Perioperative mental health intervention for depression and anxiety symptoms in older adults study protocol: design and methods for three linked randomised controlled trials.

INTRODUCTION: Preoperative anxiety and depression symptoms among older surgical patients are associated with poor postoperative outcomes, yet evidence-based interventions for anxiety and depression have not been applied within this setting. We present a protocol for randomised controlled trials (RCTs) in three surgical cohorts: cardiac, oncological and orthopaedic, investigating whether a perioperative mental health intervention, with psychological and pharmacological components, reduces perioperative symptoms of depression and anxiety in older surgical patients. METHODS AND ANALYSIS: Adults ≥60 years undergoing cardiac, orthopaedic or oncological surgery will be enrolled in one of three-linked type 1 hybrid effectiveness/implementation RCTs that will be conducted in tandem with similar methods. In each trial, 100 participants will be randomised to a remotely delivered perioperative behavioural treatment incorporating principles of behavioural activation, compassion and care coordination, and medication optimisation, or enhanced usual care with mental health-related resources for this population. The primary outcome is change in depression and anxiety symptoms assessed with the Patient Health Questionnaire-Anxiety Depression Scale from baseline to 3 months post surgery. Other outcomes include quality of life, delirium, length of stay, falls, rehospitalisation, pain and implementation outcomes, including study and intervention reach, acceptability, feasibility and appropriateness, and patient experience with the intervention. ETHICS AND DISSEMINATION: The trials have received ethics approval from the Washington University School of Medicine Institutional Review Board. Informed consent is required for participation in the trials. The results will be submitted for publication in peer-reviewed journals, presented at clinical research conferences and disseminated via the Center for Perioperative Mental Health website. TRIAL REGISTRATION NUMBERS: NCT05575128, NCT05685511, NCT05697835, pre-results.

Brain-Hazardous Medications and Potential Subadequate Antidepressant Dosing in Older Surgical Patients Receiving Home Antidepressants: An Observational Study of a Large US Health System.

BACKGROUND: Older surgical patients with depression often experience poor postoperative outcomes. Poor outcomes may stem from brain-hazardous medications and subadequate antidepressant dosing. METHODS: This was a retrospective, observational cohort study covering the period between January 1, 2021 and December 31, 2021. Patients ≥60 years of age who underwent inpatient surgery and had an overnight stay at an integrated academic health care system comprising 14 hospitals were eligible. We analyzed the prevalence of home central nervous system (CNS)-active potentially inappropriate medication (PIM) and potential subadequate antidepressant dosing in older surgical patients receiving home antidepressants. Univariable and multivariable regression models were used to identify factors associated with home CNS-active PIM prescribing and potential subadequate antidepressant dosing. Additionally, outcomes were compared among patients receiving and not receiving CNS-active PIMs and patients receiving and not receiving subadequate antidepressant dosing. RESULTS: A total of 8031 patients were included in this study (47% female, mean age = 70 years) of whom 2087 (26%) were prescribed antidepressants. Roughly one-half (49%, 95% confidence interval [CI], 46.5-50.1) of patients receiving home antidepressants were also receiving ≥1 CNS-active PIM and 29% (95% CI, 27.0-29.3) were receiving a potential subadequate dose. Factors associated with an increased likelihood of receiving a home CNS-active PIM included female sex (adjusted odds ratio [aOR], 1.46), anxiety (aOR, 2.43), asthma or chronic obstructive pulmonary disease (aOR, 1.39), and serotonin-norepinephrine reuptake inhibitor use (aOR, 1.54). Patients aged ≥75 years (aOR, 1.57), black race (aOR, 1.48) and those with congestive heart failure (aOR, 1.33) were more likely to be prescribed a potential subadequate antidepressant dose. Patients receiving potential subadequate antidepressant doses were discharged home less often (64% vs 73%), had a longer hospital length of stay (9 days vs 7 days), and a higher mortality rate (18% vs 10%) compared to patients receiving adequate home antidepressant doses (P-value for all <0.01). No differences in these outcomes were found among patients receiving home antidepressants with or without CNS-active PIMs. CONCLUSIONS: Older surgical patients receiving antidepressants are frequently prescribed brain-hazardous medications and potentially subadequate antidepressant doses. Those receiving subadequate antidepressant doses may be at risk for worse postoperative outcomes compared to patients receiving adequate doses. The role of preoperative medication optimization to improve outcomes for older surgical patients should be evaluated.

