Facilitators and barriers to post-discharge pain assessment and triage: a qualitative study of nurses' and patients' perspectives.

BACKGROUND: After hospital discharge, patients can experience symptoms prompting them to seek acute medical attention. Early evaluation of patients' post-discharge symptoms by healthcare providers may improve appropriate healthcare utilization and patient safety. Post-discharge follow-up phone calls, which are used for routine transitional care in U.S. hospitals, serve as an important channel for provider-patient communication about symptoms. This study aimed to assess the facilitators and barriers to evaluating and triaging pain symptoms in cardiovascular patients through follow-up phone calls after their discharge from a large healthcare system in Central Massachusetts. We also discuss strategies that may help address the identified barriers. METHODS: Guided by the Practical, Robust, Implementation and Sustainability Model (PRISM), we completed semi-structured interviews with 7 nurses and 16 patients in 2020. Selected nurses conducted (or supervised) post-discharge follow-up calls on behalf of 5 clinical teams (2 primary care; 3 cardiology). We used thematic analysis to identify themes from interviews and mapped them to the domains of the PRISM model. RESULTS: Participants described common facilitators and barriers related to the four domains of PRISM: Intervention (I), Recipients (R), Implementation and Sustainability Infrastructure (ISI), and External Environment (EE). Facilitators include: (1) patients being willing to receive provider follow-up (R); (2) nurses experienced in symptom assessment (R); (3) good care coordination within individual clinical teams (R); (4) electronic health record system and call templates to support follow-up calls (ISI); and (5) national and institutional policies to support post-discharge follow-up (EE). Barriers include: (1) limitations of conducting symptom assessment by provider-initiated follow-up calls (I); (2) difficulty connecting patients and providers in a timely manner (R); (3) suboptimal coordination for transitional care among primary care and cardiology providers (R); and (4) lack of emphasis on post-discharge follow-up call reimbursement among cardiology clinics (EE). Specific barriers for pain assessment include: (1) concerns with pain medication misuse (R); and (2) no standardized pain assessment and triage protocol (ISI). CONCLUSIONS: Strategies to empower patients, facilitate timely patient-provider communication, and support care coordination regarding pain evaluation and treatment may reduce the barriers and improve processes and outcomes of pain assessment and triage.

Individual vs. Group Delivery of Acupuncture Therapy for Chronic Musculoskeletal Pain in Urban Primary Care-a Randomized Trial.

BACKGROUND: Acupuncture has been shown to be effective for the treatment of chronic musculoskeletal back, neck, and osteoarthritis pain. However, access to acupuncture treatment has been limited in medically underserved and low-income populations. OBJECTIVE: Acupuncture therapy delivered in groups could reduce cost and expand access. We compared the effectiveness of group versus individual acupuncture for pain and function among ethnically diverse, low-income primary care patients with chronic musculoskeletal pain. DESIGN: This was a randomized comparative effectiveness non-inferiority trial in 6 Bronx primary care community health centers. Participants with chronic (> 3 months) back, neck, or osteoarthritis pain were randomly assigned to individual or group acupuncture therapy for 12 weeks. PARTICIPANTS: Seven hundred seventy-nine participants were randomized. Mean age was 54.8 years. 35.3% of participants identified as black and 56.9% identified as Latino. Seventy-six percent were Medicaid insured, 60% reported poor/fair health, and 37% were unable to work due to disability. INTERVENTIONS: Participants received weekly acupuncture treatment in either group or individual setting for 12 weeks. MAIN MEASURES: Primary outcome was pain interference on the Brief Pain Inventory at 12 weeks; secondary outcomes were pain severity (BPI), physical and mental well-being (PROMIS-10), and opiate use. Outcome measures were collected at baseline, 12 and 24 weeks. KEY RESULTS: 37.5% of individual arm and 30.3% in group had > 30% improvement in pain interference (d = 7.2%, 95% CI - 0.6%, 15.1%). Non-inferiority of group acupuncture was not demonstrated for the primary outcome assuming a margin of 10%. In the responder analysis of physical well-being, 63.1% of individual participants and 59.5% of group had clinically important improvement at 12 weeks (d = 3.6%, 95% CI - 4.2%, 11.4%). CONCLUSIONS: Both individual and group acupuncture therapy delivered in primary care settings reduced chronic pain and improved physical function at 12 weeks; non-inferiority of group was not shown. TRIAL REGISTRATION: Clinicaltrials.gov # NCT02456727.

