"To prescribe or not to prescribe, that is the question": Perspectives on opioid prescribing for chronic, cancer-related pain from clinicians who treat pain in survivorship.

BACKGROUND: Opioid pain management in cancer survivorship is a complex and understudied topic. METHODS: The authors conducted in-depth, qualitative interviews to understand clinician approaches to opioid pain management in chronic cancer pain and to generate ideas for improvement. They used a rigorous, inductive, qualitative, descriptive approach to examine clinician (n = 20) perspectives about opioid pain management in survivorship, including oncologists (n = 5), palliative care clinicians (n = 8), primary care clinicians (n = 5), and pain management specialists (n = 2). RESULTS: The findings indicated that no consistent medical home exists for chronic pain management in cancer survivors and that there are fundamental differences in how each subspecialty approaches chronic pain management in survivorship (e.g., "Do we think of this as noncancer pain or cancer pain?… This is in this limbo zone-this gray zone-because it's cancer-related pain, right?"). Simultaneously, clinicians are influenced by their peers' perceptions of their opioid prescribing decisions, sparking intraprofessional tension when disagreement occurs. In these instances, clinicians described overthinking and doubting their clinical decision-making as well as a sense of judgment, pressure, and/or shame. Finally, clinicians acknowledged a fear of consequences for opioid prescribing decisions. Specifically, participants cited conflict with patients, sometimes escalating to aggression and threats of violence, as well as potential disciplinary actions and/or legal consequences. CONCLUSIONS: Participants suggested that opportunities to improve chronic cancer pain care include developing clear, systematic guidance for chronic cancer pain management, facilitating clinician communication and consultation, creating tailored survivorship care plans in partnership with patients, and developing accessible, evidence-based, complementary pain treatments.

Mental health, pain and likelihood of opioid misuse among adults with sickle cell disease.

Depressive symptoms are prevalent in individuals living with sickle cell disease (SCD) and may exacerbate pain. This study examines whether higher depressive symptoms are associated with pain outcomes, pain catastrophizing, interference and potential opioid misuse in a large cohort of adults with SCD. The study utilized baseline data from the 'CaRISMA' trial, which involved 357 SCD adults with chronic pain. Baseline assessments included pain intensity, daily mood, the Patient Health Questionnaire (PHQ), the Generalized Anxiety Disorders scale, PROMIS Pain Interference, Pain Catastrophizing Scale, the Adult Sickle Cell Quality of Life Measurement Information System and the Current Opioid Misuse Measure. Participants were categorized into 'high' or 'low' depression groups based on PHQ scores. Higher depressive symptoms were significantly associated with increased daily pain intensity, negative daily mood, higher pain interference and catastrophizing, poorer quality of life and a higher likelihood of opioid misuse (all p < 0.01). SCD patients with more severe depressive symptoms experienced poorer pain outcomes, lower quality of life and increased risk of opioid misuse. Longitudinal data from this trial will determine whether addressing depressive symptoms may potentially reduce pain frequency and severity in SCD.

How to Provide Sexual and Reproductive Health Care to Patients: Focus Groups With Rheumatologists and Rheumatology Advanced Practice Providers.

OBJECTIVE: Rheumatologists have identified challenges to providing sexual and reproductive health (SRH) care to patients with gestational capacity. We conducted focus groups with rheumatologists and rheumatology advanced practice providers (APPs) to elicit their solutions to overcoming barriers to SRH care. METHODS: Qualitative focus groups were conducted with rheumatologists (3 groups) and APPs (2 groups) using videoconferencing. Discussions were transcribed and 2 trained research coordinators developed a content-based codebook. The coordinators applied the codebook to transcripts, and discrepancies were adjudicated to full agreement. The codes were synthesized and used to conduct a thematic analysis. Differences in codes were also identified between the clinician groups by provider type. RESULTS: A total of 22 clinicians were included in the sample, including 12 rheumatologists and 10 APPs. Four themes emerged: (1) clinicians recommended preparing patients to engage in SRH conversations before and during clinic visits; (2) consultation systems are needed to facilitate rapid SRH care with women's health providers; (3) clinicians advised development of training opportunities and easy-to-access resources to address SRH knowledge gaps; and (4) clinicians recommended that educational materials about SRH in the rheumatology context are provided for patients. Although similar ideas were generated between the APP and rheumatologist groups, the rheumatologists were generally more interested in additional training and education, whereas APPs were more interested in electronic health record prompts and tools. CONCLUSION: Providers identified many potential solutions and facilitators to enhancing SRH care in rheumatology that might serve as a foundation for intervention development.