Cognitive flexibility training for chronic pain: a randomized clinical study.

Introduction: Previous studies suggest an association between cognitive flexibility and development of chronic pain after surgery. It is not known whether cognitive flexibility can be improved in patients with chronic pain. Objectives: This study tested whether a neurocognitive training program results in improved cognitive flexibility and pain in patients with chronic pain. Methods: We conducted a single-center, prospective, randomized study investigating 5-week daily neurocognitive training in patients with chronic pain. Participants (n = 145) were randomized into neurocognitive training or care as usual, and they completed assessments at baseline, posttreatment, and 3 months. The treatment group was asked to spend 35 minutes daily completing a program with tasks on cognitive flexibility, memory, attention, and speed. The primary outcome was performance on the neurocognitive performance test (NCPT). Secondary outcomes included levels of pain interference and severity. Results: At 5 weeks, the treatment group showed greater improvements on NCPT compared with the control group (d = 0.37); effect size was smaller at 3 months (d = 0.18). The treatment group reported lower pain severity at 5 weeks (d = 0.16) and 3 months (d = 0.39) than the control group, but pain interference was only lower at 3 months (d = 0.20). Conclusions: Outcomes suggest that using neurocognitive training to modify cognitive flexibility in patients with chronic pain may improve pain severity. This study provided effect size estimates to inform sample size calculations for randomized controlled trials to test the effectiveness of neurocognitive interventions for the prevention and treatment of chronic pain.

Patient engagement in designing, conducting, and disseminating clinical pain research: IMMPACT recommended considerations.

ABSTRACT: In the traditional clinical research model, patients are typically involved only as participants. However, there has been a shift in recent years highlighting the value and contributions that patients bring as members of the research team, across the clinical research lifecycle. It is becoming increasingly evident that to develop research that is both meaningful to people who have the targeted condition and is feasible, there are important benefits of involving patients in the planning, conduct, and dissemination of research from its earliest stages. In fact, research funders and regulatory agencies are now explicitly encouraging, and sometimes requiring, that patients are engaged as partners in research. Although this approach has become commonplace in some fields of clinical research, it remains the exception in clinical pain research. As such, the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials convened a meeting with patient partners and international representatives from academia, patient advocacy groups, government regulatory agencies, research funding organizations, academic journals, and the biopharmaceutical industry to develop consensus recommendations for advancing patient engagement in all stages of clinical pain research in an effective and purposeful manner. This article summarizes the results of this meeting and offers considerations for meaningful and authentic engagement of patient partners in clinical pain research, including recommendations for representation, timing, continuous engagement, measurement, reporting, and research dissemination.

A Perioperative Mental Health Intervention for Depressed and Anxious Older Surgical Patients: Results From a Feasibility Study.

OBJECTIVES: The perioperative period is challenging and stressful for older adults. Those with depression and/or anxiety have an increased risk of adverse surgical outcomes. We assessed the feasibility of a perioperative mental health intervention composed of medication optimization and a wellness program following principles of behavioral activation and care coordination for older surgical patients. METHODS: We included orthopedic, oncologic, and cardiac surgical patients aged 60 and older. Feasibility outcomes included study reach, the number of patients who agreed to participate out of the total eligible; and intervention reach, the number of patients who completed the intervention out of patients who agreed to participate. Intervention efficacy was assessed using the Patient Health Questionnaire for Anxiety and Depression (PHQ-ADS). Implementation potential and experiences were collected using patient surveys and qualitative interviews. Complementary caregiver feedback was also collected. RESULTS: Twenty-three out of 28 eligible older adults participated in this study (mean age 68.0 years, 65% women), achieving study reach of 82% and intervention reach of 83%. In qualitative interviews, patients (n = 15) and caregivers (complementary data, n = 5) described overwhelmingly positive experiences with both the intervention components and the interventionist, and reported improvement in managing depression and/or anxiety. Preliminary efficacy analysis indicated improvement in PHQ-ADS scores (F = 12.13, p <0.001). CONCLUSIONS: The study procedures were reported by participants as feasible and the perioperative mental health intervention to reduce anxiety and depression in older surgical patients showed strong implementation potential. Preliminary data suggest its efficacy for improving depression and/or anxiety symptoms. A randomized controlled trial assessing the intervention and implementation effectiveness is currently ongoing.

A multi- and mixed-method adaptation study of a patient-centered perioperative mental health intervention bundle.

