Preventing venous thromboembolism for ambulatory patients with cancer: Developing the form and content of implementation strategies.

Background: For ambulatory cancer patients receiving systemic chemotherapy, adherence is low to recommended venous thromboembolism (VTE) prevention interventions. Previously, we identified implementation strategies to address barriers to adherence, including (1) conducting clinician education and training; (2) developing and distributing educational materials for clinicians; (3) adapting electronic health records to provide interactive assistance; and (4) developing and distributing educational materials for patients. The objective of this study was to develop these implementation strategies' form (i.e., how and when) and content (i.e., information conveyed) as a critical step for implementation and dissemination. Methods: To design and develop the form and content of the implementation strategies, we conducted multidisciplinary stakeholder panels with oncology clinicians, pharmacists, and hematologists. Over several panel discussions, we developed a low fidelity prototype. Participants performed preliminary usability testing, simulating patient care encounters. We also conducted interviews with three patients who provided additional feedback. Results: The form and content for each strategy, respectively, included (1) concise training with a slide deck; (2) succinct summary of evidence for the interventions and support for anticoagulation management; (3) automated VTE risk-assessment and clinical decision support, including bleeding risk assessment and anticoagulation options; and (4) patient education resources. During development, audit and feedback was identified as an additional strategy, for which we created report cards to implement. Conclusion: With stakeholder input, we successfully developed the form and content needed to put the implementation strategies into practice. The next step is to study the effect on the uptake of ambulatory VTE prevention recommendations in oncology clinics.

Implementing a Patient-Reported Outcome Dashboard in Oncology Telemedicine Encounters: Clinician and Patient Adoption and Acceptability.

PURPOSE: Telemedicine provides numerous benefits to patients, yet effective communication and symptom assessment remain a concern. The recent uptake of telemedicine provided an opportunity to use a newly developed dashboard with patient-reported outcome (PRO) information to enhance communication and shared decision making (SDM) during telemedicine appointments. The objective of this study was to identify barriers to using the dashboard during telemedicine, develop implementation strategies to address barriers, and pilot test use of this dashboard during telemedicine appointments in two practice settings to evaluate acceptability, adoption, fidelity, and effectiveness. METHODS: Patients and clinicians were interviewed to identify determinants to dashboard use in telemedicine. Implementation strategies were designed and refined through iterative feedback from stakeholders. A pilot study of dashboard use was conducted from March to September 2022. Acceptability, adoption, and fidelity were evaluated using mixed methods. SDM was evaluated using the collaboRATE measure. RESULTS: One hundred two patient encounters were evaluated. Most patients (62; 60%) had completed some PRO data at the time of their telemedicine encounter. Most (82; 80%) encounters had clinician confirmation that PRO data had been reviewed; however, collaborative review of the dashboard was documented in only 27%. Degree of SDM was high (mean collaboRATE score 3.40; SD, 0.11 [95% CI, 3.17 to 3.63] out of a maximum score of 4). Implementation strategies focused on patient engagement, education, and remote PRO completion. Clinician-facing strategies included education, practice facilitation, and small tests of change. CONCLUSION: This study demonstrated that implementation of a PRO-based dashboard into telemedicine appointments was feasible and had acceptable adoption and acceptability by patients and clinicians when several strategies were used to engage end users. Strategies targeting both patients and clinicians are needed to support routine and effective PRO integration in telemedicine.

Effect of Polypectomy Simulation-Based Mastery Learning on Skill Retention Among Practicing Endoscopists.

