Research Protocol Adaptations During the COVID-19 Pandemic: A Process Evaluation.

In general, COVID-19-related adaptations that transitioned in-person assessments and interventions to a virtual format were not routinely evaluated. We aimed to conduct a process evaluation to examine the impact of COVID-19-related adaptations on a behavior change intervention designed to increase exercise adherence among Veterans with mobility difficulty. We used secondary data from a nonrandomized study to complete a process evaluation examining the intervention's reach, recruitment, fidelity, dose delivered by physical therapists, and the dose received by the 14 participating Veterans. The physical therapist delivered 95% (133/140) of the study's 10 sessions. Sessions with the lowest delivery dose included Sessions 1 and 10 (86%; n = 12/14). The elements with the lowest dose received included using an exercise journal and developing a postintervention plan (86%; n = 12/14). Our COVID-19 adaptations allowed us to provide our intervention to the majority (67%) of eligible participants without a negative impact on fidelity, dose delivered, or dose received.

Relationship Between Unmet Social Needs and Care Access in a Veteran Cohort.

BACKGROUND: The association between unmet social needs (e.g., food insecurity) and adverse health outcomes is well-established, especially for patients with and at risk for cardiovascular disease (CVD). This has motivated healthcare systems to focus on unmet social needs. Yet, little is known about the mechanisms by which unmet social needs impact health, which limits healthcare-based intervention design and evaluation. One conceptual framework posits that unmet social needs may impact health by limiting care access, but this remains understudied. OBJECTIVE: Examine the relationship between unmet social needs and care access. DESIGN: Cross-sectional study design using survey data on unmet needs merged with administrative data from the Veterans Health Administration (VA) Corporate Data Warehouse (September 2019-March 2021) and multivariable models to predict care access outcomes. Pooled and separate rural and urban logistic regression models were utilized with adjustments from sociodemographics, region, and comorbidity. SUBJECTS: A national stratified random sample of VA-enrolled Veterans with and at risk for CVD who responded to the survey. MAIN MEASURES: No-show appointments were defined dichotomously as patients with one or more missed outpatient visits. Medication non-adherence was measured as proportion of days covered and defined dichotomously as adherence less than 80%. KEY RESULTS: Greater burden of unmet social needs was associated with significantly higher odds of no-show appointments (OR = 3.27, 95% CI = 2.43, 4.39) and medication non-adherence (OR = 1.59, 95% CI = 1.19, 2.13), with similar associations observed for rural and urban Veterans. Social disconnection and legal needs were especially strong predictors of care access measures. CONCLUSIONS: Findings suggest that unmet social needs may adversely impact care access. Findings also point to specific unmet social needs that may be especially impactful and thus might be prioritized for interventions, in particular social disconnection and legal needs.

Rural Veterans' Experiences with Social Risk Factors: Impacts, Challenges, and Care System Recommendations.

BACKGROUND: Social risk factors, such as food insecurity and financial needs, are associated with increased risk of cardiovascular diseases, health conditions that are highly prevalent in rural populations. A better understanding of rural Veterans' experiences with social risk factors can inform expansion of Veterans Health Administration (VHA) efforts to address social needs. OBJECTIVE: To examine social risk and need from rural Veterans' lived experiences and develop recommendations for VHA to address social needs. DESIGN: We conducted semi-structured interviews with participants purposively sampled for racial diversity. The interview guide was informed by Andersen's Behavioral Model of Health Services Use and the Outcomes from Addressing Social Determinants of Health in Systems framework. PARTICIPANTS: Rural Veterans with or at risk of cardiovascular disease who participated in a parent survey and agreed to be recontacted. APPROACH: Interviews were recorded and transcribed. We analyzed transcripts using directed qualitative content analysis to identify themes. KEY RESULTS: Interviews (n = 29) took place from March to June 2022. We identified four themes: (1) Social needs can impact access to healthcare, (2) Structural factors can make it difficult to get help for social needs, (3) Some Veterans are reluctant to seek help, and (4) Veterans recommended enhancing resource dissemination and navigation support. CONCLUSIONS: VHA interventions should include active dissemination of information on social needs resources and navigation support to help Veterans access resources. Community-based organizations (e.g., Veteran Service Organizations) could be key partners in the design and implementation of future social need interventions.