BACKGROUND: Anxiety and depression are common among older adults and can intensify during perioperative periods, but few mental health interventions are designed for older surgical patients' unique needs. As part of the feasibility trial, we developed and adapted a perioperative mental health (PMH) bundle for older patients comprised of behavioral activation (BA) and medication optimization (MO) to ameliorate anxiety and depressive symptoms before, during, and after cardiac, orthopedic, and oncologic surgery. METHODS: We used mixed-methods including workshop studios with patients, caregivers, clinicians, researchers, and interventionists; intervention refinement and reflection meetings; patient case review meetings; intervention session audio-recordings and documentation forms; and patient and caregiver semi-structured interviews. We used the results to refine our PMH bundle. We used multiple analytical approaches to report the nature of adaptations, including hybrid thematic analysis and content analysis informed by the Framework for Reporting Adaptations and Modifications - Expanded. RESULTS: Adaptations were categorized by content (intervention components), context (how the intervention is delivered, based on the study, target population, intervention format, intervention delivery mode, study setting, study personnel), training, and evaluation. Of 51 adaptations, 43.1% involved content, 41.2% involved context, and 15.7% involved training and evaluation. Several key adaptations were noted: (1) Intervention content was tailored to patient preferences and needs (e.g., rewording elements to prevent stigmatization of mental health needs; adjusting BA techniques and documentation forms to improve patient buy-in and motivation). (2) Cohort-specific adaptations were recommended based on differing patient needs. (3) Compassion was identified by patients as the most important element. CONCLUSIONS: We identified evidence-based mental health intervention components from other settings and adapted them to the perioperative setting for older adults. Informed by mixed-methods, we created an innovative and pragmatic patient-centered intervention bundle that is acceptable, feasible, and responsive to the needs of older surgical populations. This approach allowed us to identify implementation strategies to improve the reach, scalability, and sustainability of our bundle, and can guide future patient-centered intervention adaptations. CLINICAL TRIALS REGISTRATION: NCT05110690 (11/08/2021).

Latent profiles of biological dysregulation and risk of mortality: time-to-event analysis using the Midlife in the US longitudinal study.

BACKGROUND: There is a well-established relationship between high allostatic load (AL) and increased risk of mortality. This study expands on the literature by combined latent profile analysis (LPA) with survival data analysis techniques to assess the degree to which AL status is associated with time to death. METHODS: LPA was employed to identify underlying classes of biological dysregulation among a sample of 815 participants from the Midlife in the US study. Sex-stratified Cox proportional hazards regression models were used to estimate the association between class of biological dysregulation and time to death while controlling for sociodemographic covariates. RESULTS: The LPA resulted in three classes: low dysregulation, immunometabolic dysregulation and parasympathetic reactivity. Women in the immunometabolic dysregulation group had more than three times the risk of death as compared with women in the low dysregulation group (HR=3.25, 95% CI: 1.47 to 7.07), but that there was not a statistically significant difference between the parasympathetic reactivity group and the low dysregulation group (HR=1.80, 95% CI: 0.62 to 5.23). For men, the risk of death for those in the immunometabolic dysregulation (HR=1.79, 95% CI: 0.88 to 3.65) and parasympathetic reactivity (HR=0.90, 95% CI: 0.34 to 3.65) groups did not differ from the low dysregulation group. CONCLUSION: The findings are consistent with the previous research that demonstrates increased AL as a risk factor for mortality. Specifically, in women, that increased risk may be associated with immunometabolic dysregulation and not simply a generalised measure of cumulative risk as is typically employed in AL research.

ICD-10-CM codes infrequently used to document human trafficking in 2019 Nationwide Emergency Department Sample.

