A study of Indiana University Health's spirit of inquiry and innovation during COVID.

BACKGROUND: COVID-19 has required nursing innovations to meet patient care needs not previously encountered. PURPOSE: The purpose of this study was to describe nursing innovations conceived, implemented, and desired during the first COVID-19 surge. METHODS: The investigators invited registered nurses employed across 16 Midwest hospitals (6,207) to complete the survey. Respondents provided demographics and written descriptions of innovations they conceived, witnessed, and desired. Investigators analyzed text responses using standard content analytic procedures and summarized quantitative demographics using percentages. FINDINGS: Nurses reported seven types of innovations that would (a) improve personal protective equipment (PPE), (b) limit the need to repeatedly don and doff PPE, (c) ensure safer practice, (d) conserve and access supplies, (e) provide patient and family education and support, (f) make team member communication more efficient, and (g) improve peer support. DISCUSSION: Nurses are in a unique position to generate innovative solutions to meet patient care needs under adverse and rapidly changing situations.

SystemCHANGE™ Solutions to Improve Medication Adherence in Kidney Transplant Recipients: A Secondary Data Analysis.

The SystemCHANGE™ intervention has led to great improvements in medication adherence, which is a challenge for nearly one-third of kidney transplant recipients. This secondary data analysis sought to measure the frequency of individual solutions utilized by participants in a previously conducted randomized controlled trial of the SystemCHANGE™ intervention and to determine which classes of solutions had greatest impact on improved medication adherence. Solutions that were significant predictors of improving medication adherence to the 85% or higher level included alarm cues (p ≤ 0.0001), time cues (p = 0.006), restructuring the physical environment (p = 0.048), and social support (p = 0.023). Alarm and time cues, restructuring the environment, and social support were successful solutions largely influenced by personal routine and environment consideration that might be prioritized in future studies when implementing SystemCHANGE™.

Improving medication adherence and outcomes in adult kidney transplant patients using a personal systems approach: SystemCHANGE™ results of the MAGIC randomized clinical trial.

This study determined if a SystemCHANGE™ intervention was more efficacious than attention control in increasing immunosuppressive medication adherence and improving outcomes in adult kidney transplant recipients during a 6-month intervention phase and subsequent 6-month (no intervention) maintenance phase. The SystemCHANGE™ intervention taught patients to use person-level quality improvement strategies to link adherence to established daily routines, environmental cues, and supportive people. Eighty-nine patients (average age 51.8 years, 58% male, 61% African American) completed the 6-month intervention phase. Using an intent-to-treat analysis, at 6 months, medication adherence for SystemCHANGE™ (median 0.91, IQR 0.76-0.96) and attention control (median 0.67, IQR 0.52-0.72) patients differed markedly (difference in medians 0.24, 95% CI 0.13-0.30, P < .001). At the conclusion of the subsequent 6-month maintenance phase, the gap between medication adherence for SystemCHANGE™ (median 0.77, IQR 0.56-0.94) and attention control (median 0.60, IQR 0.44-0.73) patients remained large (difference in medians 0.17, 95% CI 0.06-0.33, P = .004). SystemCHANGE™ patients evidenced lower mean creatinine and BUN at 12 months and more infections at 6 and 12 months. This first fully powered RCT testing SystemCHANGE™ to improve and maintain medication adherence in kidney transplant recipients demonstrated large, clinically meaningful improvements in medication adherence. Clinical Trial Registration: NCT02416479.

Cognitive-behavioral therapy and buprenorphine for opioid use disorder: A systematic review and meta-analysis of randomized controlled trials.

Background: Recent systematic reviews have questioned the ability of psychosocial intervention to add substantive benefit to buprenorphine therapy. Objectives: The purpose of the present meta-analysis was to test the random effects model (REM) null hypothesis that, for opioid use disorder (OUD) and opioid biological sample outcomes, the summary effect of cognitive-behavioral therapy (CBT) + buprenorphine randomized controlled trials (RCTs) = 0. Methods: A systematic review was conducted searching electronic databases and the reference lists of included studies. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria were used to guide this review and the REM meta-analysis. Results: The initial meta-analytic model (k = 4) was insignificant (REM Hedges' g =.22, Z = 1.27, p =.206, 95% CI: -0.12-0.56) and heterogeneous (I2 = 53.47). A pre-specified categorical moderator analysis explained the heterogeneity via CBT modality. Categorical moderator analysis (k = 4) showed non-individual CBT RCTs (k = 2) to have a REM Hedges' g summary effect of.598 (p =.006) and individual-CBT RCTs (k = 2) to have a REM Hedges' g summary effect of -0.010 (p = .936). The difference between these two subgroups was significant (Q = 5.85, df = 1, p = .016). Conclusion: The evidence cautiously suggests that for OUD, there may be some benefit to adding non-individual CBT to buprenorphine therapy.

