A mixed methods evaluation of patient perspectives on the implementation of an electronic health record-integrated patient-reported symptom and needs monitoring program in cancer care.

BACKGROUND: As cancer centers have increased focus on patient-centered, evidenced-based care, implementing efficient programs that facilitate effective patient-clinician communication remains critical. We implemented an electronic health record-integrated patient-reported symptom and needs monitoring program ('cPRO' for cancer patient-reported outcomes). To aid evaluation of cPRO implementation, we asked patients receiving care in one of three geographical regions of an academic healthcare system about their experiences. METHODS: Using a sequential mixed-methods approach, we collected feedback in two waves. Wave 1 included virtual focus groups and interviews with patients who had completed cPRO. In Wave 2, we administered a structured survey to systematically examine Wave 1 themes. All participants had a diagnosed malignancy and received at least 2 invitations to complete cPRO. We used rapid and traditional qualitative methods to analyze Wave 1 data and focused on identifying facilitators and barriers to cPRO implementation. Wave 2 data were analyzed descriptively. RESULTS: Participants (n = 180) were on average 62.9 years old; were majority female, White, non-Hispanic, and married; and represented various cancer types and phases of treatment. Wave 1 participants (n = 37) identified facilitators, including cPRO's perceived value and favorable usability, and barriers, including confusion about cPRO's purpose and various considerations for responding. High levels of clinician engagement with, and patient education on, cPRO were described as facilitators while low levels were described as barriers. Wave 2 (n = 143) data demonstrated high endorsement rates of cPRO's usability on domains such as navigability (91.6%), comprehensibility (98.7%), and relevance (82.4%). Wave 2 data also indicated low rates of understanding cPRO's purpose (56.7%), education from care teams about cPRO (22.5%), and discussing results of cPRO with care teams (16.3%). CONCLUSIONS: While patients reported high value and ease of use when completing cPRO, they also reported areas of confusion, emphasizing the importance of patient education on the purpose and use of cPRO and clinician engagement to sustain participation. These results guided successful implementation changes and will inform future improvements.

Making it "EASI" for pediatricians to determine when toddler tantrums are "more than the terrible twos": Proof-of-concept for primary care screening with the Multidimensional Assessment Profiles-Early Assessment Screener for Irritability (MAPS-EASI).

BACKGROUND: Up to 20% of youth have impairing mental health problems as early as age 3. Early identification and intervention of mental health risks in pediatric primary care could mitigate this crisis via prevention prior to disease onset. The purpose of this study was to establish the feasibility and acceptability of implementing a brief transdiagnostic screening instrument in pediatric primary care for irritability and corollary impairment. METHOD: Five pediatric clinicians in a Midwest clinic implemented the Multidimensional Assessment Profiles-Early Assessment Screener of Irritability (MAPS-EASI) for toddlers (24-30 months) and their families. MAPS-EASI (psychometrically derived from the well-validated MAPS-Scales) includes six items (scored 0-5) about symptoms (e.g., tantrums, grumpy mood), context, and frequency and two items (scored 0-3) assessed impairment. Positive screens (MAPS-EASI ≥ 5 plus impairment ≥ 2) were referred to an evidence-based parenting intervention. We assessed reach and outcomes of MAPS-EASI screening. Follow-up interviews with clinicians assessed perspectives on irritability screening and MAPS-EASI implementation. RESULTS: Of 201 eligible families, 100 (49.8%) completed the screener for a 24- or 30-month well-child visit. Mean MAPS-EASI scores were 5.8 (SD = 3.2), mean impairment scores were 0.9 (SD = 0.9), and 24 (24.0%) screened positive. Clinicians indicated that irritability screening for toddlers was aligned with their prevention-oriented, developmentally based practice. MAPS-EASI had face validity and increased clinician decision-making confidence. Finally, clinicians identified barriers and facilitators to large-scale implementation. CONCLUSIONS: MAPS-EASI proved to be feasible and acceptable in pediatric primary care. Further tailoring will be needed as the MAPS-EASI processes are scaled out to new contexts and populations. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Vision Loss in Children from Immigrant and Nonimmigrant Households: Evidence from the National Survey of Children's Health 2018-2020.

