Patient-reported mental health and well-being trajectories in oncology patients during radiation therapy: an exploratory retrospective cohort analysis using the Ontario Cancer Registry.

PURPOSE: Mental health and well-being trajectories are not expected to be homogeneous in diverse clinical populations. This exploratory study aims to identify subgroups of patients with cancer receiving radiation therapy who have different mental health and well-being trajectories, and examine which socio-demographic, physical symptoms, and clinical variables are associated with such trajectories. METHODS: Retrospective analysis of radiation therapy patients diagnosed with cancer in 2017 was conducted using data from the Ontario Cancer Registry (Canada) and linked with administrative health data. Mental health and well-being were measured using items from the Edmonton Symptom Assessment System-revised questionnaire. Patients completed up to 6 repeated measurements. We used latent class growth mixture models to identify heterogeneous mental health trajectories of anxiety, depression, and well-being. Bivariate multinomial logistic regressions were conducted to explore variables associated with the latent classes (subgroups). RESULTS: The cohort (N = 3416) with a mean age of 64.5 years consisted of 51.7% females. Respiratory cancer was the most common diagnosis (30.4%) with moderate to severe comorbidity burden. Four latent classes with distinct anxiety, depression, and well-being trajectories were identified. Decreasing mental health and well-being trajectories are associated with being female; living in neighborhoods with lower income, greater population density, and higher proportion of foreign-born individuals; and having higher comorbidity burden. CONCLUSIONS: The findings highlight the importance of considering social determinants of mental health and well-being, in addition to symptoms and clinical variables, when providing care for patients undergoing radiation therapy.

The Use of Generic Patient-Reported Outcome Measures in Emergency Department Surveys: Discriminant Validity Evidence for the Veterans RAND 12-Item Health Survey and the EQ-5D.

OBJECTIVES: This study aimed to compare discriminant validity evidence of 2 generic patient-reported outcome measures (PROMs), the Veterans RAND 12-Item Health Survey (VR-12) and level 5 of EQ-5D (EQ-5D-5L), for use in emergency departments (EDs). METHODS: Data were obtained via a cross-sectional survey of 5876 patients in British Columbia (Canada) who completed a questionnaire after visiting an ED in 2018. We compared the extent to which the VR-12 and the EQ-5D-5L distinguished among groups of ED patients with different levels of comorbidity burden and self-reported physical and mental or emotional health status. Multivariable logistic regression was used to evaluate the ability of the 2 PROMs to identify patients presenting with a mental health (MH) condition. RESULTS: All the measures produced small effect sizes (ESs) for discriminating comorbidity levels (R2 range: 0.00 [VR-12 mental component summary {MCS}] to 0.10 [VR-12 physical component summary score]). The EQ-5D visual analog scale offered the largest ES for discriminating self-reported physical health (R2 = 0.48), whereas the MCS, the VR-12 MH domain, and the EQ-5D-5L anxiety/depression dimension had the largest ESs for discriminating self-reported mental or emotional health (R2 = 0.42, 0.40, and 0.38, respectively). The MCS produced a medium ES (R2 = 0.42) along with the VR-12 utility score (R2 = 0.27) compared with the EQ-5D-5L index (R2 = 0.19). Having a MH condition was predominantly identified by the MCS (Pratt index = 0.56). CONCLUSIONS: The VR-12 PROM provides a more comprehensive measurement of MH than the EQ-5D-5L, which is important to inform healthcare service needs for patients who present in EDs with MH challenges.

Growth mixture models: a case example of the longitudinal analysis of patient-reported outcomes data captured by a clinical registry.

BACKGROUND: An assumption in many analyses of longitudinal patient-reported outcome (PRO) data is that there is a single population following a single health trajectory. One approach that may help researchers move beyond this traditional assumption, with its inherent limitations, is growth mixture modelling (GMM), which can identify and assess multiple unobserved trajectories of patients' health outcomes. We describe the process that was undertaken for a GMM analysis of longitudinal PRO data captured by a clinical registry for outpatients with atrial fibrillation (AF). METHODS: This expository paper describes the modelling approach and some methodological issues that require particular attention, including (a) determining the metric of time, (b) specifying the GMMs, and (c) including predictors of membership in the identified latent classes (groups or subtypes of patients with distinct trajectories). An example is provided of a longitudinal analysis of PRO data (patients' responses to the Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) Questionnaire) collected between 2008 and 2016 for a population-based cardiac registry and deterministically linked with administrative health data. RESULTS: In determining the metric of time, multiple processes were required to ensure that "time" accounted for both the frequency and timing of the measurement occurrences in light of the variability in both the number of measures taken and the intervals between those measures. In specifying the GMM, convergence issues, a common problem that results in unreliable model estimates, required constrained parameter exploration techniques. For the identification of predictors of the latent classes, the 3-step (stepwise) approach was selected such that the addition of predictor variables did not change class membership itself. CONCLUSIONS: GMM can be a valuable tool for classifying multiple unique PRO trajectories that have previously been unobserved in real-world applications; however, their use requires substantial transparency regarding the processes underlying model building as they can directly affect the results and therefore their interpretation.

