Veterans' views of PARTNER-MH, a peer-led patient navigation intervention, to improve patient engagement in care and patient-clinician communication: A qualitative study.

OBJECTIVE: In this study, we report on participants' experiences of PARTNER-MH, a peer-led, patient-navigation intervention for racially and ethnically minoritized patients in Veterans Health Administration mental health services aimed at improving patient engagement in care and patient-clinician communication. Participants described their views of PARTNER-MH, barriers and facilitators to the intervention's implementation, and their application of varied intervention concepts to improve engagement in care and communication with their mental health clinicians. METHODS: This is a qualitative analysis of the PARTNER-MH pilot randomized controlled trial. Participants participated in semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR). Rapid data analysis approach was used to analyze the data. RESULTS: Participants (n = 13) perceived PARTNER-MH as an acceptable intervention, and viewed use of peers as interventionists, long-term outreach and engagement efforts, and navigation services favorably. Barriers to implementation included limited flexibility in peers' schedules and lack of peer/participant gender concordance, as well as limited options for program delivery modality. Three main themes summarized participants' views and perceived benefits of PARTNER-MH that contributed to improved patient-clinician communication: 1) increased patient engagement, 2) improved patient-clinician relationship, and 3) enhanced communication self-efficacy. CONCLUSIONS: Participants viewed PARTNER-MH as beneficial and identified several intervention components that contributed to improved engagement in care, communication self-efficacy, and patient-clinician communication. PRACTICE IMPLICATION: Some patients, especially minoritized patients and those who have been disenfranchised from healthcare systems may benefit from peer-led interventions that facilitate engagement in care and communication self-efficacy to improve patient-clinician communication and healthcare outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT04515771.

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.

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.

A Qualitative Analysis of Narrative Preclerkship Assessment Data to Evaluate Teamwork Skills.

Construct: Students entering the health professions require competency in teamwork. Background: Although many teamwork curricula and assessments exist, studies have not demonstrated robust longitudinal assessment of preclerkship students' teamwork skills and attitudes. Assessment portfolios may serve to fill this gap, but it is unknown how narrative comments within portfolios describe student teamwork behaviors. Approach: We performed a qualitative analysis of narrative data in 15 assessment portfolios. Student portfolios were randomly selected from 3 groups stratified by quantitative ratings of teamwork performance gathered from small-group and clinical preceptor assessment forms. Narrative data included peer and faculty feedback from these same forms. Data were coded for teamwork-related behaviors using a constant comparative approach combined with an identification of the valence of the coded statements as either "positive observation" or "suggestion for improvement." Results: Eight codes related to teamwork emerged: attitude and demeanor, information facilitation, leadership, preparation and dependability, professionalism, team orientation, values team member contributions, and nonspecific teamwork comments. The frequency of codes and valence varied across the 3 performance groups, with students in the low-performing group receiving more suggestions for improvement across all teamwork codes. Conclusions: Narrative data from assessment portfolios included specific descriptions of teamwork behavior, with important contributions provided by both faculty and peers. A variety of teamwork domains were represented. Such feedback as collected in an assessment portfolio can be used for longitudinal assessment of preclerkship student teamwork skills and attitudes.

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.

Beyond the physical: a qualitative assessment of the burden of symptomatic uterine fibroids on women's emotional and psychosocial health.

OBJECTIVE: To qualitatively assess the burden of uterine fibroids on women's emotional health. METHODS: Sixty women (n = 60) with symptomatic uterine fibroids were recruited from an urban academic medical center and community-based organizations. Women completed qualitative, semi-structured interviews and demographic surveys. Interviews were recorded and transcribed verbatim. Using a grounded theory approach, three coders independently identified major themes and subthemes that emerged from the interviews. RESULTS: The kappa among coders was 0.94. The mean age of participants was 43.0 ± 6.8. 61.7% of participants self-identified as African-American, 25.0% as Caucasian, 8.3% as Hispanic and 5.0% as Asian. Most participants exhibited a significant emotional response to their fibroids, including fear, anxiety, anger, and depression. Half of the women felt helpless and believed that they had no control over their fibroids. Many women possessed a negative self-image and cited concern over appearing less attractive, which led to difficulties becoming intimate. Several women felt that they lacked substantial support to help them deal with these issues. CONCLUSION: In addition to the known high prevalence and severe physical impact of uterine fibroids, there is a significant psychological impact on women. Many women lack support to help them deal with these issues and very few seek help from a mental health professional. There is an opportunity and a need for the mental health community to address the concerns in this population, in order to improve psychological health and quality of life in patients living with this chronic condition.