PURPOSE: Practicing endoscopists frequently perform and teach screening colonoscopies and polypectomies, but there is no standardized method to train and assess physicians who perform polypectomy procedures. The authors created a polypectomy simulation-based mastery learning (SBML) curriculum and hypothesized that completion of the curriculum would lead to immediate improvement in polypectomy skills and skill retention at 6 and 12 months after training. METHOD: The authors performed a pretest-posttest cohort study with endoscopists who completed SBML and were randomized to follow-up at 6 or 12 months from May 2021 to August 2022. Participants underwent SBML training, including a pretest, a video lecture, deliberate practice, and a posttest. All learners were required to meet or exceed a minimum passing standard on a 17-item skills checklist before completing training and were randomized to follow-up at 6 or 12 months. The authors compared simulated polypectomy skills performance on the checklist from pretest to posttest and posttest to 6- or 12-month follow-up test. RESULTS: Twenty-four of 30 eligible participants (80.0%) completed the SBML intervention, and 20 of 24 (83.3%) completed follow-up testing. The minimum passing standard was set at 93% of checklist items correct. The pretest passing rate was 4 of 24 participants (16.7%) compared with 24 of 24 participants (100%) at posttest ( P < .001). There were no significant differences in passing rates from posttest to combined 6- and 12-month posttest in which 18 of 20 participants (90.0%) passed. CONCLUSIONS: Before training and despite years of clinical experience, practicing endoscopists demonstrated poor performance of polypectomy skills. SBML was an effective method for practicing endoscopists to acquire and maintain polypectomy skills during a 6- to 12-month period.

Venous thromboembolism prevention in cancer care: implementation strategies to address underuse.

Background: Evidenced-based interventions have been developed to prevent venous thromboembolism (VTE) in ambulatory patients with cancer, including VTE-risk assessment for all patients and targeted primary thromboprophylaxis for high-risk patients. Despite supportive evidence and recommendations, oncologists rarely assess VTE risk or provide primary prophylaxis. Our previous work identified barriers and facilitators to using VTE prevention interventions in oncology practice. Objectives: To identify potential strategies that address the identified barriers and leverage facilitators to achieve successful implementation of evidence-based interventions for VTE prevention in oncology practice. Methods: We used the Implementation Research Logic Model, an implementation science framework, to map the relationships among barriers and facilitators, feasible and effective implementation strategies, and implementation and clinical outcomes that will be used to evaluate the implementation strategies. Results: We identified 12 discrete implementation strategies (eg, conducting clinician education and training and staged implementation scale-up) that address barriers and leverage facilitators through their mechanisms of action (eg, increased clinician awareness of evidence and targeting the highest effectiveness). We identified key implementation (eg, penetration, adoption, acceptability, fidelity, appropriateness, and sustainability), system (eg, integration of VTE-risk assessment into clinical workflow), and clinical (eg, lower VTE rates) outcomes targeted by the selected strategies. Conclusion: Using the Implementation Research Logic Model framework and building on our knowledge of barriers and facilitators, we identified implementation strategies and important outcomes to evaluate these strategies. We will use these results to test and measure the strategies to improve the uptake of evidence-based recommendations for VTE prevention in oncology practice.

An EHR-automated and theory-based population health management intervention for smoking cessation in diverse low-income patients of safety-net health centers: a pilot randomized controlled trial.

This study tested the preliminary effectiveness of an electronic health record (EHR)-automated population health management (PHM) intervention for smoking cessation among adult patients of a federally qualified health center in Chicago. Participants (N = 190; 64.7% women, 82.1% African American/Black, 8.4% Hispanic/Latino) were self-identified as smokers, as documented in the EHR, who completed the baseline survey of a longitudinal "needs assessment of health behaviors to strengthen health programs and services." Four weeks later, participants were randomly assigned to the PHM intervention (N = 97) or enhanced usual care (EUC; N = 93). PHM participants were mailed a single-page self-determination theory (SDT)-informed letter that encouraged smoking cessation or reduction as an initial step. The letter also addressed low health literacy and low income. PHM participants also received automated text messages on days 1, 5, 8, 11, and 20 after the mailed letter. Two weeks after mailing, participants were called by the Illinois Tobacco Quitline. EUC participants were e-referred following a usual practice. Participants reached by the quitline were offered behavioral counseling and nicotine replacement therapy. Outcome assessments were conducted at weeks 6, 14, and 28 after the mailed letter. Primary outcomes were treatment engagement, utilization, and self-reported smoking cessation. In the PHM arm, 25.8% of participants engaged in treatment, 21.6% used treatment, and 16.3% were abstinent at 28 weeks. This contrasts with no quitline engagement among EUC participants, and a 6.4% abstinence rate. A PHM approach that can reach all patients who smoke and address unique barriers for low-income individuals may be a critical supplement to clinic-based care.