Group Acupuncture Therapy With Yoga Therapy for Chronic Neck, Low Back, and Osteoarthritis Pain in Safety Net Settings for an Underserved Population: A Feasibility Pilot Study.

Background: Acupuncture and yoga have both been shown to be effective in chronic pain. Underrepresented populations have poorer pain outcomes with less access to effective pain care. Objective: To assess the feasibility of bundling group acupuncture with yoga therapy for chronic neck, back or osteoarthritis pain in safety net settings. Methods: This was a feasibility pilot in Bronx and Harlem primary care community health centers. Participants with chronic neck, back or osteoarthritis pain received acupuncture and yoga therapy over a 10-week period. Participants received 10 weekly acupuncture treatments in group setting; with Yoga therapy sessions beginning immediately following the 3rd session. Primary outcome was pain interference and pain intensity on the Brief Pain Inventory (BPI); Outcomes were measured at baseline, 10-week close of intervention, and 24-week follow-up. Results: 93 patients were determined to be eligible and completed the baseline interview. The majority of participants were non-White and Medicaid recipients. 78 (84%) completed the intervention and 10-week survey, and 58 (62%) completed the 24-week post intervention survey. Participants received an average number of 6.5 acupuncture sessions (out of a possible 10), and 4 yoga sessions (out of a possible 8) over the 10-week intervention. Patients showed statistically significant improvements in pain at the close of the intervention and at a somewhat lesser rate, at 24-weeks post intervention. Challenges included telephone outreach and site coordination integrating acupuncture with yoga therapy. The trial also had to be stopped early due to the COVID-19 pandemic. Conclusions: Bundling acupuncture therapy and yoga therapy is feasible for an underrepresented population with chronic pain in urban community health centers with preliminary indications of acceptability and benefit to participants.

Patient-centred models of hepatitis C treatment for people who inject drugs: a multicentre, pragmatic randomised trial.

BACKGROUND: To achieve WHO targets for the elimination of hepatitis C virus (HCV) as a public threat, an increased uptake of HCV treatment among people who inject drugs (PWID) is urgently needed. Optimal HCV co-located treatment models for PWID have not yet been identified. We aimed to compare two patient-centred models of HCV care in PWID with active drug use. METHODS: We did a pragmatic randomised controlled trial at eight US cities in eight opioid treatment programmes and 15 community health centres. PWID actively injecting within 90 days of study entry were randomly assigned (1:1) to either patient navigation or modified directly observed therapy (mDOT) using computer-generated variable block sizes of 2-6 stratified by city, clinical settings, and cirrhosis status. The randomisation code was concealed, in a centralised REDCap database platform, from all investigators and research staff except for an authorised data manager at the data coordinating centre. All participants received a fixed-dose combination tablet (sofosbuvir 400 mg plus velpatasvir 100 mg) orally once daily for 12 weeks. The primary outcome was sustained virological response (SVR; determined by chart review between 70 days and 365 days after end of treatment and if unavailable, by study blood draws), and secondary outcomes were treatment initiation, adherence (measured by electronic blister packs), and treatment completion. Analyses were conducted within the modified intention-to-treat (mITT; all who initiated treatment), intention-to-treat (all who were randomised), and per-protocol populations. This trial is registered with ClinicalTrials.gov, NCT02824640. FINDINGS: Between Sept 15, 2016, and Aug 14, 2018, 1891 individuals were screened and 1136 were excluded (213 declined to participate and 923 did not meet the eligibility criteria). We randomly assigned 755 participants to patient navigation (n=379) or mDOT (n=376). In the mITT sample of participants who were randomised and initiated treatment (n=623), 226 (74% [95% CI 69-79]) of 306 participants in the mDOT group and 236 (76% [69-79]) of 317 in the patient navigation group had an SVR, with no significant difference between the groups (adjusted odds ratio [AOR] 0·97 [95% CI 0·66-1·42]; p=0·35). In the ITT sample (n=755), 226 (60% [95% CI 55-65]) of 376 participants in the mDOT group and 236 (62% [57-67]) of 379 in the patient navigation group had an SVR (AOR 0·92 [0·68-1·25]; p=0·61) and in the per-protocol sample (n=501), 226 (91% [87-94]) of 248 participants in the mDOT group and 235 (93% [89-96]) of 253 in the patient navigation group had an SVR (AOR 0·79 [0·41-1·55]; p=0·44). 306 (81%) of 376 participants in the mDOT group and 317 (84%) of 379 participants in the patient navigation group initiated treatment (AOR 0·86 [0·58-1·26]; p=0·44) and, among those, 251 (82%) participants in the mDOT group and 264 (83%) participants in the patient navigation group completed treatment (AOR 0·90 [0·58-1·39]; p=0·63). Mean daily adherence was higher in the mDOT group (78% [95% CI 75-81]) versus the patient navigation group (73% [70-77]), with a difference of 4·7% ([1·9-7·4]; p=0·0010). 421 serious adverse events were reported (217 in the mDOT group and 204 in the patient navigation group), with the most common being hospital admission (176 in the mDOT group vs 161 in the patient navigation group). INTERPRETATION: In this trial of active PWID, both models resulted in high SVR. Although adherence was significantly higher in the mDOT group versus the patient navigation group, there was no significant difference in SVR between the groups. Increases in adherence and treatment completion were associated with an increased likelihood of SVR. These results suggest that active PWID can reach high SVRs in diverse settings with either mDOT or patient navigation support. FUNDING: Patient-Centered Outcomes Research Institute, Gilead Sciences, Quest Diagnostics, Monogram Biosciences, and OraSure Technologies.