The aim of this study was to determine whether immigrant generation is associated with caregiver-reported vision loss in children adjusting for sociodemographic characteristics. Nationally representative data from the National Survey of Children's Health (2018-2020) was used. The primary exposure was immigrant generation defined as: first (child and all reported parents were born outside the United States); second (child was born in the United States and at least one parent was born outside the United States); third or higher (all parents in the household were born in the United States). The main outcome was caregiver-reported vision loss in child. Adjusted odds ratios (aOR) and 95% confidence intervals were computed based on immigration generation. The study sample included 84,860 US children aged 3-17 years. First generation children had higher adjusted odds of caregiver-reported vision loss (aOR 2.30; 95% CI 1.21, 4.35) than third or higher generation children after adjusting for demographic characteristics and social determinants of health. For Hispanic families, first generation (aOR 2.99; 95% CI 1.34, 6.66), and second-generation children (aOR 1.70; 95% CI 1.06, 2.74) had a higher adjusted odds of vision loss compared with third or higher generation children. Even when adjusting for sociodemographic characteristics, first generation children had greater odds of vision loss, especially in Hispanic households, than third generation children. Immigration generation should be treated as an independent risk factor for vision loss for children and is a social determinant of eye health.

Protocol for a parallel cluster randomized trial of a participatory tailored approach to reduce overuse of antibiotics at hospital discharge: the ROAD home trial.

BACKGROUND: Antibiotic overuse at hospital discharge is common, costly, and harmful. While discharge-specific antibiotic stewardship interventions are effective, they are resource-intensive and often infeasible for hospitals with resource constraints. This weakness impacts generalizability of stewardship interventions and has health equity implications as not all patients have access to the benefits of stewardship based on where they receive care. There may be different pathways to improve discharge antibiotic prescribing that vary widely in feasibility. Supporting hospitals in selecting interventions tailored to their context may be an effective approach to feasibly reduce antibiotic overuse at discharge across diverse hospitals. The objective of this study is to evaluate the effectiveness of the Reducing Overuse of Antibiotics at Discharge Home multicomponent implementation strategy ("ROAD Home") on antibiotic overuse at discharge for community-acquired pneumonia and urinary tract infection. METHODS: This 4-year two-arm parallel cluster-randomized trial will include three phases: baseline (23 months), intervention (12 months), and postintervention (12 months). Forty hospitals recruited from the Michigan Hospital Medicine Safety Consortium will undergo covariate-constrained randomization with half randomized to the ROAD Home implementation strategy and half to a "stewardship as usual" control. ROAD Home is informed by the integrated-Promoting Action on Research Implementation in Health Services Framework and includes (1) a baseline needs assessment to create a tailored suite of potential stewardship interventions, (2) supported decision-making in selecting interventions to implement, and (3) external facilitation following an implementation blueprint. The primary outcome is baseline-adjusted days of antibiotic overuse at discharge. Secondary outcomes include 30-day patient outcomes and antibiotic-associated adverse events. A mixed-methods concurrent process evaluation will identify contextual factors influencing the implementation of tailored interventions, and assess implementation outcomes including acceptability, feasibility, fidelity, and sustainment. DISCUSSION: Reducing antibiotic overuse at discharge across hospitals with varied resources requires tailoring of interventions. This trial will assess whether a multicomponent implementation strategy that supports hospitals in selecting evidence-based stewardship interventions tailored to local context leads to reduced overuse of antibiotics at discharge. Knowledge gained during this study could inform future efforts to implement stewardship in diverse hospitals and promote equity in access to the benefits of quality improvement initiatives. TRIAL REGISTRATION: Clinicaltrials.gov NCT06106204 on 10/30/23.

Therapeutic Assessment in a University Counseling Center: A Replicated Single-Case Time-Series Pilot Study.

In this study, we pilot tested Therapeutic Assessment (TA) in a university counseling center using a replicated single-case design to generate hypotheses on the effectiveness and applicability for this setting and population. We aimed to see whether TA could be an effective brief intervention to address students' presenting mental health concerns. Further, we explored whether different types of presenting concerns were associated with differential symptomatic improvement during the intervention. An independent clinician interviewed participants before the baseline period to develop individualized rating scales pertaining to their presenting concerns. Eight consecutive students accessing the counseling center enrolled in the study and rated their presenting problems across baseline, intervention, and follow-up periods. The intervention involved five TA sessions. The results suggested that TA is associated with statistically significant reductions in clients' symptoms in the context of a university counseling center. Idiographic trajectory analysis of participant data who experienced significant and insignificant change was used to test whether changes were associated with the onset of TA. The findings suggest TA might be more effective for certain presenting concerns than for others. The implications for the implementation of TA in university counseling centers is discussed.

Modeling Long-Term Budgetary Impacts of Prevention: An Overview of Meta-analyses of Relationships Between Key Health Outcomes Across the Life-Course.

