Mapping Uncharted Terrain: A Systematic Review of Complementary and Integrative Health Communication Using Observational Data in Biomedical Settings.

Complementary and integrative health (CIH) use is diverse and highly prevalent worldwide. Prior research of CIH communication in biomedical encounters address safety, efficacy, symptom management, and overall wellness. Observational methods are rarely used to study CIH communication and avoid recall bias, preserve ecological validity, and contextualize situated clinical communication. Following PRISMA guidelines, we systematically reviewed studies at the intersection of social scientific observational research and findings about CIH communication between clinicians, patients, and caregivers in biomedical settings. We identified international, peer-reviewed publications from seven databases between January 2010 and December 2020. Titles and abstracts were first screened for inclusion, then full studies were coded using explicit criteria. We used a standard checklist was modified to assess article quality. Ten of 11,793 studies examined CIH communication using observational methods for CIH communication in biomedical settings. Studies used a range of observational techniques, including participant and non-participant observation, which includes digital audio or video recordings. Results generated two broad sets of findings, one focused on methodological insights and another on CIH communication. Despite methodological and topic similarities, included studies addressed CIH communication as a process and as proximal and intermediate health outcomes. We recommend how observational studies of CIH communication can better highlight relationships between communication processes and health outcomes. Current research using observational methods offers an incomplete picture of CIH communication in biomedical settings. Future studies should standardize how observational techniques are reported to enhance consistency and comparability within and across biomedical settings to improve comparability.

Fostering Interdisciplinary Boundary Spanning in Health Communication: A Call for a Paradigm Shift.

Scholarship in the field of health communication is broad, with interdisciplinary contributions from researchers trained in a variety of fields including communication, nursing, medicine, pharmacy, public health, and social work. In this paper, we explore the role of "health communication boundary spanners" (HCBS), individuals whose scholarly work and academic appointment reflect dual citizenship in both the communication discipline and the health professions or public health. Using a process of critical reflective inquiry, we elucidate opportunities and challenges associated with HCBS across the spectrum of health communication in order to provide guidance for individuals pursuing boundary spanning roles and those who supervise and mentor them. This dual citizen role suggests that HCBS have unique skills, identities, perspectives, and practices that contribute new ways of being and knowing that transcend traditional disciplinary boundaries. The health communication field is evolving in response to the need to address significant healthcare and policy problems. No one discipline has the ability to single-handedly fix our current healthcare systems. Narrative data from this study illustrate the importance of seeing HCBS work beyond simply being informed by disciplinary knowledge. Rather, we suggest that adapting ways of knowing and definitions of expertise is an integral part of the solution to solving persistent health problems.

Improving Uptake of a National Web-Based Psychoeducational Workshop for Informal Caregivers of Veterans: Mixed Methods Implementation Evaluation.

BACKGROUND: Although web-based psychoeducational programs may be an efficient, accessible, and scalable option for improving participant well-being, they seldom are sustained beyond trial publication. Implementation evaluations may help optimize program uptake, but few are performed. When the US Department of Veterans Affairs (VA) launched the web-based psychoeducational workshop Building Better Caregivers (BBC) for informal caregivers of veterans nationwide in 2013, the workshop did not enroll as many caregivers as anticipated. OBJECTIVE: This study aims to identify the strengths and weaknesses of initial implementation, strategies likely to improve workshop uptake, whether the VA adopted these strategies, and whether workshop enrollment changed. METHODS: We used mixed methods and the Promoting Action on Research Implementation in Health Services (PARIHS) implementation evaluation framework. In stage 1, we conducted semistructured interviews with caregivers, local staff, and regional and national VA leaders and surveys with caregivers and staff. We collected and analyzed survey and interview data concurrently and integrated the results to identify implementation strengths and weaknesses, and strategies likely to improve workshop uptake. In stage 2, we reinterviewed national leaders to determine whether the VA adopted recommended strategies and used national data to determine whether workshop enrollment changed over time. RESULTS: A total of 54 caregivers (n=32, 59%), staff (n=13, 24%), and regional (n=5, 9%) and national (n=4, 7%) leaders were interviewed. We received survey responses from 72% (23/32) of caregivers and 77% (10/13) of local staff. In stage 1, survey and interview results were consistent across multiple PARIHS constructs. Although participants from low-enrollment centers reported fewer implementation strengths and more weaknesses, qualitative themes were consistent across high- and low-enrollment centers, and across caregiver, staff, and leadership respondent groups. Identified strengths included belief in a positive workshop impact and the use of some successful outreach approaches. Implementation weaknesses included missed opportunities to improve outreach and to better support local staff. From these, we identified and recommended new and enhanced implementation strategies-increased investment in outreach and marketing capabilities; tailoring outreach strategies to multiple stakeholder groups; use of campaigns that are personal, repeated, and detailed, and have diverse delivery options; recurrent training and mentoring for new staff; and comprehensive data management and reporting capabilities. In stage 2, we determined that the VA had adopted several of these strategies in 2016. In the 3 years before and after adoption, cumulative BBC enrollment increased from 2139 (2013-2015) to 4030 (2016-2018) caregivers. CONCLUSIONS: This study expands the limited implementation science literature on best practices to use when implementing web-based psychoeducational programs. We found that robust outreach and marketing strategies and support for local staff were critical to the implementation success of the BBC workshop. Other health systems may want to deploy these strategies when implementing their web-based programs.