Perceptions of Bereaved Caregivers and Clinicians About End-of-Life Care for Patients With Destination Therapy Left Ventricular Assist Devices.

Background Patients with left ventricular assist devices (LVADs) implanted as destination therapy may receive suboptimal preparation for and care at the end of life, but there is limited understanding of the reasons for these shortcomings. Exploring perceptions of individuals (caregivers and clinicians) who are closely involved in the end-of-life experience with patients with destination therapy LVADs can help identify key opportunities for improving care. Methods and Results We conducted semistructured qualitative interviews with 7 bereaved caregivers of patients with destination therapy LVADs and 10 interdisciplinary LVAD clinicians. Interviews explored perceptions of preparing for end of life, communicating about end of life, and providing and receiving end-of-life care, and were analyzed using a 2-step team-based inductive approach to coding and analysis. Six themes pertaining to end-of-life experiences were derived: (1) timing end-of-life discussions in the setting of unpredictable illness trajectories, (2) prioritizing end-of-life preparation and decision-making, (3) communicating uncertainty while providing support and hope, (4) lack of consensus on responsibility for end-of-life discussions, (5) perception of the LVAD team as invincible, and (6) divergent perceptions of LVAD withdrawal. Conclusions This study revealed 6 unique aspects of end-of-life care for patients with destination therapy LVADs as reported by clinicians and caregivers. Themes coalesced around communication, team-based care, and challenges unique to patients with LVADs at end of life. Programmatic changes may address some aspects, including training clinicians in LVAD-specific communication skills. Other aspects, such as standardizing the role of the palliative care team and developing practical interventions that enable timely advance care planning during LVAD care, will require multifaceted interventions.

Publicly Reported Patient Satisfaction Scores in Academic Otolaryngology Departments.

OBJECTIVES/HYPOTHESIS: Despite controversy regarding their impact and validity, there is a rising national focus on patient satisfaction scores (PSS). We describe the landscape of online PSS as posted by academic otolaryngology practices. STUDY DESIGN: Retrospective cross-sectional study. METHODS: Websites of academic otolaryngology programs were reviewed for PSS scores, provider type, and geographic location. Gender was determined by picture or profile pronouns. Years of experience were determined by year of initial American Board of Otolaryngology-Head and Neck Surgery certification. We defined PSS derived from Press-Ganey or Clinician and Group Consumer Assessment of Healthcare Providers and Systems surveys as "standardized PSS". We determined potential associations between provider characteristics and standardized PSS. RESULTS: Out of 115 Otolaryngology-Head and Neck Surgery academic programs, 40 (35%) posted a total of 64,638 online PSS surveys (nonstandardized plus standardized) of 507 unique otolaryngology care providers. Standardized PSS were posted for 473 providers (370 [78%] male; 446 physicians; 27 advanced practice providers). Median overall standardized PSS was 4.8 (interquartile range 4.7-4.9; range 3.8-5.0). PSS were similar between gender, provider type, and years of experience. Male providers had more surveys than female providers (149 vs. 93; P < .01). There was a linear relationship between number of surveys and years of experience (P < .01), but no relationship between number of surveys and overall standardized PSS. CONCLUSIONS: Patient satisfaction with otolaryngology providers at academic institutions is consistently high, as demonstrated by high online PSS with little variability. The limited variation in PSS may limit their usefulness in differentiating providers and quality of care. LEVEL OF EVIDENCE: NA Laryngoscope, 131:2204-2210, 2021.

