Patients With Cirrhosis Rapidly Review Potentially Abnormal Hepatocellular Carcinoma Surveillance Results Through the Patient Portal.

INTRODUCTION: Test results are immediately released to patients through patient portals. We characterized patient and provider time-to-review of liver imaging results. METHODS: We identified 401 patients with cirrhosis enrolled in the portal with ≥1 liver imaging. We compared result review times for patients and providers and identified factors associated with rapid review. RESULTS: The median time-to-review for patients was shorter than providers (3.7 vs 17.6 hours, P < 0.001), with more than half of results reviewed by patients first. Rapid patient review was inversely associated with older age and Hispanic ethnicity. DISCUSSION: Patients rapidly review imaging results through the portal, often before providers.

Factors Associated with Veteran Self-Reported Use of Digital Health Devices.

BACKGROUND: Digital health devices (DHDs), technologies designed to gather, monitor, and sometimes share data about health-related behaviors or symptoms, can support the prevention or management of chronic conditions. DHDs range in complexity and utility, from tracking lifestyle behaviors (e.g., pedometer) to more sophisticated biometric data collection for disease self-management (e.g., glucometers). Despite these positive health benefits, supporting adoption and sustained use of DHDs remains a challenge. OBJECTIVE: This analysis examined the prevalence of, and factors associated with, DHD use within the Veterans Health Administration (VHA). DESIGN: National survey. PARTICIPANTS: Veterans who receive VHA care and are active secure messaging users. MAIN MEASURES: Demographics, access to technology, perceptions of using health technologies, and use of lifestyle monitoring and self-management DHDs. RESULTS: Among respondents, 87% were current or past users of at least one DHD, and 58% were provided a DHD by VHA. Respondents 65 + years were less likely to use a lifestyle monitoring device (AOR 0.57, 95% CI [0.39, 0.81], P = .002), but more likely to use a self-management device (AOR 1.69, 95% [1.10, 2.59], P = .016). Smartphone owners were more likely to use a lifestyle monitoring device (AOR 2.60, 95% CI [1.42, 4.75], P = .002) and a self-management device (AOR 1.83, 95% CI [1.04, 3.23], P = .037). CONCLUSIONS: The current analysis describes the types of DHDs that are being adopted by Veterans and factors associated with their adoption. Results suggest that various factors influence adoption, including age, access to technology, and health status, and that these relationships may differ based on the functionalities of the device. VHA provision of devices was frequent among device users. Providing Veterans with DHDs and the training needed to use them may be important factors in facilitating device adoption. Taken together, this knowledge can inform future implementation efforts, and next steps to support patient-team decision making about DHD use.

Improving Veteran Engagement with Virtual Care Technologies: a Veterans Health Administration State of the Art Conference Research Agenda.

Although the availability of virtual care technologies in the Veterans Health Administration (VHA) continues to expand, ensuring engagement with these technologies among Veterans remains a challenge. VHA Health Services Research & Development convened a Virtual Care State of The Art (SOTA) conference in May 2022 to create a research agenda for improving virtual care access, engagement, and outcomes. This article reports findings from the Virtual Care SOTA engagement workgroup, which comprised fourteen VHA subject matter experts representing VHA clinical care, research, administration, and operations. Workgroup members reviewed current evidence on factors and strategies that may affect Veteran engagement with virtual care technologies and generated key questions to address evidence gaps. The workgroup agreed that although extensive literature exists on factors that affect Veteran engagement, more work is needed to identify effective strategies to increase and sustain engagement. Workgroup members identified key priorities for research on Veteran engagement with virtual care technologies through a series of breakout discussion groups and ranking exercises. The top three priorities were to (1) understand the Veteran journey from active service to VHA enrollment and beyond, and when and how virtual care technologies can best be introduced along that journey to maximize engagement and promote seamless care; (2) utilize the meaningful relationships in a Veteran's life, including family, friends, peers, and other informal or formal caregivers, to support Veteran adoption and sustained use of virtual care technologies; and (3) test promising strategies in meaningful combinations to promote Veteran adoption and/or sustained use of virtual care technologies. Research in these priority areas has the potential to help VHA refine strategies to improve virtual care user engagement, and by extension, outcomes.

Assessing a Structured Mental Fitness Program for Academic Acute Care Surgeons: A Pilot Study.