A Qualitative Study of Primary Care Providers' Experiences with the Veterans Choice Program.

BACKGROUND: The Veterans Access, Choice and Accountability Act (hereafter, Choice Program) seeks to improve access to care by enabling eligible Veterans to receive care from community providers. Veterans Affairs (VA) primary care providers (PCPs) play a key role in making referrals to community specialists, but their frontline experiences with referrals are not well understood. OBJECTIVE: To understand VA PCPs' experiences referring patients to community specialists while VA works to expand and refine the implementation of the Choice Program. DESIGN: Qualitative study using interview methods. PARTICIPANTS: Semi-structured telephone interviews were conducted with VA primary care providers (N = 72 out of 599 contacted) recruited nationally. APPROACH: Open-ended interview questions elicited PCP perceptions and experiences with referrals to community specialists via the Choice Program. Keywords were identified using automated coding features in ATLAS.ti and evaluated using conventional content analysis to inductively describe the qualitative data. KEY RESULTS: VA PCPs emphasized problems with care coordination and continuity between the VA and community specialists (e.g., "It is extremely difficult for us to obtain and continue continuity of care because there's not much communication with the community specialist"). They described difficulties with tracking the initial referral, coordinating care after receiving community specialty care, accessing community medical records, and aligning community specialists' prescriptions with the VA formulary. CONCLUSIONS: The VA Choice Program provides access to community specialists for VA patients; however, VA primary care providers face challenges tracking referrals to community specialists and in coordinating care. Strategies to improve care coordination between the VA and community providers should focus on providing PCPs with information to follow Veterans throughout the Choice referral process and follow-up.

Veteran-centered barriers to VA mental healthcare services use.

BACKGROUND: Some veterans face multiple barriers to VA mental healthcare service use. However, there is limited understanding of how veterans' experiences and meaning systems shape their perceptions of barriers to VA mental health service use. In 2015, a participatory, mixed-methods project was initiated to elicit veteran-centered barriers to using mental healthcare services among a diverse sample of US rural and urban veterans. We sought to identify veteran-centric barriers to mental healthcare to increase initial engagement and continuation with VA mental healthcare services. METHODS: Cultural Domain Analysis, incorporated in a mixed methods approach, generated a cognitive map of veterans' barriers to care. The method involved: 1) free lists of barriers categorized through participant pile sorting; 2) multi-dimensional scaling and cluster analysis for item clusters in spatial dimensions; and 3) participant review, explanation, and interpretation for dimensions of the cultural domain. Item relations were synthesized within and across domain dimensions to contextualize mental health help-seeking behavior. RESULTS: Participants determined five dimensions of barriers to VA mental healthcare services: concern about what others think; financial, personal, and physical obstacles; confidence in the VA healthcare system; navigating VA benefits and healthcare services; and privacy, security, and abuse of services. CONCLUSIONS: These findings demonstrate the value of participatory methods in eliciting meaningful cultural insight into barriers of mental health utilization informed by military veteran culture. They also reinforce the importance of collaborations between the VA and Department of Defense to address the role of military institutional norms and stigmatizing attitudes in veterans' mental health-seeking behaviors.

Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review.