Central Nervous System-Active Prescriptions in Older Veterans: Trends in Prevalence, Prescribers, and High-risk Populations.

BACKGROUND: Little is known about the prevalence or chronicity of prescriptions of central nervous system-active (CNS-active) medications in older Veterans. OBJECTIVE: We sought to describe (1) the prevalence and trends in prescription of CNS-active medications in older Veterans over time; (2) variation in prescriptions across high-risk groups; and (3) where the prescription originated (VA or Medicare Part D). DESIGN: Retrospective cohort study from 2015 to 2019. PARTICIPANTS: Veterans age ≥ 65 enrolled in the Medicare and the VA residing in Veterans Integrated Service Network 4 (incorporating Pennsylvania and parts of surrounding states). MAIN MEASURES: Drug classes included antipsychotics, gabapentinoids, muscle relaxants, opioids, sedative-hypnotics, and anticholinergics. We described prescribing patterns overall and in three subgroups: Veterans with a diagnosis of dementia, Veterans with high predicted utilization, and frail Veterans. We calculated both prevalence (any fill) and percent of days covered (chronicity) for each drug class, and CNS-active polypharmacy (≥ 2 CNS-active medications) rates in each year in these groups. KEY RESULTS: The sample included 460,142 Veterans and 1,862,544 person-years. While opioid and sedative-hypnotic prevalence decreased, gabapentinoids exhibited the largest increase in both prevalence and percent of days covered. Each subgroup exhibited different patterns of prescribing, but all had double the rates of CNS-active polypharmacy compared to the overall study population. Opioid and sedative-hypnotic prevalence was higher in Medicare Part D prescriptions, but the percent of days covered of nearly all drug classes was higher in VA prescriptions. CONCLUSIONS: The concurrent increase of gabapentinoid prescribing paralleling a decrease in opioid and sedative-hypnotics is a new phenomenon that merits further evaluation of patient safety outcomes. In addition, we found substantial potential opportunities for deprescribing CNS-active medications in high-risk groups. Finally, the increased chronicity of VA prescriptions versus Medicare Part D is novel and should be further evaluated in terms of its mechanism and impact on Medicare-VA dual users.

Leveraging the timing and frequency of patient decision aids in longitudinal shared decision-making: A narrative review and applied model.

INTRODUCTION: Shared decision-making (SDM) is intended to increase patient-centredness of medical decision-making for patients with acute and chronic conditions. Concurrently, patient decision aids (PtDAs) can supplement SDM by providing information to guide communication between patients and healthcare providers. Because of the prevalence of chronic conditions, where decisions may be extended or recurring, we sought to explore how effectively these tools have been leveraged in this context. METHODS: We conducted a narrative review of the literature on both SDM and PtDAs, searching PubMed and Boston University's library database search tool for English-language articles published from January 2005 until March 2021. Additional search terms focused on temporality. Drawing from our findings, we developed a combined framework to highlight areas for future research using the discussion of end-of-life decisions as an exemplar to illustrate its relevance to chronic care contexts. RESULTS: After screening 57 articles, we identified 25 articles that fulfilled the inclusion criteria on SDM, PtDA use and temporality for chronic care. The literature on SDM highlighted time outside of the medical visit and opportunity to include outside decision partners as important elements of the process. PtDAs were commonly evaluated for process-related and proximal outcomes, but less often for distal outcomes. Early evidence points to the value of comparative outcome evaluation based on the timing of PtDA distribution. CONCLUSION: Our review of the literature on SDM and PtDAs reveals less attention to the timing of PtDAs relative to that of SDM. We highlight the need for further study of timing in PtDA use to improve longitudinal SDM for chronic care. The model that we propose in our discussion provides a starting point for future research on PtDA efficacy. PATIENT OR PUBLIC CONTRIBUTION: Five patient consultants provided input and feedback on the development and utility of our model.

Deprescribing for Community-Dwelling Older Adults: a Systematic Review and Meta-analysis.