INTRODUCTION: People who experience human trafficking (HT) visit emergency departments (ED). The International Classification of Diseases, Clinical Modification (ICD-10-CM) introduced codes to document HT in June 2018. The aim of this study is to identify characteristics of ED patients who experienced forced labor or sexual exploitation as a documented external cause of morbidity in US visits. METHODS: Nationally representative surveillance based on patient visits to 989 hospital-owned EDs in the Nationwide Emergency Department Sample in 2019 became available in 2021. Eight ICD-10-CM codes to classify HT as an external cause of morbidity were combined into one HT variable for analysis in 2021-2022. RESULTS: A weighted count of 517 of 33.1 million ED visits (0.0016%) documented HT as an external cause of morbidity. Of them, sexual exploitation (71.6%) was documented more frequently than labor exploitation (28.4%). Most HT-related codes were visits by females (87.3%) from large metropolitan areas, and identified as white. Approximately 40% of visits were from ZIP codes with a median household income less than $48,000 annually. Relative to all other ED visits, patients with HT as an external cause of morbidity had higher odds of being female (OR = 6.54, 95% CI:3.59, 11.92) and being a minor (OR = 1.76, 95% CI:1.02, 3.04). CONCLUSION: HT was rarely documented as an external cause of morbidity in 989 hospitals' ED visits from a nationally representative sample in 2019. Documentation of recently added HT ICD-10-CM codes does not appear to have been implemented sufficiently to yield an unbiased representation of those who experienced HT and presented in the ED. Efforts to enhance the utility of ICD-10-CM HT codes for surveillance and documentation must first address ED personnel training on identification and response to HT. In doing so, ED personnel also need to address ethical concerns (e.g. stigma, confidentiality, risk of patient harm) and allow for informed consent among trafficked patients in order to be scaled up responsibly.

Perspectives on Participation in Clinical Trials Among Individuals With Pain, Depression, and/or Anxiety: An ACTTION Scoping Review.

For individuals experiencing pain, the decision to engage in clinical trials may be influenced by a number of factors including current and past care, illness severity, physical functioning, financial stress, and caregiver support. Co-occurring depression and anxiety may add to these challenges. The aim of this scoping review was to describe perspectives about clinical trial participation, including recruitment and retention among individuals with pain and pain comorbidities, including depression and/or anxiety. We searched PubMed, CINAHL, PsycINFO, and Cochrane CENTRAL databases. Study features, sample demographics, perspectives, barriers and/or motivations were collected and described. A total of 35 assessments were included in this scoping review with 24 focused on individuals with pain (24/35, 68.6%), 9 on individuals with depression and/or anxiety (9/35, 25.7%), and 2 on individuals with pain and co-occurring depression/anxiety (2/35, 5.7%). Barriers among participants with pain and those with depression included: research team's communication of information, fear of interventional risks, distrust (only among respondents with pain), too many procedures, fear of inadequate treatment, disease-life stressors, and embarrassment with study procedures (more commonly reported in participants with depression). Facilitators in both groups included: altruism and supportive staff, better access to care, and the ability to have outcome feedback (more commonly among individuals with depression). Individuals with pain and depression experience challenges that affect trial recruitment and retention. Engaging individuals with pain within research planning may assist in addressing these barriers and the needs of individuals affected by pain and/or depression. PERSPECTIVE: This review highlights the need to address barriers and facilitators to participation in clinical trials, including the need for an assessment of perspectives from underserved or marginalized populations.

Perioperative mental health intervention bundle for older surgical patients: protocol for an intervention development and feasibility study.

INTRODUCTION: The perioperative period is high risk for older adults. Depression and anxiety are common perioperative problems, frequently coexisting with cognitive impairment. Older patients with these conditions are more likely than younger patients to experience postoperative delirium, long hospital stays, poor quality of life and rehospitalisation. These experiences can, in turn, exacerbate anxiety and depressive symptoms. Despite these risks, little is known about how to treat perioperative anxiety and depression among older adults. METHODS AND ANALYSIS: We designed a feasibility study of a perioperative mental health intervention bundle to improve perioperative mental health, specifically depression and anxiety. The overarching goals of this study are twofold: first, to adapt and refine an intervention bundle comprised of behavioural activation and medication optimisation to meet the needs of older adults within three surgical patient populations (ie, orthopaedic, oncological and cardiac); and second, to test the feasibility of study procedures and intervention bundle implementation. Quantitative data on clinical outcomes such as depression, anxiety, quality of life, delirium, falls, length of stay, hospitalisation and pain will be collected and tabulated for descriptive purposes. A hybrid inductive-deductive thematic approach will be employed to analyse qualitative feedback from key stakeholders. ETHICS AND DISSEMINATION: The study received approval from the Washington University Institutional Review Board. Results of this study will be presented in peer-reviewed journals, at professional conferences, and to our perioperative mental health advisory board. TRIAL REGISTRATION NUMBER: NCT05110690.

Gender Differences in Prescription Medications Among Transitioning Justice-Involved Individuals.

