Outcomes of Telehealth for Wound Care: A Scoping Review.

OBJECTIVE: To synthesize the literature on delivering wound care via telehealth and compare clinical, healthcare utilization, and cost outcomes when wound care is provided via telehealth (telewound) modalities compared with in-person care. DATA SOURCES: An electronic search of PubMed, CINAHL, and Cochrane Clinical Trials databases for articles published from 1999 to 2019 was conducted using the following MeSH search terms: telewound, wound, wound care, remote care, telehealth, telemedicine, eHealth, mobile health, pressure injury, and ulcer. STUDY SELECTION: Articles were included if they were a scientific report of a single study; evaluated a telehealth method; identified the type of wound of focus; and provided data on clinical, healthcare utilization, or cost outcomes of telewound care. In total, 26 articles met these criteria. DATA EXTRACTION: Data were extracted and grouped into 13 categories, including study design, wound type, telehealth modality, treatment intervention, and outcomes measured, among others. DATA SYNTHESIS: Of the 26 studies, 19 reported on clinical outcomes including overall healing and healing time; 17 studies reported on healthcare utilization including hospitalizations and length of stay; and 12 studies reported costs. CONCLUSIONS: Evidence regarding the use of telewound care is weak, and findings related to the impact of telewound care on outcomes are inconsistent but indicate that it is not inferior to in-person care. Greater use of telehealth as a result of the COVID-19 pandemic points to further development of navigation and education models of telehealth for wound care. However, additional studies using rigorous research design and leveraging robust sample sizes are needed to demonstrate value.

The interactive effects of peers and alcohol on functional brain connectivity in young adults.

Alcohol and peer influence are known to have independent effects on risky decision making. We investigated combined influences of peers and alcohol on functional brain connectivity and behavior. Young adults underwent fMRI while completing response inhibition (Go/No-Go) and risky driving (Stoplight) tasks. Intoxicated participants made more mistakes on Go/No-Go, and showed diminished connectivity between the anterior insular cortex (AIC) and regions implicated in executive function (e.g., dorsal anterior cingulate). During the Stoplight game, peer observation was associated with increased connectivity between the AIC and regions implicated in social cognition (e.g., ventromedial prefrontal cortex). Alcohol and peers also exerted interactive influences, such that some connectivity changes only occurred when participants were observed by peers and under the influence of alcohol. These findings suggest that brain systems underlying decision making function differently under the combined influence of alcohol and peers, and highlight mechanisms through which this combination of factors is particularly risky for youth.

Adolescent risk-taking is predicted by individual differences in cognitive control over emotional, but not non-emotional, response conflict.

While much research on adolescent risk behaviour has focused on the development of prefrontal self-regulatory mechanisms, prior studies have elicited mixed evidence of a relationship between individual differences in the capacity for self-regulation and individual differences in risk taking. To explain these inconsistent findings, it has been suggested that the capacity for self-regulation may be, for most adolescents, adequately mature to produce adaptive behaviour in non-affective, "cold" circumstances, but that adolescents have a more difficult time exerting control in affective, "hot" contexts. To further explore this claim, the present study examined individual differences in self-control in the face of affective and non-affective response conflict, and examined whether differences in the functioning of cognitive control processes under these different conditions was related to risk taking. Participants completed a cognitive Stroop task, an emotional Stroop task, and a risky driving task known as the Stoplight game. Regression analyses showed that performance on the emotional Stroop task predicted laboratory risk-taking in the driving task, whereas performance on the cognitive Stroop task did not exhibit the same trend. This pattern of results is consistent with theories of adolescent risk-taking that emphasise the impacts of affective contextual influences on the ability to enact effective cognitive control.

Joint Effects of Peer Presence and Fatigue on Risk and Reward Processing in Late Adolescence.

Peers are thought to increase adolescents' risk-taking behavior, at least in part, by heightening their sensitivity to rewards. In this study, we investigate whether the effect of peers on late adolescent males is exacerbated when youth are cognitively fatigued, a state characterized by weakened cognitive control and heightened orientation toward rewards, and well established as a factor that compromises decision making. We hypothesized that fatigued adolescents' top-down regulation of reward-related impulses may be compromised, thereby potentially amplifying the effect of peers on reward- and risk-seeking behavior. Late adolescent males between 18 and 22 years old (mean age = 19.64, SD = 1.22; 61% Caucasian) completed a decision-making battery either alone or in the presence of 3 same-sex peers, and were either cognitively fatigued or non-fatigued. We compared behavior between four experimental groups-fatigued adolescents in a peer group, non-fatigued adolescents in a peer group, fatigued adolescents by themselves, and non-fatigued adolescents by themselves. The findings showed that cognitive fatigue and peer presence evinced independent effects on risk taking and sensitivity to rewards, but that these factors do not influence adolescent decision-making in an additive or synergistic fashion. To our surprise, being fatigued reduces (but does not eliminate) the effect of peers of risk taking. Moreover, the impact of peers on adolescent males' ability to learn from negative consequences is not compromised when adolescents are in a state of mental fatigue. Our results suggest that mental fatigue increases late adolescent males' reward sensitivity to the same extent as peer presence, but does not amplify the peer effect on risk-taking behavior. In this regard, grouping adolescents when they are fatigued may be less dangerous than when they are rested. Similarly, the added presence of peers does not further exacerbate the effect of fatigue on adolescent's reward- and risk-seeking inclinations. In fact, given peers' unique effect on adolescents' ability to learn from costly decisions, our findings suggest that seeking the presence of peers-which is often a rewarding experience in and of itself-may be an adaptive response to mitigate the impact of fatigue on decision making.