BACKGROUND: Polypharmacy and use of inappropriate medications have been linked to increased risk of falls, hospitalizations, cognitive impairment, and death. The primary objective of this review was to evaluate the effectiveness, comparative effectiveness, and harms of deprescribing interventions among community-dwelling older adults. METHODS: We searched OVID MEDLINE Embase, CINAHL, and the Cochrane Library from 1990 through February 2019 for controlled clinical trials comparing any deprescribing intervention to usual care or another intervention. Primary outcomes were all-cause mortality, hospitalizations, health-related quality of life, and falls. The secondary outcome was use of potentially inappropriate medications (PIMs). Interventions were categorized as comprehensive medication review, educational initiatives, and computerized decision support. Data abstracted by one investigator were verified by another. We used the Cochrane criteria to rate risk of bias for each study and the GRADE system to determine certainty of evidence (COE) for primary outcomes. RESULTS: Thirty-eight low and medium risk of bias clinical trials were included. Comprehensive medication review may have reduced all-cause mortality (OR 0.74, 95% CI: 0.58 to 0.95, I2 = 0, k = 12, low COE) but probably had little to no effect on falls, health-related quality of life, or hospitalizations (low to moderate COE). Nine of thirteen trials reported fewer PIMs in the intervention group. Educational interventions probably had little to no effect on all-cause mortality, hospitalizations, or health-related quality of life (low to moderate COE). The effect on falls was uncertain (very low COE). All 11 education trials that included PIMs reported fewer in the intervention than in the control groups. Two of 4 computerized decision support trials reported fewer PIMs in the intervention arms; none included any primary outcomes. DISCUSSION: In community-dwelling people aged 65 years and older, medication deprescribing interventions may provide small reductions in mortality and use of potentially inappropriate medications. REGISTRY INFORMATION: PROSPERO - CRD42019132420.

Patient Possession of Excess Medication Supply in the VA: A Retrospective Database Study.

BACKGROUND: Medication overlap leading to medication excess is a form of therapeutic duplication, itself a type of potentially inappropriate prescribing. OBJECTIVE: To determine the prevalence of potential medication excess in the Veterans Health Administration (VHA) and identify associated medication-level, patient-level, and system-level factors. RESEARCH DESIGN: A retrospective database study. SUBJECTS: All veterans who received ≥1 prescription dispensed by a VHA pharmacy in fiscal year 2014. MEASURES: The primary outcome of "medication excess" was defined for each patient as the number of excess days' worth of medications for all overlap episodes (concurrently dispensed medications with the same name for >10 d). Predictors included medication-level, patient-level, and system-level factors. Multivariable negative binomial regression analyses estimated the rate ratio of each predictor with medication excess. RESULTS: Among 4,687,453 veterans, 64% had ≥1 medication overlap episodes. Patients were prescribed a median of 7 [interquartile range (IQR), 3-12] unique medications, had a median of 2 (IQR, 0-5) overlap episodes, and a median of 27 (IQR, 0-96) days of medication excess. In adjusted regression models, factors associated with greater risk of medication excess included having more comorbidities, multiple prescribers, a combination of filling locations (consolidated mail-order pharmacy vs. local pharmacy), and multiple prescription durations (≥90 d vs. less). CONCLUSIONS: Medication excess was high among VHA users, with nearly two-thirds of patients experiencing at least 1 duplicative medication. As systems such as mail-order pharmacies and 90-day supply are increasingly implemented to reduce costs and improve medication adherence, it is important to recognize the potential for systems-level inefficiencies and potentially inappropriate prescribing.

Usability evaluation of a medication reconciliation tool: Embedding safety probes to assess users' detection of medication discrepancies.

