Adaptations for remote research work: a modified web-push strategy compared to a mail-only strategy for administering a survey of healthcare experiences.

BACKGROUND: The COVID-19 pandemic required that our research team change our mail-only (MO) strategy for a research survey to a strategy more manageable by staff working remotely. We used a modified web-push approach (MWP), in which patients were mailed a request to respond online and invited to call if they preferred the questionnaire by mail or phone. We also changed from a pre-completion gift to a post-completion gift card incentive. Our objective is to compare response patterns between modes for a survey that used an MO strategy pre-pandemic followed by an MWP strategy peri-pandemic for data collection. METHODS: Observational study using data from a national multi-scale survey about patients' experience of specialty care coordination administered via MO in 2019 and MWP from 2020 to 2021 to Veterans receiving primary care and specialty care within the Veterans Health Administration (VA). We compared response rates, respondent characteristics and responses about care coordination between MO and MWP, applying propensity weights to account for differences in the underlying samples. RESULTS: The response rate was lower for MWP vs. MO (13.4% vs. 36.6%), OR = 0.27, 95% CI = 0.25-0.30, P < .001). Respondent characteristics were similar across MO and MWP. Coordination scale scores tended to be slightly higher for MWP, but the effect sizes for these differences between modes were small for 9 out of 10 scales. CONCLUSIONS: While the logistics of MWP survey data collection are well-suited to the remote research work environment, response rates were lower than those for the MO method. Future studies should examine addition of multi-mode contacts and/or pre-completion incentives to increase response rates for MWP.

Use of Structured Templates to Improve Completeness of Endocrinology Referrals.

OBJECTIVE: Endocrinology referrals frequently lack important clinical information, which may increase the risk of inefficiency and adverse outcomes. This quality improvement project aimed to improve the completeness of new referrals by utilizing structured referral templates for common endocrine conditions at a large Veterans Health Administration medical center. Our target was of at least a 30% improvement in referral completeness for each condition after the intervention. METHODS: Electronic structured referral templates were designed utilizing existing resources and input from primary care providers and endocrinologists. Essential elements were identified and included in the templates. We conducted a retrospective chart review to compare referrals for 125 patients referred between January 1, 2021 and September 1, 2021 (preintervention) and 125 patients referred between October 1, 2021 and September 30, 2022 (postintervention). Each referral was rated using a scoring system derived from the criteria in the data abstraction tool formulated by the investigators. RESULTS: On average, preintervention referrals included 52% of the essential elements and postintervention referrals included 93%. Improvements in referral scores for each condition all met the prespecified 30% improvement target. The greatest improvement was for the element "type of visit preference." A separate analysis excluding that element showed an average improvement from 64% of essential elements preintervention to 92% postintervention. CONCLUSION: Structured referral templates, designed with the input of primary care providers and endocrinologists and embedded into an electronic referral system, can improve the availability of essential information and increase the quality of referrals. Future work should examine the effect of structured referral templates on efficiency, specialist experience, patient experience of care, and clinical outcomes.

Impact of Electronic Consultation on Timeliness and Guideline Concordance of Workups Leading to Thyroid Nodule Fine-Needle Aspiration Biopsy.

OBJECTIVE: Electronic consultations (e-consults) are commonly used to obtain endocrinology input on clinical questions without a face-to-face visit, but sparse data exist on the resultant quality of care for specific conditions. We examined workups resulting in a thyroid nodule fine-needle aspiration (FNA) biopsy to investigate whether endocrinology e-consults were more timely and similarly guideline-concordant compared with endocrinology face-to-face visits and whether endocrinology e-consults were more guideline-concordant compared with workups without endocrinology input. METHODS: We retrospectively reviewed charts of 302 thyroid FNA biopsies conducted in the Veterans Affairs health system between May 1, 2017, and February 4, 2020 (e-consult, n = 99; face-to-face visit, n = 100; no endocrinology input, n = 103). We used t tests to compare timeliness, χ2 tests to compare the proportion of guideline-concordant workups, and multivariable linear and logistic models to control for demographic factors. RESULTS: FNAs preceded by an endocrinology e-consult had more timely workups compared with those preceded by endocrinology face-to-face visits in terms of days elapsed between referral and FNA biopsy (geometric mean 44.7 days vs 61.7 days, P = .01). The difference in the summary measure of guideline concordance across groups was not statistically significant (P =.38). CONCLUSION: E-consults were faster than face-to-face consults and similarly guideline-concordant compared with both face-to-face consults and no endocrinology input for workups resulting in FNA. Decisions about the appropriate use of e-consults for thyroid nodules should take into account these data while also considering the potential benefits of direct patient-endocrinologist interaction for complex situations.

