Practical Strategies for Co-design: The Case of Engaging Patients in Developing Patient-Facing Shared-Decision Making Materials for Lung Cancer Screening.

Co-design provides a meaningful way to engage patients in research. However, there is limited practical guidance. We used our co-design project to identify strategies for other researchers. An ethnographic case study design was used. Data included participant observation of co-design meetings, meeting minutes, analytic fieldnotes, qualitative patient interviews, and research team member self-reflections. Additionally, we got external feedback. We analyzed data iteratively. Our team included 5 patients and 6 researchers. We identified 3 strategies to include patients in co-design: (1) Deliberately build the team, from recruiting patients to specifying roles. (2) Tailor the meeting format to thoughtfully use patients' time and expertise. (3) Disrupt traditional hierarchies, to empower patients to actively participate. Researchers seeking to include patients as team members should consider: team composition and roles, leveraging meeting formats to optimize contributions and purposefully creating a culture of collaboration, so patient expertise informs the end product. Our work provides practical guidance for researchers to incorporate patient expertise in the co-design process and meaningfully involve them in their work.

Promoting Health and Wellbeing Through Non-Clinical Arts Programming: Multi-Stakeholder Perspectives From the Veterans Health Administration.

PURPOSE: While the value of art therapy is well-established and arts are increasingly leveraged to promote health and wellbeing more broadly, little is known about the impacts of non-clinical arts programs. In this preliminary investigation, we sought to fill this gap by exploring diverse stakeholders' perspectives on the impacts of non-clinical arts programming on Veterans receiving care at the Veterans Health Administration (VA). DESIGN: Semi-structured qualitative interviews with Veterans, VA staff, and community partners. SETTING: Interviewees were recruited from 7 VA medical centers that have recently implemented non-clinical arts programming to promote Veterans' health and wellbeing, some of them in partnership with community organizations. PARTICIPANTS: 33 individuals were interviewed, including 9 Veterans, 14 VA staff, and 10 community partners involved in non-clinical arts program implementation. METHOD: Interview transcripts were analyzed using iterative rounds of qualitative content analysis. RESULTS: The following impacts on Veterans were described: (1) mental health improvements, (2) renewed sense of purpose; (3) increased social connectedness, (4) improved self-esteem, and (5) self-driven engagement in art activities. CONCLUSION: Non-clinical arts programming was perceived by diverse stakeholders to offer important benefits for Veterans' health and well-being. Offering non-clinical arts programming inside and outside healthcare facilities' walls is a promising direction for the field of public health undergoing a shift towards holistic approaches to improving individual and population health outcomes.

Greater Protein Intake Emphasizing Lean Beef Does Not Affect Resistance Training-Induced Adaptations in Skeletal Muscle and Tendon of Older Women: A Randomized Controlled Feeding Trial.

BACKGROUND: Although experimental research supports that resistance training (RT), especially with greater dietary protein intake, improves muscle mass and strength in older adults, comparable research on tendons is needed. OBJECTIVES: We assessed the effects of a protein-rich diet emphasizing lean beef, compared with 2 control diets, on RT-induced changes in skeletal muscle and tendon size and strength in older women. METHODS: We randomly assigned women [age: 66 ± 1 y, body mass index (BMI): 28 ± 1] to groups that consumed 1) 0.8 g total protein/kg body weight/day from mixed food sources (normal protein control, n = 16); 2) 1.4 g/kg/d protein from mixed food sources (high protein control, n = 17); or 3) 1.4 g/kg/d protein emphasizing unprocessed lean beef (high protein experimental group, n = 16). Participants were provided with all foods and performed RT 3 times/wk, 70% of 1-repetition maximum for 12 wk. We measured quadriceps muscle volume via magnetic resonance imaging (MRI). We estimated patellar tendon biomechanical properties and cross-sectional area (CSA) using ultrasound and MRI. RESULTS: Dietary intake did not influence RT-induced increases in quadriceps strength (P < 0.0001) or muscle volume (P < 0.05). We noted a trend for an RT effect on mean tendon CSA (P = 0.07), with no differences among diets (P > 0.05). Proximal tendon CSA increased with RT (P < 0.05) with no difference between dietary groups (P > 0.05). Among all participants, midtendon CSA increased with RT (P ≤ 0.05). We found a decrease in distal CSA in the 0.8 g group (P < 0.05) but no change in the 1.4 g group (P > 0.05). Patellar tendon MRI signal or biomechanical properties were unchanged. CONCLUSIONS: Our findings indicated that greater daily protein intake, emphasizing beef, did not influence RT-induced changes in quadriceps muscle strength or muscle volume of older women. Although we noted trends in tendon CSA, we did not find a statistically significant impact of greater daily protein intake from beef on tendon outcomes. This trial was registered at clinicaltrials.gov as NCT04347447.

