Shallow Subsidies for Veterans Facing Housing Barriers in the VA Supportive Services for Veteran Families Program.

The Department of Veterans Affairs provides a shallow subsidy (i.e., subsidizing 50% of an individual's rent for two years) to Veterans experiencing housing instability. We sought to describe the characteristics of Veterans who received these subsidies. Methods. We conducted a retrospective cohort study of Veterans between 10/2019-9/2021. We identified Veteran-level characteristics associated with receiving a shallow subsidy using a multivariable two-part regression model. We also conducted qualitative interviews to identify how shallow subsidies are allocated. Results Black race, higher income, more education, and older age were positively associated with receiving a shallow subsidy; previous homelessness, prior VA outpatient cost, and participating in permanent supportive housing were negatively associated with receiving a shallow subsidy. Interviews revealed that income was the most influential determinant of whether to give shallow subsidies. Discussion Our mixed methods findings were consistent, indicating that socioeconomic stability is an important driver of shallow subsidy allocation decisions.

Inpatient opioid withdrawal: a qualitative study of the patient perspective.

Opioid withdrawal is common among hospitalized patients. Those with substance use disorders exhibit higher rates of patient-directed discharge. The literature lacks information regarding the patient perspective on opioid withdrawal in the hospital setting. In this study, we aimed to capture the patient-reported experience of opioid withdrawal during hospitalization and its impact on the desire to continue treatment for opioid use disorder after discharge. We performed a single-center qualitative study involving semi-structured interviews of hospitalized patients with opioid use disorder (OUD) experiencing opioid withdrawal. Investigators conducted in-person interviews utilizing a combination of open-ended and dichotomous questions. Interview transcripts were then analyzed with open coding for emergent themes. Nineteen interviews were performed. All participants were linked to either buprenorphine (79%) or methadone (21%) at discharge. Eight of nineteen patients (42%) reported a patient-directed discharge during prior hospitalizations. Themes identified from the interviews included: (1) opioid withdrawal was well-managed in the hospital; (2) patients appreciated receiving medication for opioid use disorder (MOUD) for withdrawal symptoms; (3) patients valued and felt cared for by healthcare providers; and (4) most patients had plans to follow-up for opioid use disorder treatment after hospitalization. In this population with historically high rates of patient-directed discharge, patients reported having a positive experience with opioid withdrawal management during hospitalization. Amongst our hospitalized patients, we observed several different individualized MOUD induction strategies. All participants were offered MOUD at discharge and most planned to follow-up for further treatment.

Challenges and Opportunities in the Elective Management of Diverticulitis: Perspectives From a National Sample of Colorectal Surgeons.