Barriers to Prevention and Timely Presentation of Diabetic Foot Ulcers: Perspectives of Patients from a High-risk Urban Population in the United States.

Diabetic foot amputation is a preventable complication that is increasing in incidence in the United States, with disparities across geography, race, ethnicity, and income. This qualitative study explored the experiences of people in a low-income urban area in the United States in preventing and obtaining care for foot ulcers. Sixteen adults with foot ulcers were identified through purposive sampling based on records of hospital stays and primary care visits. Semi-structured interviews were transcribed and analyzed for key themes. Participants described inadequate understanding of diabetic foot disease: many sought care only after developing advanced symptoms. They identified social and health system factors as barriers to timely access to care. Some participants described a realization of the seriousness of their condition and an ability to improve self-care after developing an ulcer. Patients' experiences can inform the design of amputation-reduction initiatives to achieve more desirable results, including enhanced self-management capabilities, timely access, and attention to social determinants.

Developing and employing a 'responsive manualization' in the 'Acupuncture Approaches to Decrease Disparities in Outcomes of Pain Treatment' comparative effectiveness study.

OBJECTIVE: The aim of this article is to describe the process used to develop an acupuncture therapy manual for a large effectiveness trial comparing individual care against group care for chronic pain in an underserved population. The design needed to not only ensure research consistency and replicability but also be 'responsive' to real world heterogeneous and evolving presentations in challenging physical settings. BACKGROUND: Chronic pain is prevalent in the United States. While acupuncture is effective for chronic pain, minority, ethnically diverse and lower socioeconomic populations have limited access. Group acupuncture is proposed as a lower cost option to facilitate access in safety net settings, but research on the effectiveness of group versus individual acupuncture is lacking. METHODS: We engaged a modified Delphi process with expert practitioners from diverse backgrounds who were experienced in individual and group practice. All contributions were recorded and collated for second- and third-round consensus discussions that included contributions by the trial's research acupuncturists. RESULTS: A 'responsive manual' flow chart was created with suggested sequencing that included interviews concurrent with palpation, Tui na, Gua sha, acupuncture needling, ear treatment, basic recommendations and options for departure with rationale. The manual was implemented by six research acupuncturists in five primary care settings in the Bronx, New York, with weekly team meetings to discuss manual use. There were no serious adverse events (AE) and few minor AE reported in this trial. CONCLUSION: A 'responsive manual' can be structured and implemented that is not only consistent and replicable but also flexible to accommodate the real-world clinical needs of practitioners and patients in challenging physical settings.

How to Make or Break Implicit Bias Instruction: Implications for Curriculum Development.

