Acceptability, usability, and credibility of a mindfulness-based digital therapeutic for pediatric concussion: A mixed-method study.

Background: The ability to cope with concussion symptoms and manage stress is an important determinant of risk for prolonged symptoms. Objective: This open-label mixed-methods pilot study assessed the acceptability and credibility of a mindfulness-based intervention delivered through a digital therapeutic (DTx; therapeutic smartphone app) for pediatric concussion. Methods: Participants aged 12 to 18 years were recruited from an emergency department within 48 hours of a concussion (acute cohort) or from a tertiary care clinic at least 1-month post-concussion (persisting symptoms cohort). Participants completed a novel 4-week mindfulness-based intervention, for 10 to 15 minutes/day, at a minimum of 4 days/week. At 2 weeks, participants completed a credibility and expectancy questionnaire. At 4 weeks, participants completed questionnaires assessing satisfaction, usability and working alliance, as well as a semi-structured phone interview. Results: Ten participants completed the study outcomes (7 acute; 3 persisting symptoms). The intervention was perceived as credible (median/max possible = 6.50/9.00 [6.83,8.75]) and DTx was usable (median/max possible = 70.00/100.00 [55.00,82.50]). Participants rated their satisfaction with the DTx (median/max possible = 27.00/32.00 [24.50,29.50]) and the working alliance with the digital mindfulness guides (median/max possible = 3.92/5.00 [3.38-4.33]) as high. Four themes were identified from the qualitative data: (a) positive attributes; (b) negative attributes; (c) ideas for modifications; and (d) technical issues. Conclusion: Results show modifications to the DTx, instructions and mindfulness intervention, and potential ways to increase adherence by leveraging positive attributes. A randomized control trial will assess the effectiveness of the DTx MBI to decrease the risk of persisting symptoms and reduce the symptom burden following pediatric concussion.

A qualitative study of a blended therapy using problem solving therapy with a customised smartphone app in men who present to hospital with intentional self-harm.

BACKGROUND: Blended therapy describes the use of computerised therapy combined with face-to-face therapy to extend the depth, range and nature of the face-to-face therapy. We wanted to develop a treatment manual for a randomised trial of blended therapy combining face-to-face problem solving and a smartphone app in men who present to hospital with self-harm. OBJECTIVE: To develop a treatment manual and to describe the experience of receiving and delivering a blended therapy. METHODS: After completion of the blended therapy, semistructured qualitative interviews were conducted with participants to describe their experience of the treatment. Two independent coders analysed the material using a thematic, grounded theory approach. FINDINGS: Seven men were enrolled in the study, and six completed the qualitative interviews. The two main themes identified were of trust and connection. Participants attended 85% of their appointments. CONCLUSIONS: In the treatment manual, we emphasised the themes of trust and connection by allowing time to discuss the app in the face-to-face to sessions, ensuring that therapists are familiar with the app and know how to respond to technical queries. Identification of trust and connection generates novel questions about the importance of the therapeutic alliance with technology rather than with people. CLINICAL IMPLICATIONS: Clinicians and app developers need to pay attention to the therapeutic relationship with technology as trust and good communication can be easily damaged, resulting in disengagement with the app. Blended therapy may result in increased adherence to face-to-face sessions. TRIAL REGISTRATION NUMBER: NCT02718248.

Implementation of a structured hospital-wide morbidity and mortality rounds model.

IMPORTANCE: There is a paucity of literature on the quality and effectiveness of institutional morbidity & mortality (M&M) rounds processes. OBJECTIVE: We sought to implement and evaluate the effectiveness of a hospital-wide structured M&M rounds model at improving the quality of M&M rounds across multiple specialties. DESIGN, SETTING, PARTICIPANTS: We conducted a prospective interventional study involving 24 clinical groups (1584 physicians) at a tertiary care teaching hospital from January 2013 to June 2015. INTERVENTION: We implemented the published Ottowa M&M Model (OM3): appropriate case selection, cognitive/system issues analyses, interprofessional participation, dissemination of lessons and effector mechanisms. MAIN OUTCOMES AND MEASURES: We created an OM3 scoring index reflecting these elements to measure the quality of M&M rounds. Secondary outcomes include explicit discussions of cognitive/system issues and resultant action items. RESULTS: OM3 scores for all participating groups improved significantly from a median of 12.0/24 (95% CI 10 to 14) to 20.0/24 (95% CI 18 to 21). An increased frequency of in-rounds discussion around cognitive biases (pre 154/417 (37%), post 256/466 (55%); p<0.05) and system issues (pre 175/417 (42%), post 259/466 (62%); p<0.05) were reported by participants via online surveys postintervention, while in-person surveys throughout the intervention period demonstrated even higher frequencies (cognitive biases 1222/1437 (85%); system issues 1250/1437 (87%)). We found 45 action items resulting directly from M&M rounds postintervention, compared with none preintervention. CONCLUSIONS AND RELEVANCE: Implementation of a structured model enhanced the quality of M&M rounds with demonstrable policy improvements hospital wide. The OM3 can be feasibly implemented at other hospitals to effectively improve quality of M&M rounds across different specialties.