Preventing venous thromboembolism in oncology practice: Use of risk assessment and anticoagulation prophylaxis.

BACKGROUND: Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in patients with cancer. Expert consensus recommends a risk-based approach to guide prophylactic anticoagulation to prevent VTE in ambulatory patients with cancer receiving chemotherapy. However, oncology practice patterns for VTE prevention remain unclear. PATIENTS/METHODS: We conducted (i) a retrospective, single-center cohort study of patients with pancreatic and gastric cancers to examine rates of prophylactic anticoagulation prescription for eligible patients at high risk of VTE based on the validated Khorana score, and (ii) a 15-question survey of oncology clinicians at the same institution to assess current practice patterns and knowledge regarding VTE risk assessment and primary thromboprophylaxis in February 2020. RESULTS: Of 437 patients who met study criteria, 181 (41%) had a score of ≥ 3 (high-risk), and none had an anticoagulation prescription for prophylaxis without an alternate treatment indication. In a survey sent to 98 oncology clinicians, of which 34 participated, 67% were unfamiliar with the Khorana score or guideline recommendations regarding risk-based VTE prophylaxis, and 90% "never" or "rarely" used VTE risk assessment. CONCLUSIONS: Despite available evidence and existing guideline recommendations for VTE risk assessment for ambulatory patients with cancer, and primary prophylaxis for high-risk patients, this study demonstrates that there is limited uptake in clinical practice.

Colonoscopy education delivered via the patient portal does not improve adherence to scheduled first-time screening colonoscopy.

Background and study aims Non-adherence to scheduled colonoscopy burdens endoscopic practices and innovative approaches to improve adherence are needed. We aimed to assess the effect of an educational video emphasizing colonoscopy importance delivered through the electronic health record patient portal upon "no-show" and late cancellation rates (non-adherence) in patients scheduled for first-time screening colonoscopy. Patients and methods We conducted a single center randomized controlled trial among patients scheduled for their first screening colonoscopy. Patients were randomized to routine care ("control") or video education ("video"). Control patients received a portal message 14 days prior to colonoscopy date; video patients additionally received a link to the educational video. Results In total, 830 patients (59 % female, median age 55 years) were randomized ("control": 406; "video": 424). Nearly all (88 %) opened the message; in the video arm, most (72 %) watched a majority of the video. Overall, 80 % attended their scheduled colonoscopy appointment (late cancel: 18 %, "no show": 1 %) and 90 % underwent colonoscopy within 3 months of appointment. Adherence rates did not differ between video and control arms for the scheduled appointment (OR 1.2, CI 0.9-1.8) or for colonoscopy within 3 months of scheduled appointment (OR 1.3, CI 0.8-2.1). Bowel preparation quality did not differ between the groups. Conclusion Most patients scheduled for colonoscopy will open a patient portal message and, when delivered, watch an educational video. However, delivery of an educational video two weeks prior to screening colonoscopy appointment did not improve adherence.

The Effects of a Multicomponent Colorectal Cancer Screening Intervention on Knowledge, Recommendation, and Screening among Underserved Populations.

This trial tested a multicomponent intervention to increase colorectal cancer (CRC) screening among underserved patients. Participants were randomized to: (1) physician + patient intervention, (2) physician-only intervention, or (3) usual care (UC). Study outcomes included patient knowledge, physician recommendation of CRC screening, and screening completion via colonoscopy or stool tests. Among 538 participants, those exposed to the physician + patient intervention had significantly increased knowledge over patients in physician-only (p=.0008) or UC arms (p=.0003). However, there were no statistically significant differences in completion of CRC screening, with 10%, 20%, and 16% of UC, physician-only, and physician + patient participants screened, respectively. In UC, all completed screenings were colonoscopy, whereas in the physician-only and physician + patient arms, 39% and 46% of completed tests were via stool test, respectively. The multicomponent intervention did not increase overall CRC screening, yet results underscore the need to provide patients options for completing CRC screening.