BACKGROUND: Diverticulitis is a complex, heterogeneous disease process that affects a diverse population of patients. In the elective management of this disease, treatment guidelines have shifted toward patient-centered, individualized decision-making. It is not known what challenges surgeons face as they approach these nuanced treatment decisions in practice. OBJECTIVE: This study aimed to identify opportunities to support colorectal surgeons in elective diverticulitis treatment. DESIGN: This was a qualitative study using standardized, semistructured interviews to explore the perspectives of 29 colorectal surgeons recruited using a purposive sampling technique. Data were analyzed using an "open-coding" approach. SETTINGS: Interviews with a national sample of colorectal surgeons were conducted from a single center using an online video platform. PATIENTS: This study did not involve patients. MAIN OUTCOME MEASURES: Interviews explored surgeons' experiences treating diverticulitis in the elective setting, focusing on perceived challenges in providing patient-centered care as well as opportunities to improve treatment decisions. RESULTS: Our qualitative analysis identified an overarching challenge in elective diverticulitis management for surgeons: difficulty ensuring adequate patient understanding of the risks and benefits of various treatments. This was thought to be due to 1) preexisting patient expectations about treatment and 2) lack of data regarding long-term treatment outcomes. Surgeons identified 2 potential opportunities to combat these challenges: 1) patient education and 2) additional research regarding treatment outcomes, with potential for the development of diverticulitis-specific decision support tools. LIMITATIONS: These results are based on a national sample of colorectal surgeons, but they capture qualitative data that is not intended to provide generalizable findings. CONCLUSIONS: As surgeons work toward providing individualized care for diverticulitis patients, they find it difficult to adequately counsel patients regarding the patient-specific risks of various treatments. The results of this study identify specific contributors to this problem as well as potential targets for intervention, which can guide future efforts to support surgeons in providing patient-centered care. See Video Abstract . DESAFOS Y OPORTUNIDADES EN EL MANEJO ELECTIVO DE LA DIVERTICULITIS PERSPECTIVAS DE UNA MUESTRA NACIONAL DE CIRUJANOS COLORRECTALES: ANTECEDENTES:La diverticulitis es un proceso patológico complejo y heterogéneo que afecta a una población diversa de pacientes. En el manejo electivo de esta enfermedad, las pautas de tratamiento se han desplazado hacia una toma de decisiones individualizada y centrada en el paciente. No se sabe qué desafíos enfrentan los cirujanos al abordar estas decisiones de tratamiento matizadas en la práctica.OBJETIVO:Identificar oportunidades para apoyar a los cirujanos colorrectales en el tratamiento electivo de la diverticulitis.DISEÑO:Este fue un estudio cualitativo que utilizó entrevistas semiestructuradas estandarizadas para explorar las perspectivas de 29 cirujanos colorrectales reclutados mediante una técnica de muestreo intencional. Los datos se analizaron utilizando un enfoque de "codificación abierta".ESCENARIO:Las entrevistas con una muestra nacional de cirujanos colorrectales se realizaron desde un solo centro utilizando una plataforma de video en línea.PRINCIPALES MEDIDAS DE RESULTADO:Las entrevistas exploraron las experiencias de los cirujanos en el tratamiento de la diverticulitis en el entorno electivo, centrándose en los desafíos percibidos en la prestación de atención centrada en el paciente, así como en las oportunidades para mejorar las decisiones de tratamiento.RESULTADOS:Nuestro análisis cualitativo identificó un desafío general en el manejo de la diverticulitis electiva para los cirujanos: la dificultad para asegurar que el paciente comprenda adecuadamente los riesgos y beneficios de los diversos tratamientos. Se pensó que esto se debía a 1) las expectativas preexistentes del paciente sobre el tratamiento y 2) la falta de datos sobre los resultados del tratamiento a largo plazo. Los cirujanos identificaron dos oportunidades potenciales para combatir estos desafíos: 1) educación del paciente y 2) investigación adicional sobre los resultados del tratamiento, con potencial para el desarrollo de herramientas de apoyo a la toma de decisiones específicas para la diverticulitis.LIMITACIONES:Estos resultados se basan en una muestra nacional de cirujanos colorrectales, pero capturan datos cualitativos que no pretenden proporcionar hallazgos generalizables.CONCLUSIONES:A medida que los cirujanos trabajan para brindar atención individualizada a los pacientes con diverticulitis, les resulta difícil aconsejar adecuadamente a los pacientes sobre los riesgos específicos de los pacientes para los diversos tratamientos. Los resultados de este estudio identifican contribuyentes específicos a este problema, así como objetivos potenciales para la intervención, que pueden guiar los esfuerzos futuros para ayudar a los cirujanos a brindar atención centrada en el paciente. (Traducción-Dr. Felipe Bellolio ).

Excellence in Antibiotic Stewardship: A mixed methods study comparing High, Medium, and Low Performing Hospitals.