Patient-reported outcomes and the identification of subgroups of atrial fibrillation patients: a retrospective cohort study of linked clinical registry and administrative data.

PURPOSE: Previous research about the health and quality of life of people with atrial fibrillation has typically identified a single health trajectory. Our study aimed to examine variability in health trajectories and patient characteristics associated with such variability. METHODS: We conducted a retrospective analysis of data collected between 2008 and 2016 for a cardiac registry in British Columbia (Canada) linked with administrative health data. The Atrial Fibrillation Effect on Quality of Life Questionnaire was used to measure health status at up to 10 clinic visits. Growth mixture models were used and a three-step multinomial logistic regression was conducted to identify predictors of subgroups with different trajectories. RESULTS: The patients (N = 7439) were primarily men (61.1%) over 60 years of age (72.9%). Three subgroups of health status trajectories were identified: "poor but improving", "good and stable", and "excellent and stable" health. Compared with the other two groups, patients in the "poor but improving group" were more likely to (1) be less than 60 years of age; (2) be women; (3) have greater risk of stroke; (4) have had ablation therapy within 6 months to 1 year or more than 2 years after their initial consultation; and (5) have had anticoagulation therapy within 6 months. CONCLUSION: Using growth mixture models, we found that not all health trajectories are the same. These models can help to understand variability in trajectories with different patient characteristics that could inform tailored interventions and patient education strategies.

Implications of response shift for micro-, meso-, and macro-level healthcare decision-making using results of patient-reported outcome measures.

PURPOSE: Results of patient-reported outcome measures (PROMs) are increasingly used to inform healthcare decision-making. Research has shown that response shift can impact PROM results. As part of an international collaboration, our goal is to provide a framework regarding the implications of response shift at the level of patient care (micro), healthcare institute (meso), and healthcare policy (macro). METHODS: Empirical evidence of response shift that can influence patients' self-reported health and preferences provided the foundation for development of the framework. Measurement validity theory, hermeneutic philosophy, and micro-, meso-, and macro-level healthcare decision-making informed our theoretical analysis. RESULTS: At the micro-level, patients' self-reported health needs to be interpreted via dialogue with the clinician to avoid misinterpretation of PROM data due to response shift. It is also important to consider the potential impact of response shift on study results, when these are used to support decisions. At the meso-level, individual-level data should be examined for response shift before aggregating PROM data for decision-making related to quality improvement, performance monitoring, and accreditation. At the macro-level, critical reflection on the conceptualization of health is required to know whether response shift needs to be controlled for when PROM data are used to inform healthcare coverage. CONCLUSION: Given empirical evidence of response shift, there is a critical need for guidelines and knowledge translation to avoid potential misinterpretations of PROM results and consequential biases in decision-making. Our framework with guiding questions provides a structure for developing strategies to address potential impacts of response shift at micro-, meso-, and macro-levels.

Interpretation and use of patient-reported outcome measures through a philosophical lens.

PURPOSE: As patient-reported outcome measures (PROMs) increasingly become key outcome indicators in health care, there has been growing concern about the potential negative consequences that could result when interpretations are being made to inform clinical and policy decisions. Therefore, we explored theoretical issues, assumptions, and consequences of using PROMs from a philosophical point of view. METHODS: Our analysis of the literature was informed by Gadamerian hermeneutics, which emphasizes the dialectical processes that occur during interpretation, to provide insights as to how different users interpret and use standardized questions about health and quality of life. RESULTS: We structured our consideration according to three tenets of using PROMs: (1) the use of PROMs involves the interpretation of contextual elements; (2) interpretation of PROMs is an ongoing dialectical interaction; and (3) the use of PROMs involves openness and reflexivity. These findings suggest that hermeneutics provides a useful approach to examining the complexities of measuring patient-reported outcomes by attending to the perspectives of different users (e.g., patients, clinicians, administrators, and policy-makers) at the micro-, meso-, and macro-levels and the broader socio-historical and economic situation. CONCLUSION: Because PROMs can have different meanings and are used for different purposes, we propose that hermeneutics be used as a lens to ask reflexive questions about the problems of measurement and open a pluralistic dialogue with respect to the way we use PROMs and the interpretations we make of the findings that derive from our studies.