Coordination of Care as Experienced by the Specialist: Validation of the CSC-Specialist Survey in the Private Sector and the Effect of a Shared Electronic Health Record.

BACKGROUND: We previously developed 2 complementary surveys to measure coordination of care as experienced by the specialist and the primary care provider (PCP). These Coordination of Specialty Care (CSC) surveys were developed in the Veterans Health Administration (VA), under an integrated organizational umbrella that includes a shared electronic health record (EHR). OBJECTIVE: To develop an augmented version of the CSC-Specialist in the private sector and use that version (CSC-Specialist 2.0) to examine the effect of a shared EHR on coordination. RESEARCH DESIGN: We administered the survey online to a national sample of clinicians from 10 internal medicine subspecialties. We used multitrait analysis and confirmatory factor analysis to evaluate the psychometric properties of the original VA-based survey and develop an augmented private sector survey (CSC-Specialist 2.0). We tested construct validity by regressing a single-item measure of overall coordination onto the 4 scales. We used analysis of variance to examine the relationship of a shared EHR to coordination. RESULTS: Psychometric assessment supported the 13-item, 4-scale structure of the original VA measure and the augmented 18-item, 4-scale structure of the CSC-Specialist 2.0. The CSC-Specialist 2.0 scales together explained 45% of the variance in overall coordination. A shared EHR was associated with significantly better scores for the Roles and Responsibilities and Data Transfer scales, and for overall coordination. CONCLUSIONS: The CSC-Specialist 2.0 is a unique survey that demonstrates adequate psychometric performance and is sensitive to use of a shared EHR. It can be used alone or with the CSC-PCP to identify coordination problems, guide interventions, and measure improvements.

Concerns of Primary Care Clinicians Practicing in an Integrated Health System: a Qualitative Study.

BACKGROUND: Clinician well-being is a major priority for healthcare organizations. However, the impact of workplace environment on clinicians' well-being is poorly understood. Integrated health systems are a particularly relevant type of practice environment to focus on, given the increasing rates of practice consolidation and integration. OBJECTIVE: To improve understanding of the concerns of primary care clinicians (PCCs) practicing in an integrated health system. DESIGN: We analyzed free-text comment box responses offered on a national survey about care coordination by 555 PCCs in the Veterans Health Administration, one of the largest integrated health systems in the USA. PARTICIPANTS: A total of 555 PCCs who left free-text comments on a national survey of care coordination in the VHA (30% out of 1862 eligible respondents). Demographics and coordination scale scores were similar between respondents who left comments vs. those who did not. APPROACH: The data were coded and analyzed in line with the grounded theory approach. Key themes were identified by team consensus and illustrative quotations were chosen to illustrate each theme. KEY RESULTS: VHA PCCs described some pressures shared across practice environments, such as prohibitive administrative burden, but also reported several concerns particular to integrated settings, including "dumping" by specialists and moral distress related to a concern for patients. Frustrations due to several aspects of responsibility around referrals may be unique to integrated health systems with salaried clinicians and/or where specialists have the ability to reject referrals. CONCLUSION: PCCs in integrated health systems feel many of the same pressures as their counterparts in non-integrated settings, but they are also confronted with unique stressors related to these systems' organizational features that restrict clinicians' autonomy. An understanding of these concerns can guide efforts to improve the well-being of PCCs in existing integrated health systems, as well as in practices on their way to integration.

Assessing Patients' Perceptions of Clinician Communication: Acceptability of Brief Point-of-Care Surveys in Primary Care.