Budget analysis entities often cannot capture the full downstream impacts of investments in prevention services, programs, and interventions. This study describes and applies an approach to synthesizing existing literature to more fully account for these effects. This study reviewed meta-analyses in PubMed published between Jan 1, 2010 and Dec 31, 2019. The initial search included meta-analyses on the association between health risk factors, including maternal behavioral health, intimate partner violence, child maltreatment, depression, and obesity, with a later health condition. Through a snowball sampling-type approach, the endpoints of the meta-analyses identified became search terms for a subsequent search, until each health risk was connected to one of the ten costliest health conditions. These results were synthesized to create a path model connecting the health risks to the high-cost health conditions in a cascade. Thirty-seven meta-analyses were included. They connected early-life health risk factors with six high-cost health conditions: hypertension, diabetes, asthma and chronic obstructive pulmonary disorder, mental disorders, heart conditions, and trauma-related disorders. If confounders could be controlled for and causality inferred, the cascading associations could be used to more fully account for downstream impacts of preventive interventions. This would support budget analysis entities to better include potential savings from investments in chronic disease prevention and promote greater implementation at scale.

Implementation Preparation Costs of Virtual Reality Job Interview Training in Prisons: A Budget Impact Analysis.

Virtual Reality Job Interview Training (VR-JIT) has increased employment rates for returning citizens when added to a successful prison-based employment readiness program. However, implementation preparation cost-expenses prior to offering VR-JIT to intended recipients-is unknown. We estimated the cost of implementation preparation activities (e.g., organizing workflow) for two prisons to deliver VR-JIT. We conducted a budget impact analysis and enumerated the labor costs incurred during this important stage of implementation. Labor costs were approximately $8,847 per prison. Our sensitivity analysis estimated the labor costs to replicate this effort in a new prison to range from $2,877 to $4,306 per prison. Thus, VR-JIT may be an affordable tool for prison-based employment readiness programs to improve gainful employment.

Process of Engaging Community and Scientific Partners in the Development of the CIRCL-Chicago Study Protocol.

Objectives: Hypertension affects 1 in 3 adults in the United States and disproportionately affects African Americans. Kaiser Permanente demonstrated that a "bundle" of evidence-based interventions significantly increased blood pressure control rates. This paper describes a multiyear process of developing the protocol for a trial of the Kaiser bundle for implementation in under-resourced urban communities experiencing cardiovascular health disparities during the planning phase of this biphasic award (UG3/UH3). Methods: The protocol was developed by a collaboration of faith-based community members, representatives from community health center practice-based research networks, and academic scientists with expertise in health disparities, implementation science, community-engaged research, social care interventions, and health informatics. Scientists from the National Institutes of Health and the other grantees of the Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease Risk (DECIPHeR) Alliance also contributed to developing our protocol. Results: The protocol is a hybrid type 3 effectiveness-implementation study using a parallel cluster randomized trial to test the impact of practice facilitation on implementation of the Kaiser bundle in community health centers compared with implementation without facilitation. A central strategy to the Kaiser bundle is to coordinate implementation via faith-based and other community organizations for recruitment and navigation of resources for health-related social risks. Conclusions: The proposed research has the potential to improve identification, diagnosis, and control of blood pressure among under-resourced communities by connecting community entities and healthcare organizations in new ways. Faith-based organizations are a trusted voice in African American communities that could be instrumental for eliminating disparities.

Planning the Implementation of a Multilevel Blood Pressure Control Intervention in Chicago: Community and Clinical Perspectives.

Objectives: Hypertension is associated with high morbidity and mortality. The complications of hypertension disproportionately impact African American residents in Chicago's South Side neighborhood. To inform the implementation of an evidence-based multilevel hypertension management intervention, we sought to identify community member- and clinician-level barriers to diagnosing and treating hypertension, and strategies for addressing those barriers. Methods: We conducted 5 focus groups with members of faith-based organizations (FBOs) (n=40) and 8 focus groups with clinicians and administrators (n=26) employed by community health centers (CHCs) located in Chicago's South Side. Results: Participants across groups identified the physical environment, including lack of access to clinics and healthy food, as a risk factor for hypertension. Participants also identified inconsistent results from home blood pressure monitoring and medication side effects as barriers to seeking diagnosis and treatment. Potential strategies raised by participants to address these barriers included (1) addressing patients' unmet social needs, such as food security and transportation; (2) offering education that meaningfully engages patients in discussions about managing hypertension (eg, medication adherence, diet, follow-up care); (3) coordinating referrals via community-based organizations (including FBOs) to CHCs for hypertension management; and (4) establishing a setting where community members managing hypertension diagnosis can support one another. Conclusions: Clinic-level barriers to the diagnosis and treatment of hypertension, such as competing priorities and resource constraints, are exacerbated by community-level stressors. Community members and clinicians agreed that it is important to select implementation strategies that leverage and enhance both community- and clinic-based resources.