BACKGROUND: Despite antibiotic stewardship programs existing in most acute care hospitals, there continues to be variation in appropriate antibiotic use. While existing research examines individual prescriber behavior, contextual reasons for variation are poorly understood. METHODS: We conducted an explanatory, sequential mixed methods study of a purposeful sample of 7 hospitals with varying discharge antibiotic overuse. For each hospital, we conducted surveys, document analysis, and semi-structured interviews with antibiotic stewardship and clinical stakeholders. Data were analyzed separately and mixed during the interpretation phase, where each hospital was examined as a case, with findings organized across cases using a strengths, weaknesses, opportunities, and threats framework to identify factors accounting for differences in antibiotic overuse across hospitals. RESULTS: Surveys included 85 respondents. Interviews included 90 respondents (31 hospitalists, 33 clinical pharmacists, 14 stewardship leaders, 12 hospital leaders). On surveys, clinical pharmacists at hospitals with lower antibiotic overuse were more likely to report feeling: respected by hospitalist colleagues (p=0.001), considered valuable team members (p=0.001), comfortable recommending antibiotic changes (p=0.02). Based on mixed-methods analysis, hospitals with low antibiotic overuse had four distinguishing characteristics: a) robust knowledge of and access to antibiotic stewardship guidance, b) high quality clinical pharmacist-physician relationships, c) tools and infrastructure to support stewardship, and d) highly engaged Infectious Diseases physicians who advocated stewardship principles. CONCLUSION: This mixed-method study demonstrates the importance of organizational context for high performance in stewardship and suggests improving antimicrobial stewardship requires attention to knowledge, interactions, and relationships between clinical teams and infrastructure that supports stewardship and team interactions.

Cancer Treatment Decision-Making for People Living With HIV: Physician-Reported Barriers, Facilitators, and Recommendations.

BACKGROUND: Compared with the general cancer population, people living with HIV (PLWH) and cancer are less likely to receive treatment and have significantly elevated cancer-specific mortality for many common cancer types. Physician recommendations drive the cancer therapy that patients receive, yet there is limited information assessing how cancer treatment decisions are made for people living with HIV and cancer. We sought to understand oncologist decision-making in PLWH and cancer by eliciting barriers, facilitators, and recommendations for enhancing care delivery. SETTING: Participants were recruited between May 2019 and May 2021 from one academic medical center in the western United States (n = 13), another in the southeastern United States (n = 7), and community practices nationwide (n = 5). METHODS: Using an inductive qualitative approach, we conducted in-depth interviews with 25 oncologists from two academic medical centers and community practices. RESULTS: Facilitators of cancer care delivery included readily available information regarding HIV status and stage, interdepartmental communication, and antiviral therapy adherence. Barriers included a lack of formal education on HIV malignancies, perceptions of decreased life expectancy, fear of inadvertent disclosure, and drug-drug interactions. Recommendations included improved provider communication, patient social and mental health resources, and continuing education opportunities. CONCLUSION: The study revealed drivers of cancer treatment decision-making, highlighting physician-reported barriers and facilitators, and recommendations to support treatment decision-making. This is the first known study examining oncologists' perceptions of caring for PLWH. Given that cancer is a leading cause of death among PLWH, there is an urgent need to improve care and outcomes.

Differences in perceptions and acceptance of COVID-19 vaccination between vaccine hesitant and non-hesitant persons.

Acceptance of the COVID-19 vaccination becomes more critical as new variants continue to evolve and the United States (US) attempts to move from pandemic response to management and control. COVID-19 stands out in the unique way it has polarized patients and generated sustained vaccine hesitancy over time. We sought to understand differences in perceptions and acceptance of COVID-19 vaccination between vaccine hesitant and non-hesitant patients, with the goal of informing communication and implementation strategies to increase uptake of COVID-19 vaccines in Veteran and non-Veteran communities. This qualitative study used interview data from focus groups conducted by the Department of Veterans Affairs (VA) and the University of Utah; all focus groups were conducted using the same script March-July 2021. Groups included forty-six United States Veterans receiving care at 28 VA facilities across the country and 166 non-Veterans across Utah for a total of 36 one-hour focus groups. We identified perceptions and attitudes toward COVID-19 vaccination through qualitative analysis of focus group participant remarks, grouping connections with identified themes within domains developed based on the questions asked in the focus group guide. Responses suggest participant attitudes toward the COVID-19 vaccine were shaped primarily by vaccine attitude changes over time, impacted by perceived vaccine benefits, risks, differing sources of vaccine information and political ideology. Veterans appeared more polarized, being either largely non-hesitant, or hesitant, whereas non-Veterans had a wider range of hesitancy, with more participants identifying minor doubts and concerns about receiving the vaccine, or simply being altogether unsure about receiving it. Development of COVID-19 vaccine communication strategies in Veteran and non-Veteran communities should anticipate incongruous sources of information and explicitly target community differences in perceptions of risks and benefits associated with the vaccine to generate candid discussions and repair individuals' trust. We believe this could accelerate vaccine acceptance over time.

