Experiences and Perceptions of Healthcare Stakeholders in Disclosing Errors and Adverse Events to Historically Marginalized Patients.

OBJECTIVES: We sought to assess the experiences and perceptions of healthcare stakeholders involved in the response to historically marginalized patients who have been harmed in healthcare. We investigated the challenges in disclosing errors and adverse events and the types of tools and resources that would better address the needs of historically marginalized patient populations. METHODS: We conducted separate focus groups with two healthcare stakeholder groups: (1) frontline clinicians directly involved in the clinical care of historically marginalized patients and (2) risk and patient safety professionals involved in the hospital response to care breakdowns. We conducted an inductive analysis of the qualitative data to identify thematic clusters. RESULTS: We interviewed 7 clinicians and 5 risk safety professionals, with a total sample size of 12 participants. Participants shared multilevel challenges in responding to historically marginalized patients after harm (system-, organizational-, and patient-level), such as fragmentation of care, lack of standardized protocols, and patient mistrust. Participants also identified their desired tools and resources for disclosure to meet the needs of historically marginalized patients, which included culturally appropriate toolkits, disclosure training, and the inclusion of multidisciplinary healthcare team members in the disclosure process. CONCLUSIONS: Our results suggest that multiple interventions will be needed to achieve the goal of prompt disclosure of errors and adverse events across all populations engaged in health care. Future studies should investigate the perspectives of historically marginalized patients and their family members on how error and adverse event disclosure conversations should unfold.

Usability and acceptability of virtual reality for chronic pain management among diverse patients in a safety-net setting: a qualitative analysis.

Objective: The aim of this study was to understand the usability and acceptability of virtual reality (VR) among a racially and ethnically diverse group of patients who experience chronic pain. Materials and Methods: Using the Technology Acceptance Model theory, we conducted semistructured interviews and direct observation of VR use with English-speaking patients who experience chronic pain treated in a public healthcare system (n = 15), using a commercially available VR technology platform. Interviews included questions about current pain management strategies, technology use, experiences and opinions with VR, and motivators for future use. Results: Before the study, none of the 15 participants had heard about or used VR for pain management. Common motivators for VR use included a previous history of substance use and having exhausted many other options to manage their pain and curiosity. Most participants had a positive experience with VR and 47% found that the VR modules distracted them from their pain. When attempting the navigation-based usability tasks, most participants (73%-92%) were able to complete them independently. Discussion: VR is a usable tool for diverse patients with chronic pain. Our findings suggest that the usability of VR is not a barrier and perhaps a focus on improving the accessibility of VR in safety-net settings is needed to reduce disparities in health technology use. Conclusions: The usability and acceptability of VR are rarely studied in diverse patient populations. We found that participants had a positive experience using VR, showed interest in future use, and would recommend VR to family and friends.

Virtual Reality for Chronic Pain Management Among Historically Marginalized Populations: Systematic Review of Usability Studies.

BACKGROUND: Virtual reality (VR) has potential to improve chronic pain management outcomes. However, the majority of studies assessing VR are conducted in predominantly White populations in well-resourced settings, thus leaving a gap in knowledge of VR use among diverse populations who experience a significant chronic pain burden. OBJECTIVE: This review aims to examine the extent to which usability of VR for chronic pain management has been studied within historically marginalized patient groups. METHODS: We conducted a systematic search to identify studies with usability outcomes located in high-income countries that included a historically marginalized population, defined by a mean age greater than or equal to 65 years, lower educational attainment (greater than or equal to 60% having attained high school education or less), and being a racial or ethnic minority (less than or equal to 50% non-Hispanic White people for studies based in the United States). RESULTS: Our analysis included 5 papers, which we used to conduct a narrative analysis. Three studies examined VR usability as a primary outcome. All studies assessed VR usability using different measures, of which 4 found VR to be usable by their respective study population. Only 1 study found a significant improvement in pain levels post-VR intervention. CONCLUSIONS: The use of VR shows promise for chronic pain management, but few studies include populations that are older, have limited educational attainment, or have racial or ethnic diversity. Additional studies with these populations are needed to further develop VR systems that work best for diverse patients with chronic pain.

Public Figure Vaccination Rhetoric and Vaccine Hesitancy: Retrospective Twitter Analysis.