Evaluating the Prevalence of Four Recommended Practices for Suicide Prevention Following Hospital Discharge.

BACKGROUND: The Joint Commission's National Patient Safety Goal (NPSG) for suicide prevention (NPSG.15.01.01) requires that accredited hospitals maintain policies/procedures for follow-up care at discharge for patients identified as at risk for suicide. The proportion of hospitals meeting these requirements through use of recommended discharge practices is unknown. METHODS: This cross-sectional observational study explored the prevalence of suicide prevention activities among Joint Commission-accredited hospitals. A questionnaire was sent to 1,148 accredited hospitals. The authors calculated the percentage of hospitals reporting implementation of four recommended discharge practices for suicide prevention. RESULTS: Of 1,148 hospitals, 346 (30.1%) responded. The majority (n = 212 [61.3%]) of hospitals had implemented formal safety planning, but few of those (n = 41 [19.3%]) included all key components of safety planning. Approximately a third of hospitals provided a warm handoff to outpatient care (n = 128 [37.0%)] or made follow-up contact with patients (n = 105 [30.3%]), and approximately a quarter (n = 97 [28.0%]) developed a plan for lethal means safety. Very few (n = 14 [4.0%]) hospitals met full criteria for implementing recommended suicide prevention activities at time of discharge. CONCLUSION: The study revealed a significant gap in implementation of recommended practices related to prevention of suicide postdischarge. Additional research is needed to identify factors contributing to this implementation gap.

Use of the Veterans Health Administration online patient portal among Veterans with spinal cord injuries and disorders.

CONTEXT/OBJECTIVE: Online patient portals like the Veteran Health Administration's (VA) My HealtheVet (MHV) may be particularly useful for Veterans with spinal cord injuries/disorders (SCI/D), many of whom experience barriers to care. The objective of this analysis was to examine MHV use among Veterans with SCI/D. DESIGN: Retrospective database analysis. SETTING: VA SCI/D System of Care. PARTICIPANTS: Veterans with SCI/D who utilize VA care. INTERVENTIONS: N/A. OUTCOME MEASURES: MHV registration and use of key portal features among Veterans who newly registered for MHV. Veteran characteristics associated with registration and use of portal features using multiple logistic regression. RESULTS: 14.6% of Veterans with SCI/D in our sample registered to use MHV. 48.7% used the medication refill feature, 28.7% used the appointment view feature, 25.0% sent or read at least one secure message and 10.8% used the Blue Button feature. Adjusted analyses indicate that having a C5-8 (OR: 1.36, CI95%: 1.06-1.76, P < 0.05) or T1-S5 (OR: 1.41, CI95%: 1.13-1.78, P < 0.01) (vs. C1-C4), having (vs. not having) neurogenic bladder (OR: 1.45, CI95%: 1.18-1.77, P < 0.01), being married (vs. not married) (OR: 2.00, CI95%: 1.67-2.39, P < 0.01), and increased healthcare utilization in the third (OR: 1.71, CI95%: 1.31-2.24, P < 0.01) and fourth (OR: 1.73, CI95%: 1.27-2.34, P < 0.01) quartiles (vs. first quartile) were associated with increased odds of MHV registration. We also identified factors associated with use of key MHV features. CONCLUSIONS: Our results suggest that MHV registration and use of key portal features was limited among Veterans with SCI/D. Effort to increase portal use in this population are warranted.

Home Health Agency Patient Experience Measures and Their Relationship to Joint Commission Accreditation.