Goals-of-Care Decisions by Hospitalized Patients With Advanced Cancer: Missed Clinician Opportunities for Facilitating Shared Decision-Making.

CONTEXT: Hospitalized patients with advanced cancer often face complex, preference-sensitive decisions. How clinicians and patients engage in shared decision-making during goals-of-care discussions is not well understood. OBJECTIVE: The objective of this study was to explore decision-making by patients and clinicians during inpatient goals-of-care discussions. METHODS: This is a qualitative study of audio-recorded goals-of-care discussions between hospitalized patients with advanced cancer and their clinicians. Grounded theory was used to analyze transcripts. RESULTS: Sixty-two patients participated in goals-of-care discussions with 51 unique clinicians. Nearly half of patients (n = 30) were female and their mean age was 60.1 years (SD = 12.7). A palliative care attending or fellow was present in 58 of the 62 discussions. Decisions centered on three topics: 1) disease-modifying treatments; 2) hospice; and 3) code status. Clinicians' approach to decision-making included the following stages: "information exchange," "deliberation," "making a patient-centered recommendation," and "wrap-up: decisional status." Successful completion of each stage varied by the type of decision. When discussing code status, clinicians missed opportunities to engage patients in information exchange and to wrap up decisional status. By contrast, clinicians discussing disease-modifying treatments and hospice failed to integrate patient preferences. Clinicians also missed opportunities to make patient-centered recommendations when discussing treatment decisions. CONCLUSION: Clinicians missed opportunities to facilitate shared decision-making regarding goals of care, and these missed opportunities differed by type of decision being discussed. Opportunities for clinician communication training include engagement in collaborative deliberation with patients and making patient-centered recommendations in situations of high medical uncertainty.

What does risk of future cancer mean to breast cancer patients?

PURPOSE: Newly diagnosed breast cancer patients greatly overestimate their risk of developing contralateral breast cancer (CBC). Better understanding of patient conceptions of risk would facilitate doctor-patient communication and surgical decision making. In this mixed methods study, we prospectively examined breast cancer patients' perceived risk of future cancer and the reported factors that drove their risk perceptions. METHODS: Women age 21-60 diagnosed with breast cancer without a BRCA mutation or known distant metastases completed a study interview between surgical consult and surgical treatment. Participants completed a 12-item Perceived Risk Questionnaire, which assessed 10-year and lifetime risks of ipsilateral local recurrence, CBC, and distant recurrence. Patients provided qualitative explanations for their answers. RESULTS: Sixty-three patients completed study interviews (mean age 50.3). Participants were primarily White (85.7%) and 90.5% had attended college. Patients estimated their 10-year risk of CBC as 22.0%, nearly 4 times the established 10-year risk. Women attributed their risk perceptions to "gut feelings" about future cancer, even when women knew those feelings contradicted medically established risk. Perceptions of risk also reflected beliefs that cancer is random and that risk for local recurrence, CBC, and distant recurrence are the same. CONCLUSIONS: Our findings point to the need for novel ways of presenting factual information regarding both risk of recurrence and of new primary cancers, as well as the necessity of acknowledging cognitive and affective processes many patients use when conceptualizing risk. By differentiating women's intuitive feelings about risk from their knowledge of medically estimated risk, doctors can enhance informed decision making.

A qualitative exploration of social and environmental factors affecting diet and activity in knee replacement patients.