Barriers to rural health care from the provider perspective.

INTRODUCTION: Rural populations routinely rank poorly on common health indicators. While it is understood that rural residents face barriers to health care, the exact nature of these barriers remains unclear. To further define these barriers, a qualitative study of primary care physicians practicing in rural communities was performed. METHODS: Semistructured interviews were conducted with primary care physicians practicing in rural areas within western Pennsylvania, the third largest rural population within the USA, using purposively sampling. Data were then transcribed, coded, and analyzed by thematic analysis. RESULTS: Three key themes emerged from the analysis addressing barriers to rural health care: (1) cost and insurance, (2) geographic dispersion, and (3) provider shortage and burnout. Providers mentioned strategies that they either employed or thought would be beneficial for their rural communities: (1) subsidize services, (2) establish mobile and satellite clinics (particularly for specialty care), (3) increase utilization of telehealth, (4) improve infrastructure for ancillary patient support (ie social work services), and (5) increase utilization of advanced practice providers. CONCLUSION: There are numerous barriers to providing rural communities with quality health care. Barriers that are encountered are multidimensional. Patients are unable to obtain the care they need because of cost-related barriers. More providers need to be recruited to rural areas to combat the shortage and burnout. Advanced care-delivery methods such as telehealth, satellite clinics, or advanced practice providers can help bridge the gaps caused by geographic dispersion. Policy efforts should target all these aspects in order to appropriately address rural healthcare needs.

Use of Chart-Stimulated Recall to Explore Uncertainty in Medical Decision-Making Among Senior Internal Medicine Residents.

BACKGROUND: Uncertainty is common and impacts both patients and clinicians. The approach to uncertainty in medical trainees may be distinct from that of practicing clinicians and has important implications for medical education. OBJECTIVE: Describe trainee approach to uncertainty with the use of chart-stimulated recall (CSR)-based interviews, as well as the utility of such interviews in promoting reflection about decision-making among senior internal medicine (IM) residents. DESIGN: Qualitative analysis of CSR-based interviews with IM residents. PARTICIPANTS: Senior IM residents rotating on inpatient night float at the University of Pittsburgh Medical Center from February to September 2019. INTERVENTION: Each participant completed one, 20-min CSR session based on a self-selected case in which there was uncertainty in decision-making. Interviews explored the sources of, approaches to, and feelings about uncertainty. APPROACH: Two independent coders developed a codebook and independently coded all transcripts. Transcripts were then analyzed using thematic analysis. KEY RESULTS: The perceived acuity of the patient presentation was the main driver of the approach to and stress related to uncertainty. Perceived level of responsibility in resolving uncertainty during the overnight shift also varied among individual participants. Attending expression of uncertainty provided comfort to residents and alleviated stress related to uncertainty. Residents felt comfortable discussing their uncertainty and felt that the opportunity to think aloud during the exercise was valuable. CONCLUSIONS: Our study demonstrated a novel approach to the exploration of uncertainty in medical decision-making, with the use of CSR. Variations in resident perceived level of responsibility in resolving uncertainty during the overnight shift suggest a need for curriculum development in approach to uncertainty during night shifts. Though residents often experienced stress related to uncertainty, attending expression of uncertainty was an important mitigator of that stress, emphasizing the important role that the trainee-attending interaction plays in the diagnostic process.

Primary care physicians' approaches to low-value prescribing in older adults: a qualitative study.