Examining the Primary Care Experience of Patients With Opioid Use Disorder: A Qualitative Study.

OBJECTIVES: Despite substantial investment in expanding access to treatment for opioid use disorder (OUD), overdose deaths continue to increase. Primary care holds enormous potential to expand access to OUD treatment, but few patients receive medications for OUD (MOUD) in primary care. Understanding both patient and clinician experiences is critical to expanding access to patient-centered MOUD care, yet relatively little research has examined patient perspectives on primary care-based MOUD. We sought to examine the care experiences of patients with OUD receiving medication-based treatment in a primary care setting. METHODS: We conducted semistructured interviews with patients receiving MOUD at a single primary care site at the University of Utah. Interviews were performed and transcribed by qualitative researchers, who used rapid qualitative analysis using a grounded theory-based approach to identify key themes pertaining to patient experiences receiving medication-based OUD treatment in primary care. RESULTS: Twenty-one patients were screened, and 14 completed the interview. In general, participants had numerous medical and psychiatric comorbidities. The following key themes pertaining to primary care-based OUD treatment were identified: (1) overall health improvement, (2) team-based care, (3) comparing primary care to specialty addiction treatment, (4) access to medications for OUD, and (5) discrimination and stigma. CONCLUSIONS: Patients reported many advantages to receiving primary care-based MOUD treatment. In particular, the flexibility and added support of team-based care along with the convenience of receiving addiction treatment alongside regular medical care were highly valued. These findings can be used to develop patient-centered initiatives aimed at expanding OUD treatment within primary care.

Women's Health Provider Perspectives on Reproductive Services Provision in the Veterans Health Administration.

OBJECTIVES: Women veterans are a fast-growing population in the Veterans Health Administration (VHA), and ensuring reproductive service availability is a VHA priority. As such, we sought to explore barriers and facilitators to VHA reproductive service provision across a catchment area from women's health providers' perspectives. METHODS: We performed a mixed-methods study, including semistructured, qualitative provider interviews with a quantitative survey on training, comfort, and knowledge of reproductive services. All women's health providers and their support staff from the Salt Lake City Veterans Affairs Medical Center and nine VHA community-based outpatient clinics were asked to participate. We conducted qualitative interviews and knowledge surveys with providers and staff to explore training, care processes, and improvement opportunities in reproductive service provision. We completed descriptive analyses of all of the quantitative data and used an open, iterative process to analyze provider interviews for emergent themes. RESULTS: We interviewed 15 providers (7 advanced practice nurses, 4 registered nurses, and 4 physicians) across nine sites (50% response rate). The commonly identified barriers included provider training and staffing, scheduling/referral processes, inconsistent services/supplies, and lack of veteran awareness of reproductive services. Facilitators included prior non-VHA reproductive health experience among providers, invested support staff, and the integrated VHA health system. CONCLUSIONS: Addressing barriers to VHA reproductive healthcare provision may overcome reproductive service variations related to clinic location and improve reproductive health outcomes for women veterans.

Improving Cancer Care for People Living With HIV: A Qualitative Study of Provider Knowledge, Attitudes, and Practice.