BACKGROUND: Expert guidelines recommend reducing or discontinuing long-term opioid therapy (LTOT) when risks outweigh benefits, but evidence on the effect of dose reduction on patient outcomes has not been systematically reviewed. PURPOSE: To synthesize studies of the effectiveness of strategies to reduce or discontinue LTOT and patient outcomes after dose reduction among adults prescribed LTOT for chronic pain. DATA SOURCES: MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library from inception through April 2017; reference lists; and expert contacts. STUDY SELECTION: Original research published in English that addressed dose reduction or discontinuation of LTOT for chronic pain. DATA EXTRACTION: Two independent reviewers extracted data and assessed study quality using the U.S. Preventive Services Task Force quality rating criteria. All authors assessed evidence quality using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Prespecified patient outcomes were pain severity, function, quality of life, opioid withdrawal symptoms, substance use, and adverse events. DATA SYNTHESIS: Sixty-seven studies (11 randomized trials and 56 observational studies) examining 8 intervention categories, including interdisciplinary pain programs, buprenorphine-assisted dose reduction, and behavioral interventions, were found. Study quality was good for 3 studies, fair for 13 studies, and poor for 51 studies. Many studies reported dose reduction, but rates of opioid discontinuation ranged widely across interventions and the overall quality of evidence was very low. Among 40 studies examining patient outcomes after dose reduction (very low overall quality of evidence), improvement was reported in pain severity (8 of 8 fair-quality studies), function (5 of 5 fair-quality studies), and quality of life (3 of 3 fair-quality studies). LIMITATION: Heterogeneous interventions and outcome measures; poor-quality studies with uncontrolled designs. CONCLUSION: Very low quality evidence suggests that several types of interventions may be effective to reduce or discontinue LTOT and that pain, function, and quality of life may improve with opioid dose reduction. PRIMARY FUNDING SOURCE: Veterans Health Administration. (PROSPERO: CRD42015020347).

Practical application of opt-out recruitment methods in two health services research studies.

BACKGROUND: Participant recruitment is an ongoing challenge in health research. Recruitment may be especially difficult for studies of access to health care because, even among those who are in care, people using services least often also may be hardest to contact and recruit. Opt-out recruitment methods (in which potential participants are given the opportunity to decline further contact about the study (opt out) following an initial mailing, and are then contacted directly if they have not opted out within a specified period) can be used for such studies. However, there is a dearth of literature on the effort needed for effective opt-out recruitment. METHODS: In this paper we describe opt-out recruitment procedures for two studies on access to health care within the U.S. Department of Veterans Affairs. We report resource requirements for recruitment efforts (number of opt-out packets mailed and number of phone calls made). We also compare the characteristics of study participants to potential participants via t-tests, Fisher's exact tests, and chi-squared tests. RESULTS: Recruitment rates for our two studies were 12 and 21%, respectively. Across multiple study sites, we had to send between 4.3 and 9.2 opt-out packets to recruit one participant. The number of phone calls required to arrive at a final status for each potentially eligible Veteran (i.e. study participation or the termination of recruitment efforts) were 2.9 and 6.1 in the two studies, respectively. Study participants differed as expected from the population of potentially eligible Veterans based on planned oversampling of certain subpopulations. The final samples of participants did not differ statistically from those who were mailed opt-out packets, with one exception: in one of our two studies, participants had higher rates of mental health service use in the past year than did those mailed opt-out packets (64 vs. 47%). CONCLUSIONS: Our results emphasize the practicality of using opt-out methods for studies of access to health care. Despite the benefits of these methods, opt-out alone may be insufficient to eliminate non-response bias on key variables. Researchers will need to balance considerations of sample representativeness and feasibility when designing studies investigating access to care.

What advanced cancer patients with limited treatment options know about clinical research: a qualitative study.

PURPOSE: Discussions between oncologists and advanced cancer patients (ACPs) may touch on the complex issue of clinical trial participation. Numerous initiatives have sought to improve the quality of these potentially difficult conversations. However, we have limited data about what ACPs know about clinical research as they enter such discussions as, to date, such research has focused on the period following informed consent. This study examines ACPs' understanding of clinical research in the treatment period before consent. METHODS: We conducted in-depth interviews with adult ACPs with limited treatment options at four clinics in an academic medical center. So as not to influence patients' perspectives, interviewers probed patients' knowledge of clinical research only if the patient first brought up the topic. Interviews (40-60 min) were audio-recorded, transcribed, and analyzed thematically and via quantitative content analysis by an interdisciplinary team. RESULTS: Of 78 patients recruited, 56 (72%) spontaneously brought up the topic of clinical research during interview and are included in this analysis. Qualitative thematic analysis and quantitative content analysis revealed that patients' knowledge varied in terms of (1) accuracy and (2) specificity (level of detail). ACPs who spoke with high specificity were not always accurate, and ACPs with accurate knowledge included both high- and low-specificity speakers. CONCLUSIONS: ACPs' knowledge of clinical research is variable. Patients who can discuss the technical details of their care may or may not understand the broader purpose and procedures of clinical trials. Understanding this variability is important for improving patient-provider communication about clinical research and supporting efforts to provide individualized care for ACPs.