Little is known-especially with regard to gender differences-about the prescription trends among justice-involved individuals with health conditions after release from correctional facilities. This article presents initial findings from a large outreach program designed to provide prescription support during the turbulent prison-to-community transition period. We analyzed data derived from a prescription outreach program during the years 2018-2019. Multivariate logistic regression was employed to examine the association between gender and therapeutic areas, controlling for age and race. Compared with men, women were at higher odds of receiving prescriptions for psychiatric conditions followed by neurological conditions, but lower odds of receiving prescriptions for cardiovascular conditions. Further research is necessary to unpack the causal pathways that underlie the associational trends observed in our current analysis.

Partnering with patients in clinical trials of pain treatments: a narrative review.

ABSTRACT: The interest and the rationale for meaningful engagement of patients as partners in clinical trials of pain treatments has been increasing. No specific guidance on patient engagement for pain research studies currently exists; thus, the goal of this narrative review was to provide a historical perspective and a current evaluation of the literature on engaging patients as partners in clinical studies in general and in pain-related studies more specifically. We described how regulatory and funding agencies have developed approaches to incorporate input from patients and patient partners in their decision-making processes. We provided an overview on key practices of patient recruitment and engagement as partners in clinical research and highlighted the perceived benefits and challenges of such partnerships. We summarized factors that can facilitate or hinder meaningful patient engagement in clinical trials of pain treatments and outlined gaps that future research should address to optimize patient-centered clinical research.

Effects of Persistent Exposure to COVID-19 on Mental Health Outcomes Among Trainees: a Longitudinal Survey Study.

BACKGROUND: The rapid spread of the coronavirus disease 2019 (COVID-19) has created considerable strain on the physical and mental health of healthcare workers around the world. The effects have been acute for physician trainees-a unique group functioning simultaneously as learners and care providers with limited autonomy. OBJECTIVE: To investigate the longitudinal effects of physician trainee exposure to patients being tested for COVID-19 on stress, anxiety, depression, and burnout using three surveys conducted during the early phase of the pandemic. DESIGN: Longitudinal survey study. PARTICIPANTS: All physician trainees (N = 1375) at an academic medical center. MAIN MEASURE: Assess the relationship between repeated exposure to patients being tested for COVID-19 and stress, anxiety, depression, and burnout. KEY RESULTS: Three hundred eighty-nine trainees completed the baseline survey (28.3%). Of these, 191 and 136 completed the ensuing surveys. Mean stress, anxiety, and burnout decreased by 21% (95% confidence interval (CI): - 28 to - 12%; P < 0.001), 25% (95% CI: - 36 to - 11%; P < 0.001), and 13% (95% CI: - 18 to - 7%; P < 0.001), respectively, per survey. However, for each survey time point, there was mean increase in stress, anxiety, and burnout per additional exposure: stress [24% (95% CI: + 12 to + 38%; P < 0.001)], anxiety [22% (95% CI: + 2 to + 46%; P = 0.026)], and burnout [18% (95% CI: + 10 to + 28%; P < 0.001)]. For depression, the association between exposure was strongest for the third survey, where mean depression scores increased by 33% per additional exposure (95% CI: + 18 to + 50%; P < 0.001). CONCLUSIONS: Training programs should adapt to address the detrimental effects of the "pileup" of distress associated with persistent exposure through adaptive programs that allow flexibility for time off and recovery.

Prevalence and correlates of antisocial personality disorder in older adults.

OBJECTIVES: There is a paucity of research on antisocial personality disorder (ASPD) in the geriatric population and the majority of knowledge on the disorder is drawn from young adult samples. Researchers posit that the prevalence of ASPD as well as other personality disorders (PDs) is underestimated among older adults. Using a nationally representative sample, the present study examines the prevalence and correlates of ASPD in adults ages 50 and older. METHODS: We analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions Waves I and III. Multivariate logistic regression analyses were employed to investigate associations between ASPD and sociodemographic characteristics. A series of logistic regression analyses were also conducted to study associations between ASPD and medical conditions (liver and cardiovascular disease, arthritis, and stomach ulcer), major psychiatric disorders (lifetime major depressive disorder, mania, and generalized anxiety disorder), and substance use disorders (lifetime alcohol, marijuana, cocaine, heroin, and nicotine use disorders). RESULTS: Findings indicated that the prevalence of ASPD increases through early adulthood, with a peak at 3.91% in younger adults and decline to 0.78% in adults ages ≥65. Older adults with ASPD are more likely to be diagnosed with a substance use disorder, major depression, mania, and generalized anxiety disorder as well as each medical condition. CONCLUSION: Older adults with ASPD experience increased rates of medical and psychiatric comorbidities. These conditions exacerbate the existing challenges associated with diagnosing and treating this population and may have serious consequences for the patient, their caregivers and society.

