo Clinic during the 15-year period, 1995-2009 were identified. A previously validated PTS survey instrument and age appropriate Pediatric Quality of Life inventory, version 4 (PedsQL 4.0) were mailed to eligible patients. Linear regression models were fit to compare the HRQoL scores between PTS groups (none, mild, moderate/severe), after adjusting for the presence of potential covariates. RESULTS: Of the 90 respondents, 65 (72%) reported signs and/or symptoms of PTS. Mean age (± SD) at DVT diagnosis and survey completion were 12.8 (± 6.1) and 19.3 (± 7.7) years, respectively. Self-report PedsQL 4.0 module was completed by 79 patients, and 34 guardians completed the parent-proxy module. Patients with moderate to severe PTS reported significantly worse total HRQoL score (mean ± SD, 71.3 ± 13.4) as compared to patients with mild PTS (84.8 ± 14.2) and no PTS (83.4 ± 14) (P = 0.001). CONCLUSION: Moderate to severe PTS has a significant impact on self-reported HRQoL as measured using the generic PedsQL 4.0. Further research is warranted to develop a venous disease-specific quality of life measure for children with a history of DVT.

Screening for Barrett's esophagus: results from a population-based survey.

BACKGROUND: Screening for Barrett's esophagus (BE) and adenocarcinoma (EAC) is controversial, but interest remains in finding the optimal method. Attitudes on screening within the community are unknown. We aimed to assess these attitudes via a survey. STUDY: A mixed-mode survey was conducted in adults >50 years to assess awareness regarding BE, willingness to participate in screening, and preferences regarding method of screening. Methods evaluated were sedated endoscopy (sEGD), unsedated transnasal endoscopy (uTNE) and video capsule (VCE). RESULTS: A total of 136 from 413 (33%) adults responded [47% males, mean (SD) age 63 (10.2) years], and 26% of responders knew of BE at baseline. After reading the information on BE, 72% were interested in screening. A history of undergoing screening tests and GI symptoms were predictive of interest. Unsedated techniques were preferred by 64% (VCE: 56% and uTNE: 8%) versus sEGD (36%). CONCLUSIONS: The majority of adults were willing to undergo screening for BE/EAC, with a preference for unsedated techniques.

An observational study of emergency department utilization among enrollees of Minnesota Health Care Programs: financial and non-financial barriers have different associations.

BACKGROUND: Emergency department (ED) use is costly, and especially frequent among publicly insured populations in the US, who also disproportionately encounter financial (cost/coverage-related) and non-financial/practical barriers to care. The present study examines the distinct associations financial and non-financial barriers to care have with patterns of ED use among a publicly insured population. METHODS: This observational study uses linked administrative-survey data for enrollees of Minnesota Health Care Programs to examine patterns in ED use-specifically, enrollee self-report of the ED as usual source of care, and past-year count of 0, 1, or 2+ ED visits from administrative data. Main independent variables included a count of seven enrollee-reported financial concerns about healthcare costs and coverage, and a count of seven enrollee-reported non-financial, practical barriers to access (e.g., limited office hours, problems with childcare). Covariates included health, health care, and demographic measures. RESULTS: In multivariate regression models, only financial concerns were positively associated with reporting ED as usual source of care, but only non-financial barriers were significantly associated with greater ED visits. Regression-adjusted values indicated notable differences in ED visits by number of non-financial barriers: zero non-financial barriers meant an adjusted 78% chance of having zero ED visits (95% C.I.: 70.5%-85.5%), 15.9% chance of 1(95% C.I.: 10.4%-21.3%), and 6.2% chance (95% C.I.: 3.5%-8.8%) of 2+ visits, whereas having all seven non-financial barriers meant a 48.2% adjusted chance of zero visits (95% C.I.: 30.9%-65.6%), 31.8% chance of 1 visit (95% C.I.: 24.2%-39.5%), and 20% chance (95% C.I.: 8.4%-31.6%) of 2+ visits. CONCLUSIONS: Financial barriers were associated with identifying the ED as one's usual source of care but non-financial barriers were associated with actual ED visits. Outreach/literacy efforts may help reduce reliance on/perception of ED as usual source of care, whereas improved targeting/availability of covered services may help curb frequent actual visits, among publicly insured individuals.

Engaging Public Health Alumni in the Tracking of Career Trends: Results From a Large-Scale Experiment on Survey Fielding Mode.