Patient and provider perspectives on methicillin-resistant Staphylococcus aureus: a qualitative assessment of knowledge, beliefs, and behavior.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause of healthcare-associated infection. Individuals with spinal cord injuries and disorders (SCI/D) are at high risk of MRSA colonization and infection. The Department of Veterans Affairs (VA) released guidelines to prevent the spread of MRSA in Veterans with SCI/D; however, available patient educational materials did not address the unique issues for this population. OBJECTIVE: To assess perceptions of SCI/D providers and Veterans with SCI/D regarding MRSA and their educational needs about MRSA prevention, with an ultimate goal of developing patient educational materials that address the issues unique to SCI/D. METHODS: Purposive samples of SCI/D providers (six groups) and Veterans with SCI/D (one group) at two VA facilities participated in 60-90-minute focus group sessions. Qualitative data were analyzed using latent content and constant comparative techniques to identify focal themes. PARTICIPANTS: Thirty-three providers (physicians and nurses working in inpatient, outpatient, and homecare settings) and eight Veterans participated. RESULTS: Three overarching themes emerged from the analysis: knowledge about MRSA, hand hygiene, and barriers to educating Veterans with SCI/D. CONCLUSIONS: SCI/D providers and Veterans with SCI/D identified gaps in general MRSA knowledge, gaps in knowledge of good hand hygiene practices and of required frequency of hand hygiene, and barriers to educating Veterans with SCI/D during inpatient stays. Future educational materials and strategies should address these gaps.

Patient knowledge and recall of health information following exposure to "facts and myths" message format variations.

OBJECTIVE: To assess if exposure to varying "facts and myths" message formats affected participant knowledge and recall accuracy of information related to influenza vaccination. METHODS: Consenting patients (N=125) were randomized to receive one of four influenza related messages (Facts Only; Facts and Myths; Facts, Myths, and Refutations; or CDC Control), mailed one week prior to a scheduled physician visit. Knowledge was measured using 15 true/false items at pretest and posttest; recall accuracy was assessed using eight items at posttest. RESULTS: All participants' knowledge scores increased significantly (p<0.05); those exposed to the CDC Control message had a higher posttest knowledge score (adjusted mean=11.18) than those in the Facts Only condition (adjusted mean 9.61, p=<0.02). Participants accurately recalled a mean of 4.49 statements (SD=1.98). ANOVA demonstrated significant differences in recall accuracy by condition [F(3, 83)=7.74, p<.001, η(2)=0.22]. CONCLUSION: Messages that include facts, myths, and evidence to counteract myths appear to be effective in increasing participants' knowledge. We found no evidence that presenting both facts and myths is counterproductive to recall accuracy. PRACTICE IMPLICATIONS: Use of messages containing facts and myths may engage the reader and lead to knowledge gain. Recall accuracy is not assured by merely presenting factual information.

Black women's awareness of breast cancer disparity and perceptions of the causes of disparity.

Black women face the greatest breast cancer mortality burden of any racial or ethnic group in the United States. Breast cancer disparity is particularly pronounced in Chicago, where Black women were 62 percent more likely to die of breast cancer than their White counterparts in 2007. No work to date has examined views of disparity among a population living in the context of a large, well-documented, and grave health disparity. We examined (1) awareness of breast cancer disparities among Black women in Chicago; and (2) Black women's perceptions of the causes of breast cancer disparity. Four focus groups with Black women were held in Chicago. Participants completed a brief survey about their views of breast cancer prior to the group discussion. In response to the survey question, "In your opinion, who is more likely to die from breast cancer?" 51 % of participants believed all women have the same chance of dying from breast cancer. In focus group discussions, participants placed responsibility for disparity on individual behaviors and community culture. Participants believed that disparity resulted from Black women's lack of awareness of cancer screening and their failure to be screened or treated for breast cancer. The majority of participants were unaware of breast cancer mortality disparities. Moreover, while health researchers and professionals believe disparity in Chicago results from healthcare system inequalities, Black women largely viewed breast cancer disparity as a consequence of individual behaviors, knowledge and attitudes.

An exploration of women's reasons for termination timing in the setting of fetal abnormalities.