PURPOSE: Cancer is now the leading cause of non-AIDS death in the US population with HIV. People living with HIV (PLWH) are known to have lower cancer treatment rates and worse cancer outcomes. Disparate cancer treatment is driven by health system, patient, and clinician factors. Little attention has been given to the factors oncologists consider when making cancer treatment recommendations to PLWH. This study sought to examine oncologists' knowledge, attitudes, and practices that influence cancer treatment decision-making. METHODS AND MATERIALS: This study used qualitative methods to explore oncologists' treatment decision-making processes for PLWH and cancer. The sample included 25 radiation, medical, and surgical oncologists from 2 academic centers and 5 community practices. The interview domains were developed from the Andersen Healthcare Utilization Model, the Health Belief Model, and the PEN-3 Model, as well as our prior survey research. RESULTS: This study describes elements of cancer treatment decision-making for PLWH. Oncologists highlighted the need for formal HIV education to support cancer treatment. One main concern with patient-provider interactions pertained to maintaining patient confidentiality during clinical encounters. Lastly, the importance of multidisciplinary care among health care providers allowed oncologists to facilitate both cancer care and logistical support. CONCLUSIONS: As cancer becomes an increasingly common cause of death among PLWH, it is critical to understand the drivers of the observed disparities in cancer treatment. To our knowledge, this is the first qualitative study to describe oncologists' knowledge, attitudes, and practices toward patients who have a comorbid diagnosis of HIV and cancer. Several themes for future interventions emerge, including HIV training for cancer care providers, fostering interdisciplinary collaboration, enhancing HIV education for oncology learners and clinicians, and minimizing implicit bias.

Supporting families during pediatric critical illness: Opportunities identified in a multicenter, qualitative study.

Critical illness resulting in a pediatric intensive care unit (PICU) admission is a profoundly stressful experience for a child and their family. Increasing evidence for emotional and behavioral sequelae post-PICU emphasizes a need to provide better support for families throughout this period of care and recovery. The aim of this qualitative investigation was to identify salient and modifiable aspects of a critical care experience that can be addressed to better support families of critically ill children. Individual semi-structured interviews were conducted with 26 caregivers of children who survived a PICU admission. Interviews were audio-recorded and transcribed verbatim; themes were identified via thematic analysis. Caregivers were enrolled using convenience sampling from seven tertiary care PICUs in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. Themes from caregiver interviews were identified within two overarching categories containing three themes each. Advice for future PICU families: (1) Be intentional about caring for your own well-being, (2) speak up, ask questions, and challenge decisions you're not comfortable with, and (3) continue to engage with your child. Characteristics of a satisfactory PICU experience: (1) A caregiver-provider relationship of mutual trust established through clear communication and respectful collaboration, (2) hospital environments that provide physical and social supports to maintain humanity in healthcare, and (3) preparing families for care transitions. Targeted, interdisciplinary approaches to partner with families during critical care may improve their PICU experience and contribute to improved long-term outcomes for PICU survivors.

Provider perceptions of their patients' dropout from trauma-focused therapy for PTSD in the U.S. Veterans Health Administration.

OBJECTIVE: Many patients who initiate prolonged exposure (PE) and cognitive processing therapy (CPT) do not complete a full course, although little is known about how providers view PE and CPT dropout among their own patients. METHOD: Semistructured interviews were conducted with providers (n = 29) in the Veterans Health Administration to understand each provider's experience of dropout by a specific patient whom they treated using PE or CPT. Content analysis was used to categorize perceptions of dropout as negative, somewhat negative, or not negative. Themes associated with somewhat or not negative views of dropout were identified via inductive coding. RESULTS: Fourteen percent of providers viewed their patient's dropout from PE or CPT as wholly negative, 38% as somewhat negative, and 48% as not a negative outcome. Themes associated with viewing dropout as something other than wholly negative included belief that the patient would not benefit from treatment if they were not ready, the importance of maintaining the therapeutic relationship, the view that trauma-focused therapy was not what the patient needed or that the patient could benefit from other approaches, the impression that the patient had made some gains, and that patients are responsible for treatment engagement and have the right to disengage. CONCLUSIONS: Providers' perceptions of dropout from PE or CPT for individual patients were rarely viewed as entirely negative. Research is needed to help providers determine when patient dropout is an undesirable outcome and when efforts to reengage patients in trauma-focused treatment are warranted. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Factors influencing engagement in hospital-based exercise oncology programs: A narrative review.