PURPOSE: To analyze faculty experiences regarding facilitating discussions as part of the institution's curriculum on racial and ethnic implicit bias recognition and management. METHOD: Between July 2014 and September 2016, the authors conducted 21 in-depth interviews with faculty who had experience teaching in implicit bias instruction or were interested in facilitating discussions related to implicit bias and the Implicit Association Test. Grounded theory methodology was used to analyze interview transcripts. RESULTS: Participants identified challenges that affect their ability to facilitate instruction in implicit bias. Faculty described the influence of their own background and identities as well as the influence of institutional values on their ability to facilitate implicit bias discussions. They noted the impact of resistant learners and faculty during discussions and made suggestions for institutional measures including the need for implementation of formalized longitudinal implicit bias curricula and faculty development. CONCLUSIONS: Faculty facilitating sessions on implicit bias must attend faculty development sessions to be equipped to deal with some of the challenges they may face. Buy-in from institutional leadership is essential for successful implementation of implicit bias teaching, and medical educators need to consider formalized longitudinal curricula addressing the recognition and management of implicit biases.

"I Felt Like It Was God's Hands Putting the Needles In": A Qualitative Analysis of the Experience of Acupuncture for Chronic Pain in a Low-Income, Ethnically Diverse, and Medically Underserved Patient Population.

OBJECTIVES: To examine the experience of patients from a low-income, ethnically diverse medically underserved population receiving acupuncture for chronic pain. DESIGN: Qualitative analysis using inductive thematic analysis of interviews with participants from an acupuncture trial. SETTINGS/LOCATION: Four community health centers in the Bronx, New York. PARTICIPANTS: Thirty-seven adults with chronic neck or back pain or osteoarthritis who participated in a previous acupuncture trial. INTERVENTIONS: Up to 14 weekly acupuncture treatments. OUTCOME MEASURES: Pain and quality of life were examined in the original trial; this study examines qualitative outcomes. RESULTS: The themes grouped naturally into three domains of the acupuncture experience: the decision-making process, the treatment experience, and the effect of acupuncture on health. Regarding decision-making, important factors were a willingness to try something new even if you do not necessarily "believe" in it or have specifically positive expectations; a sense that medications were not working for their pain, that they also caused significant adverse effects, and that natural strategies might be preferable; and a feeling of desperation. Cost and access were significant barriers to acupuncture treatment. Regarding the process of acupuncture, the open and personal communication with the acupuncturist was an important factor, as were the sense that the process of acupuncture related to a natural process of healing or correction within the body and that part of making acupuncture successful required being open to the power of the mind to generate a positive outcome. Regarding the effect of treatment, notable aspects were the deep sense of rest and relaxation participants reported during treatment as well as the benefit they experienced for conditions other than pain. CONCLUSIONS: The themes that emerged in this ethnically diverse, low-income population were very similar to those that have emerged over the past decade of qualitative research on the acupuncture experience in other patient populations.

Depression and negative life events among pregnant African-American and Hispanic women.

Depression, social support, and life events were assessed in a sample of African-American and Hispanic women (N = 148) with uncomplicated pregnancies. Over half (51%) showed elevated depressive symptoms. Overall, women had fewer social supports and more negative life events than found in previous studies. African-Americans had more practical social support and persons in their support networks than Hispanics. Over a third of the sample (37%) had lost an important person in the past year. Depressed women reported more negative events than nondepressed women. Many negative life events and few social supports place minority women at risk for prenatal depression.

Examining role change in primary care practice.

PURPOSE: While experts suggest that primary care needs far-reaching transformation that includes adding or reconfiguring roles to improve patient care, little is known about how role change occurs in practice settings. Methods This was a cross-case comparative analysis of 3 projects designed to improve health behavior counseling in primary care practices by adding to or changing clinical support staff roles. Qualitative data (site visits notes, grantee reports, interviews with grantees, and online diary entries) were analyzed to examine instances of role change in depth, using role change theory as an organizing framework. Results Practice team members had greater success taking on new roles when patients valued the services provided. Often, it was easier to a hire a new person into a new role rather than have an existing practice member shift responsibilities. This was because new personnel had the structural autonomy, credibility, and organizational support needed to develop new responsibilities and routines. CONCLUSION: As primary care delivery systems are redesigned in ways that rely on new roles to deliver care, understanding how to effectively add or change staff roles is essential and requires attention to patients', practice members', and institutions' support for new roles.

Resident physician interactions with surrogate decision-makers: the resident experience.