BACKGROUND: Low-value prescribing may result in adverse patient outcomes and increased medical expenditures. Clinicians' baseline strategies for navigating patient encounters involving low-value prescribing remain poorly understood, making it challenging to develop acceptable deprescribing interventions. Our objective was to characterize primary care physicians' (PCPs) approaches to reduce low-value prescribing in older adults through qualitative analysis of clinical scenarios. METHODS: As part of an overarching qualitative study on low-value prescribing, we presented two clinical scenarios involving potential low-value prescribing during semi-structured interviews of 16 academic and community PCPs from general internal medicine, family medicine and geriatrics who care for patients aged greater than or equal to 65. We conducted a qualitative analysis of their responses to identify salient themes related to their approaches to prescribing, deprescribing, and meeting patients' expectations surrounding low-value prescribing. RESULTS: We identified three key themes. First, when deprescribing, PCPs were motivated by their desire to mitigate patient harms and follow medication safety and deprescribing guidelines. Second, PCPs emphasized good communication with patients when navigating patient encounters related to low-value prescribing; and third, while physicians emphasized the importance of shared decision-making, they prioritized patients' well-being over satisfying their expectations. CONCLUSIONS: When presented with real-life clinical scenarios, PCPs in our cohort sought to reduce low-value prescribing in a guideline-concordant fashion while maintaining good communication with their patients. This was driven primarily by a desire to minimize the potential for harm. This suggests that barriers other than clinician knowledge may be driving ongoing use of low-value medications in clinical practice.

Staff Perceptions of Barriers and Facilitators to Implementation of Behavioral Health Homes at Community Mental Health Provider Settings.

Individuals living with a serious mental illness are disproportionately affected by preventable and/or manageable chronic conditions. Integrated care and support for behavioral and physical health within community mental health provider (CMHP) settings, also known as behavioral health homes (BHH), can lead to improvements in care and cost outcomes. This study explored staff perceptions of barriers and facilitators to BHH implementation. We conducted semi-structured interviews with CMHP staff at baseline, 1, and 2 years after the start of implementation. We analyzed interviews to identify major themes. We conducted 65 total interviews with 30 unique staff members. Common barriers included staff turnover, hesitation to change care processes, and acute service user needs. Facilitators included agency-wide culture change, intervention champions, and integration of intervention processes into daily workflows. Despite common barriers, CMHP staff identified several elements related to successful BHH implementation, including the CMHP-wide cultural shift to comprehensively address health/wellness that benefitted service users and staff alike.

"How much desire should I have?": a qualitative study of low libido in postmenopausal women.

We conducted 15 interviews and 3 focus groups (total N = 36) among women 60 and older with low libido to better understand the role that it plays in their lives. Interviews and focus groups were led by facilitators using open-ended questions. A codebook was developed, then codes were assigned to all data. We identified three themes. First, women reported that sex was an important aspect of their lives. Second, women desired to know what was "normal" with regards to sexuality and aging. Third, women were distressed by low libido, concerned that it could have negative effects on romantic relationships and self-image.

Caregiver Decision-making in Pediatric Intestinal Failure: A Qualitative Study Focused on Iron Deficiency Anemia.

BACKGROUND: Caregivers of children with intestinal failure (IF) face difficult decisions without a clear best alternative. Providers assist in decision-making but often lack knowledge of caregiver perspectives. Using decision-making around anemia treatment as a focal point, we explored how caregivers of children with IF prefer to make decisions. Our goal was to offer insight to guide providers as they assist in decision-making. METHODS: We conducted 12 half-hour semistructured interviews with parents of children with IF. Interview questions addressed general decision-making and specifics of iron supplementation, including key factors and stakeholders in decision-making. Interviews were transcribed verbatim. Two investigators coded the transcripts and inductively derived themes. RESULTS: Four themes were identified regarding decision-making. They involved the search for reliable, accurate, and positive information; the role of caretakers on the medical team; the relationships between caretakers and the medical team; and effective communication. Themes around anemia treatment included: identification of anemia by bloodwork; proactive supplementation; individualized regimens; prioritizing safety and convenience. CONCLUSIONS: Understanding caregiver perspectives regarding anemia treatment in pediatric IF identifies opportunities for systematic quality improvement.

Internal Medicine Resident Perceptions of Patients with Substance Use Disorder After Attending a Mutual Support Group Meeting.