AIMS AND OBJECTIVES: To examine perceived social and environmental barriers and facilitators for healthy eating and activity before and after knee replacement. BACKGROUND: Many patients undergoing knee replacement surgery are overweight or obese. While obesity treatment guidelines encourage diet and activity modifications, gaps exist in understanding social and environmental determinants of these behaviours for knee replacement patients. Identifying these determinants is critical for treatment, as they are likely amplified due to patients' mobility limitations, the nature of surgery and reliance on others during recovery. DESIGN: This qualitative study used semi-structured interviews. METHODS: Twenty patients (M = 64.7 ± 9.8 years, 45% female, 90% Caucasian, body mass index 30.8 ± 5.5 kg/m2 ) who were scheduled for or had recently undergone knee replacement were interviewed. Participants were asked to identify social and environmental factors that made it easier or harder to engage in healthy eating or physical activity. Deidentified transcripts were analysed via constant comparative analysis to identify barriers and facilitators to healthy eating and activity. This paper was written in accordance with COnsolidated criteria for REporting Qualitative research standards. RESULTS: Identified social and environmental healthy eating barriers included availability of unhealthy food and attending social gatherings; facilitators included availability of healthy food, keeping unhealthy options "out of sight," and social support. Weather was the primary activity barrier, while facilitators included access to physical activity opportunities and social support. CONCLUSIONS: Results provide salient factors for consideration by clinicians and behavioural programmes targeting diet, activity, and weight management, and patient variables to consider when tailoring interventions. RELEVANCE TO CLINICAL PRACTICE: Practitioners treating knee replacement patients would be aided by an understanding of patients' perceived social and environmental factors that impede or facilitate surgical progress. Particularly for those directly interacting with patients, like nurses, physiotherapists, or other professionals, support from health professionals appears to be a strong facilitator of adherence to diet and increased activity.

Comparison of a Patient-Centered Weight Loss Program starting before versus after knee replacement: A pilot study.

BACKGROUND: Most patients risk gaining weight in the years after knee replacement, adding further concern to a population that is mostly overweight/obese prior to surgery. OBJECTIVE: Via a randomised pilot study, we assessed changes in weight during a Patient Centered Weight Loss Program (PACE) initiated either before or after knee replacement, while simultaneously examining the feasibility of recruiting and retaining participants over 26 weeks. METHODS: Recruitment outreach was made to 133 patients scheduled for knee replacement. Sixteen participants were randomised to a 14-session weight loss program that started either ≤6 weeks before surgery (PACE) or at 12 weeks post-op (Delayed PACE). Repeated measures ANOVAs were used to examine preliminary changes in weight, function, patient-reported outcomes, and physical activity across time (baseline/pre-op, 12 and 26 weeks after surgery) and group. RESULTS: Retention was 75% and 69% at 12 and 26 weeks after surgery, respectively. Weight significantly decreased across the 26 weeks (P<0.001). A group by time interaction (P=0.03) demonstrated Delayed PACE [-7.6±5.9kg (-7.9±5.9%)] lost significantly more weight than PACE [-2.5±2.7kg (-2.6±2.6%)] participants at 26 weeks. Significant improvements across time were seen for all function and patient reported outcomes, however activity did not change. CONCLUSION: Conducting a behavioural intervention was challenging but feasible in a knee replacement population, with preliminary evidence suggesting that initiating a program 12 weeks after surgery produces greater weight losses at 26 weeks compared to a program starting before knee replacement.

Understanding barriers and facilitators to healthy eating and physical activity from patients either before and after knee arthroplasty.