BACKGROUND: Improving patient-centered (PC) communication is a priority in many healthcare organizations. Most PC communication metrics are distal to the care encounter and lack clear attribution, thereby reducing relevance for leaders and clinicians. OBJECTIVE: We assessed the acceptability of measuring PC communication at the point-of-care. DESIGN: A brief patient survey was conducted immediately post-primary care appointments at one Veterans Affairs Medical Center. Audit-feedback reports were created for clinicians and discussed in qualitative interviews. PARTICIPANTS: A total of 485 patients completed the survey. Thirteen interviews were conducted with clinicians and hospital leaders. MAIN MEASURE(S): Measures included collaboRATE (a 3-item tool measuring PC communication), a question about how well needs were met, and overall visit satisfaction. Data were analyzed using descriptive statistics to characterize the mean and distribution of collaboRATE scores and determine the proportion of patients giving clinicians a "top score" on each item. Associations among responses were examined. Interviews focused on the value of measuring PC communication and were analyzed using a framework approach. KEY RESULTS: The proportion of patients giving PC communication "top scores" ranged from 41 to 92% for 16 clinicians who had ≥ 25 completed surveys. Among patients who gave "top scores" for PC communication, the odds of reporting that needs were "completely met" were 10.8 times higher (p < .001) and the odds of reporting being "very satisfied" with their care were 13.3 times higher (p < .001) compared with patients who did not give "top scores." Interviewees found clinician-specific feedback useful; concerns included prioritizing this data when other measures are used to evaluate clinicians' performance. Difficulties improving PC communication given organizational structures were noted. Recommendations for interventions included peer-to-peer education and mentoring by top-scoring clinicians. CONCLUSIONS: Assessing provider communication at the point-of-care is acceptable and useful to clinicians. Challenges remain to properly incentivize and support the use of this data for improving PC communication.

The influence of fear on risk taking: a meta-analysis.

A common finding in the study of emotion and decision making is the tendency for fear and anxiety to decrease risk taking. The current meta-analysis summarises the strength and variability of this effect in the extant empirical literature. Our analysis of 136 effect sizes, derived from 68 independent samples and 9,544 participants, included studies that experimentally manipulated fear or measured naturally varying levels of fear or anxiety in both clinical and non-clinical samples, and studies measuring risky decision making and risk estimation. A multilevel random effects model estimated a small to moderate average effect size (r = 0.22), such that fear was related to decreased risky decision making and increased risk estimation. There was also high heterogeneity in the effect sizes. Moderator analyses showed that effect sizes were greater when risk tasks used tangible (e.g. monetary) outcomes and when studies used clinically anxious participants. However, there also remained considerable variability in effect sizes, the sources of which remain unknown. We posit several potential factors that may contribute to observed variability in this effect for future study, including factors concerning both the nature of fear experience and the risk taking context.

Vegetarians' and omnivores' affective and physiological responses to images of food.

Many vegetarians report that meat is unpleasant, but little else is known about their affective responses to meat and non-meat foods. Here we explored affective responses to food images in vegetarians and omnivores and tested the hypothesis that vegetarians have global differences in affective processing (e.g., increased disgust sensitivity). We presented pictures of different food items and recorded participants' affective experience while we recorded peripheral physiology. We found that vegetarians' self-reported experience of meat meal images was less pleasant than omnivores', but that other food images were equally pleasant across the two groups. Moreover, vegetarians and omnivores had strikingly similar physiological responses to all food images - including meat meals. We interpret these results from a psychological constructionist perspective, which posits that individuals conceptualize changes in their bodily states in ways that match their beliefs, such that increased sympathetic nervous system activity may be conceptualized as an experience of excitement about a delicious meat meal for omnivores but as an experience of displeasure for a vegetarian who believes meat is cruel, wasteful, impure, or unhealthy. This interpretation is consistent with emerging neuroscience evidence that the brain constructs experience by predicting and making meaning of internal sensations based on past experience and knowledge.

Seeing What You Feel: Affect Drives Visual Perception of Structurally Neutral Faces.