Among cancer survivors, there are numerous health benefits of exercise engagement; however, less than 15% of survivors meet current aerobic and strength physical activity guidelines. Exercise programs provided by a cancer hospital are commonly noted as a facilitator and preference to exercise engagement. The study aimed to review the evidence and describe the barriers, facilitators, preferences, and factors associated with cancer survivors' engagement in hospital-based exercise oncology programs. Electronic databases (PubMed and Scopus) were searched to identify relevant papers published before July 1, 2021. Original research papers reporting on barriers, facilitators, preferences, or factors associated with participation in hospital-based exercise oncology programs were included. A total of 300 potentially relevant articles were identified, of which 10 met eligibility criteria. Barriers to participation in hospital-based exercise oncology programs included program accessibility, treatment-related side effects, and uncertainty about exercise. Program individualization, peer support, and staff support were reported as facilitators. Survivors also expressed that they preferred flexibility in the time, location, and mode of exercise programming. Baseline quality of life, fitness, and marital status were all identified as potential factors associated with engagement in hospital-based exercise oncology programs. These findings are useful for the development and implementation of hospital-based exercise oncology programs to optimize exercise program engagement.

Identifying Perceptions, Experiences, and Recommendations of Telehealth Physical Therapy for Patients With Chronic Low Back Pain: A Mixed Methods Survey.

OBJECTIVE: To describe concerns, advantages, and disadvantages encountered in an evidence-based physical therapy (PT) program for persons with chronic low back pain (CLBP) delivered by telehealth. DESIGN: Mixed methods survey and semistructured interview of persons with CLBP. SETTING: Prospective observational cohort study of persons with CLBP from 3 health care systems receiving 8 sessions of evidence-based telehealth PT. PARTICIPANTS: Participants were selected after completing week 10 (from baseline) assessment from an ongoing cohort study. We enrolled 31 of 126 participants (mean age, 42.4 years; 71.0% female) from the cohort study (N=31). INTERVENTIONS: Participants had completed 8 sessions of evidence-based telehealth PT and participated in semistructured interviews. MAIN OUTCOME MEASURES: Baseline and week 10 and 26 assessments assessed psychosocial risk (StarTBack Screening Tool), working alliance (Working Alliance Inventory-Short Form), pain (Oswestry Disability Index), and health-related quality of life (Patient-Reported Outcomes Measurement Information System-29 profile, version 2). Semistructured interviews were conducted by telephone and consisted of open-ended questions assessing perception, satisfaction, and likelihood of recommending telehealth PT. Participants identified advantages and disadvantages to telehealth PT. Interviews were recorded, transcribed, and coded using an iterative qualitative process. Statistical comparisons by experience were made using analysis of variance (continuous) and Fisher exact test (categorical). RESULTS: Compared with the negative experience group (n=5), participants in positive (n=16) and neutral (n=10) experience groups endorsed higher bond working alliance with their therapist. Participants with a positive experience were more likely to view telehealth PT as cost-saving (n=10, 62.5%) compared with those with a neutral (n=1, 10.0%) or negative (n=1, 20.0%) experience and less likely to view telehealth PT as lower quality (n=0, 0.0%; n=1, 10.0%; n=2, 40.0%, respectively). Prior to starting telehealth, based on semistructured interviews, 18 participants (58.1%) had concerns and these persisted after starting in half of this group. Concerns regarded telehealth being different from or inferior to in-person PT, lack of physical correction, and worries of not using technology appropriately. Convenience, time savings, and personalization were seen as advantages. Difficulty making a personal connection with the therapist, lack of physical correction, and problems with technology were seen as disadvantages. Many participants endorsed a hybrid approach that included in-person and telehealth PT. Providing necessary equipment and technology assistance was seen as ways to improve telehealth PT experience. CONCLUSIONS: Telehealth is an acceptable modality to deliver PT for patients with CLBP with most having a positive experience and reporting advantages. Improvements could include offering a hybrid approach (in-person and telehealth combined) and providing necessary equipment and technical support. More research is needed to optimize the most effective strategies for providing telehealth PT for patients with CLBP.

Patient-centered quality measurement for opioid use disorder: Development of a taxonomy to address gaps in research and practice.