The Process of Interactional Sensitivity Coding in Health Care: Conceptually and Operationally Defining Patient-Centered Communication.

This study aimed to develop a process for measuring sensitivity in provider-patient interactions to better understand patient-centered communication. The authors developed the Process of Interactional Sensitivity Coding in Healthcare (PISCH) by incorporating a multimethod investigation into conversations between physicians and their patients with type 2 diabetes. The PISCH was then applied and assessed for its reliability across the unitization of interactions, the activities that were reflected, and the characteristics of patient-centered interactional sensitivity that were observed within each unit. In most cases, the PISCH resulted in reliable analysis of the interactions, but a few key areas (shared decision making, enabling self-management, and responding to emotion) were not reliably assessed. Implications of the test of this coding scheme include the expansion of the theoretical notion of interactional sensitivity to the health care context, rigorous implementation of a multimethod measurement development that relied on qualitative and quantitative assessments, and important future questions about the role of communication concepts in future interpersonal research.

The design of a low literacy decision aid about rheumatoid arthritis medications developed in three languages for use during the clinical encounter.

BACKGROUND: Shared decision-making in rheumatoid arthritis (RA) care is a priority among policy makers, clinicians and patients both nationally and internationally. Demands on patients to have basic knowledge of RA, treatment options, and details of risk and benefit when making medication decisions with clinicians can be overwhelming, especially for those with limited literacy or limited English language proficiency. The objective of this study is to describe the development of a medication choice decision aid for patients with rheumatoid arthritis (RA) in three languages using low literacy principles. METHODS: Based on the development of a diabetes decision aid, the RA decision aid (RA Choice) was developed through a collaborative process involving patients, clinicians, designers, decision-aid and health literacy experts. A combination of evidence synthesis and direct observation of clinician-patient interactions generated content and guided an iterative process of prototype development. RESULTS: Three iterations of RA Choice were developed and field-tested before completion. The final tool organized data using icons and plain language for 12 RA medications across 5 issues: frequency of administration, time to onset, cost, side effects, and special considerations. The tool successfully created a conversation between clinician and patient, and garnered high acceptability from clinicians. CONCLUSIONS: The process of collaboratively developing an RA decision aid designed to promote shared decision making resulted in a graphically-enhanced, low literacy tool. The use of RA Choice in the clinical encounter has the potential to enhance communication for RA patients, including those with limited health literacy and limited English language proficiency.

Trust and perceived mental health access: Exploring the relationship between perceived access barriers and veteran-reported trust.

The importance of patients' trust in health care is well known. However, identifying actionable access barriers to trust is challenging. The goal of these exploratory analyses is to identify actionable access barriers that correlate with and predict patients' lack of trust in providers and in the health care system. This article combines existing data from three studies regarding perceived access to mental health services to explore the relationship between provider and system trust and other access barriers. Data from the Perceived Access Inventory (PAI) were analyzed from three studies that together enrolled a total of 353 veterans who screened positive for a mental health problem and had a VA mental health encounter in the previous 12 months. The PAI includes actionable barriers to accessing VA mental health services. The data are cross-sectional, and analyses include Spearman rank correlations of PAI access barriers and provider and system trust, and linear regressions examining the effect of demographic, clinical, and PAI barriers on lack of trust in VA mental health providers and in the VA health care system. Age, depression, and anxiety symptoms and PAI items demonstrated statistically significant bivariate correlations with provider and system trust. However, in multivariate linear regressions, only PAI items remained statistically significant. The PAI items that predicted provider and system trust could be addressed in interventions to improve provider- and system-level trust. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Strengthening Primary Care Workforce Capacity in Dementia Diagnosis and Care: A Qualitative Study of Project Alzheimer's Disease-ECHO.