OBJECTIVE: An electronic medication reconciliation tool was previously developed by another research team to aid provider-patient communication for medication reconciliation. To evaluate the usability of this tool, we integrated artificial safety probes into standard usability methods. The objective of this article is to describe this method of using safety probes, which enabled us to evaluate how well the tool supports users' detection of medication discrepancies. MATERIALS AND METHODS: We completed a mixed-method usability evaluation in a simulated setting with 30 participants: 20 healthcare professionals (HCPs) and 10 patients. We used factual scenarios but embedded three artificial safety probes: (1) a missing medication (i.e., omission); (2) an extraneous medication (i.e., commission); and (3) an inaccurate dose (i.e., dose discrepancy). We measured users' detection of each probe to estimate the probability that a HCP or patient would detect these discrepancies. Additionally, we recorded participants' detection of naturally occurring discrepancies. RESULTS: Each safety probe was detected by ≤50% of HCPs. Patients' detection rates were generally higher. Estimates indicate that a HCP and patient, together, would detect 44.8% of these medication discrepancies. Additionally, HCPs and patients detected 25 and 45 naturally-occurring discrepancies, respectively. DISCUSSION: Overall, detection of medication discrepancies was low. Findings indicate that more advanced interface designs are warranted. Future research is needed on how technologies can be designed to better aid HCPs' and patients' detection of medication discrepancies. CONCLUSION: This is one of the first studies to evaluate the usability of a collaborative medication reconciliation tool and assess HCPs' and patients' detection of medication discrepancies. Results demonstrate that embedded safety probes can enhance standard usability methods by measuring additional, clinically-focused usability outcomes. The novel safety probes we used may serve as an initial, standard set for future medication reconciliation research. More prevalent use of safety probes could strengthen usability research for a variety of health information technologies.

Patient attitudes and experiences that predict medication discontinuation in the Veterans Health Administration.

OBJECTIVES: Polypharmacy is associated with adverse medication effects. One potential solution is deprescribing, which is the intentional, proactive, rational discontinuation of a medication that is no longer indicated or for which the potential harms outweigh the potential benefits. We identified patient characteristics, attitudes, and health care experiences associated with medication discontinuation. DESIGN, SETTING, AND PARTICIPANTS: We conducted a national mail survey, with the use of the Patient Perceptions of Discontinuation (PPoD) instrument, of 1600 veterans receiving primary care at Veterans Affairs (VA) medical centers and prescribed 5 or more concurrent medications. MAIN OUTCOME MEASURES: The primary outcome was the response to: "Have you ever stopped taking a medicine (with or without your doctor's knowledge)?" The primary predictors of interest were 8 validated attitudinal scales. Other predictors included demographics, health status, and health care experiences. RESULTS: Respondents (n = 803; adjusted response rate 52%) were predominantly male (85%); non-Hispanic white (68%), 65 years of age or older (60%), and with poor (16%) or fair (45%) health. Participant attitudes toward medications and their providers were generally favorable. One in 3 patients (34%) reported having stopped a medicine in the past. In a multivariable logistic regression model (P < 0.001; pseudo-R2 = 0.31; c-statistic = 0.82), factors associated with discontinuation included being told or asking to stop a medicine, greater interest in deprescribing and shared decision making, and higher education. Factors associated with decreased discontinuation were more prescriptions, higher trust in provider, and seeing a VA clinical pharmacist. CONCLUSION: More highly educated patients with interest in deprescribing and shared decision making may be more receptive to discontinuation discussions. Future research evaluating how to incorporate this survey and these findings into clinical workflow through the design of clinical interventions may help to promote safe and rational medication use.

Patient Perceptions of Deprescribing: Survey Development and Psychometric Assessment.