INTRODUCTION: There is a well-established positive correlation between improved physician wellness and patient care outcomes. Mental fitness is a component of wellness that is understudied in academic medicine. We piloted a structured mental fitness Positive Intelligence (PQ) training program for academic surgeons, hypothesizing this would be associated with improvements in PQ scores, wellness, sleep, and trainee evaluations. METHODS: This is a single-institution, prospective, mixed-methods pilot study. All active Burn/Trauma/Acute & Critical Care Surgical faculty and fellows in our division were offered the PQ program and the option to participate in this research study. The 6-wk program consists of daily exercises on a smartphone application, weekly readings, and small-group meetings with a trained mindfulness coach. Study outcomes included changes in pretraining versus post-training PQ scores, sleep hygiene, wellness, and teaching scores. A Net Promoter Score was calculated to measure user overall experience (range -100 to 100; positive scores being supportive). For secondary analysis, participants were stratified into high versus low user groups by "muscle" scores, which were calculated by program use over time. A postintervention focus group was also held to evaluate perceptions of wellness and experience with the PQ program. RESULTS: Data were analyzed for 15 participants who provided consent. The participants were primarily White (73.3%), Assistant Professors (66.7%) with Surgical Critical Care fellowship training (86.7%), and a slight female predominance (53.3%). Comparison of scores pretraining versus post-training demonstrated statistically significant increases in PQ (59 versus 65, P = 0.004), but no significant differences for sleep (24.0 versus 29.0, P = 0.33) or well-being (89.0 versus 94.0, P = 0.10). Additionally, there was no significant difference in teaching evaluations for both residents (9.1 versus 9.3, P = 0.33) and medical students (8.3 versus 8.5, P = 0.77). High versus low user groups were defined by the median muscle score (166 [Interquartile range 95.5-298.5]). High users demonstrated a statistically higher proportion of ongoing usage (75% versus 14%, P < 0.05). The final Net Promoter Score score was 25, which demonstrates program support within this group. Focus group content analysis established eight major categories: current approaches to wellness, preknowledge, reasons for participation, expected gains, program strengths, suggestions for improvement, recommendations for approaches, and sustainability. CONCLUSIONS: Our pilot study highlighted certain benefits of a structured mental fitness program for academic acute care surgeons. Our mixed-methods data demonstrate significant improvement in PQ scores, ongoing usage in high user participants, as well as interpersonal benefits such as improved connectedness and creation of a shared language within participants. Future work should evaluate this program on a higher-powered scale, with a focus on intentionality in wellness efforts, increased exposure to mental fitness, and recruitment of trainees and other health-care providers, as well as identifying the potential implications for patient outcomes.

VHA Whole Health Services and Complementary and Integrative Health Therapies: a Gateway to Evidence-Based Mental Health Treatment.

BACKGROUND: Engagement in evidence-based psychotherapy (EBP) among veterans with behavioral health conditions is often low. The Veterans Health Administration (VHA) is implementing a "Whole Health (WH)" system of care, to identify veteran personal health goals, align care with those goals, and offer services designed to engage and empower veterans to achieve well-being. OBJECTIVE: To examine the relationship between veteran WH utilization and subsequent engagement in EBP. DESIGN: Retrospective analysis of VHA administrative records from 18 facilities implementing WH. SUBJECTS: Veterans (n = 265,364) with a diagnosis of depression, post-traumatic stress disorder (PTSD), and/or anxiety who had a mental healthcare encounter but no EBP use in fiscal year (FY) 2018. Among this cohort, 33,146 (12.5%) began using WH in FY2019. MAIN MEASURES: We examined use of an EBP for depression, anxiety, and/or PTSD within 1 year of the index date of WH use compared to use of an EBP anytime during FY2019 for veterans not identified as using WH. We used multiple logistic regression to examine the association between veteran WH use and EBP engagement. KEY RESULTS: Approximately 3.0% (n = 7,860) of the veterans in our overall cohort engaged in an EBP in the year following their index date. Controlling for key demographic, health, and utilization variables, WH users had 2.4 (95% CI: 2.2-2.5) times higher odds of engaging in an EBP the following year than those with no WH utilization. Associations between utilization of specific WH services (vs. no utilization of that service) and engagement in an EBP in the subsequent year ranged from 1.6 (95% CI: 1.0-2.6) to 3.5 (95% CI: 3.2-3.9) across the different types of WH services used. CONCLUSIONS: WH use was associated with increased engagement in EBPs among veterans with depression, anxiety, and/or PTSD. Future interventions intended to promote veteran engagement in EBPs may benefit from leveraging WH services and therapies.

Nativity Status is an Important Social Determinant of Health for Hispanic Patients with Gastric Cancer in Texas.