Primary care practitioners (PCPs) are the first point of contact for most patients with suspected dementia and have identified a need for more training and support around dementia diagnosis and care. This qualitative study examined the Alzheimer's Disease-Extension for Community Healthcare Outcomes (AD-ECHO) program. AD-ECHO was designed to strengthen PCP capacity in dementia through bimonthly virtual meetings with a team of dementia experts. We conducted 24 hr of direct observations at AD-ECHO sessions and interviewed 14 participants about their experiences participating. Using thematic analysis, we found that participants valued the supportive learning environment and resources; knowledge gained empowered them to take more action around dementia; they identified ways of disseminating knowledge gained into their practice settings, and many desired ongoing AD-ECHO engagement. However, most identified time as a barrier to participation. AD-ECHO has the potential to strengthen the primary care workforce's knowledge and confidence around dementia care.

Passing the baton: a grounded practical theory of handoff communication between multidisciplinary providers in two Department of Veterans Affairs outpatient settings.

BACKGROUND: Handoffs are communication processes that enact the transfer of responsibility between providers across clinical settings. Prior research on handoff communication has focused on inpatient settings between provider teams and has emphasized patient safety. This study examines handoff communication within multidisciplinary provider teams in two outpatient settings. OBJECTIVE: To conduct an exploratory study that describes handoff communication among multidisciplinary providers, to develop a theory-driven descriptive framework for outpatient handoffs, and to evaluate the strengths and weaknesses of different handoff types. DESIGN & SETTING: Qualitative, in-depth, semi-structured interviews with 31 primary care, mental health, and social work providers in two Department of Veterans Affairs (VA) Medical Center outpatient clinics. APPROACH: Audio-recorded interviews were transcribed and analyzed using Grounded Practical Theory to develop a theoretical model of and a descriptive framework for handoff communication among multidisciplinary providers. RESULTS: Multidisciplinary providers reported that handoff decisions across settings were made spontaneously and without clear guidelines. Two situated values, clinic efficiency and patient-centeredness, shaped multidisciplinary providers' handoff decisions. Providers reported three handoff techniques along a continuum: the electronic handoff, which was the most clinically efficient; the provider-to-provider handoff, which balanced clinic efficiency and patient-centeredness; and the collaborative handoff, which was the most patient-centered. Providers described handoff choice as a practical response to manage constituent features of clinic efficiency (time, space, medium of communication) and patient-centeredness (information continuity, management continuity, relational continuity, and social interaction). We present a theoretical and descriptive framework to help providers evaluate differential handoff use, reflect on situated values guiding clinic communication, and guide future research. CONCLUSIONS: Handoff communication reflected multidisciplinary providers' efforts to balance clinic efficiency with patient-centeredness within the constraints of day-to-day clinical practice. Evaluating the strengths and weaknesses among alternative handoff options may enhance multidisciplinary provider handoff decision-making and may contribute to increased coordination and continuity of care across outpatient settings.

"All of those things we don't eat": a culture-centered approach to dietary health meanings for Asian Indians living in the United States.

This article applies a culture-centered approach to analyze the dietary health meanings for Asian Indians living in the United States. The data were collected as part of a health promotion program evaluation designed to help Asian Indians reduce their risk of chronic disease. Community members who used two aspects of the program participated in two focus groups to learn about their health care experiences and to engage them in dialogue about how culture impacts their overall health. Using constructionist grounded theory, we demonstrate that one aspect of culture, the discourses around routine dietary choice, is an important, but underrecognized, aspect of culture that influences community members' experiences with health care. We theorize community members' dietary health meanings operate discursively through a dialectic tension between homogeneity and heterogeneity, situated amid culture, structure, and agency. Participants enacted discursive homogeneity when they affirmed dietary health meanings around diet as an important means through which members of the community maintain a sense of continuity of their identity while differentiating them from others. Participants enacted discursive heterogeneity when they voiced dietary health meanings that differentiated community members from one another due to unique life-course trajectories and other membership affiliations. Through this dialectic, community members manage unique Asian Indian identities and create meanings of health and illness in and through their discourses around routine dietary choice. Through making these discursive health meanings audible, we foreground how community members' agency is discursively enacted and to make understandable how discourses of dietary practice influence the therapeutic alliance between primary care providers and members of a minority community.

Initial concurrent and convergent validity of the Perceived Access Inventory (PAI) for mental health services.