BACKGROUND: Although clinicians ultimately decide when to discontinue (deprescribe) medications, patients' perspectives may guide the process. OBJECTIVES: To develop a survey instrument that assesses patients' experience with and attitudes toward deprescribing. RESEARCH DESIGN: We developed a questionnaire with established and newly created items. We used exploratory factor analysis and confirmatory factor analysis (EFA and CFA) to assess the psychometric properties. SUBJECTS: National sample of 1547 Veterans Affairs patients prescribed ≥5 medications. MEASURES: In the EFA, percent variance, a scree plot, and conceptual coherence determined the number of factors. In the CFA, proposed factor structures were evaluated using standardized root mean square residual, root mean square error of approximation, and comparative fit index. RESULTS: Respondents (n=790; 51% response rate) were randomly assigned to equal derivation and validation groups. EFA yielded credible 4-factor and 5-factor models. The 4 factors were "Medication Concerns," "Provider Knowledge," "Interest in Stopping Medicines," and "Unimportance of Medicines." The 5-factor model added "Patient Involvement in Decision-Making." In the CFA, a modified 5-factor model, with 2 items with marginal loadings moved based upon conceptual fit, had an standardized root mean square residual of 0.06, an RMSEA of 0.07, and a CFI of 0.91. The new scales demonstrated internal consistency reliability, with Cronbach α's of: Concerns, 0.82; Provider Knowledge, 0.86; Interest, 0.77; Involvement, 0.61; and Unimportance, 0.70. CONCLUSIONS: The Patient Perceptions of Deprescribing questionnaire is a novel, multidimensional instrument to measure patients' attitudes and experiences related to medication discontinuation that can be used to determine how to best involve patients in deprescribing decisions.

Supporting medication discontinuation: provider preferences for interventions to facilitate deprescribing.

BACKGROUND: One approach to prevent adverse drug events is to discontinue ("deprescribe") medications that are outdated, not indicated, or of limited benefit relative to risk for a particular patient. However, there is little guidance to clinicians about how to integrate the process of deprescribing into the workflow of clinical practice. We sought to determine clinical prescribers' preferences for interventions that would improve their ability to appropriately and proactively discontinue medications. METHODS: We conducted a national web-based survey of 2475 prescribers [physicians, nurse practitioners (NP), physician assistants (PA), and clinical pharmacy specialists] practicing in US Veterans Affairs (VA) primary care clinics. One survey question presented 15 potential changes to medication-related practices and respondents ranked their top three choices for changes that would "most improve [their] ability to discontinue medications." We summed the weighted rankings for each of the 15 response options. Preferences were determined for the whole sample and within subgroups of respondents defined by demographic and background characteristics, medication-relevant experience, and beliefs. RESULTS: Among the 326 respondents who provided rankings, the top choice for a change that would help improve their ability to discontinue medications was "Requiring all medication prescriptions to have an associated 'indication for use.'" This preference was followed by "Assistance with follow-up of patients as they taper or discontinue medications is performed by another member of the Patient Aligned Care Team (PACT)" and "Increased patient involvement in prescribing decisions." This combination of options, albeit in varying rank order, was the most commonly selected, with 250 respondents (77%) who answered the question including at least one of these items in their three highest ranked choices, regardless of their demographics, experience, or beliefs. CONCLUSIONS: Continued efforts to improve clinicians' ability to make prescribing decisions, especially around deprescribing, have many potential benefits, including decreased pharmaceutical and health care costs, fewer adverse drug events and complications, and improved patient involvement and satisfaction with their care. Future work, whether as research or quality improvement, should incorporate clinicians' preferences for interventions, as greater buy-in from front-line staff leads to better adoption of changes.

Medication Complexity, Medication Number, and Their Relationships to Medication Discrepancies.

BACKGROUND: Medication reconciliation to identify discrepancies is a National Patient Safety Goal. Increasing medication number and complex medication regimens are associated with discrepancies, nonadherence, and adverse events. The Medication Regimen Complexity Index (MRCI) integrates information about dosage form, dosing frequency, and additional directions. OBJECTIVE: This study evaluates the association of MRCI scores and medication number with medication discrepancies and commissions, a discrepancy subtype. METHODS: This was a retrospective cohort study of a convenience sample of 104 ambulatory care patients seen from April 2010 to July 2011 within the Department of Veterans Affairs. Primary outcomes included any medication discrepancy and commissions. Primary exposures included MRCI scores and medication number. Multivariable logistic regression models associated MRCI scores and medication number with discrepancies. Receiver operating characteristic (ROC) curves provided discrepancy thresholds. RESULTS: For the 104 patients analyzed, the median MRCI score was 25 (interquartile range [IQR] = 14-43), and the median medication number was 8 (IQR = 5-13); 60% of patients had any discrepancy, whereas 36% had a commission. In adjusted analyses, patients with MRCI scores ≥25 or medication number ≥8 were more likely to have commissions (odds ratio [OR] = 3.64, 95% CI = 1.41-9.41; OR = 4.51, 95% CI = 1.73-11.73, respectively). The unadjusted ROC threshold for commissions was 36 for MRCI (sensitivity, 59%; specificity, 82%) and 9 for medication number (sensitivity 68%; specificity 67%). CONCLUSION: Patients with either MRCI scores ≥25 or ≥8 medications were more likely to have commissions. Given equal performance in predicting discrepancies, the efficiency and simplicity of medication number supports its use in identifying patients for intensive medication review beyond medication reconciliation.