PURPOSE: We sought to identify patient-reported barriers and facilitators to healthy eating and physical activity among patients before or after knee arthroplasty. MATERIALS AND METHODS: Twenty patients with knee osteoarthritis aged 40-79 years who had knee arthroplasty surgery scheduled or completed within 3 months were interviewed. Interview topics included perceived barriers and facilitators to healthy eating and activity before or after surgery. Interviews were coded and analyzed using constant comparative analysis. RESULTS: Interviews were completed with 11 pre-operative (67.1 ± 7.6 years, 45.5% female, BMI 31.2 ± 6.3) and nine post-operative patients (61.7 ± 11.7 years, 44.4% female, BMI 30.2 ± 4.7 kg/m2). The most commonly identified personal barriers to healthy eating identified were desire for high-fat/high-calorie foods, managing overconsumption and mood. Factors related to planning, portion control and motivation to improve health were identified as healthy eating facilitators. Identified personal barriers for activity included pain, physical limitations and lack of motivation, whereas facilitators included having motivation to improve knee symptoms/outcomes, personal commitment to activity and monitoring activity levels. CONCLUSION: Identifying specific eating and activity barriers and facilitators, such as mood and motivation to improve outcomes, provides critical insight from the patient perspective, which will aid in developing weight management programs during rehabilitation for knee arthroplasty patients. Implications for rehabilitation This study provides insight into the identified barriers and facilitators to healthy eating and physical activity in knee arthroplasty patients, both before and after surgery. Intrapersonal barriers that may hinder engagement in physical activity and rehabilitation include pain, physical limitations and lack of motivation; factors that may help to improve activity and the rehabilitation process include being motivated to improve knee outcomes, having a personal commitment to activity and tracking activity levels. Barriers that may interfere with healthy eating behaviors and knee arthroplasty rehabilitation include the desire for high-fat/high-calorie foods, overeating and mood; whereas planning and portion control may help to facilitate healthy eating. Understanding barriers and facilitators to healthy eating and physical activity can help guide rehabilitation professionals with their discussions on weight management with patients who had or are contemplating knee arthroplasty.

Preferences and motivation for weight loss among knee replacement patients: implications for a patient-centered weight loss intervention.

BACKGROUND: Most knee replacement patients are overweight/obese, yet are commonly excluded from evidence-based weight loss programs due to mobility limitations and barriers faced around the time of surgery. The purpose of this study was to identify knee replacement patient preferences for weight loss programs and qualitatively understand previous motives for weight loss attempts as well as strategies used to facilitate behavior changes. METHODS: Patients who were either scheduled to have knee replacement or had one recently completed within the last 3 months were recruited to participate. Patients completed a brief weight loss program preference questionnaire assessing preferred components of a weight loss program (i.e. self-monitoring, educational topics, program duration). Qualitative interviews were completed to identify motives for and strategies used during past weight loss attempts. All interviews were transcribed, de-identified, and analyzed using constant comparative analysis. RESULTS: Twenty patients (11 pre-operative and 9 post-operative) between 47 and 79 years completed the study (55% male, 90% White, and 85% with a BMI ≥25 kg/m2). Patients reported a preference for a weight loss program that starts before surgery, is at least 6 months in duration, and focuses both on diet and exercise. The majority of patients preferred to have a telephone-based program and wanted to track diet and physical activity on a smartphone application. The most common motive for weight loss mentioned by patients related to physical appearance (including how clothing fit), followed by wanting to lose weight to improve knee symptoms or to prevent or delay knee replacement. Strategies that patients identified as helpful during weight loss attempts included joining a formal weight loss program, watching portion sizes, and self-monitoring their dietary intake, physical activity, or weight. CONCLUSIONS: This study provides a preliminary examination into the motives for weight loss, strategies utilized during past weight loss attempts, and preferences for future weight loss programs as described by knee replacement patients. These results will help guide the development and adaptation of future patient-centered weight loss programs as well as help clinicians recommend targeted weight programs based on the specific preferences of the knee replacement population.

Emergency Department Patient Perspectives on the Risk of Addiction to Prescription Opioids.