Building the case for actionable ethics in digital health research supported by artificial intelligence.

The digital revolution is disrupting the ways in which health research is conducted, and subsequently, changing healthcare. Direct-to-consumer wellness products and mobile apps, pervasive sensor technologies and access to social network data offer exciting opportunities for researchers to passively observe and/or track patients 'in the wild' and 24/7. The volume of granular personal health data gathered using these technologies is unprecedented, and is increasingly leveraged to inform personalized health promotion and disease treatment interventions. The use of artificial intelligence in the health sector is also increasing. Although rich with potential, the digital health ecosystem presents new ethical challenges for those making decisions about the selection, testing, implementation and evaluation of technologies for use in healthcare. As the 'Wild West' of digital health research unfolds, it is important to recognize who is involved, and identify how each party can and should take responsibility to advance the ethical practices of this work. While not a comprehensive review, we describe the landscape, identify gaps to be addressed, and offer recommendations as to how stakeholders can and should take responsibility to advance socially responsible digital health research.

Behavior change interventions: the potential of ontologies for advancing science and practice.

A central goal of behavioral medicine is the creation of evidence-based interventions for promoting behavior change. Scientific knowledge about behavior change could be more effectively accumulated using "ontologies." In information science, an ontology is a systematic method for articulating a "controlled vocabulary" of agreed-upon terms and their inter-relationships. It involves three core elements: (1) a controlled vocabulary specifying and defining existing classes; (2) specification of the inter-relationships between classes; and (3) codification in a computer-readable format to enable knowledge generation, organization, reuse, integration, and analysis. This paper introduces ontologies, provides a review of current efforts to create ontologies related to behavior change interventions and suggests future work. This paper was written by behavioral medicine and information science experts and was developed in partnership between the Society of Behavioral Medicine's Technology Special Interest Group (SIG) and the Theories and Techniques of Behavior Change Interventions SIG. In recent years significant progress has been made in the foundational work needed to develop ontologies of behavior change. Ontologies of behavior change could facilitate a transformation of behavioral science from a field in which data from different experiments are siloed into one in which data across experiments could be compared and/or integrated. This could facilitate new approaches to hypothesis generation and knowledge discovery in behavioral science.

Medication-taking behaviours in chronic kidney disease with multiple chronic conditions: a meta-ethnographic synthesis of qualitative studies.

AIMS AND OBJECTIVES: To identify behaviours associated with taking medications and medication adherence reported in qualitative studies of adults with chronic kidney disease and coexisting multiple chronic conditions. BACKGROUND: To inform medication adherence interventions, information is needed to clarify the nature of the relationships between behaviours that support medication-taking and medication adherence in multiple chronic conditions. DESIGN: Meta-ethnographic review and synthesis. METHODS: CINAHL Complete, MEDLINE and PsycINFO databases were searched. Five qualitative studies met the inclusion criteria. A meta-ethnographic approach was used for synthesis. Medication-taking behaviours were abstracted from study findings and synthesised according to the contexts in which they occur and interpreted within a new developing framework named the Medication-taking Across the Care Continuum and Adherence-related Outcomes. RESULTS: Twenty categories of medication-taking behaviours occurred in three main contexts: (1) patient-provider clinical encounters, (2) pharmacy encounters and (3) day-to-day management. These behaviours are distinctly different, multilevel and interrelated. Together they represent a process occurring across a continuum. CONCLUSIONS: Future medication adherence research should consider using a multilevel ecological view of medication management. Clinical practice and policy development can benefit from further understanding socio-contextual behaviours that occur across the continuum. Nurses should have greater presence in chronic disease management and be positioned to support the day-to-day home management of patients' medications. RELEVANCE TO CLINICAL PRACTICE: Healthcare professionals can partner with patients to elucidate how these behaviours are enacted across the care continuum and in day-to-day management to identify opportunities to intervene on specific behaviours and promote medication adherence.