Deprescribing medications among patients with multiple prescribers: A socioecological model.

Deprescribing is the intentional dose reduction or discontinuation of a medication. The development of deprescribing interventions should take into consideration important organizational, interprofessional, and patient-specific barriers that can be further complicated by the presence of multiple prescribers involved in a patient's care. Patients who receive care from an increasing number of prescribers may experience disruptions in the timely transfer of relevant healthcare information, increasing the risk of exposure to drug-drug interactions and other medication-related problems. Furthermore, the fragmentation of healthcare information across health systems can contribute to the refilling of discontinued medications, reducing the effectiveness of deprescribing interventions. Thus, deprescribing interventions must carefully consider the unique characteristics of patients and their prescribers to ensure interventions are successfully implemented. In this special article, an international working group of physicians, pharmacists, nurses, epidemiologists, and researchers from the United States Deprescribing Research Network (USDeN) developed a socioecological model to understand how multiple prescribers may influence the implementation of a deprescribing intervention at the individual, interpersonal, organizational, and societal level. This manuscript also includes a description of the concept of multiple prescribers and outlines a research agenda for future investigations to consider. The information contained in this manuscript should be used as a framework for future deprescribing interventions to carefully consider how multiple prescribers can influence the successful implementation of the service and ensure the intervention is as effective as possible.

Incorporating Physical Activity Assessments and Behavior Change Techniques Into Geriatrics.

Ninety-one percent of adults 65 years and older do not perform the recommended levels of physical activity (PA), resulting in increased risk of disability, morbidity, and mortality. Despite knowing the benefits of PA and acknowledging the importance of assessing and addressing inadequate PA levels, 50%-75% of health care providers do not incorporate behavior change techniques into clinical practice. This clinical gap can be explained by a lack of knowledge or confidence in (1) assessing PA levels; (2) addressing inadequate PA levels; and (3) justifying the time needed to use these techniques in clinical practice. In this special communication, we address this gap by providing a 3-step theoretical-based clinical decision pathway that guides health care providers on how to identify older adults with inadequate PA levels, determine readiness to increase PA, and empower patents to develop an action plan that will increase their PA levels. We also provide a conceptual model that supports the use of techniques that assess and address inadequate PA by tying PA to the Age-Friendly Health System's 4Ms (ie, What Matters to the older adult, Mentation, Mobility, and Medications).

Prevalence and Determinants of Unmet Social Needs Among Rural and Urban Veterans.

PURPOSE: To examine the prevalence and determinants of nine unmet social needs among rural compared with urban Veterans. METHODS: Retrospective study using survey data collected in 2020 merged with Veterans Health Administration (VA) administrative data. For each unmet need, separate logistic regression modes were run predicting the odds of rural compared with urban Veterans endorsing the need adjusting for sociodemographic characteristics and comorbidities. FINDINGS: 2,801 Veterans responded to the survey (53.7% response rate). Veterans experienced high rates of need (e.g., 22% reported food insecurity). Unmet need prevalence varied minimally between rural and urban Veterans and where they did, rural Veterans were less likely to endorse the need (e.g., loneliness). For many unmet needs, Black compared with White Veterans were at higher risk. Regional unmet need disparities were also observed. CONCLUSIONS: As VA considers expanding unmet need interventions, tailoring interventions to the sub-populations most at risk may be warranted.

Impact of the COVID-19 Pandemic on Providing Recommendations During Goals-of-Care Conversations: A Multisite Survey.