OBJECTIVE: We sought to understand the relative impact of fielding mode on response rate among public health alumni. METHODS: As part of the 2021 Career Trends Survey of alumni from the University of Minnesota School of Public Health, we designed a fielding mode experiment to ascertain whether a paper survey, a postcard with a custom survey link ("postcard push-to-web"), a mobile telephone call or text (mobile), or an email invitation would garner the highest response rates. Invitations were randomly assigned from available contact information. RESULTS: Of 8531 alumni invited, 1671 alumni (19.6%) completed the survey. Among the initial fielding modes, the paper survey had the highest response rate (28%), followed by mobile (19%), email (10%), and postcard push-to-web (10%). More robust recent engagement with alumni relations, paper survey invitation or mode switch, and recent graduation were all significantly associated with a higher likelihood of response. CONCLUSIONS: Paper and mobile invitations had the highest response rates to our survey among public health alumni. Findings from this fielding mode experiment are relevant to schools and programs of public health seeking to capture similar information among their alumni, especially given current trends in investment in the public health workforce.

Characteristics and co-morbidities associated with hospital discharges for opioid and methamphetamine co-use, United States 2016-2019.

Introduction: The US overdose crisis is increasingly characterized by opioid and methamphetamine co-use. Hospitalization is an important opportunity to engage patients in substance use treatment. Understanding characteristics of co-use-related hospital stays can inform the development of services to better support this growing patient population. Methods: We used 2016-2019 National Inpatient Sample data to conduct a cross sectional analysis of hospitalizations involving use of opioids, methamphetamine, or both. We used bivariate analysis to compare patient demographics. We then used multinomial logistic regressions to compare the proportion of hospital stays which indicated co-morbid diagnosis. To account for correlated data, we used generalized linear models to compare outcomes in hospital mortality, patient-directed discharge, and length of stay. Results: Co-use-related stays had a higher proportion of co-morbid mental health (60.7%; 95% CI: 59.9-61.4%) and infectious diseases (41.5%; 95% CI: 40.8-42.2%), than opioid- or methamphetamine-related stays. Co-use-related stays increased between 2016 and 2019 and were associated with a higher proportion of patient directed discharge (10.7%; 95% CI: 10.4-11.0%) and longer length of stay (6.3 days; 95% CI: 6.2-6.4 days) compared to opioid (8.1%; 95% CI: 7.9-8.3% and 5.8 days; 95% CI: 5.8-5.9 days) and methamphetamine-related stays (6.5%; 95% CI: 6.3-6.6% and 5.5 days; 95% CI: 5.4-5.5 days). Conclusion: Patients discharged with co-use differ from patients with opioid or methamphetamine use alone, representing a range of challenges and opportunities. In addition to offering treatment for both substance use disorders, hospital-based services that address co-occurring conditions may better support patients with co-use through targeted and tailored approaches.

Evaluation of a Clinical Decision Support Tool to Guide Adoption of the American Heart Association Telemetry Monitoring Practice Standards.

BACKGROUND: The objectives of this study were to (1) evaluate telemetry use pre- and postimplementation of clinical decision support tools to support American Heart Association practice standards for telemetry monitoring and (2) understand the factors that may contribute to variation of telemetry monitoring in practice. METHODS AND RESULTS: First, we captured overall variability in telemetry use pre- and postimplementation of the clinical decision support intervention. We then conducted semistructured interviews with telemetry-ordering providers to identify key barriers and facilitators to adoption. During the study period, 399 physicians met criteria for inclusion and were divided into excessive and nonexcessive orderers. Distribution of telemetry use was bimodal. Among nonexcessive users, 24.4% of patient days were with telemetry compared with 51.6% among excessive users. On average, both excessive (6.1% reduction) and nonexcessive users (2.8% reduction) decreased telemetry use postimplementation, and these reductions were sustained over a 16-month period. Sixteen interviews were conducted. Physicians believed that the tool was successful because it caused them to more closely consider if telemetry was indicated for each patient. Physicians also voiced frustration with interruptions to their workflow, and some noted that they commonly use telemetry outside of practice standards to monitor patients who were acutely but not critically ill. CONCLUSIONS: Embedding telemetry practice standards into the electronic health record in the form of clinical decision support is effective at reducing excess telemetry use. Although the intervention was well received, there are persistent barriers, such as preexisting views on telemetry and existing workflow habits, that may inhibit higher adoption of standards.

Providers' Experiences and Perspectives in Treating Patients With Co-Occurring Opioid and Stimulant Use Disorders in the Hospital.