Using National Measures of Patients' Perceptions of Health Care to Design and Debrief Clinical Simulations.

This article describes an innovative approach to using national measures of patients' perspectives of quality health care. Nurses from a regional simulation consortium designed and executed a simulation using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to prepare nurses to improve care and, in turn, enhance patients' perceptions of care. The consortium is currently revising the reporting mechanism to collect data about specific learning objectives based on national quality indicator benchmarks, specifically HCAHPS. This revision reflects the changing needs of health care to include quality metrics in simulation.

Pillbox intervention fidelity in medication adherence research: A systematic review.

BACKGROUND: Pillboxes are widely available, have evidence of effectiveness, but translating pillboxes in self-management interventions requires an understanding of intervention components. PURPOSE: To review components of intervention design, interventionist training, delivery, receipt, enactment, and targeted behaviors in adherence studies. METHODS: Five multidisciplinary databases were searched to find reports of controlled trials testing pillboxes and medication adherence interventions in adults managing medications. Details of treatment fidelity, that is, design, training, delivery, receipt, and enactment, were abstracted. FINDINGS: A total of 38 articles reporting 40 studies were included. Treatment fidelity descriptions were often lacking, especially reporting receipt and enactment, important for both control and intervention groups. Clearly reported details are needed to avoid making assumptions when translating evidence. CONCLUSION: These findings serve as a call to action to explicitly state intervention details. Lack of reported intervention detail is a barrier to translating which components of pillboxes work in influencing medication adherence behaviors and outcomes.

Knowledge and Awareness Among Patients with Chronic Kidney Disease Stage 3.

Knowledge is a prerequisite for changing behavior, and is useful for improving outcomes and reducing mortality rates in patients diagnosed with chronic kidney disease (CKD). The purpose of this article is to describe baseline CKD knowledge and awareness obtained as part of a larger study testing the feasibility of a self-management intervention. Thirty patients were recruited who had CKD Stage 3 with coexisting diabetes and hypertension. Fifty-four percent of the sample were unaware of their CKD diagnosis. Participants had a moderate amount of CKD knowledge. This study suggests the need to increase knowledge in patients with CKD Stage 3 to aid in slowing disease progression.

Thematic Analysis of Alzheimer's Medication Management Discussion in a Non-Moderated Online Forum.

BACKGROUND: Managing medications for Alzheimer's disease and related dementias is challenging for caregivers. Information about caregivers' strategies to manage these challenges is needed to inform intervention development. OBJECTIVE: This study aimed to understand caregivers' medication management experiences by analyzing online community discussions. METHODS: Posts were extracted from the ALZConnected® Forum using keywords "medication" and "drug" via web scraping. The researchers applied thematic analysis. RESULTS: Four major themes emerged: (1) role transition of medication management responsibilities, (2) caregivers' uncertainty about medication purpose and values, (3) conflicts between the care recipients and caregivers, and (4) difficulty accessing and affording medications. CONCLUSIONS: The experiences shared on a non-moderated, unstructured online forum indicate that medication management is challenging and overwhelming for caregivers of people living with Alzheimer's disease and related dementias. Since this is a progressive disease with various stages and changing needs, caregivers' strategies vary and are often limited by available resources and support. Health care providers should offer training and support for caregivers to navigate the transfer of medication management responsibilities and changing care needs as the disease progresses.

Understanding Processes, Outcomes, and Contexts in Medication Adherence: The Medication Adherence Context and Outcomes (MACO) Framework.