Affective realism, the phenomenon whereby affect is integrated into an individual's experience of the world, is a normal consequence of how the brain processes sensory information from the external world in the context of sensations from the body. In the present investigation, we provided compelling empirical evidence that affective realism involves changes in visual perception (i.e., affect changes how participants see neutral stimuli). In two studies, we used an interocular suppression technique, continuous flash suppression, to present affective images outside of participants' conscious awareness. We demonstrated that seen neutral faces are perceived as more smiling when paired with unseen affectively positive stimuli. Study 2 also demonstrated that seen neutral faces are perceived as more scowling when paired with unseen affectively negative stimuli. These findings have implications for real-world situations and challenge beliefs that affect is a distinct psychological phenomenon that can be separated from cognition and perception.

Avoiding premature closure and reaching diagnostic accuracy: some key predictive factors.

CONTEXT: Early studies suggested that experienced clinicians simply generate more accurate diagnoses than those less experienced. However, more recent studies indicate that experienced clinicians may be subject to biases in formulating and confirming hypotheses that lead to inaccuracy. OBJECTIVES: The goal of this study was to identify factors associated with the ability to process information in ways that overcome premature closure and result in accurate diagnosis using a set of vignettes in which inconsistent information was introduced midway. METHODS: Seventy-five participants (25 Year 3 medical students, 25 internal medicine residents in their second year of residency and 25 internal medicine faculty) were recruited to solve each of four complex clinical vignettes. In each vignette, the first four rounds of information pointed toward a narrowing range of diagnostic possibilities, but patient information presented in and after the fifth round was inconsistent with prior findings. In addition to accuracy, outcome measures were length of differential diagnosis, certainty of diagnosis, persistence in data collection and tendency to switch diagnoses. RESULTS: There were no significant differences in diagnostic accuracy across the three groups, each of which differed in level of training. However, across experience levels, diagnostic accuracy was associated with the mean number of items in the differential, tendency to persist (e.g. to request a greater number of rounds of information), and openness to switch (e.g. to change the most likely diagnosis on receipt of disconfirming information). CONCLUSIONS: Level of training (i.e. clinical experience) was not associated with accuracy on this task. As faculty clinicians certainly have more knowledge than their junior counterparts, it is important to identify ways in which cognitive factors can lead to more or less persistence and openness, and to teach clinicians how to overcome tendencies associated with error.

Threat perception after the Boston Marathon bombings: The effects of personal relevance and conceptual framing.

We examined how the Boston Marathon bombings affected threat perception in the Boston community. In a threat perception task, participants attempted to "shoot" armed targets and avoid shooting unarmed targets. Participants viewing images of the bombings accompanied by affectively negative music and text (e.g., "Terror Strikes Boston") made more false alarms (i.e., more errors "shooting" unarmed targets) compared to participants viewing the same images accompanied by affectively positive music and text (e.g., "Boston Strong") and participants who did not view bombing images. This difference appears to be driven by decreased sensitivity (i.e., decreased ability to distinguish guns from non-guns) as opposed to a more liberal bias (i.e., favouring the "shoot" response). Additionally, the more strongly affected the participant was by the bombings, the more their sensitivity was reduced in the negatively framed condition, suggesting that this framing was particularly detrimental to the most vulnerable individuals in the affected community.

Adaptive thresholding increases sensitivity to detect changes in the rate of skin conductance responses to psychologically arousing stimuli in both laboratory and ambulatory settings.

Psychophysiologists recording electrodermal activity (EDA) often derive measures of slow, tonic activity-skin conductance level (SCL)-and faster, more punctate changes-skin conductance responses (SCRs). A SCR is conventionally considered to have occurred when the local amplitude of the EDA signal exceeds a researcher-determined threshold (e.g., 0.05 µS), typically fixed across study participants and conditions. However, fixed SCR thresholds can preferentially exclude data from individuals with low SCL because their SCRs are smaller on average, thereby reducing statistical power for group-level analyses. Thus, we developed a fixed plus adaptive (FA) thresholding method that adjusts identification of SCRs based on an individual's SC at the onset of the SCR to increase statistical power and include data from more participants. We assess the utility of applying FA thresholding across two independent samples and explore age and race-related associations with EDA outcomes. Study 1 uses wired EDA measurements from 254 healthy adults responding to evocative images and sounds in a laboratory setting. Study 2 uses wireless EDA measurements from 20 children with autism in a clinical environment while they completed behavioral tasks. Compared to a 0.01, 0.03, and 0.05 µS fixed threshold, FA thresholding at 1.9% modestly increases statistical power to detect a difference in SCR rate between tasks with higher vs. lower subjective arousal and reduces exclusion of participants by up to 5% across both samples. This novel method expands the EDA analytical toolbox and may be useful in populations with highly variable basal SCL or when comparing groups with different basal SCL. Future research should test for reproducibility and generalizability in other tasks, samples, and contexts. IMPACT STATEMENTS: This article is important because it introduces a novel method to enhance sensitivity and statistical power in analyses of skin conductance responses from electrodermal data.