Access to high-quality health care, including mental health care, remains a high priority for the Department of Veterans Affairs and civilian health care systems. Increased access to mental health care is associated with improved outcomes, including decreased suicidal behavior. Multiple policy changes and interventions are being developed and implemented to improve access to mental health care. The Perceived Access Inventory (PAI) is a patient-centered questionnaire developed to understand the veteran perspective about access to mental health services. The PAI is a self-report measure that includes 43 items across 5 domains: Logistics (6 items), Culture (4 items), Digital (9 items), Systems of Care (13 items), and Experiences of Care (11 items). This article is a preliminary examination of the concurrent and convergent validity of the PAI with respect to the Hoge Perceived Barriers to Seeking Mental Health Services scale (concurrent) and the Client Satisfaction Questionnaire (CSQ; convergent). Telephone interviews were conducted with veterans from 3 geographic regions. Eligibility criteria included screening positive for posttraumatic stress disorder, alcohol use disorder, or depression in the past 12 months. Data from 92 veterans were analyzed using correlation matrices. PAI scores were significantly correlated with the Hoge total score (concurrent validity) and CSQ scores (convergent validity). The PAI items with the strongest correlation with CSQ were in the Systems of Care domain and the weakest were in the Logistics domain. Future efforts will evaluate validity using larger data sets and utilize the PAI to develop and test interventions to improve access to care. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A systematic review of communication about Complementary and Integrative Health (CIH) in global biomedical settings.

OBJECTIVES: A systematic review to analyze communication rates of complementary and integrative health (CIH) and analyze how communication terms, such as "disclosure," are measured and operationalized. METHODS: We searched seven databases for studies published between 2010 and 2018 with quantitative measurements of patients' communication of CIH to a biomedical clinician. We analyzed communication terms used to describe patients reporting CIH usage. We also examined the conceptual and operational definitions of CIH provided and whether those terms were explicitly operationalized. We aggregated the percentage, rate, or ratio of CIH users that communicated about CIH with their clinicians by disease type and geographical region. RESULTS: 7882 studies were screened and 89 included in the review. Studies used a wide range of conceptual and operational definitions for CIH, as well as 23 different terms to report communication related to reporting CIH usage. Usage varied by disease type and geographical region. CONCLUSIONS: Studies of CIH and CIH communication may measure different kinds of social and communicative phenomena, which makes comparison across international studies challenging. PRACTICE IMPLICATIONS: Future studies should employ standardized, replicable measures for defining CIH and for reporting CIH communication. Clinicians can incorporate questions about prior, current, and future CIH use during the medical visit.

Telephone veteran peer coaching for mental health treatment engagement among rural veterans: The importance of secondary outcomes and qualitative data in a randomized controlled trial.

PURPOSE: To determine the effectiveness of telephone motivational coaching delivered by veteran peers to improve mental health (MH) treatment engagement among veterans. METHODS: Veterans receiving primary care from primarily rural VA community-based outpatient clinics were enrolled. Veterans not engaged in MH treatment screening positive for ≥1 MH problem(s) were randomized to receive veteran peer-delivered feedback on MH screen results and referrals plus 4 sessions of telephone motivational coaching (intervention) versus veteran peer-delivered MH results and referrals without motivational coaching (control). Blinded telephone assessments were conducted at baseline, 8, 16, and 32 weeks. Cox proportional hazard models compared MH clinician-directed treatment initiation between groups; descriptive analyses compared MH treatment retention, changes in MH symptoms, quality of life, and self-care. FINDINGS: Among 272 veterans screening positive for ≥1 MH problem(s), 45% who received veteran peer telephone motivational coaching versus 46% of control participants initiated MH treatment (primary outcome) (hazard ratio: 1.09, 95% CI: 0.76-1.57), representing no between-group differences. In contrast, veterans receiving veteran peer motivational coaching achieved significantly greater improvements in depression, posttraumatic stress disorder and cannabis use scores, quality of life domains, and adoption of some self-care strategies than controls (secondary outcomes). Qualitative data revealed that veterans who received veteran peer motivational coaching may no longer have perceived a need for MH treatment. CONCLUSIONS: Among veterans with MH problems using predominantly rural VA community clinics, telephone peer motivational coaching did not enhance MH treatment engagement, but instead had positive effects on MH symptoms, quality of life indicators, and use of self-care strategies.

Development of the Perceived Access Inventory: A patient-centered measure of access to mental health care.