Poor medication adherence is a significant problem, yet interventions to improve it have been largely ineffective. Existing ecological models indicate that adherence is multi-dimensional; however, they do not reflect understanding of context-specific processes and how they lead to adherence outcomes. A framework that reflects context-specific processes is important because it could be used to inform context-specific intervention delivery and measure associated adherence outcomes. The purpose of this paper is to describe the Medication Adherence Context and Outcomes (MACO) framework, which includes contexts (ie, clinics, pharmacies, and home) and context-specific processes (ie, shared decision-making, prescription filling strategies, home medication management) that lead to adherence outcomes (initiation, implementation, discontinuation, and persistence). The Medication and Adherence Contexts and Outcomes (MACO) framework was iteratively developed between 2015 and 2018 based on theory, practice, and research and combining patient experience journey mapping to chronologically describe the environmental contexts and actions (processes) that occur within the contexts and how they contribute to medication adherence as outcome. The three distinct yet interrelated contexts described in the MACO framework are 1) clinical encounters, 2) pharmacy encounters, and 3) day-to-day home management. Within these contexts are specific medication management actions that occur (processes) in order to produce adherence-related outcomes (initiation, implementation, and discontinuation/persistence). The MACO framework distinguishes context-specific processes and outcomes. The MACO framework may be useful to understand at which point(s) along the continuum people experience problems with managing medications. This understanding is potentially useful for developing and delivering context-specific interventions that are based on processes that underlie nonadherence and selecting adherence measures appropriate for the contexts.

Managing Medications and Medication Adherence Among US Adults During the Early Phase of the COVID-19 Pandemic.

Purpose: Before the COVID-19 pandemic and the disruptions it brought, medication adherence was already a challenging and complex health behavior. The purpose of this study was to describe patients' interactions in clinic, pharmacy, and home contexts and associated medication management and adherence during the early phase of the COVID-19 pandemic. Patients and Methods: A survey questionnaire was developed using the Medication Adherence Context and Outcomes framework and distributed via social media between May and July 2020 targeting adults taking a daily prescribed medication. Survey questions assessed sociodemographics, interactions with healthcare providers, clinics, pharmacies, medication management experiences, habit strength, and life chaos perceptions during the pandemic. Medication adherence was assessed by the self-report BAASIS© scale to measure implementation, discontinuation, and overall nonadherence. Results: A total of 134 adults from the United States, mean age 50.0 (SD 16.1) years were included in this analysis. Respondents took a median of 3.50 (interquartile range 4) daily medications. Delays in seeing a provider were reported by 47 (35.1%). Pharmacy encounters were impacted; 25 (18.7%) indicated their method for obtaining medication changed. Medication nonadherence was reported among 62 (46.3%) and was significantly greater among those who delayed prescription refills (p=0.032), pillbox users (p=0.047), and those who experienced greater life chaos (p=0.040) and lower habit strength (p<0.001) in the early phase of the pandemic. Conclusion: Although the early phase of the pandemic affected access to care for nearly one-third of the sample, distance-accessible care options and strategies to obtain needed services without being in-person supported respondents medication management. Helpful strategies included provider accessibility, telehealth, home delivery/mail-order, drive-thru's, 90-day supplies, and online/automatic refills. Methods to develop and reestablish habits are critical. Care providers in clinic and pharmacy settings can educate and remind patients about services like distance-accessible technologies and online ordering of medications and establishing routines to support medication adherence.

The AACN Essentials journey.

The new AACN Essentials: Core Competencies for Professional Nursing Education create an opportunity to nursing education to transform the educational preparation of our workforce with new standards for all member schools to implement into their academic programs as we prepare the future nursing workforce. With the advent of these updated academic standards, many nursing schools across the nation are reviewing program outcomes and transitioning from concepts to competencies. The purpose of the article is to describe the early phases of a quality improvement initiative to implement the new AACN Essentials within the undergraduate curriculum of a large school of nursing spanning multiple campuses. The article conveys lessons learned to help support and guide other schools of nursing.

A Descriptive, Correlational Study of Perceptions of Adult Kidney Transplant Recipients and Those Waiting for a Kidney Transplant About Managing Their Medications During a Pandemic.