Reduced stereotypicality and spared use of facial expression predictions for social evaluation in autism.

Background/Objective: Autism has been investigated through traditional emotion recognition paradigms, merely investigating accuracy, thereby constraining how potential differences across autistic and control individuals may be observed, identified, and described. Moreover, the use of emotional facial expression information for social functioning in autism is of relevance to provide a deeper understanding of the condition. Method: Adult autistic individuals (n = 34) and adult control individuals (n = 34) were assessed with a social perception behavioral paradigm exploring facial expression predictions and their impact on social evaluation. Results: Autistic individuals held less stereotypical predictions than controls. Importantly, despite such differences in predictions, the use of such predictions for social evaluation did not differ significantly between groups, as autistic individuals relied on their predictions to evaluate others to the same extent as controls. Conclusions: These results help to understand how autistic individuals perceive social stimuli and evaluate others, revealing a deviation from stereotypicality beyond which social evaluation strategies may be intact.

Bystander Intervention in Intimate Partner Violence: An Audio Vignette Study of Heterosexual, Gay, and Lesbian Dating Partners.

Intimate partner violence (IPV) is a prolific and growing issue that can have long-lasting negative consequences for the health and safety of those involved. Bystander intervention is one method for helping to combat incidents of IPV, as research suggests that bystanders are frequently present at the scene of assaults and incidents of IPV. This study explored individual differences of bystanders that may influence whether they decide to intervene in an unfolding incident of IPV, as well as how the likelihood of intervening may vary as a function of the apparent gender or sexual orientation of the individuals involved in an incident of IPV. Participants were recruited from an online survey platform to obtain a balanced sample of heterosexual and sexual minority individuals. Participants completed a bystander task where they listened to an audio vignette of an unfolding IPV incident and were instructed to stop the audio if/when they would intervene in a real-life context. Participants were randomly assigned to listen to one of four versions of the vignette in which the apparent gender of the aggressor and victim were manipulated. Results revealed participants were more likely to intervene if they identified as a sexual minority (vs. as a heterosexual), reported less rape myth acceptance, or had greater endorsement of gender equality. Results also revealed that associations between bystander characteristics and intervening behavior largely did not differ across vignette conditions, suggesting that they may influence the likelihood of intervening consistently across incidents of IPV regardless of the apparent gender and sexual orientation of the aggressor and victim. However, participants in general were most likely to intervene in the male aggressor/female victim vignette. Implications for IPV prevention programming-including the need to include more diverse and less heteronormative depictions of IPV-are discussed.

Multimodal, Idiographic Ambulatory Sensing Will Transform our Understanding of Emotion.

Emotions are inherently complex - situated inside the brain while being influenced by conditions inside the body and outside in the world - resulting in substantial variation in experience. Most studies, however, are not designed to sufficiently sample this variation. In this paper, we discuss what could be discovered if emotion were systematically studied within persons 'in the wild', using biologically-triggered experience sampling: a multimodal and deeply idiographic approach to ambulatory sensing that links body and mind across contexts and over time. We outline the rationale for this approach, discuss challenges to its implementation and widespread adoption, and set out opportunities for innovation afforded by emerging technologies. Implementing these innovations will enrich method and theory at the frontier of affective science, propelling the contextually situated study of emotion into the future.

Patients' Experience of Specialty Care Coordination: Survey Development and Validation.