Crime and Violence in Older Adults: Findings From the 2002 to 2017 National Survey on Drug Use and Health.

Studies on criminal behaviors largely focus on youth and younger adults. While criminal engagement declines with age, the aging population and significant costs associated with older offenders warrant their increased clinical and research attention. The present study utilizes data from the 2002 to 2017 National Survey on Drug Use and Health to estimate the prevalence and explore the sociodemographic and psychosocial correlates of criminal behavior in adults aged 50 years and older. The overall prevalence of older adults engaging in criminal behaviors during this time was approximately 1.20%. There was no significant difference in crime involvement between adults aged 50 to 64 years and 65 years and older. Older individuals who committed crimes were more likely to be male and Black and earning low income. Criminality was also associated with use of illicit substances and depression as well as receipt of mental health treatment.

Emergency Department Admissions for Physical Child Abuse: Evidence from the 2006-2017 Nationwide Emergency Department Sample.

Physical child abuse continues to be a serious public health issue in the United States. This study expands on previous research by exploring trends in physical child abuse diagnoses among children admitted to emergency departments (EDs) across the United States. The analysis aimed to explicate the association between physical child abuse and both sociodemographic and behavioral health covariates to better inform and identify risk factors associated with ED admissions for abuse. The study also explicated differences between confirmed and suspected physical child abuse cases. The study utilized a nationally representative sample of hospital-owned EDs that included 319,676,625 ED admissions between 2006 and 2017 for children under 18-years-old. The analysis included a trend analysis, bivariate descriptive statistics, and multivariate logistic regression models were employed. Children with a physical child abuse diagnosis were less likely to be from higher income communities (aOR = 0.61, 95% CI [0.53, 0.71]), less likely to be female (aOR = 0.93, 95% CI [0.90, 0.96]), and more likely to be uninsured (aOR = 1.65, 95% CI [1.48, 1.84]). Children with attention-deficit hyperactivity disorder (aOR = 1.36, 95% CI [1.14, 1.62]) and a conduct disorder (aOR = 1.28, 95% CI [1.04, 1.58]) were more likely to have a physical abuse diagnosis. The sex-stratified analyses found that the higher rates of physical abuse among children with attention-deficit hyperactivity disorder were driven by the male subsample, while higher rates of abuse for those with conduct disorders were the result of the female subsample. A supplemental analysis of suspected versus confirmed physical child abuse for the fourth quarter of 2015 through 2017 also revealed sociodemographic and behavioral health differences. This study supports the need to consider sociodemographic and behavioral risk factors associated with physical child abuse to inform treatment and potential reoccurrence of abuse.

Ascertaining Design and Implementation Requirements for a Perioperative Neurocognitive Training Intervention for the Prevention of Persistent Pain After Surgery.

BACKGROUND: Persistent postsurgical pain (PPSP) is a common complication that impacts quality of life, often necessitating long-term opioid treatment. Certain neurocognitive factors, including reduced performance on cognitive flexibility tasks, are associated with increased risk of PPSP. We examine the perceptions of surgical patients and clinicians with regard to perioperative pain management activities and needs; patient acceptance and use of a perioperative neurocognitive training intervention; and implementation feasibility. METHODS: We conducted both individual and focus group interviews with patients undergoing thoracic surgery and clinicians in an academic medical center. The Consolidated Framework for Intervention Research guided the development of interview questions related to the adoption and implementation of a neurocognitive intervention to mitigate PPSP. A thematic analysis was used to analyze the responses. RESULTS: Forty patients and 15 clinicians participated. Interviews revealed that there is minimal discussion between clinicians and patients about PPSP. Most participants were receptive to a neurocognitive intervention to prevent PPSP, if evidence demonstrating its effectiveness were available. Potential barriers to neurocognitive training program adoption included fatigue, cognitive overload, lack of familiarity with the technology used for delivering the intervention, and immediate postoperative pain and stress. Implementation facilitators would include patient education about the intervention, incentives for its use, and daily reminders. CONCLUSION: The study identified several guiding principles for addressing patients' and clinicians' barriers to effectively implementing a neurocognitive training intervention to mitigate PPSP after surgery. To ensure the sustainability of neurocognitive interventions for preventing PPSP, such interventions would need to be adapted to meet patients' and clinicians' needs within the perioperative context.