Introduction: Little is known about COVID-19 impact on patient medication management. Research Question: The aim was to describe medication management, healthcare team interactions, and adherence during the COVID-19 pandemic in kidney transplant patients and those on the kidney transplant wait list. Design: Using a descriptive, correlational design 340 adults from a midwestern US transplant program were recruited. The Managing Medications in the Midst of a Pandemic Survey measured healthcare team encounters and medication management. The Basel assessment of adherence to medications scale measured medication adherence. Results: The response rate was 35% (119/340). During the pandemic, 88% had practiced/were currently practicing socially distancing, 85% had worn/were currently wearing a face mask in public, 18% had been/were currently diagnosed with COVID-19 and 82% received the vaccine. Medication management: 76% planned and organized their own medications. Healthcare team interactions: 89% met in the office, 20% via phone, 12% telehealth, and 13% delayed seeing a healthcare provider because of COVID-19 concerns. Pharmacy interactions: 11% changed their method of obtaining medications from pharmacy due to social distancing. Medication adherence implementation was problematic with 19% missing a dose; results from the binary logistic regression suggested that those with higher levels of education were more likely to report missing a dose. Conclusions: Patients acted to prevent COVID-19 but some still contracted the virus. The pandemic changed healthcare team medication management interactions. Adherence implementation problems were nearly 20%. Findings are relevant to the transplant healthcare team to understand the impact of a pandemic on patient/team interactions and medication adherence.

O-Know Opioid Knowledge Test: Development and Psychometric Testing in a Community Setting.

Given the various sources and consequences of opioid use disorder (OUD) stigma, the mechanisms by which stigma occurs becomes more important. Educational deficits regarding OUD as a disease and treatment influence OUD stigma. The purpose of the study was to develop, pilot test and psychometrically evaluate the Opioid-Knowledge (O-Know) test in a community setting. A social media strategy was used to recruit 294 participants, in 2019, from a midwestern region experiencing an HIV epidemic, stemming from opioid and injection drug use. The Factor analysis used a tetrachoric correlation matrix, with principal axis factor extraction and Promax rotation. Horn's parallel analysis supported the factorial validity of a two-factor model representing OUD as a Disease (Cronbach's alpha = .57) and OUD Treatment and Recovery (Cronbach's alpha = .62). The reliability estimates were deemed adequate given the intended group-level uses for the instrument. Convergent construct validity was partially supported via the OUD Treatment and Recovery factor's negative correlation with personal opioid stigmatization (B = -.29, p =.001). OUD research must produce measures that convert observations to empirical generalizations. The psychometric analysis of the O-Know scale demonstrated progress in reducing measurement error to facilitate that conversion.

Attitudinal and social predictors of adherence to oral endocrine therapy: A psychometrically-informed model.

There is a need for a psychometrically-informed model identifying attitudinal and social factors explaining adherence to oral endocrine therapy (OET) for women with hormone receptor positive breast cancer. This study tested a model with variables selected by stringent psychometric criteria, including attitudes about benefit and burden, patient-practitioner alliance and confusion, and positive and negative interpersonal interactions. Self-report scales were completed by 150 current or past OET users. Fourteen correlations and six mediated pathways implied by the model were tested. All hypothesized associations were significant. This preliminary study suggests the model is a valuable framework for OET adherence research and intervention.

Development of a decision-making checklist tool to support technology selection in digital health research.

Digital technologies offer researchers new approaches to test personalized and adaptive health interventions tailored to an individual. Yet, research leveraging technologies to capture personal health data involve technical and ethical consideration during the study design phase. No guidance exists to facilitate responsible digital technology selection for research purposes. A stakeholder-engaged and iterative approach was used to develop, test, and refine a checklist designed to aid researchers in selecting technologies for their research. First, stakeholders (n = 7) discussed and informed key decision-making domains to guide app/device selection derived from the American Psychiatric Association's framework that included safety, evidence, usability, and interoperability. We added "ethical principles" to the APA's hierarchical model and created a checklist that was used by a small group of behavioral scientists (n = 7). Findings revealed the "ethical principles" domains of respect, beneficence, and justice cut across each decision-making domains and the checklist questions/prompts were revised accordingly and can be found at thecore.ucsd.edu. The refined checklist contains four decision-making domains with prompts/questions and ethical principles embedded within the domains of privacy, risk/benefit, data management, and access/evidence. This checklist is the first step in leading the narrative of decision-making when selecting digital health technologies for research. Given the dynamic and rapidly evolving nature of digital health technology use in research, this tool will need to be further evaluated for usefulness in technology selection.

Self-Reported Nonadherence Associated with Pharmacy and Home Medication Management Inconvenience Factors in a US Adult Population.