Background: Goals-of-care conversations (GoCCs) are essential for individualized end-of-life care. Shared decision-making (SDM) that elicits patients' goals and values to collaboratively make life sustaining treatment (LST) decisions is best practice. However, it is unknown how the COVID-19 pandemic onset and associated changes to care delivery, stress on providers, and clinical uncertainty affected SDM and recommendation-making during GoCCs. Aim: To assess providers' attitudes and behaviors related to GoCCs during the COVID-19 pandemic and identify factors associated with provision of LST recommendations. Design: Survey of United States Veterans Health Administration (VA) health care providers. Setting/Participants: Health care providers from 20 VA facilities with high COVID-19 caseloads early in the pandemic who had authority to place LST orders and practiced in select specialties (n = 3398). Results: We had 323 respondents (9.5% adjusted response rate). Most were age ≥50 years (51%), female (63%), non-Hispanic white (64%), and had ≥1 GoCC per week during peak-COVID-19 (78%). Compared with pre-COVID-19, providers believed it was less appropriate and felt less comfortable giving an LST recommendation during peak-COVID-19 (p < 0.001). One-third (32%) reported either "never" or "rarely" giving an LST recommendation during GoCCs at peak-COVID-19. In adjusted regression models, being a physician and discussing patients' goals and values were positively associated with giving an LST recommendation (B = 0.380, p = 0.031 and B = 0.400, p < 0.001, respectively) at peak-COVID-19. Conclusion: Providers who discuss patients' preferences and values are more likely to report giving a recommendation; both behaviors are markers of SDM during GoCCs. Our findings suggest potential areas for training in conducting patient-centered GoCCs.

Addressing clinician moral distress: Implications from a mixed methods evaluation during Covid-19.

Clinician moral distress has been documented over the past several decades as occurring within numerous healthcare disciplines, often in relation to clinicians' involvement in patients' end-of-life decision-making. The resulting harms impact clinician well-being, patient well-being, and healthcare system functioning. Given Covid-19's catastrophic death toll and associated demands on end-of-life decision-making processes, the pandemic represents a particularly important context within which to understand clinician moral distress. Thus, we conducted a convergent mixed methods study to examine its prevalence, associations with clinicians' demographic and professional characteristics, and contributing circumstances among Veterans Health Administration (VA) clinicians. The study, conducted in April 2021, consisted of a cross-sectional on-line survey of VA clinicians at 20 VA Medical Centers with professional jurisdiction to place life-sustaining treatment orders working who were from a number of select specialties. The survey collected quantitative data on respondents' demographics, clinical practice characteristics, attitudes and behaviors related to goals of care conversations, intensity of moral distress during "peak-Covid," and qualitative data via an open-ended item asking for respondents to describe contributing circumstances if they had indicated any moral distress. To understand factors associated with heightened moral distress, we analyzed quantitative data using bivariate and multivariable regression analyses and qualitative data using a hybrid deductive/inductive thematic approach. Mixed methods analysis followed, whereby we compared the quantitative and qualitative datasets and integrated findings at the analytic level. Out of 3,396 eligible VA clinicians, 323 responded to the survey (9.5% adjusted response rate). Most respondents (81%) reported at least some moral distress during peak-Covid. In a multivariable logistic regression, female gender (OR 3.35; 95% CI 1.53-7.37) was associated with greater odds of moral distress, and practicing in geriatrics/palliative care (OR 0.40; 95% CI 0.18-0.87) and internal medicine/family medicine/primary care (OR 0.46; 95% CI 0.22-0.98) were associated with reduced odds of moral distress compared to medical subspecialties. From the 191 respondents who completed the open-ended item, five qualitative themes emerged as moral distress contributors: 1) patient visitation restrictions, 2) anticipatory actions, 3) clinical uncertainty related to Covid, 4) resource shortages, and 5) personal risk of contracting Covid. Mixed methods analysis found that quantitative results were consistent with these last two qualitative themes. In sum, clinician moral distress was prevalent early in the pandemic. This moral distress was associated with individual-, system-, and situation-level contributors. These identified contributors represent leverage points for future intervention to mitigate clinician moral distress and its negative outcomes during future healthcare crises and even during everyday clinical care.