BACKGROUND: Mutual support groups (MSGs) are support systems for patients with substance use disorders (SUDs), yet medical residents lack awareness in the role MSGs play in addiction treatment. AIM: We developed an educational intervention to expose residents to MSGs and improve attitudes toward patients with SUD. SETTING: The study took place from October 2017 to March 2018 within a large academic medical center. PARTICIPANTS: First- to third-year internal medicine residents participated. PROGRAM DESCRIPTION: Residents attended a MSG meeting. They completed surveys pre- and post-meeting and attended a focus group debrief session. Focus group transcripts were coded and thematically analyzed. PROGRAM EVALUATION: Sixty-eight residents participated in the curriculum, 54 attended the focus group and 47 completed the pre- and post-survey. Qualitative themes included (1) appreciation for the sense of community at meetings, (2) improved perspective taking of patients with SUDs, (3) concern regarding religion, and (4) improved confidence in MSG referrals. Post-intervention, residents had more positive attitudes toward patients with SUD (p < 0.05 for 9 of 14 questions) and toward MSGs (p < 0.05 for 2 of 4 questions). DISCUSSION: Implementing an educational intervention on MSGs gives residents an experience that impacts attitudes toward patients with SUD and confidence with MSG referrals.

Experiences of American Older Adults with Pre-existing Depression During the Beginnings of the COVID-19 Pandemic: A Multicity, Mixed-Methods Study.

OBJECTIVE: To determine the effect of the COVID-19 pandemic on the mental health of older adults with pre-existing major depressive disorder (MDD). PARTICIPANTS: Participants were 73 community-living older adults with pre-existing MDD (mean age 69 [SD 6]) in Los Angeles, New York, Pittsburgh, and St Louis. DESIGN AND MEASUREMENTS: During the first 2 months of the pandemic, the authors interviewed participants with a semistructured qualitative interview evaluating access to care, mental health, quality of life, and coping. The authors also assessed depression, anxiety, and suicidality with validated scales and compared scores before and during the pandemic. RESULTS: Five themes from the interviews highlight the experience of older adults with MDD: 1) They are more concerned about the risk of contracting the virus than the risks of isolation. 2) They exhibit resilience to the stress and isolation of physical distancing. 3) Most are not isolated socially, with virtual contact with friends and family. 4) Their quality of life is lower, and they worry their mental health will suffer with continued physical distancing. 5) They are outraged by an inadequate governmental response to the pandemic. Depression, anxiety, and suicidal ideation symptom scores did not differ from scores before the pandemic. CONCLUSION: Most older adults with pre-existing MDD show resilience in the first 2 months of the COVID-19 pandemic but have concerns about the future. Policies and interventions to provide access to medical services and opportunities for social interaction are needed to help to maintain mental health and quality of life as the pandemic continues.

Illness narratives and preferences for treatment among older veterans living with treatment-resistant depression and insomnia.

BACKGROUND: Despite the prevalence of comorbid late-life treatmentresistant depression (LLTRD) and insomnia in older adults, there is a gap in the literature describing patient factors, such as patients' beliefs about their illnesses and preferences for treatment, that can facilitate recovery. Therefore, we explored the perceptions and treatment preferences of older veterans with LLTRD and insomnia. METHODS: Semi-structured interviews were completed with 11 older veterans. A thematic analysis of the interviews was conducted. RESULTS: Four main themes were identified: 1. Insomnia and medical problems were considered to be significant contributors to depression, which was defined by low mood and anhedonia; 2. "Overthinking" was thought to be a cause of insomnia; 3. Participants' preference for psychotherapy was driven by their past experiences with therapy; and 4. Participants viewed patient education as a facilitator for compliance. CONCLUSIONS: Older veterans with LLTRD and insomnia have a preference for behavioral interventions. However, they lack knowledge about available treatment options, such as behavioral interventions for sleep that can improve both their sleep and mood while being a good fit with their illness narratives, such as "overthinking." There is a need for patient education, which should be offered early and often during treatment.

Radiation oncologists' attitudes and beliefs about intensity-modulated radiation therapy and stereotactic body radiation therapy for prostate cancer.