BACKGROUND: The overdose crisis is increasingly characterized by opioid and stimulant co-use. Despite effective pharmacologic treatment for both opioid use disorder (OUD) and contingency management for stimulant use disorders, most individuals with these co-occurring conditions are not engaged in treatment. Hospitalization is an important opportunity to engage patients and initiate treatment, however existing hospital addiction care is not tailored for patients with co-use and may not meet the needs of this population. METHODS: Semi-structured interviews were conducted with hospital providers about their experiences and perspectives treating patients with opioid and stimulant co-use. We used directed content analysis to identify common experiences and opportunities to improve hospital-based treatment for patients with co-use. RESULTS: From qualitative interviews with 20 providers, we identified 4 themes describing how co-use complicated hospital-based substance use treatment: (1) patients' unstable circumstances impacting the treatment plan, (2) co-occurring withdrawals are difficult to identify and treat, (3) providers holding more stigmatizing views of patients with co-use, and (4) stimulant use is often "ignored" in the treatment plans. Participants also described a range of potential opportunities to improve hospital-based treatment of co-use that fall into 3 categories: (1) provider practice changes, (2) healthcare system changes, and (3) development and validation of clinical tools and treatment approaches. CONCLUSIONS: We identified unique challenges providing hospital addiction medicine care to patients who use both opioids and stimulants. These findings inform the development, implementation, and testing of hospital-based interventions for patients with co-use.

A brief Patient-Reported Outcomes Quality of Life (PROQOL) instrument to improve patient care.

Jeff Sloan and colleagues describe the development of the Patient-Reported Outcomes Quality of Life (PROQOL) instrument, which captures and stores patient-recorded outcomes in the medical record for patients with diabetes. Please see later in the article for the Editors' Summary.

Clinical implementation of quality of life instruments and prediction tools for localized prostate cancer: results from a national survey of radiation oncologists and urologists.

PURPOSE: Although clinical guidelines recommend assessing quality of life, cancer aggressiveness and life expectancy for making localized prostate cancer treatment decisions, it is unknown whether instruments that objectively measure such outcomes have disseminated into clinical practice. In this context we determined whether quality of life and prediction instruments for prostate cancer have been adopted by radiation oncologists and urologists in the United States. MATERIALS AND METHODS: Using a nationally representative mail survey of 1,422 prostate cancer specialists in the United States, we queried about self-reported clinical implementation of quality of life instruments, prostate cancer nomograms and life expectancy prediction tools in late 2011. The Pearson chi-square test and multivariate logistic regression were used to determine differences in the use of each instrument by physician characteristics. RESULTS: A total of 313 radiation oncologists and 328 urologists completed the survey for a 45% response rate. Although 55% of respondents reported using prostate cancer nomograms, only 27% and 23% reported using quality of life and life expectancy prediction instruments, respectively. On multivariate analysis urologists were less likely to use quality of life instruments than radiation oncologists (OR 0.40, p <0.001). Physicians who spent 30 minutes or more counseling patients were consistently more likely to use quality of life instruments (OR 2.57, p <0.001), prostate cancer nomograms (OR 1.83, p = 0.009) and life expectancy prediction tools (OR 1.85, p = 0.02) than those who spent less than 15 minutes. CONCLUSIONS: Although prostate cancer nomograms have been implemented into clinical practice to some degree, the use of quality of life and life expectancy tools has been more limited. Increased attention to implementing validated instruments into clinical practice may facilitate shared decision making for patients with prostate cancer.

An assessment of incentive versus survey length trade-offs in a Web survey of radiologists.

BACKGROUND: It is generally understood that shorter Web surveys and use of incentives result in higher response rates in Web surveys directed to health care providers. Less is known about potential respondent preference for reduced burden as compared to increased reward. OBJECTIVE: To help elicit preference for minimized burden compared to reward for completion of a survey, we observed physician preferences for shorter Web surveys compared to incentives as well as incentive preference (small guaranteed incentive compared to larger lottery incentive) accompanying an electronic request to complete a survey. METHODS: This was an observational study that accompanied a large Web survey study of radiology staff, fellows, and residents at select academic medical centers in the United States. With the request to complete the survey, potential respondents were offered three options: (1) a 10-minute Web survey with the chance to win an iPad, (2) a 10-minute Web survey with a guaranteed nominal incentive ($5 amazon.com gift card), or (3) a shorter (5-7 minute) Web survey with no incentive. A total of 254 individuals responded to the Web survey request. RESULTS: Overwhelmingly, individuals chose a longer survey accompanied by an incentive compared to a shorter survey with no incentive (85% compared to 15%, P<.001). Of those opting for an incentive, a small, but not significant majority chose the chance to win an iPad over a guaranteed $5 gift card (56% compared to 44%). CONCLUSIONS: When given the choice, radiologists preferred a reward (either guaranteed or based on a lottery) to a less burdensome survey, indicating that researchers should focus more attention at increasing perceived benefits of completing a Web survey compared to decreasing perceived burden.