Exploring Acceptability of Employment Interventions to Support People Living With Cancer: Qualitative Study of Cancer Survivors, Health Care Providers, and Employers.

BACKGROUND: Employment contributes to cancer survivors' quality of life, but this population faces a variety of challenges when working during and after treatment. Factors associated with work outcomes among cancer survivors include disease and treatment status, work environment, and social support. While effective employment interventions have been developed in other clinical contexts, existing interventions have demonstrated inconsistent effectiveness in supporting cancer survivors at work. We conducted this study as a preliminary step toward program development for employment support among survivors at a rural comprehensive cancer center. OBJECTIVE: We aimed (1) to identify supports and resources that stakeholders (cancer survivors, health care providers, and employers) suggest may help cancer survivors to maintain employment and (2) to describe stakeholders' views on the advantages and disadvantages of intervention delivery models that incorporate those supports and resources. METHODS: We conducted a descriptive study collecting qualitative data from individual interviews and focus groups. Participants included adult cancer survivors, health care providers, and employers living or working in the Vermont-New Hampshire catchment area of the Dartmouth Cancer Center in Lebanon, New Hampshire. We grouped interview participants' recommended supports and resources into 4 intervention delivery models, which ranged on a continuum from less to more intensive to deliver. We then asked focus group participants to discuss the advantages and disadvantages of each of the 4 delivery models. RESULTS: Interview participants (n=45) included 23 cancer survivors, 17 health care providers, and 5 employers. Focus group participants (n=12) included 6 cancer survivors, 4 health care providers, and 2 employers. The four delivery models were (1) provision of educational materials, (2) individual consultation with cancer survivors, (3) joint consultation with both cancer survivors and their employers, and (4) peer support or advisory groups. Each participant type acknowledged the value of providing educational materials, which could be crafted to improve accommodation-related interactions between survivors and employers. Participants saw usefulness in individual consultation but expressed concern about the costs of program delivery and potential mismatches between consultant recommendations and the limits of what employers can provide. For joint consultation, employers liked being part of the solution and the possibility of enhanced communication. Potential drawbacks included additional logistical burden and its perceived generalizability to all types of workers and workplaces. Survivors and health care providers viewed the efficiency and potency of peer support as benefits of a peer advisory group but acknowledged the sensitivity of financial topics as a possible disadvantage of addressing work challenges in a group setting. CONCLUSIONS: The 3 participant groups identified both common and unique advantages and disadvantages of the 4 delivery models, reflecting varied barriers and facilitators to their potential implementation in practice. Theory-driven strategies to address implementation barriers should play a central role in further intervention development.

Analysis of Outpatient Telemedicine Reimbursement in an Integrated Healthcare System.

BACKGROUND: Current reimbursement policy surrounding telemedicine has been cited as a barrier for the adaptation of this care model. The objective of this study is to analyze the reimbursement figures for outpatient telemedicine consultation in vascular surgery. METHODS: Patients first underwent synchronous telemedicine visits after receiving point-of-care ultrasound at one of 3 satellite locations of Henry Ford Health System in Michigan. Visit types included new, return, and postoperative patients. Reimbursement information related to payor, adjustment, denial, paid and outstanding balances were recorded for each telemedicine visit. Then, using an enterprise data warehouse, a retrospective analysis was performed for the aforementioned telemedicine visits. The data were analyzed to determine the outcome of total billed charges, number of denied claims, reimbursement per payor, reimbursement per patient, and out-of-pocket costs to the patients. RESULTS: Among 184 virtual clinical encounters, the payors included Aetna US Healthcare, Blue Advantage, Blue Cross Blue Shield, Cofinity Plan, Health Alliance Plan, HAP Medicare Advantage, Humana Medicare Advantage, Medicaid, Medicare, Molina Medicaid HMO, United Healthcare, Blue Care Network, Aetna Better Health of Michigan, Priority Health, and self-pay. Among the 15 payors, reimbursement ranged from 0% to 67% of the total charges billed. Among the 184 virtual visits, a grand total of $22,145 was collected or an average of $120.35 per virtual encounter. The breakdown of charges billed was 40% adjusted, 41% paid by insurance, 10% paid by patient, and 13% denied. There were 27 total denials (15%). Denial of payment included telehealth and nontelehealth reasons, citing noncovered charges, payment included for other prior services, new patient quality not met, and not covered by payor. The average out-of-pocket cost to patients was $12.59 per visit. CONCLUSIONS: These reimbursement data validate the economic potential within this new platform of healthcare delivery. As our experience with the business model grows, we expect to see an increase in reimbursement from private payors and acceptance from patients. Within a tertiary care system, telemedicine for chronic vascular disease has proven to be a viable means to reach a broader population base, and without significant cost to the patients.