Association of serum phosphate, calcium and alkaline phosphatase with risk of incident fractures in healthy older adults.

BACKGROUND: Aging increases fracture risk through bone loss and microarchitecture deterioration due to an age-related imbalance in bone resorption and formation during bone remodelling. We examined the associations between levels of phosphate, calcium, and alkaline phosphatase, and fracture risk in initially-healthy older individuals. METHODS: A post-hoc analysis of the Aspirin in Reducing Events in the Elderly (ASPREE) trial recruited 16,703 Australian participants aged ≥70 years and 2,411 US participants aged ≥65 years. Analyses were conducted on ASPREE-Fracture substudy participants from Australia with serum calcium, phosphate, and alkaline phosphatase measurement. Fracture data were collected post-randomization. Cox regression was used to calculate hazard ratios (HR) and 95% confidence intervals (CIs). Phosphate, calcium, and alkaline phosphatase were analysed in deciles (D1-D10), with deciles 4-7 (31-70%) as the reference category. Restricted cubic spline curves were used to identify nonlinear associations. RESULTS: Of the 9915 participants, 907 (9·2%) persons had incident fractures recorded over 3·9 (SD 1·4) years. In the fully adjusted model, males in the top decile (D10) of phosphate had 78% higher risk of incident fracture (HR 1·78, 95% CI 1·25-2·54). No such association was observed for females (HR 1·09, 95% CI 0·83-1·44). The population attributable fraction in men within the D10 phosphate category is 6·9%. CONCLUSION: This result confirms that, high-normal serum phosphate levels are associated with increased fracture risk in older men.

Strategies for engaging patients in co-design of an intervention.

OBJECTIVE: We provide practical guidance about using co-design methods to collaborate with patients to create patient-facing interventions, which others can use when undertaking similar projects. METHODS: This is a narrative review synthesizing co-design principles and published literature with our experience working alongside five Veteran patients of the U.S. Department of Veterans Affairs in New England to co-design a portfolio of patient-facing materials to improve patient-centered care coordination. Our process took 12 weeks (April - June 2022) and was conducted entirely via video conference. RESULTS: Co-design is a participatory research method. Its principles include sharing power over the research process and products, agency for all participants, embracing a plurality of forms of knowledge, and mutual and reciprocal benefit. We describe three stages of the co-design process (preparatory work; design and development; feedback and closure), strategies and techniques we used at each stage, challenges we faced, and considerations for addressing them. CONCLUSION: Co-designing patient-facing interventions blends different forms of knowledge to produce practical, contextually specific interventions with ownership by the people who will use them. PRACTICE IMPLICATIONS: Co-design is a feasible methodology for most health services research teams whose goal is to intensify patient engagement in research.

Early Deep Sedation Practices Worsened During the Pandemic Among Adult Patients Without COVID-19: A Retrospective Cohort Study.

BACKGROUND: There is substantial evidence that patients with COVID-19 were treated with sustained deep sedation during the pandemic. However, it is unknown whether such guideline-discordant care had spillover effects to patients without COVID-19. RESEARCH QUESTION: Did patterns of early deep sedation change during the pandemic for patients on mechanical ventilation without COVID-19? STUDY DESIGN AND METHODS: We used electronic health record data from 4,237 patients who were intubated without COVID-19. We compared sedation practices in the first 48 h after intubation across prepandemic (February 1, 2018, to January 31, 2020), pandemic (April 1, 2020, to March 31, 2021), and late pandemic (April 1, 2021, to March 31, 2022) periods. RESULTS: In the prepandemic period, patients spent an average of 13.0 h deeply sedated in the first 48 h after intubation. This increased 1.9 h (95% CI, 1.0-2.8) during the pandemic period and 2.9 h (95% CI, 2.0-3.8) in the late pandemic period. The proportion of patients that spent over one-half of the first 48 h deeply sedated was 18.9% in the prepandemic period, 22.3% during the pandemic period, and 25.9% during the late pandemic period. Ventilator-free days decreased during the pandemic, with a subdistribution hazard ratio of being alive without mechanical ventilation at 28 days of 0.87 (95% CI, 0.79-0.95) compared with the prepandemic period. Tracheostomy placement increased during the pandemic period compared with the prepandemic period (OR, 1.41; 95% CI, 1.08-1.82). In the medical ICU, early deep sedation increased 2.5 h (95% CI, 0.6-4.4) during the pandemic period and 4.9 h (95% CI, 3.0-6.9) during the late pandemic period, compared with the prepandemic period. INTERPRETATION: We found that among patients on mechanical ventilation without COVID-19, sedation use increased during the pandemic. In the subsequent year, these practices did not return to prepandemic standards.