Background: Social media has emerged as a critical mass communication tool, with both health information and misinformation now spread widely on the web. Prior to the COVID-19 pandemic, some public figures promulgated anti-vaccine attitudes, which spread widely on social media platforms. Although anti-vaccine sentiment has pervaded social media throughout the COVID-19 pandemic, it is unclear to what extent interest in public figures is generating anti-vaccine discourse. Objective: We examined Twitter messages that included anti-vaccination hashtags and mentions of public figures to assess the connection between interest in these individuals and the possible spread of anti-vaccine messages. Methods: We used a data set of COVID-19-related Twitter posts collected from the public streaming application programming interface from March to October 2020 and filtered it for anti-vaccination hashtags "antivaxxing," "antivaxx," "antivaxxers," "antivax," "anti-vaxxer," "discredit," "undermine," "confidence," and "immune." Next, we applied the Biterm Topic model (BTM) to output topic clusters associated with the entire corpus. Topic clusters were manually screened by examining the top 10 posts most highly correlated in each of the 20 clusters, from which we identified 5 clusters most relevant to public figures and vaccination attitudes. We extracted all messages from these clusters and conducted inductive content analysis to characterize the discourse. Results: Our keyword search yielded 118,971 Twitter posts after duplicates were removed, and subsequently, we applied BTM to parse these data into 20 clusters. After removing retweets, we manually screened the top 10 tweets associated with each cluster (200 messages) to identify clusters associated with public figures. Extraction of these clusters yielded 768 posts for inductive analysis. Most messages were either pro-vaccination (n=329, 43%) or neutral about vaccination (n=425, 55%), with only 2% (14/768) including anti-vaccination messages. Three main themes emerged: (1) anti-vaccination accusation, in which the message accused the public figure of holding anti-vaccination beliefs; (2) using "anti-vax" as an epithet; and (3) stating or implying the negative public health impact of anti-vaccination discourse. Conclusions: Most discussions surrounding public figures in common hashtags labelled as "anti-vax" did not reflect anti-vaccination beliefs. We observed that public figures with known anti-vaccination beliefs face scorn and ridicule on Twitter. Accusing public figures of anti-vaccination attitudes is a means of insulting and discrediting the public figure rather than discrediting vaccines. The majority of posts in our sample condemned public figures expressing anti-vax beliefs by undermining their influence, insulting them, or expressing concerns over public health ramifications. This points to a complex information ecosystem, where anti-vax sentiment may not reside in common anti-vax-related keywords or hashtags, necessitating further assessment of the influence that public figures have on this discourse.

Preferences and Perceptions of Medical Error Disclosure Among Marginalized Populations: A Narrative Review.

BACKGROUND: Disclosure of medical errors, in which a health care provider informs the patient/family of the error and takes responsibility, is an ethical imperative. Little is known about how medical error disclosure preferences or perceptions may vary for patients who are people of color, are older, or have lower educational attainment. METHODS: The researchers conducted a narrative review on medical errors and disclosure. Included were studies in high-income countries that included a predominantly marginalized population, defined by any one of the following: older age adults (mean age > 65 years); low educational attainment (> 55% of participants with less than a high school education); and/or racial/ethnic minority (< 55% of participants identifying as non-Hispanic white for US studies). RESULTS: The literature search yielded 3,050 articles, resulting in 6 studies included for analysis. Four studies used hypothetical vignettes; 1 used focus groups, and 1 used a survey. Three studies met the marginalized population criteria based on education; 3 met the criteria based on race/ethnicity. No study met the inclusion criteria for age. All 6 articles examined patient preferences for disclosure, and 2 studies also examined patient perceptions of disclosure. Overall, participants preferred that medical errors be disclosed to them. Most of the studies lacked multiple regression analysis to investigate differences in disclosure preferences by race/ethnicity, age, and education. CONCLUSION: Participants from marginalized populations may have similar disclosure preferences to white and highly educated participants. Future studies should aim to examine differences in error disclosure preferences among patients who have experienced adverse events across race/ethnicity, educational attainment, and age.

Diagnostic Trajectories in Primary Care at 12 Months: An Observational Cohort Study.

BACKGROUND: Little is known about the epidemiology of diagnosis in primary care. METHODS: A prospective observational cohort study was conducted of adults presenting between August and December 2018 to primary care clinics across two health systems with an undiagnosed medical problem. Primary outcomes were (1) likelihood of a definitive diagnosis by 12 months and (2) time to diagnosis. Multivariate logistic regression was used to assess for factors associated with the likelihood of reaching a diagnosis, and multivariable Cox regression was used to assess for factors associated with time to diagnosis. Bivariate models were used to explore unadjusted relationships between the cases' organ systems and likelihood of and time to diagnosis. RESULTS: Among 410 cases in a diverse patient population, 206 (50.2%) reached a final diagnosis within 12 months, with a median time to diagnosis of 5 days (interquartile range = 0-46). Among these cases, 32.4% reached a diagnosis within the first month. A majority of cases not diagnosed within a month of the first presentation remained undiagnosed at 12 months. The likelihood of diagnosis and time to diagnosis did not differ by clinician or patient characteristics, clinicians' level of diagnostic uncertainty, chronicity of the medical issue, or visit type. There were no significant associations between organ system and likelihood of time to diagnosis. CONCLUSION: Patients presenting with new or unresolved problems in ambulatory primary care often remain undiagnosed after a year. There were no provider or patient-level variables associated with such lack of diagnosis. The causes, contributors, and consequences of lack of timely diagnosis and potential solutions require further research.

Do patient-reported outcome measures measure up? A qualitative study to examine perceptions and experiences with heart failure proms among diverse, low-income patients.