BACKGROUND: The U.S. foreign-born population is rapidly increasing, and cancer incidence/mortality rates have been shown to differ by nativity status. Our study aimed to characterize differences in gastric cancer presentation and survival among Hispanic patients in Texas by nativity status. METHODS: We conducted a retrospective review of the Texas Cancer Registry to identify Hispanic patients diagnosed with gastric adenocarcinoma between 2004 and 2017. Existing indices applied to 2010 census tract-level data were utilized to measure neighborhood socioeconomic status (nSES) and Hispanic enclaves. Nativity status was imputed for patients with missing data. Multivariable Cox proportional hazard models were fit for overall survival adjusted for age, insurance status, diagnosis year, tumor location, stage, grade, reporting source, nativity status, nSES, and Hispanic enclave. RESULTS: Our study cohort consisted of 6186 patients and 39% were foreign-born. A greater proportion of foreign-born patients were diagnosed at < 45 years old (16% vs. 11%, p < 0.0001) and had metastatic disease at presentation (47% vs. 34%, p < 0.0001). Foreign-born patients were more often uninsured, in the lowest nSES quintile, and the highest (most ethnically distinct) quintile for Hispanic enclave. Stage-specific overall survival was significantly higher among foreign-born patients. In our multivariate model, foreign-born Hispanic patients had improved survival versus US-born (hazard ratio [HR] 0.90, 95% confidence interval [CI] 0.82-0.99). CONCLUSIONS: The clinical presentation of gastric cancer differs significantly between foreign-born and U.S.-born Hispanic patients. Foreign-born Hispanic patients have improved survival after adjusting for socioeconomic, neighborhood, and clinical factors. Further studies are needed to identify specific causal mechanisms driving the observed survival difference by nativity status.

Uncertainty as a critical determinant of antibiotic prescribing in patients with an asthma exacerbation: a qualitative study.

OBJECTIVE: To identify factors that influence providers' decisions to prescribe antibiotics in patients presenting to the hospital with an asthma exacerbation. METHODS: We performed semi-structured interviews with a purposive sample of providers including sixteen hospitalists, emergency room providers, or pulmonologists, and one focus group with internal medicine residents recruited from one large, urban, teaching hospital and one small, rural, community hospital. Questions were informed by the Theoretical Domains Framework to determine factors that may influence behaviors. Directed content analysis was used to code and analyze transcripts of the interviews. RESULTS: Uncertainty regarding the diagnostic (asthma vs. COPD) and the cause of exacerbation (bacterial vs. viral infection) emerged as the main driver for prescribing behavior. Provider response to uncertainty included: "watchful waiting" or immediate antibiotic prescribing. The following factors played important roles in providers' prescribing decision: 1) awareness/agreement with existing guidelines 2) confidence in their ability to apply the guidelines in challenging cases; 3) perceived risk of patient deterioration without antibiotics; 4) fear of litigation; 5) habit and clinical inertia 6) prescribing within the group 7) lack of information of antibiotic prescribing rates and 8) lack of time and/or resources. CONCLUSIONS: We identified diagnostic uncertainty as the primary determinant of antibiotic prescribing in asthma exacerbations and developed a conceptual model to explain provider responses and factors that influenced their responses. These results enhance our understanding of the factors that can contribute to low-value and wasteful practices like superfluous antibiotic prescribing and will support the development of interventions to de-implement such practices.

Digital Mental Health Interventions for Depression: Scoping Review of User Engagement.

BACKGROUND: While many digital mental health interventions (DMHIs) have been found to be efficacious, patient engagement with DMHIs has increasingly emerged as a concern for implementation in real-world clinical settings. To address engagement, we must first understand what standard engagement levels are in the context of randomized controlled trials (RCTs) and how these compare with other treatments. OBJECTIVE: This scoping review aims to examine the state of reporting on intervention engagement in RCTs of mobile app-based interventions intended to treat symptoms of depression. We sought to identify what engagement metrics are and are not routinely reported as well as what the metrics that are reported reflect about standard engagement levels. METHODS: We conducted a systematic search of 7 databases to identify studies meeting our eligibility criteria, namely, RCTs that evaluated use of a mobile app-based intervention in adults, for which depressive symptoms were a primary outcome of interest. We then extracted 2 kinds of information from each article: intervention details and indices of DMHI engagement. A 5-element framework of minimum necessary DMHI engagement reporting was derived by our team and guided our data extraction. This framework included (1) recommended app use as communicated to participants at enrollment and, when reported, app adherence criteria; (2) rate of intervention uptake among those assigned to the intervention; (3) level of app use metrics reported, specifically number of uses and time spent using the app; (4) duration of app use metrics (ie, weekly use patterns); and (5) number of intervention completers. RESULTS: Database searching yielded 2083 unique records. Of these, 22 studies were eligible for inclusion. Only 64% (14/22) of studies included in this review specified rate of intervention uptake. Level of use metrics was only reported in 59% (13/22) of the studies reviewed. Approximately one-quarter of the studies (5/22, 23%) reported duration of use metrics. Only half (11/22, 50%) of the studies reported the number of participants who completed the app-based components of the intervention as intended or other metrics related to completion. Findings in those studies reporting metrics related to intervention completion indicated that between 14.4% and 93.0% of participants randomized to a DMHI condition completed the intervention as intended or according to a specified adherence criteria. CONCLUSIONS: Findings suggest that engagement was underreported and widely varied. It was not uncommon to see completion rates at or below 50% (11/22) of those participants randomized to a treatment condition or to simply see completion rates not reported at all. This variability in reporting suggests a failure to establish sufficient reporting standards and limits the conclusions that can be drawn about level of engagement with DMHIs. Based on these findings, the 5-element framework applied in this review may be useful as a minimum necessary standard for DMHI engagement reporting.