BACKGROUND: Health care accreditation is a widely accepted mechanism for improving the quality of care and promoting patient safety. An integral dimension of health care quality is the patient experience of care. However, the influence of accreditation on the patient experience is unclear. The Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) survey is the standard for collecting patient care experience data in the home health setting. The aim of this study was to examine the association of Joint Commission accreditation on patients' experience of care by comparing HHCAHPS ratings from Joint Commission-accredited and non-Joint Commission-accredited home health agencies (HHAs). METHODS: This multiyear observational study used 2015-2019 HHCAHPS data obtained from the Centers for Medicare & Medicaid Services (CMS) website and Joint Commission databases. The data set included 1,454 (23.8%) Joint Commission-accredited and 4,643 (76.2%) non-Joint Commission-accredited HHAs. Dependent variables included three composite measures of care (Care of Patients, Provider-Patient Communications, and Specific Care Issues) and two global rating measures. Data were analyzed using a series of longitudinal random effects logistic regression models. RESULTS: This study found no association between Joint Commission accreditation and the two global HHCAHPS measures, modest significant increases for Joint Commission-accredited HHAs in measure rates for the Care of Patients and Communication composite measures (p < 0.05), and a more significant increase for the Specific Care Issues composite measure related to medication safety and home safety (p < 0.001). CONCLUSIONS: These findings suggest that Joint Commission accreditation may be positively associated with some patient experience of care outcomes. This relationship was most pronounced when there was significant overlap between the focus of the accreditation standards and focus of the HHCAHPS items.

Indigenous Alaskan and mainstream identification explain the link between perceived discrimination and acculturative stress.

Drawing from the rejection-identification model, acculturation, and acceptance threat literatures, we examined how Indigenous and mainstream identification influence the effect of discrimination on acculturative and physical stress. A community sample of 126 Indigenous Alaskans reported discrimination, identification with Indigenous Alaskans and mainstream Americans, and acculturative and physical stress. As perceptions of personal discrimination increased, so did Indigenous identification and reports of acculturative and physical stress. Contrary to the rejection-identification hypothesis, Indigenous identification did not reduce the effect of discrimination on stress. Instead, following personal discrimination, Indigenous and mainstream identification interacted to predict acculturative stress. As Indigenous identification increased, so did acculturative stress - particularly among those who strongly identified with mainstream culture. These associations were not present for group-based discrimination. Thus, experiencing personal rejection from mainstream society may be particularly stressful for Indigenous people who strongly identify with their ethnic group, placing them at higher risk for mental and physical illness.

TeleWound Practice Within the Veterans Health Administration: Protocol for a Mixed Methods Program Evaluation.

BACKGROUND: Chronic wounds, such as pressure injuries and diabetic foot ulcers, are a significant predictor of mortality. Veterans who reside in rural areas often have difficulty accessing care for their wounds. TeleWound Practice (TWP), a coordinated effort to incorporate telehealth into the provision of specialty care for patients with skin wounds, has the potential to increase access to wound care by allowing veterans to receive this care at nearby outpatient clinics or in their homes. The Veterans Health Administration (VA) is championing the rollout of the TWP, starting with regional implementation. OBJECTIVE: This paper aims to describe the protocol for a mixed-methods program evaluation to assess the implementation and outcomes of TWP in VA. METHODS: We are conducting a mixed-methods evaluation of 4 VA medical centers and their community-based outpatient clinics that are participating in the initial implementation of the TWP. Data will be collected from veterans, VA health care team members, and other key stakeholders (eg, clinical leadership). We will use qualitative methods (ie, semistructured interviews), site visits, and quantitative methods (ie, surveys, national VA administrative databases) to assess the process and reach of TWP implementation and its impact on veterans' clinical outcomes and travel burdens and costs. RESULTS: This program evaluation was funded in October 2019 as a Partnered Evaluation Initiative by the US Department of Veterans Affairs, Diffusion of Excellence Office, and Office of Research and Development, Health Services Research and Development Service, Quality Enhancement Research Initiative Program (PEC 19-310). CONCLUSIONS: Evaluation of the TWP will identify barriers and solutions to TeleWound implementation in a small number of sites that can be used to inform successful rollout of the TWP nationally. Our evaluation work will inform future efforts to scale up the TWP across VA and optimize reach of the program to veterans across the nation. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/20139.

Working Memory Training in Adolescents Decreases Laboratory Risk Taking in the Presence of Peers.

Adolescence is a period of heightened risk-taking relative to both adulthood and childhood, due in part to peers' increased influence on adolescent decision making. Because adolescents' choices have harmful consequences, there is great interest in specific interventions that might attenuate risk taking. We hypothesized that it might be possible to reduce adolescent risk taking through an intervention targeting the ability/tendency to engage cognitive control processes. While some studies of Working Memory Training (WMT) have indicated subsequent enhancement of adults' cognitive control abilities, potential impacts on adolescent cognitive control have not been explored. Accordingly, we tested whether four weeks of WMT (relative to Active Control Training, ACT) might increase performance on cognitive control measures and decrease risk-taking in adolescents. Adolescents receiving WMT, compared to those receiving ACT, exhibited some evidence of improved short-term memory performance following the 4-week training period. Improvements did not significantly transfer to performance on basic cognitive control measures. However, on two risk-taking tasks administered at post-training either with or without an anonymous peer audience, adolescents who received WMT evinced suppressed levels of risk taking when observed by peers, an effect not seen in ACT. Further work is needed to more fully characterize the potential of WMT interventions in stemming risk behavior within adolescent samples.