Background: Evidence-based treatment is provided infrequently and inconsistently to patients with opioid use disorder (OUD). Treatment guidelines call for high-quality, patient-centered care that meets individual preferences and needs, but it is unclear whether current quality measures address individualized aspects of care and whether measures of patient-centered OUD care are supported by evidence. Methods: We conducted an environmental scan of OUD care quality to (1) evaluate patient-centeredness in current OUD quality measures endorsed by national agencies and in national OUD treatment guidelines; and (2) review literature evidence for patient-centered care in OUD diagnosis and management, including gaps in current guidelines, performance data, and quality measures. We then synthesized these findings to develop a new quality measurement taxonomy that incorporates patient-centered aspects of care and identifies priority areas for future research and quality measure development. Results: Across 31 endorsed OUD quality measures, only two measures of patient experience incorporated patient preferences and needs, while national guidelines emphasized providing patient-centered care. Among 689 articles reviewed, evidence varied for practices of patient-centered care. Many practices were supported by guidelines and substantial evidence, while others lacked evidence despite guideline support. Our synthesis of findings resulted in EQuIITable Care, a taxonomy comprised of six classifications: (1) patient Experience and engagement, (2) Quality of life; (3) Identification of patient risks; (4) Interventions to mitigate patient risks; (5) Treatment; and (6) Care coordination and navigation. Conclusions: Current quality measurement for OUD lacks patient-centeredness. EQuIITable Care for OUD provides a roadmap to develop measures of patient-centered care for OUD.

Divergent experiences of U.S. veterans who did and did not complete trauma-focused therapies for PTSD: A national qualitative study of treatment dropout.

Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) are first-line treatments for posttraumatic stress disorder (PTSD) and have been disseminated throughout the U.S. Veterans Health Administration. Treatment non-completion is common and lessens clinical effectiveness; however, prior work has failed to identify factors consistently associated with non-completion. Semi-structured interviews were conducted with a national sample of veterans who recently completed (n = 60) or did not complete (n = 66) PE or CPT. Non-completer interviews focused on factors that contributed to veterans' decisions to drop out and efforts undertaken to complete PE/CPT. Completer interviews focused on challenges faced in completing treatment and facilitators of completion. Transcripts were coded using a mixed deductive/inductive approach; constant comparison was used to identify differences between completers and non-completers. Completers and non-completers differed in the extent of treatment-specific therapist support received, therapists' flexibility in treatment delivery, the type of encouragement offered by the care team and social supports, their interpretation of symptom worsening, the perceived impact of treatment on functioning, and the impact of stressors on their treatment engagement. Treatment-specific therapist support, more patient-centered and flexible treatment delivery, leveraging the full care team, and addressing functional concerns are potential targets for PE and CPT engagement interventions.

Veteran Engagement in Health Services Research: a Conceptual Model.

With 20 million living veterans and millions more immediate family members, and approximately 9 million veterans enrolled in the nationally networked VA healthcare system, representing the interests and needs of veterans in this complex community is a substantial endeavor. Based on the importance of engaging Veterans in research, the VA Health Services Research and Development (HSR&D) Service convened a Working Group of VA researchers and Veterans to conduct a review of patient engagement models and develop recommendations for an approach to engage Veterans in health research that would incorporate their unique lived experiences and interests, and their perspectives on research priorities. The Working Group considered the specific context for Veteran engagement in research that includes other VA stakeholders from the operational and clinical leadership of the VA Health Administration (VHA). The resulting model identifies the range of potential stakeholders and three domains of relevant constructs-processes expected to facilitate Veteran engagement in research with other stakeholders, individual stakeholder and external factors, and outcomes. The expectation is that Veteran engagement will benefit research to policy and practice translation, including increasing the transparency of research and producing knowledge that is readily accepted and implemented in healthcare.

Psychosocial determinants of colorectal Cancer screening uptake among African-American men: understanding the role of masculine role norms, medical mistrust, and normative support.