Nurses "Seeing Forest for the Trees" in the Age of Machine Learning: Using Nursing Knowledge to Improve Relevance and Performance.

Although machine learning is increasingly being applied to support clinical decision making, there is a significant gap in understanding what it is and how nurses should adopt it in practice. The purpose of this case study is to show how one application of machine learning may support nursing work and to discuss how nurses can contribute to improving its relevance and performance. Using data from 130 specialized hospitals with 101 766 patients with diabetes, we applied various advanced statistical methods (known as machine learning algorithms) to predict early readmission. The best-performing machine learning algorithm showed modest predictive ability with opportunities for improvement. Nurses can contribute to machine learning algorithms by (1) filling data gaps with nursing-relevant data that provide personalized context about the patient, (2) improving data preprocessing techniques, and (3) evaluating potential value in practice. These findings suggest that nurses need to further process the information provided by machine learning and apply "Wisdom-in-Action" to make appropriate clinical decisions. Nurses play a pivotal role in ensuring that machine learning algorithms are shaped by their unique knowledge of each patient's personalized context. By combining machine learning with unique nursing knowledge, nurses can provide more visibility to nursing work, advance nursing science, and better individualize patient care. Therefore, to successfully integrate and maximize the benefits of machine learning, nurses must fully participate in its development, implementation, and evaluation.

Collaborative peer review process as an informal interprofessional learning tool: Findings from an exploratory study.

Despite numerous studies on formal interprofessional education programes, less attention has been focused on informal interprofessional learning opportunities. To provide such an opportunity, a collaborative peer review process (CPRP) was created as part of a peer-reviewed journal. Replacing the traditional peer review process wherein two or more reviewers review the manuscript separately, the CPRP brings together students from different professions to collaboratively review a manuscript. The aim of this study was to assess whether the CPRP can be used as an informal interprofessional learning tool using an exploratory qualitative approach. Eight students from Counselling Psychology, Occupational and Physical Therapy, Nursing, and Rehabilitation Sciences were invited to participate in interprofessional focus groups. Data were analysed inductively using thematic analysis. Two key themes emerged, revealing that the CPRP created new opportunities for interprofessional learning and gave practice in negotiating feedback. The results reveal that the CPRP has the potential to be a valuable interprofessional learning tool that can also enhance reviewing and constructive feedback skills.

Examining gender-related differential item functioning of the Veterans Rand 12-item Health Survey.

PURPOSE: Previous research suggests that gender differences in patient-reported outcome measures (PROMs) may reflect measurement bias rather than true differences in underlying health status. The aim of this study is to examine whether the Veterans Rand 12-item Health Survey (VR-12) allows for unbiased comparisons of physical and mental health scores across gender. The VR-12 is a generic PROM consisting of 12 items with 3-6 response options for the measurement of mental and physical health. METHODS: Study data were from the 2015 Health Outcomes Survey pertaining to the Medicare beneficiaries. A total of 277,518 participants included 116,817 (42.1%) males and 160,701 (57.9%) females. Scale-level and item-level differential functioning methods were applied using multiple-group confirmatory factor analysis and ordinal logistic regression, respectively. RESULTS: The scale-level differential functioning showed support for strict invariance (RMSEA = 0.045; CFI = 0.995) across gender. Although we found statistically significant differential item functioning for several items, the magnitude was negligible (maximum ΔR 2 = 0.007). CONCLUSION: The VR-12 physical and mental health status scores are unbiased with respect to gender.

Personas to Guide Understanding Traditions of Gay Men Living With HIV Who Smoke.

Gay men living with HIV (GMLWH) who smoke are less responsive to generalized smoking reduction and cessation (SRC) programs than heterosexual persons. This study explored perspectives of GMLWH during the design of a web-based SRC intervention. Participatory design techniques were used to guide the creation of personas that are composite representations of a person who would use the web-based SRC intervention. Researcher-participants (n = 13) created all data. Data analysis involved thematic coding drawing from an ethnographic perspective. Thematic analysis revealed seven intersecting themes related to SRC among participants, and an overarching theme navigating life. Concepts drawn from our ethnographic approach highlight cultural differences between GMLWH and mainstream society. Personas offer a mechanism for interpreting experiences and traditions of GMLWH. SRC interventions with GMLWH must address their social realities that include tools for navigating life, disease, and social identity.

Heterosexual gender relations and masculinity in fathers who smoke.