OBJECTIVE: To characterize emergency department (ED) patients' knowledge and beliefs about the addictive potential of opioids. DESIGN: Mixed methods analysis of data from a randomized controlled trial. SETTING: Urban academic ED (>88,000 visits). SUBJECTS: One hundred and seventy four discharged ED patients prescribed hydrocodone-acetaminophen for acute pain. METHODS: The study analyzed data collected from a randomized controlled trial investigating patients' knowledge of opioids. ED patients discharged with hydrocodone-acetaminophen completed an audio-recorded phone interview 4­7 days later. This analysis focuses on responses about addiction. Responses were categorized using content analysis; thematic analysis identified broad themes common across different categories. RESULTS: Participants' mean age was 45.5 years (SD, 14.8), 58.6% female, 50.6% white, and the majority had an orthopedic diagnosis (24.1% back pain, 52.3% other injuries). Responses were categorized first based on whether the patient believed that opioids could be addictive (categorized as: yes, 58.7%; no, 19.5%; depends, 17.2%; or do not know, 4.6%), and second based on whether or not the patient discussed his/her own experience with the medication (categorized as: personalized, 35.6%; or not personalized, 64.4%). Cohen's Kappa was 0.84 for all categories. Three themes emerged in the thematic analysis: theme 1) patients expect to "feel" addicted if they are addicted, theme 2) patients fear addiction, and theme 3) side effects affected patient views of addiction. CONCLUSION: In this sample, patients had misconceptions about opioid addiction. Some patients did not know opioids could be addictive, others underestimated their personal risk of addiction, and others overtly feared addiction and, therefore, risked inadequate pain management. Despite limited data, we recommend providers discuss opioid addiction with their patients.

Racial/Ethnic Differences in Inpatient Palliative Care Consultation for Patients With Advanced Cancer.

PURPOSE: Inpatient palliative care consultation (IPCC) may help address barriers that limit the use of hospice and the receipt of symptom-focused care for racial/ethnic minorities, yet little is known about disparities in the rates of IPCC. We evaluated the association between race/ethnicity and rates of IPCC for patients with advanced cancer. PATIENTS AND METHODS: Patients with metastatic cancer who were hospitalized between January 1, 2009, and December 31, 2010, at an urban academic medical center participated in the study. Patient-level multivariable logistic regression was used to evaluate the association between race/ethnicity and IPCC. RESULTS: A total of 6,288 patients (69% non-Hispanic white, 19% African American, and 6% Hispanic) were eligible. Of these patients, 16% of whites, 22% of African Americans, and 20% of Hispanics had an IPCC (overall P < .001). Compared with whites, African Americans had a greater likelihood of receiving an IPCC (odds ratio, 1.21; 95% CI, 1.01 to 1.44), even after adjusting for insurance, hospitalizations, marital status, and illness severity. Among patients who received an IPCC, African Americans had a higher median number of days from IPCC to death compared with whites (25 v 17 days; P = .006), and were more likely than Hispanics (59% v 41%; P = .006), but not whites, to be referred to hospice. CONCLUSION: Inpatient settings may neutralize some racial/ethnic differences in access to hospice and palliative care services; however, irrespective of race/ethnicity, rates of IPCC remain low and occur close to death. Additional research is needed to identify interventions to improve access to palliative care in the hospital for all patients with advanced cancer.

Comparing the Performance of the S-TOFHLA and NVS Among and Between English and Spanish Speakers.

Given the growing body of evidence demonstrating the significant implications of health literacy on a myriad of outcomes, researchers continue to incorporate health literacy metrics in studies. With this proliferation in measurement of health literacy in research, it has become increasingly important to understand how various health literacy tools perform in specific populations. Our objective was to compare the performance of two widely used tests, the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and the Newest Vital Sign (NVS) among and between a sample of English and Spanish-speaking patients. Adults (N = 402) ages 50-75 years participating in a trial to promote colorectal cancer screening completed in-person interviews which included both measures of health literacy. In the full sample, the tests were moderately correlated (r = 0.69, p < .0001); however, there was a stronger correlation among those completing the test in Spanish (r = 0.83) as compared with English (r = 0.58, p < .0001). English speakers more often were categorized as having adequate literacy by the S-TOFHLA as compared with the NVS, whereas Spanish speakers scored consistently low on both instruments. These findings indicate that the categorization of participants into levels of literacy is likely to vary, depending on whether the NVS or S-TOFHLA is used for assessment, a factor which researchers should be aware of when selecting literacy assessments.