OBJECTIVES: Despite having the highest colorectal cancer (CRC) incidence and mortality across all major racial/ethnic groups, African-American men consistently have poor CRC screening rates. Gendered and racialized beliefs and norms have been associated with African-American men's lower medical assistance-seeking rates, but how these notions influence African-American men's CRC screening practices merits further investigation. The purpose of this study was to examine the influence of psychosocial determinants of men's health on CRC screening uptake among African-American men in three states. DESIGN: Participants were recruited via CuttingCRC.com and through culturally-tailored flyers, newspaper ads, and snowball sampling, among other methods. From April 2019-August 2019, 11 focus groups were conducted with English-speaking Black/African-American men who (a) were between ages 45-75, (b) were born in the United States, (c) had a working telephone, and (d) lived in Minnesota, Ohio, or Utah. Multiple-cycle coding, Hatch's 9-step approach, and constant comparative data analysis was employed for de-identified transcript data. RESULTS: Eighty-four African-American men met inclusion criteria and participated. Their mean age was 59.34 ± 7.43. In regards to CRC screening status, Ohio had the most previously screened participants (85%), followed by Minnesota (84%) and Utah (76%). Two major CRC screening barriers (masculine role norms and medical mistrust) - both encompassed 3-5 subthemes, and one major facilitator (normative support from family members or social networks) emerged. CONCLUSIONS: Despite CRC screening's life-saving potential, African-American men have had the lowest 5-year relative survival for more than 40 years. When developing interventions and health promotion programs aiming to eliminate the racial disparity in CRC outcomes, addressing both masculine role norms and medical mistrust barriers to CRC screening completion among African-American men is warranted.

Determinants of Risk-Aligned Bladder Cancer Surveillance-Mixed-Methods Evaluation Using the Tailored Implementation for Chronic Diseases Framework.

PURPOSE: For many patients with cancer, the frequency of surveillance after primary treatment depends on the risk for cancer recurrence or progression. Lack of risk-aligned surveillance means too many unnecessary surveillance procedures for low-risk patients and not enough for high-risk patients. Using bladder cancer as an example, we examined whether practice determinants differ between Department of Veterans Affairs sites where risk-aligned surveillance was more (risk-aligned sites) or less common (need improvement sites). METHODS: We used our prior quantitative data to identify two risk-aligned sites and four need improvement sites. We performed semistructured interviews with 40 Veterans Affairs staff guided by the Tailored Implementation for Chronic Diseases framework that were deductively coded. We integrated quantitative data (risk-aligned site v need improvement site) and qualitative data from interviews, cross-tabulating salient determinants by site type. RESULTS: There were 14 participants from risk-aligned sites and 26 participants from need improvement sites. Irrespective of site type, we found a lack of knowledge on guideline recommendations. Additional salient determinants at need improvement sites were a lack of resources ("the next available without overbooking is probably seven to eight weeks out") and an absence of routines to incorporate risk-aligned surveillance ("I have my own guidelines that I've been using for 35 years"). CONCLUSION: Knowledge, resources, and lack of routines were salient barriers to risk-aligned bladder cancer surveillance. Implementation strategies addressing knowledge and resources can likely contribute to more risk-aligned surveillance. In addition, reminders for providers to incorporate risk into their surveillance plans may improve their routines.

Parents' decision-making for their foetus or neonate with a severe congenital heart defect.

BACKGROUND: Parents who receive a diagnosis of a severe, life-threatening CHD for their foetus or neonate face a complex and stressful decision between termination, palliative care, or surgery. Understanding how parents make this initial treatment decision is critical for developing interventions to improve counselling for these families. METHODS: We conducted focus groups in four academic medical centres across the United States of America with a purposive sample of parents who chose termination, palliative care, or surgery for their foetus or neonate diagnosed with severe CHD. RESULTS: Ten focus groups were conducted with 56 parents (Mage = 34 years; 80% female; 89% White). Results were constructed around three domains: decision-making approaches; values and beliefs; and decision-making challenges. Parents discussed varying approaches to making the decision, ranging from relying on their "gut feeling" to desiring statistics and probabilities. Religious and spiritual beliefs often guided the decision to not terminate the pregnancy. Quality of life was an important consideration, including how each option would impact the child (e.g., pain or discomfort, cognitive and physical abilities) and their family (e.g., care for other children, marriage, and career). Parents reported inconsistent communication of options by clinicians and challenges related to time constraints for making a decision and difficulty in processing information when distressed. CONCLUSION: This study offers important insights that can be used to design interventions to improve decision support and family-centred care in clinical practice.