Practicing mind-body medicine before Freud: John G. Gehring, the "Wizard of the Androscoggin".

This article describes the psychotherapy practice of physician John G. Gehring and places it in historical context. Forgotten today, Gehring was a highly sought-after therapist from the 1890s to the 1920s by prominent figures in the arts, sciences, business, and law. He practiced a combination of work therapy, suggestion, and autosuggestion that has similarities to Cognitive Behavior Therapy and Behavioral Activation. Using biographies, memoirs, and archival records, the details of Gehring's work are reconstructed and the reasons for its success are analyzed. His invisibility in the history of psychiatry is attributed to the later dominance of Freudianism within the field.

24-h sleep deprivation impairs early attentional modulation of neural processing: An event-related brain potential study.

Prior research indicates sleep deprivation negatively impacts selective attention, although less is known about the neural bases of these effects. The present study used event-related brain potentials (ERPs) to examine whether the effects of total sleep deprivation could be traced to the earliest stages of sensory processing influenced by selective attention. Participants were randomly assigned either to a regular sleep or 24-h total sleep deprivation condition. Following either sleep deprivation or regular sleep, participants completed a dichotic listening selective attention task while ERPs were acquired. Well-rested participants showed typical attentional modulation of the N1 between 150 and 250 msec, with larger amplitude responses to attended relative to unattended auditory probes. In contrast, these effects were significantly reduced in sleep-deprived participants, who did not show significant effects of selective attention on early neural processing. Similar group differences were observed in the later processing negativity, from 300 to 450 msec. Taken together, these results indicate that 24-h total sleep deprivation can significantly reduce, or eliminate, early effects of selective attention on neural processing.

Implementation of a virtual vascular clinic with point-of-care ultrasound in an integrated health care system.

OBJECTIVE: Using secured videoconferencing technologies, telemedicine may replace traditional clinic visits, save patients' time and travel, and improve use of limited surgeon and facility resources. We report our initial experience of the remote clinical encounter (RCE) by evaluating vascular surgery patients. METHODS: In this proof-of-concept pilot study, we conducted telemedicine evaluations of vascular patients at a tertiary care institution from October 2015 to August 2016. Patients were offered synchronous virtual visits from a surgical provider in lieu of an in-person visit. We used Skype for Business (Microsoft, Redmond, Wash) over secured networks for patient-provider interaction, clinical data entry in the Epic electronic medical record (Epic Systems Corporation, Verona, Wisc) for documentation, and established satellite facilities with existing vascular laboratories for imaging and laboratory testing. We evaluated feasibility, demographics, encounter type, and satisfaction of the patient through web-based questionnaires. RESULTS: During a 10-month period, 41 women and 14 men with an average age of 57 years (range, 29-79 years) underwent 82 RCEs. There were 43 white (78.1%), 9 black (16.3%), 1 Asian (1.8%), and 2 Middle Eastern (3.6%) patients. Diagnoses included both arterial (aneurysm, carotid, and occlusive disease) and venous (deep venous thrombosis and varicose vein) disease. Among the 82 RCEs, visit types included 15 new patients, 30 postoperative visits, and 37 follow-up visits. Ultrasound imaging was performed in conjunction with the RCE in 74 patients (90.2%). Most patients (57%) had multiple RCEs during the study period. All 55 patients responded to the satisfaction questionnaire; 91% stated that they would highly recommend a virtual physician encounter to a friend or colleague, and all of the respondents found their encounter more convenient than having a traditional office visit. All patients thought that they were able to communicate clearly with the provider, and overall quality responses were overwhelmingly positive. CONCLUSIONS: Secured virtual visits can be conducted using commercially available hardware and software solutions. Synchronous telemedicine with point-of-care ultrasound is effective in evaluating common vascular conditions. Virtual care may be used for management of patients with chronic vascular disease.

Atypical auditory refractory periods in children from lower socio-economic status backgrounds: ERP evidence for a role of selective attention.