BACKGROUND: To better understand how radiation oncologists perceive intensity-modulated radiation therapy (IMRT) and stereotactic body radiation therapy (SBRT) for prostate cancer and how these perceptions may influence treatment decisions. METHODS: We conducted semi-structured interviews of radiation oncologists between January-May, 2016. We used a purposeful sampling technique to select participants across a wide range of experience, regions, and practice types. Two trained qualitative researchers used an inductive, iterative approach to code transcripts and identify themes. We then used content analysis and thematic analysis of the coded transcripts to understand radiation oncologists' attitudes and beliefs about IMRT and SBRT. RESULTS: Thematic saturation was achieved after 20 interviews. Participants were affiliated with academic (n = 13; 65%), private (n = 5; 25%), and mixed (n = 2; 10%) practices and had a wide range of clinical experience (median 19 years; range 4-49 years). Analysis of interview transcripts revealed four general themes: 1) most radiation oncologists offered surgery, brachytherapy, IMRT, and active surveillance for low-risk patients; 2) there was no consensus on the comparative effectiveness of IMRT and SBRT; 3) key barriers to adopting SBRT included issues related to insurance, reimbursement, and practice inertia; and 4) despite these barriers, most participants envisioned SBRT use increasing over the next 5-10 years. CONCLUSIONS: In the absence of strong opinions about effectiveness, nonclinical factors influence the choice of radiation treatment. Despite a lack of consensus, most participants agreed SBRT may become a standard of care in the future.

A qualitative study of gender differences in the experiences of general surgery trainees.

BACKGROUND: Women surgeons continue to face unique challenges to professional advancement. Higher attrition rates and lower confidence among female surgical residents suggest that experiences during residency differ by gender. Few studies have investigated gender-specific experiences during training. This study identifies gender-based differences in the experiences of general surgery residents that could affect professional development. MATERIALS AND METHODS: Male and female general surgery residents at the University of Pittsburgh Medical Center participated in a semi-structured interview study exploring the significance of gender in training. Recurring themes were identified from transcribed interviews using inductive methods. Two individuals independently coded interviews. Themes were compared for male and female residents. Certain themes arose with greater frequency in reference to one gender over the other. RESULTS: Twenty-four male and eighteen female residents participated (87.5%) in the study. Fewer female residents self-identified as a "surgeon" (11.1% versus 37.5%, P < 0.001). Residents felt that patients and physicians more frequently disregarded female residents' professional role (P < 0.001). Female residents also more often mentioned perceiving aggressive behaviors from attendings and support staff (9% versus 1% and 10% versus 3%, respectively). Relative to men, women more often mentioned lack of mentorship (0% versus 8%), discomfort (4% versus 8%), feeling pressured to participate in unprofessional behaviors (2% versus 5%), and having difficulty completing tasks (5% versus 10%, P < 0.001). CONCLUSIONS: Women experience gender-based challenges during surgical training. Further investigation is needed to determine how these experiences affect professional development.

Mindfulness for Chronic Low Back Pain: A Qualitative Analysis.

Objective: Mindfulness is a nonpharmacologic mind-body therapy that has been shown to be effective in older adults with chronic low back pain (cLBP). There are few first-person accounts in the literature that describe the older adult experience and perspective while learning mindfulness and meditation to treat pain. The objective of this study was to investigate dominant themes present in the experiences of older adults applying mindfulness and meditation to cope with cLBP. Design: Qualitative analysis of four focus groups. Subject: Twenty-five adults age 65 years or older who had completed an eight-week mindfulness program. Methods: The focus groups met for a comprehensive discussion session about their experience with mindfulness and meditation. The audio for each session was recorded, and the discussions were transcribed. Codebook development, qualitative coding, and thematic analysis were performed. The coders each coded all four transcripts, following which they met to adjudicate all coding differences until they were in complete agreement on coding. Results: Several key themes were brought up by older adults utilizing mindfulness as a means of coping with pain, which included overcoming fear of pain ("Before [learning mindfulness], I used to dread pain"), pain awareness ("You're focusing more on being aware than the pain; now that's what helps me"), and pain significance ("It becomes insignificant"). Conclusions: The themes identify several ways mindfulness impacts older adults with cLBP, including decreased negative emotions related to chronic pain such as fear of pain, a different perspective or change in awareness about pain, and reducing the significance of pain.