BACKGROUND: Over 3% of pregnancies are complicated by a fetal abnormality, of which, approximately 80% are terminated. Despite early screening options, women often present at the cusp of legal limits for termination. STUDY DESIGN: A qualitative study was conducted with women terminating pregnancies for fetal abnormalities. Semi-structured interviews explored reasons for termination timing. Analysis utilized latent content and constant comparative methods. RESULTS: Of 30 participants between 13+4 and 23+5 weeks gestation, their median age was 35 years, 73.3% were white, 70% were religiously affiliated, and 60% had children. The median time from abnormality identification until termination was 16.5 days (range 2-73). The major themes for termination timing included (1) an abrupt shift in "low-risk" pregnancy perception; (2) challenging medical interactions; (3) an emotional decision-making process; and (4) termination access barriers. CONCLUSIONS: Timing of termination for fetal abnormalities is attributable to multiple issues. Future research should identify optimal prenatal counseling strategies, address systemic barriers, and identify patient decision-making resources.

Media and memory: the efficacy of video and print materials for promoting patient education about asthma.

OBJECTIVE: We examined the effects of presentation medium on immediate and delayed recall of information and assessed the effect of giving patients take-home materials after initial presentations. METHODS: Primary-care patients received video-based, print-based or no asthma education about asthma symptoms and triggers and then answered knowledge-based questions. Print participants and half the video participants received take-home print materials. A week later, available participants completed the knowledge assessment again. RESULTS: Participants receiving either intervention outperformed controls on immediate and delayed assessments (p<0.001). For symptom-related information, immediate performance did not significantly differ between print and video participants. A week later, receiving take-home print predicted better performance (p<0.05), as did self-reported review among recipients of take-home print (p<0.01). For content about inhaler usage, although video watchers outperformed print participants immediately after seeing the materials (p<0.001), a week later these two groups' performance did not significantly differ. Among participants given take-home materials, review predicted marginally better recall (p=0.06). CONCLUSION: Video and print interventions can promote recall of health-related information. Additionally, reviewable materials, if they are utilized, may improve retention. PRACTICE IMPLICATIONS: When creating educational tools, providers should consider how long information must be retained, its content, and the feasibility of providing tangible supporting materials.

Gender disparities in health and healthcare use among older adults.

BACKGROUND: Gender differences in health and the use of health services are a long-standing concern for the U.S. medical system. Our purpose was to examine if there are patterns of gender differences in the type of medical service used among older Americans. METHODS: We conducted a prospective study of 9164 Americans aged >or=65 followed through the Health and Retirement Study (HRS), a national probability sample of community dwelling adults. Self-reported medical utilization between 2002 and 2004 was modeled as a function of 2002 baseline characteristics of the sample. RESULTS: Health needs were substantially greater among older women compared with men, but women had fewer economic resources. Controlling for health needs did little to explain gender differences in preventive care and increased gender differences in the use of hospital services. Women were less likely to have hospital stays (adjusted odds ratio [OR] = 0.79) and had fewer physician visits (3.07 vs. 3.30 median visits within 2 years) than men with similar demographic and health profiles. In contrast, the greater use of home healthcare among women was almost entirely explained by their greater health needs. CONCLUSIONS: These national data show that simple evaluations of age-adjusted gender differences in the use of hospital and physician services that do not account for underlying health needs are in danger of understating these disparities.

Potential use of 10-year and lifetime coronary risk information for preventive cardiology prescribing decisions: a primary care physician survey.

BACKGROUND: Data are sparse regarding how physicians use coronary risk information for prescribing decisions. METHODS: We presented 5 primary prevention scenarios to primary care physicians affiliated with an academic center and surveyed their responses after they were provided with (1) patient risk factor information, (2) 10-year estimated coronary disease risk information, and (3) 10-year and lifetime risk estimates. We asked about aspirin prescribing, lipid testing, and lipid-lowering drug prescribing. RESULTS: Of 202 physicians surveyed, 99 (49%) responded. The physicians made guideline-concordant aspirin decisions 51% to 91% of the time using risk factor information alone. Providing 10-year risk estimates increased concordant aspirin prescribing when the 10-year coronary risk was moderately high (15%) and decreased guideline-discordant prescribing when the 10-year risk was low (2 of 4 cases). Providing the lifetime risk information sometimes increased guideline-discordant aspirin prescribing. The physicians selected guideline-concordant thresholds for initiating treatment with lipid-lowering drugs 44% to 75% of the time using risk factor information alone. Selecting too low or too high low-density lipoprotein cholesterol thresholds was common. Ten-year risk information improved concordance when the 10-year risk was moderately high. Providing lifetime risk information increased willingness to initiate pharmacotherapy at low-density lipoprotein cholesterol levels that were lower than those recommended by guidelines when the 10-year risk was low but the lifetime risk was high. CONCLUSIONS: Providing 10-year coronary risk information improved some hypothetical aspirin-prescribing decisions and improved lipid management when the short-term risk was moderately high. High lifetime risk sometimes led to more intensive prescription of aspirin or lipid-lowering medication. This outcome suggests that, to maximize the benefits of risk-calculating tools, specific guideline recommendations should be provided along with risk estimates.