According to recent Congressional testimony by the Secretary for Veterans Affairs (VA), improving the timeliness of services is one of five current priorities for VA. A comprehensive access measure, grounded in veterans' experience, is essential to support VA's efforts to improve access. In this article, the authors describe the process they used to develop the Perceived Access Inventory (PAI), a veteran-centered measure of perceived access to mental health services. They used a multiphase, mixed-methods approach to develop the PAI. Each phase built on and was informed by preceding phases. In Phase 1, the authors conducted 80 individual, semistructured, qualitative interviews with veterans from 3 geographic regions to elicit the barriers and facilitators they experienced in seeking mental health care. In Phase 2, they generated a preliminary set of 77 PAI items based on Phase 1 qualitative data. In Phase 3, an external expert panel rated the preliminary PAI items in terms of relevance and importance, and provided feedback on format and response options. Thirty-nine PAI items resulted from Phase 3. In Phase 4, veterans gave feedback on the readability and understandability of the PAI items generated in Phase 3. Following completion of these 4 developmental phases, the PAI included 43 items addressing 5 domains: logistics (five items), culture (three items), digital (nine items), systems of care (13 items), and experiences of care (13 items). Future work will evaluate concurrent and predictive validity, test/retest reliability, sensitivity to change, and the need for further item reduction. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Before Consent: Qualitative Analysis of Deliberations of Patients With Advanced Cancer About Early-Phase Clinical Trials.

PURPOSE: Patients with advanced cancer and oncologists deliberate about early-phase (EP) trials as they consider whether to pursue EP trial enrollment. We have limited information about those deliberations and how they may facilitate or impede trial initiation. This study describes these deliberations and their relationship to trial initiation. PATIENTS AND METHODS: We collected longitudinal, ethnographic data on deliberations of patients with advanced cancer at two academic medical centers. We used constant comparative and framework analyses to characterize the deliberative process and its relationship to trial initiation. RESULTS: Of 96 patients with advanced cancer, 26% initiated EP enrollment and 19% joined a trial. Constant comparative analysis revealed two foci of deliberation. Setting the stage focused on patient and physician support for EP trial involvement, including patients' interest in research and oncologists' awareness of trials and assessment of patient fit. Securing a seat focused on eligibility for and entrance to a specific trial and involved trial availability, treatment history, disease progression, and enrollment timing. Patients enrolled in a trial only when both stages could be successfully navigated. CONCLUSION: Ethnographic data revealed two foci of deliberation about EP trial enrollment among patients with advanced cancer. Physician support played a consequential role in both stages, but enrollment also reflected factors beyond the control of any specific individual. Insights from this study, combined with other recent studies of trial enrollment, advance our understanding of the complex process of EP trial accrual and may help identify strategies to improve rates of participation.

Managing professional knowledge boundaries during ECHO telementoring consultations in two Veterans Affairs specialty care liver clinics: A theme-oriented discourse analysis.

INTRODUCTION: Consultations are the traditional method of communication between generalist and specialist providers managing patients with specialty care needs. Traditional written consultations have limitations, including inadequate clinical information and inappropriate, or unclear consultation questions. Teleconsultations minimize these limitations through real-time communication between generalist and specialist providers to actively manage professional knowledge boundaries about specialty care problems. METHODS: We video-recorded 37 teleconsultation sessions, resulting in 115 consultations between generalist and specialty care providers participating in Veterans Affairs (VA) Extension for Community Healthcare Outcomes (ECHO) liver clinics. Data were collected at two US sites across nine months to observe consultation communication among 33 primary care generalists and three liver specialists. Video recordings were transcribed verbatim and analysed using theme-oriented discourse analysis to characterize consultation question content and format. RESULTS: Generalists' consultation question content addressed a range of topics, including treatment, diagnosis, interpreting results, patient communication, screening and surveillance, and care coordination. Some generalists relied on descriptive narratives rather than a specific question to convey complex patient cases. Consultation question format showed nearly even division between targeting general medical knowledge and specialty care knowledge domains, including specialty care, medical, organizational, and experiential knowledge. DISCUSSION: Timely access to specialists through teleconsultation has the potential to transform specialty care delivery. This article examines provider-to-provider interactions to understand how the communication process contributes to knowledge management during teleconsultations. Video studies of health information technology use provide a rich opportunity for analysing real-time communication that may help improve cross-specialty collaboration and the coordinated management of patients with specialty care needs.