Previous neuroimaging studies indicate that lower socio-economic status (SES) is associated with reduced effects of selective attention on auditory processing. Here, we investigated whether lower SES is also associated with differences in a stimulus-driven aspect of auditory processing: the neural refractory period, or reduced amplitude response at faster rates of stimulus presentation. Thirty-two children aged 3 to 8 years participated, and were divided into two SES groups based on maternal education. Event-related brain potentials were recorded to probe stimuli presented at interstimulus intervals (ISIs) of 200, 500, or 1000 ms. These probes were superimposed on story narratives when attended and ignored, permitting a simultaneous experimental manipulation of selective attention. Results indicated that group differences in refractory periods differed as a function of attention condition. Children from higher SES backgrounds showed full neural recovery by 500 ms for attended stimuli, but required at least 1000 ms for unattended stimuli. In contrast, children from lower SES backgrounds showed similar refractory effects to attended and unattended stimuli, with full neural recovery by 500 ms. Thus, in higher SES children only, one functional consequence of selective attention is attenuation of the response to unattended stimuli, particularly at rapid ISIs, altering basic properties of the auditory refractory period. Together, these data indicate that differences in selective attention impact basic aspects of auditory processing in children from lower SES backgrounds.

Differences in the neural mechanisms of selective attention in children from different socioeconomic backgrounds: an event-related brain potential study.

Previous research indicates that children from lower socioeconomic backgrounds show deficits in aspects of attention, including a reduced ability to filter irrelevant information and to suppress prepotent responses. However, less is known about the neural mechanisms of group differences in attention, which could reveal the stages of processing at which attention deficits arise. The present study examined this question using an event-related brain potential (ERP) measure of selective auditory attention. Thirty-two children aged from 3 to 8 years participated in the study. Children were cued to attend selectively to one of two simultaneously presented narrative stories. The stories differed in location (left/right speaker), narration voice (male/female), and content. ERPs were recorded to linguistic and non-linguistic probe stimuli embedded in the attended and unattended stories. Children whose mothers had lower levels of educational attainment (no college experience) showed reduced effects of selective attention on neural processing relative to children whose mothers had higher levels of educational attainment (at least some college). These differences occurred by 100 milliseconds after probe onset. Furthermore, the differences were related specifically to a reduced ability to filter irrelevant information (i.e. to suppress the response to sounds in the unattended channel) among children whose mothers had lower levels of education. These data provide direct evidence for differences in the earliest stages of processing within neural systems mediating selective attention in children from different socioeconomic backgrounds. Results are discussed in the context of intervention programs aimed at improving attention and self-regulation abilities in children at-risk for school failure.

Neural mechanisms of selective auditory attention are enhanced by computerized training: electrophysiological evidence from language-impaired and typically developing children.

Recent proposals suggest that some interventions designed to improve language skills might also target or train selective attention. The present study examined whether six weeks of high-intensity (100 min/day) training with a computerized intervention program designed to improve language skills would also influence neural mechanisms of selective auditory attention previously shown to be deficient in children with specific language impairment (SLI). Twenty children received computerized training, including 8 children diagnosed with SLI and 12 children with typically developing language. An additional 13 children with typically developing language received no specialized training (NoTx control group) but were tested and retested after a comparable time period to control for maturational and test-retest effects. Before and after training (or a comparable delay period for the NoTx control group), children completed standardized language assessments and an event-related brain potential (ERP) measure of selective auditory attention. Relative to the NoTx control group, children receiving training showed increases in standardized measures of receptive language. In addition, children receiving training showed larger increases in the effects of attention on neural processing following training relative to the NoTx control group. The enhanced effect of attention on neural processing represented a large effect size (Cohen's d=0.8), and was specific to changes in signal enhancement of attended stimuli. These findings indicate that the neural mechanisms of selective auditory attention, previously shown to be deficient in children with SLI, can be remediated through training and can accompany improvements on standardized measures of language.

Neurophysiological evidence for selective auditory attention deficits in children with specific language impairment.

Recent behavioral studies suggest that children with poor language abilities have difficulty with attentional filtering, or noise exclusion. However, as behavioral performance represents the summed activity of multiple stages of processing, the temporal locus of the filtering deficit remains unclear. Here, we used an event-related potential (ERP) paradigm to compare the earliest mechanisms of selective auditory attention in 12 children with specific language impairment (SLI) and 12 matched control children. Participants were cued to attend selectively to one of two simultaneously presented narrative stories. The stories differed in location (left/right speaker), narration voice (male/female), and content. ERPs were recorded to linguistic and nonlinguistic probe stimuli embedded in the attended and unattended story. By 100 ms, typically developing children showed an amplification of the sensorineural response to attended as compared to unattended stimuli. In contrast, children with SLI showed no evidence of sensorineural modulation with attention, despite behavioral performance indicating that they were performing the task as directed. These data are the first to show that SLI children have marked and specific deficits in the neural mechanisms of attention and, further, localize the timing of the attentional deficit to the earliest stages of sensory processing. Deficits in the effects of selective attention on early sensorineural processing may give rise to the diverse set of sensory and linguistic impairments in SLI children.