PURPOSE: Medication nonadherence is a significant and multidimensional problem contributing to an increased risk of morbidity and mortality. Inconveniences in pharmacy and home contexts may increase nonadherence. This research examined inconveniences in pharmacy and home contexts associated with self-reported nonadherence, controlling for demographic and medication-taking covariates. METHODS: Data from 4682 individuals who reported self-managing medications in an online marketing survey between October and December 2017 were analyzed in this secondary analysis. Nonadherence was dichotomized using a single question about likelihood to take medications as prescribed (adherence=always; nonadherence=most of the time, some of the time, never). Multivariable logistic regression with backwards elimination was used to examine the pharmacy (use of home delivery, number prescriptions picked up and visits to pharmacy) and home context (method used to organize/manage medications, satisfaction, and bother with management) variables and the demographic (age, sex, race/ethnicity, education, income, insurance) and medication (number of oral medications, medication changes and frequency of taking) covariates associated with nonadherence. RESULTS: Overall, 25.8% of the responses indicated nonadherence. Nonadherence was more likely for individuals making fewer separate pharmacy trips (OR 0.98; 95% CI 0.97-0.99); picking up fewer prescriptions (OR 0.96; 95% CI 0.93-0.99); never, rarely or sometimes using mail order compared with always (OR 1.71; 95% CI 1.30-2.26); not satisfied with managing medications (OR 2.13; 95% CI 1.42-3.19); and using pill pouches and being bothered by them (OR 8.28; 95% CI 1.83-37.31). Using pill pouches or a pillbox and not being bothered by them significantly decreased nonadherence likelihood. Younger and female respondents and those reporting medication changes in the last year were also more likely to report nonadherence. CONCLUSION: Though reasons for nonadherence are multidimensional, this study suggests that inconveniences in both the pharmacy and home context are important. Improving adherence requires addressing issues of inconvenience across the care continuum.

The Feasibility of a Using a Smart Button Mobile Health System to Self-Track Medication Adherence and Deliver Tailored Short Message Service Text Message Feedback.

BACKGROUND: As many as 50% of people experience medication nonadherence, yet studies for detecting nonadherence and delivering real-time interventions to improve adherence are lacking. Mobile health (mHealth) technologies show promise to track and support medication adherence. OBJECTIVE: The study aimed to evaluate the feasibility and acceptability of using an mHealth system for medication adherence tracking and intervention delivery. The mHealth system comprises a smart button device to self-track medication taking, a companion smartphone app, a computer algorithm used to determine adherence and then deliver a standard or tailored SMS (short message service) text message on the basis of timing of medication taking. Standard SMS text messages indicated that the smartphone app registered the button press, whereas tailored SMS text messages encouraged habit formation and systems thinking on the basis of the timing the medications were taken. METHODS: A convenience sample of 5 adults with chronic kidney disease (CKD), who were prescribed antihypertensive medication, participated in a 52-day longitudinal study. The study was conducted in 3 phases, with a standard SMS text message sent in phases 1 (study days 1-14) and 3 (study days 46-52) and tailored SMS text messages sent during phase 2 (study days 15-45) in response to participant medication self-tracking. Medication adherence was measured using: (1) the smart button and (2) electronic medication monitoring caps. Concordance between these 2 methods was evaluated using percentage of measurements made on the same day and occurring within ±5 min of one another. Acceptability was evaluated using qualitative feedback from participants. RESULTS: A total of 5 patients with CKD, stages 1-4, were enrolled in the study, with the majority being men (60%), white (80%), and Hispanic/Latino (40%) of middle age (52.6 years, SD 22.49; range 20-70). The mHealth system was successfully initiated in the clinic setting for all enrolled participants. Of the expected 260 data points, 36.5% (n=95) were recorded with the smart button and 76.2% (n=198) with electronic monitoring. Concordant events (n=94), in which events were recorded with both the smart button and electronic monitoring, occurred 47% of the time and 58% of these events occurred within ±5 min of one another. Participant comments suggested SMS text messages were encouraging. CONCLUSIONS: It was feasible to recruit participants in the clinic setting for an mHealth study, and our system was successfully initiated for all enrolled participants. The smart button is an innovative way to self-report adherence data, including date and timing of medication taking, which were not previously available from measures that rely on recall of adherence. Although the selected smart button had poor concordance with electronic monitoring caps, participants were willing to use it to self-track medication adherence, and they found the mHealth system acceptable to use in most cases.