Exploring patient perspectives on telemedicine monitoring within the operating room.

BACKGROUND: Clinical decision support systems and telemedicine for remote monitoring can together support clinicians' intraoperative decision-making and management of surgical patients' care. However, there has been limited investigation on patient perspectives about advanced health information technology use in intraoperative settings, especially an electronic OR (eOR) for remote monitoring and management of surgical patients. PURPOSE: Our study objectives were: (1) to identify participant-rated items contributing to patient attitudes, beliefs, and level of comfort with eOR monitoring; and (2) to highlight barriers and facilitators to eOR use. METHODS: We surveyed 324 individuals representing surgical patients across the United States using Amazon Mechanical Turk, an online platform supporting internet-based work. The structured survey questions examined the level of agreement and comfort with eOR for remote patient monitoring. We calculated descriptive statistics for demographic variables and performed a Wilcoxon matched-pairs signed-rank test to assess whether participants were more comfortable with familiar clinicians from local hospitals or health systems monitoring their health and safety status during surgery than clinicians from hospitals or health systems in other regions or countries. We also analyzed open-ended survey responses using a thematic approach informed by an eight-dimensional socio-technical model. RESULTS: Participants' average age was 34.07 (SD = 10.11). Most were white (80.9%), male (57.1%), and had a high school degree or more (88.3%). Participants reported a higher level of comfort with clinicians they knew monitoring their health and safety than clinicians they did not know, even within the same healthcare system (z = -4.012, p < .001). They reported significantly higher comfort levels with clinicians within the same hospital or health system in the United States than those in a different country (z = -10.230, p < .001). Facilitators and barriers to eOR remote monitoring were prevalent across four socio-technical dimensions: 1) organizational policies, procedures, environment, and culture; 2) people; 3) workflow and communication; and 4) hardware and software. Facilitators to eOR use included perceptions of improved patient safety through a safeguard system and perceptions of streamlined care. Barriers included fears of incorrect eOR patient assessments, decision-making conflicts between care teams, and technological malfunctions. CONCLUSIONS: Participants expressed significant support for intraoperative telemedicine use and greater comfort with local telemedicine systems instead of long-distance telemedicine systems. Reservations centered on organizational policies, procedures, environment, culture; people; workflow and communication; and hardware and software. To improve the buy-in and acceptability of remote monitoring by an eOR team, we offer a few evidence-based guidelines applicable to telemedicine use within the context of OR workflow. Guidelines include backup plans for technical challenges, rigid care, and privacy standards, and patient education to increase understanding of telemedicine's potential to improve patient care.

Impact of Changes in EHR Use during COVID-19 on Physician Trainee Mental Health.

OBJECTIVES: This article investigates the association between changes in electronic health record (EHR) use during the coronavirus disease 2019 (COVID-19) pandemic on the rate of burnout, stress, posttraumatic stress disorder (PTSD), depression, and anxiety among physician trainees (residents and fellows). METHODS: A total of 222 (of 1,375, 16.2%) physician trainees from an academic medical center responded to a Web-based survey. We compared the physician trainees who reported that their EHR use increased versus those whose EHR use stayed the same or decreased on outcomes related to depression, anxiety, stress, PTSD, and burnout using univariable and multivariable models. We examined whether self-reported exposure to COVID-19 patients moderated these relationships. RESULTS: Physician trainees who reported increased use of EHR had higher burnout (adjusted mean, 1.48 [95% confidence interval [CI] 1.24, 1.71] vs. 1.05 [95% CI 0.93, 1.17]; p = 0.001) and were more likely to exhibit symptoms of PTSD (adjusted mean = 15.09 [95% CI 9.12, 21.05] vs. 9.36 [95% CI 7.38, 11.28]; p = 0.035). Physician trainees reporting increased EHR use outside of work were more likely to experience depression (adjusted mean, 8.37 [95% CI 5.68, 11.05] vs. 5.50 [95% CI 4.28, 6.72]; p = 0.035). Among physician trainees with increased EHR use, those exposed to COVID-19 patients had significantly higher burnout (2.04, p < 0.001) and depression scores (14.13, p = 0.003). CONCLUSION: Increased EHR use was associated with higher burnout, depression, and PTSD outcomes among physician trainees. Although preliminary, these findings have implications for creating systemic changes to manage the wellness and well-being of trainees.