BACKGROUND: The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a Patient-Reported Outcome Measure (PROM) used to evaluate the health status of patients with heart failure (HF) but has predominantly been tested in settings serving predominately white, male, and economically well-resourced populations. We sought to examine the acceptability of the shorter version of the KCCQ (KCCQ-12) among racially and ethnically diverse patients receiving care in an urban, safety-net setting. METHODS: We conducted cognitive interviews with a diverse population of patients with heart failure in a safety net system to assess their perceptions of the KCCQ-12. We conducted a thematic analysis of the qualitative data then mapped themes to the Capability, Opportunity, Motivation Model of Behavior framework. RESULTS: We interviewed 18 patients with heart failure and found that patients broadly endorsed the concepts of the KCCQ-12 with minor suggestions to improve the instrument's content and appearance. Although patients accepted the KCCQ-12, we found that the instrument did not adequately measure aspects of health care and quality of life that patients identified as being important components of managing their heart failure. Patient-important factors of heart failure management coalesced into three main themes: social support, health care environment, and mental health. CONCLUSIONS: Patients from this diverse, low-income, majority non-white population experience unique challenges and circumstances that impact their ability to manage disease. In this study, patients were receptive to the KCCQ-12 as a tool but perceived that it did not adequately capture key health components such as mental health and social relationships that deeply impact their ability to manage HF. Further study on the incorporation of social determinants of health into PROMs could make them more useful tools in evaluating and managing HF in diverse, underserved populations.

Mobile health strategies for blood pressure self-management in urban populations with digital barriers: systematic review and meta-analyses.

Mobile health (mHealth) technologies improve hypertension outcomes, but it is unknown if this benefit applies to all populations. This review aimed to describe the impact of mHealth interventions on blood pressure outcomes in populations with disparities in digital health use. We conducted a systematic search to identify studies with systolic blood pressure (SBP) outcomes located in urban settings in high-income countries that included a digital health disparity population, defined as mean age ≥65 years; lower educational attainment (≥60% ≤high school education); and/or racial/ethnic minority (<50% non-Hispanic White for US studies). Interventions were categorized using an established self-management taxonomy. We conducted a narrative synthesis; among randomized clinical trials (RCTs) with a six-month SBP outcome, we conducted random-effects meta-analyses. Twenty-nine articles (representing 25 studies) were included, of which 15 were RCTs. Fifteen studies used text messaging; twelve used mobile applications. Studies were included based on race/ethnicity (14), education (10), and/or age (6). Common intervention components were: lifestyle advice (20); provision of self-monitoring equipment (17); and training on digital device use (15). In the meta-analyses of seven RCTs, SBP reduction at 6-months in the intervention group (mean SBP difference = -4.10, 95% CI: [-6.38, -1.83]) was significant, but there was no significant difference in SBP change between the intervention and control groups (p = 0.48). The use of mHealth tools has shown promise for chronic disease management but few studies have included older, limited educational attainment, or minority populations. Additional robust studies with these populations are needed to determine what interventions work best for diverse hypertensive patients.

The Intersection of Work and Home Challenges Faced by Physician Mothers During the Coronavirus Disease 2019 Pandemic: A Mixed-Methods Analysis.

Objectives: The coronavirus disease 2019 (COVID-19) pandemic has presented extreme challenges for health care workers. This study sought to characterize challenges faced by physician mothers, compare differences in challenges by home and work characteristics, and elicit specific needs and potential solutions. Methods: We conducted a mixed-methods online survey of the Physician Moms Group (PMG) and PMG COVID19 Subgroup on Facebook from April 18th to 29th, 2020. We collected structured data on personal and professional characteristics and qualitative data on home and work concerns. We analyzed qualitative data thematically and used bivariate analyses to evaluate variation in themes by frontline status and children's ages. Results: We included 1,806 participants in analysis and identified 10 key themes. The most frequently identified need/solution was for Community and Government Support (n = 545, 47.1%). When comparing frontline and nonfrontline physicians, those on the frontline more frequently raised concerns about Personal Health and Safety (67.8% vs. 48.4%, p < 0.001), Organizational Communication and Relationships (31.8% vs. 23.8%, p < 0.001), and Family Health and Safety (27.2 vs. 16.6, p < 0.001), while nonfrontline physicians more frequently addressed Patient Care and Safety (56.4% vs. 48.2%, p < 0.001) and Financial/Job Security (33.8% vs. 46.9%, p < 0.001). Participants with an elementary school-aged child more frequently raised concerns about Parenting/Homeschooling (44.0% vs. 31.1%, p < 0.001) and Work/Life Balance (28.4 vs. 13.7, p < 0.001), and participants with a preschool-aged child more frequently addressed Access to Childcare (24.0 vs. 7.7, p < 0.001) and Spouse/Partner Relationships (15.8 vs. 9.5, p < 0.001), when compared to those without children in these age groups. Conclusions: The physician workforce is not homogenous. Health care and government leaders need to understand these diverse challenges in order to meet physicians' professional and family needs during the pandemic.