Patient-Centered Outcomes and Treatment Preferences Regarding Sexual Problems: A Qualitative Study Among Midlife Women.

BACKGROUND: Sexual dysfunction is common in midlife women and can have a significant negative impact on quality of life. Although treatments exist, there is little research on which sexual function outcomes and treatments midlife women prefer. AIM: To better understand the sexual function outcomes that were most important to sexually active women 45 to 60 years old and the types of treatments they would prefer from individual interviews and focus groups. METHODS: Twenty individual interviews and three focus groups (N = 39) were led by a trained facilitator, audio recorded, and transcribed. Two investigators developed a codebook, and the primary investigator coded all data. A second investigator coded five randomly selected interviews to ensure intercoder reliability. Codes relating to outcomes and treatment preferences were examined to identify central themes. RESULTS: The mean age was 52.8 years (range = 45-59). When asked what they would want a sexual dysfunction treatment to do, women sought solutions to specific sexual problems: low desire, vaginal pain and dryness, and decreased arousal or ability to achieve orgasm. However, when asked about the most important aspect of their sex life, most women indicated emotional outcomes, such as enhanced intimacy with their partner, were most important to them. Most women preferred behavioral over pharmaceutical treatments, citing concerns about side effects. These women felt that behavioral treatments might be better equipped to address physical and psychological aspects of sexual problems. CLINICAL IMPLICATIONS: This study highlights the importance of considering not only physical but also emotional outcomes when evaluating and treating sexual dysfunction in midlife women. It also emphasizes the importance of developing behavioral treatments in addition to pharmaceutical treatments. STRENGTHS AND LIMITATIONS: By using a qualitative approach, this study allowed women the time and space to speak their own words about their experiences with sexuality at midlife. In addition, different racial and ethnic groups and menopausal statuses were represented. Limitations include limited generalizability, as is true for most qualitative research. In addition, although most women did endorse sexual problems, we did not exclude women with no sexual complaints. CONCLUSIONS: Midlife women value physical and emotional outcomes with regard to sexual function. Many midlife women in this sample expressed a preference for behavioral approaches over pharmaceutical approaches for the treatment of sexual dysfunction. Thomas HN, Hamm M, Hess R, et al. Patient-Centered Outcomes and Treatment Preferences Regarding Sexual Problems: A Qualitative Study Among Midlife Women. J Sex Med 2017;14:1011-1017.

Using Health Information Technology to Foster Engagement: Patients' Experiences with an Active Patient Health Record.

Personal health records (PHRs) typically employ "passive" communication strategies, such as non-personalized medical text, rather than direct patient engagement in care. Currently there is a call for more active PHRs that directly engage patients in an effort to improve their health by offering elements such as personalized medical information, health coaches, and secure messaging with primary care providers. As part of a randomized clinical trial comparing "passive" with "active" PHRs, we explore patients' experiences with using an "active" PHR known as HealthTrak. The "passive" elements of this PHR included problem lists, medication lists, information about patient allergies and immunizations, medical and surgical histories, lab test results, health reminders, and secure messaging. The active arm included all of these elements and added personalized alerts delivered through the secure messaging platform to patients for services coming due based on various demographic features (including age and sex) and chronic medical conditions. Our participants were part of the larger clinical trial and were eligible if they had been randomized to the active PHR arm, one that included regular personalized alerts. We conducted focus group discussions on the benefits of this active PHR for patients who are at risk for cardiovascular disease. Forty-one patients agreed to participate and were organized into five separate focus group sessions. Three main themes emerged from the qualitatively analyzed focus groups: participants reported that the active PHR promoted better communication with providers; enabled them to more effectively partner with their providers; and helped them become more proactive about tracking their health information. In conclusion, patients reported improved communication, partnership with their providers, and a sense of self-management, thus adding insights for PHR designers hoping to address low adoption rates and other patient barriers to the development and use of the technology.