Investigating Hispanic/Latino perceptions about colorectal cancer screening: a community-based approach to effective message design.

OBJECTIVE: The Hispanic/Latino population has been documented as having the lowest colorectal cancer (CRC) screening rates in the United States, putting this group at-risk for late-stage presentation of disease. We assessed knowledge, attitudes, and behavior regarding CRC screening to inform the development of messages that promote screening among Hispanic/Latino patients. METHODS: In-person structured interviews with Spanish-speaking adults age 50-80 at two clinics and a senior center in a Hispanic/Latino community (N=234). RESULTS: Most (67.1%) participants had no more than an eighth-grade education and 63.3% reported their reading ability as less than "very good." Only 18.4% of participants correctly identified the colon on a diagram; 19.2% correctly described at least one aspect of a polyp. Less than half of the participants perceived themselves as at-risk for CRC, and less than one-third knew about any of the standard screening tests. After hearing descriptions of the screening tests, participants perceived stool cards as easier, safer, less painful, less embarrassing, and less scary than endoscopy (p<.001). Approximately two-thirds of unscreened patients said that screening had never been mentioned or suggested to them; about one-quarter said they did not get screened because they felt fine or were not worried. Over 96% of participants said they would get screened if a doctor suggested it. CONCLUSION: Assessing knowledge, attitudes, beliefs, and experiences in the community of interest is a promising approach for developing effective targeted health messages. PRACTICE IMPLICATIONS: Messages to increase CRC screening knowledge and behavior in the Hispanic/Latino community should address risk factors, identify relevant anatomy, explain polyps and their asymptomatic presentation, and clearly describe options.

Stepping back from social norms campaigns: comparing normative influences to other predictors of health behaviors.

Recent health campaigns on college campuses have used a social norms approach, which suggests that one's perceptions of others' attitudes and behaviors are the key components in attitude and behavior change. However, the efficacy of social norms campaigns has been mixed. This study was conducted to assess the relationships among sociodemographics, normative perceptions, and individual attitudes on 3 health behaviors. Students at 2 universities (N = 393) completed questionnaires assessing how these variables related to their consumption of alcohol, tobacco use, and exercise behaviors. Regressions indicated that each of these variables was associated with behavior, but varied independent variables emerged as the salient predictors among behaviors. In several conditions the effect of normative perceptions on behaviors was not significant, a finding in direct opposition to social norms marketing. In all 3 behavioral conditions, the variable accounting for the greatest variance was whether or not the individual liked participating in that particular behavior. Thus, although some social norms marketing may be meeting with success, it may be the case that predicted attitudinal and behavioral changes will not be found when applied across diverse health topics.

Patients' attitudes toward health care providers collecting information about their race and ethnicity.

BACKGROUND: Experts recommend that health care providers (HCPs) collect patients' race/ethnicity, but HCPs worry that this may alienate patients. OBJECTIVE: To determine patients' attitudes toward HCPs collecting race/ethnicity data. DESIGN: Cross-sectional survey. PARTICIPANTS: General Internal Medicine patients (n=220). MEASUREMENTS: Perceived importance of having HCPs collect race/ethnicity data, their concerns about this, comfort level providing this information, and reactions to 4 statements explaining the rationale for collecting this. RESULTS: Approximately 80% somewhat or strongly agreed that HCPs should collect information on patients' race/ethnicity. However, 28% had significant discomfort (score 5 or less on 10-point scale) reporting their own race/ethnicity to a clerk, and 58% were somewhat or very concerned that this information could be used to discriminate against patients. Compared with whites, blacks, and Hispanics felt less strongly that HCPs should collect race/ethnicity data from patients (P=.04 for both pairwise comparisons), and blacks were less comfortable reporting their own race/ethnicity than whites (P=.03). Telling patients that this information would be used for monitoring quality of care improved comfort more than telling patients that the data collected (a) was mandated by others, (b) would be used to guide staff hiring and training, and (c) would be used to ensure the patient got the best care possible. CONCLUSIONS: Most patients think HCPs should collect information about race/ethnicity, but many feel uncomfortable giving this information, especially among minorities. Health care providers can increase patients' comfort levels by telling them this will be used to monitor quality of care.