Purpose: Specialty care coordination relies on information flowing bidirectionally between all three participants in the "specialty care triad" - patients, primary care providers (PCPs), and specialists. Measures of coordination should strive to account for the perspectives of each. As we previously developed two surveys to measure coordination of specialty care as experienced by PCPs and specialists, this study aimed to develop and evaluate the psychometric properties of a related survey of specialty care coordination as experienced by the patient, thereby completing the suite of surveys among the triad. Methods: We developed a draft survey based on literature review, patient interviews, adaptation of existing measures, and development of new items. Survey responses were collected via mail and online in two waves, August 2019-November 2019 and September 2020-May 2021, among patients (N=939) receiving medical specialty care and primary care in the Veterans Affairs health system. Exploratory and confirmatory factor analysis were used to assess scale structure. Multiple linear regression was used to examine the relationship of the final coordination scales to patients' overall experience of specialty care coordination. Results: A 38-item measure representing 10 factors that assess the patient's experience of coordination in specialty care among the patient, PCP, and specialist was finalized. Scales demonstrated good internal consistency reliability and, together, explained 59% of the variance in overall coordination. Analyses revealed an unexpected construct describing organization of care between patient and specialist that accounted for patient goals and preferences; this 10-item scale was named Patient-Centered Care Coordination. Conclusions: The final survey, Coordination of Specialty Care - Patient, or CSC-Patient for short, is a reliable instrument that can be used alone or with its companions (CSC-PCP, CSC-Specialist) to provide a detailed assessment of specialty care coordination and identify targets for coordination improvement.

Sociodemographic Variations in Women's Reports of Discussions With Clinicians About Breast Density.

Importance: Breast density notifications advise women to discuss breast density with their clinicians, yet little is known about such discussions. Objectives: To examine the content of women's reports of breast density discussions with clinicians and identify variations by women's sociodemographic characteristics (age, income, state legislation status, race and ethnicity, and literacy level). Design, Setting, and Participants: This US nationwide, population-based, random-digit dial telephone survey study was conducted from July 1, 2019, to April 30, 2020, among 2306 women aged 40 to 76 years with no history of breast cancer who underwent mammography in the prior 2 years and had heard the term dense breasts or breast density. Results were analyzed from a subsample of 770 women reporting a conversation about breast density with their clinician after their last mammographic screening. Statistical analysis was conducted in April and July 2023. Main Outcomes and Measures: Survey questions inquired whether women's clinicians had asked about breast cancer risk or their worries or concerns about breast density, had discussed mammography results or other options for breast cancer screening or their future risk of breast cancer, as well as the extent to which the clinician answered questions about breast density. Results: Of the 770 women (358 [47%] aged 50-64 years; 47 Asian [6%], 125 Hispanic [16%], 204 non-Hispanic Black [27%], 317 non-Hispanic White [41%], and 77 other race and ethnicity [10%]) whose results were analyzed, most reported that their clinicians asked questions about breast cancer risk (88% [670 of 766]), discussed mammography results (94% [724 of 768]), and answered patient questions about breast density (81% [614 of 761]); fewer women reported that clinicians had asked about worries or concerns about breast density (69% [524 of 764]), future risk of breast cancer (64% [489 of 764]), or other options for breast cancer screening (61% [459 of 756]). Women's reports of conversations varied significantly by race and ethnicity; non-Hispanic Black women reported being asked questions about breast cancer risk more often than non-Hispanic White women (odds ratio [OR], 2.08 [95% CI, 1.05-4.10]; P = .04). Asian women less often reported being asked about their worries or concerns (OR, 0.42 [95% CI, 0.20-0.86]; P = .02), and Hispanic and Asian women less often reported having their questions about breast density answered completely or mostly (Asian: OR, 0.28 [95% CI, 0.13-0.62]; P = .002; Hispanic: OR, 0.48 [95% CI, 0.27-0.87]; P = .02). Women with low literacy were less likely than women with high literacy to report being asked about worries or concerns about breast density (OR, 0.64 [95% CI, 0.43-0.96]; P = .03), that mammography results were discussed with them (OR, 0.32 [95% CI, 0.16-0.63]; P = .001), or that their questions about breast density were answered completely or mostly (OR, 0.51 [95% CI, 0.32-0.81]; P = .004). Conclusions and Relevance: In this survey study, although most women reported that their clinicians counselled them about breast density, the unaddressed worries or concerns and unanswered questions, especially among Hispanic and Asian women and those with low literacy, highlighted areas where discussions could be improved.