Association of Secure Messaging with Primary Care In-Person and Telephone Visits Among Veterans: a Matched Difference-in-Difference Analysis.

BACKGROUND: Secure messaging (SM) between patients and primary care teams has expanded care access but may impact other clinical encounters. OBJECTIVE: To study associations between SM use and primary care in-person and telephone visits in the Veterans Health Administration (VHA). DESIGN: The SM feature of VHA's patient portal, MyHealtheVet, supports asynchronous communication between patients and primary care teams. To study the impact of SM on in-person and telephone visits, two analyses were performed: (1) a retrospective pre-/post-analysis comparing changes after initiating SM use and (2) a difference-in-difference comparison among SM users and non-users 1 year before and after index SM use. Matching to non-users was by primary care team, demographics, and predicted propensity of SM use by Nosos comorbidity score and drive time to clinic. PATIENTS: In 2016, 154,053 Veterans initiated SM from all primary care patients (N = 5,891,893); 25,683 were propensity-matched to controls (N = 49,266) from the same primary care team not using SM. MAIN MEASURES: Primary care provider in-person visits and telephone contacts between patients and their primary care team were assessed 1 year prior and post index SM. KEY RESULTS: Overall, primary care in-person visits decreased 13.3% (p < 0.0001); telephone visits increased 13.5% (p < 0.0001). In the matched analysis, in-person primary care visits decreased by 16.0% (p < 0.0001) by SM users and 9.9% (p < 0.0001) among controls, resulting in a across-group decrease of 6.1% in-person visits after SM initiation. Telephone visits increased by 11.0% (p < 0.0001) for SM users and 4.5% for controls (p < 0.0001) resulting in an across-group increase of 6.5% telephone visits after SM initiation. CONCLUSIONS: Use of SM was associated with decreased in-person visits and increased telephone visits. This may improve clinic appointment availability, while increasing time commitments for providers for non-traditional forms of access.

Impact of Patient Access to Online VA Notes on Healthcare Utilization and Clinician Documentation: a Retrospective Cohort Study.

BACKGROUND: In an effort to foster patient engagement, some healthcare systems provide their patients with open notes, enabling them to access their clinical notes online. In January 2013, the Veterans Health Administration (VA) implemented online access to clinical notes ("VA Notes") through the Blue Button feature of its patient portal. OBJECTIVE: To measure the association of online patient access to clinical notes with changes in healthcare utilization and clinician documentation behaviors. DESIGN: A retrospective cohort study. PATIENTS: Patients accessing My HealtheVet (MHV), the VA's online patient portal, between July 2011 and January 2015. MAIN MEASURES: Use of healthcare services (primary care clinic visits and online electronic secure messaging), and characteristics of physician clinical documentation (readability of notes). KEY RESULTS: Among 882,575 unique portal users, those who accessed clinical notes (16.2%; N = 122,972) were younger, more racially homogenous (white), and less likely to be financially vulnerable. Compared with non-users, Notes users more frequently used the secure messaging feature on the portal (mean of 2.6 messages (SD 7.0) v. 0.87 messages (SD 3.3) in January-July 2013), but their higher use of secure messaging began prior to VA Notes implementation, and thus was not temporally related to the implementation. When comparing clinic visit rates pre- and post-implementation, Notes users had a small but significant increase in rate of 0.36 primary care clinic visits (2012 v. 2013) compared to portal users who did not view their Notes (p = 0.01). At baseline, the mean reading ease of primary care clinical notes was 53.8 (SD 10.1) and did not improve after implementation of VA Notes. CONCLUSIONS: VA Notes users were different than patients with portal access who did not view their notes online, and they had higher rates of healthcare service use prior to and after VA Notes implementation. Opportunities exist to improve clinical note access and readability.