This study explored interactions between medical residents and patient surrogates in order to clarify resident understanding of roles and relationships, resident emotional experience, and resident learning processes. Qualitative analysis of in-depth interviews were used involving three family medicine residency programs serving culturally diverse, urban, underserved patient populations. Eighteen second- and third-year trainees described a memorable interaction with a surrogate and then were prompted to discuss their learning experience and their role in the interaction. Interviews were transcribed verbatim and analyzed through an iterative process. Residents experienced significant emotional burden during interactions yet continued to value their relationships with surrogates. Despite their reservations about giving recommendations, residents adopted a variety of roles with surrogates as they gave support, information, and advice. Although residents reported little formal education about surrogate decision-making, they relied on passive role modeling and their own previous experiences to help surrogates make decisions. Residents have complex and emotionally significant interactions with surrogates despite minimal formal education about surrogate decision-making. Educational efforts should seek to help residents understand their own emotions and the ethical beliefs that underlie the roles they adopt with surrogates. This will help residents to facilitate value-based conversations with surrogates and better support surrogates in the decision-making process.

A collaborative approach to control hypertension in diabetes: outcomes of a pilot intervention.

We sought to develop and pilot an intervention to improve blood pressure (BP) and other intermediate outcomes (hemoglobin A1c, low-density lipoprotein cholesterol) of diabetes in a low-income, ethnically diverse population. English- or Spanish-speaking primary care patients with BP ≥ 140/90 on 2 visits in the past 12 months and any level of A1c were randomized to usual care (n = 24) or intervention (n = 31). Home health nurses assessed self-management and medication adherence, and they performed health behavior counseling. Participants transmitted daily BP and glucose results using simple home telemetry units to the nurse coordinator; these results were then aggregated and transmitted weekly to primary care providers to facilitate intensified treatment. After controlling for baseline levels, a significantly larger proportion of the intervention group was at goal for BP (adjusted OR = 9.3, P = .006) and A1c (AOR = 4.3, P = .049), but not for low-density lipoprotein cholesterol (AOR = 1.1, P =.86). Clinicians made more BP medication changes in the intervention group compared to the control group (8.3 vs 3.8, approaching significance at P = .06). Self-reported medication adherence and self-care behaviors were not significantly improved. We successfully developed a telephone- and email-based collaboration between home health nurses and primary care clinicians to address poorly controlled hypertension in an ethnically diverse population. The intervention, combining enhanced feedback to patients and their primary care providers and individualized behavior change support by home health nurses, is effective for improving BP and glucose in this setting.

Testing adolescents for sexually transmitted infections in urban primary care practices: results from a baseline study.

OBJECTIVE: Sexually active urban adolescents experience a high burden of sexually transmitted infections (STI). Adolescents often access medical care through general primary care providers; their time alone with a provider increases the likelihood that youth will disclose risky behavior, which may result in STI testing. Our goals were to assess the association (if any) between the provision of time alone and STI testing, and describe the rates of STI testing among sexually active adolescents in urban primary care. METHODS: Youth (aged 12-19 years) presenting for care at 4 urban health centers were invited to complete post-visit surveys of their experience. Sexually transmitted infection screening rates were obtained from the clinical information systems (CIS); CIS data were linked to survey responses. RESULTS: We received 101 surveys. Surveyed youth experienced time alone in 69% of all visits. Time alone varied by age (older teens experienced more time alone), and it occurred more frequently in preventive visits (71%) versus nonpreventive visits (33%). It did not vary by gender. Forty-two of the 46 sexually active youth experienced time alone. Screening rates for sexually active females, either at the index visit or within 6 months prior to the index visit, were 17.9% for human immunodeficiency virus and 32.1% for gonorrhea/Chlamydia. No sexually active surveyed males were tested. Overall screening rates varied widely across practices (human immunodeficiency virus 0%-29%; gonorrhea/Chlamydia 7%-29%). There was no difference in screening rates among youth with and without time alone. CONCLUSION: STI testing for adolescents is being conducted in this primary care urban population, especially for sexually active females. However, clinicians in this setting are not screening females consistently enough and rarely screen males. We were unable to test our hypothesis that provision of time alone was associated with a higher rate of STI testing. Site differences suggest substantial variation in clinician practices that should be addressed in quality improvement interventions.