The purpose of this research was to explore the role of masculinity and heterosexual gender relations in new and expectant fathers' explanations of their continued smoking. We conducted a secondary analysis of in-depth interviews with 20 fathers. Two themes were identified: (1) reconciling with partners to maintain a smoke-free family home; and (2) smoking to self-regulate emotions and maintain relationships. Fathers' decisions to smoke and changes in smoking behavior were shaped by ideals of masculinity and by partner relationships and family and social contexts, including division of domestic duties and childcare. Recognizing the influence of both masculinity and gender relations could provide new directions for supporting men's smoking cessation efforts during early parenthood.

Electronic patient-reported outcomes in clinical kidney practice (ePRO Kidney): a process evaluation of educational support for clinicians.

Background: Patient-reported outcomes (PROs) are increasingly mandated in kidney care to incorporate patients' perspectives. Objectives: We assessed whether educational support for clinicians using electronic (e)PROs could enhance person-centered care. Design: A process evaluation, using a mixed methods longitudinal comparative concurrent design was undertaken of educational support to clinicians on routine use of ePROs. In two urban home dialysis clinics in Alberta, Canada, patients completed ePROs. At the implementation site, clinicians were provided with ePROs and clinician-oriented education via voluntary workshops. At the non-implementation site, neither were provided. Person-centered care was measured using the Patient Assessment of Chronic Illness Care-20 (PACIC-20). Methods: Longitudinal structural equation models (SEMs) compared change in overall PACIC scores. The interpretive description approach, using thematic analysis of qualitative data, further evaluated processes of implementation. Results: Data were collected from questionnaires completed by 543 patients, 4 workshops, 15 focus groups, and 37 interviews. There was no overall difference in person-centered care throughout the study, including after delivery of workshops. The longitudinal SEMs revealed substantial individual-level variability in overall PACIC trajectories. However, there was no improvement at the implementation site and no difference between the sites during both the pre- and post-workshop periods. Similar results were obtained for each PACIC domain. Qualitative analysis provided insights into why there was no substantial difference between sites: (1) clinicians wanted to see kidney symptoms, not quality of life, (2) workshops were tailored to clinicians' educational needs, not patients' needs, and (3) variable use of ePRO data by clinicians. Conclusion: Training clinicians on use of ePROs is complex and likely only part of what is required to enhance person-centered care. Registration: NCT03149328. https://clinicaltrials.gov/ct2/show/NCT03149328.

Seeing the person before the numbers: Personas for understanding patients' life stories when using patient-reported outcome measures in practice settings.

AIMS: While patient-reported outcome measures (PROMs) are increasingly being integrated into health information technologies, one challenge has been to assist clinicians in understanding how the responses to PROMs relate to patient stories for identifying and addressing the care needs of individual patients. Personas, hypothetical representations of patients, can be used as an innovative strategy to support clinicians' use of PROMs in their practice. These personas embody patients' life stories, making them a valuable tool for understanding the person when using PROMs. The aim of this project focused on cancer-related experiences to develop personas as a knowledge translation strategy to support clinicians' use of PROMs for person-centred cancer care. METHODS: Eight older adults participated in online workshops (n = 2-3 participants/workshop; 1.5-hour sessions) to co-develop personas that reflected their collective experiences at a particular stage of their cancer journeys. Participants were asked to identify themes that focused on what the personas were thinking and feeling, what influenced how the personas acted, and the personas' overall goals. Participants subsequently completed an emotional well-being PROM from the perspective of the persona. Personas were further refined based on key themes identified during the workshop discussions. RESULTS: Four personas representing the cumulative experiences of the workshop participants were developed to help clinicians link PROM responses to patient stories. These personas became the basis of four practice scenarios, which were examples of interactions between a clinician and each persona, to demonstrate the use of PROMs in practice. CONCLUSION: Personas can be used to illustrate patients' life stories and contextualize PROMs data. As a knowledge translation strategy, personas can foster clinician awareness of how responses to PROMs can be used to initiate conversations to better understand patients' unique life situations.

Patient-Reported Outcomes Measurement in Radiation Oncology: Interpretation of Individual Scores and Change over Time in Clinical Practice.

Tools for measuring patients' perceived health and quality of life, such as patient-reported outcome measures (PROMs), inform clinical decisions for patients requiring radiation therapy. However, there may be inconsistencies in how patients interpret and respond to PROMs due to cultural, environmental, personal, or experiential factors. Differential item functioning (DIF) and response shift (RS) refer to differences in the meaning of PROMs between patients or over time (respectively). DIF and RS can threaten the accurate interpretation and use of PROMs, potentially resulting in erroneous conclusions about effectiveness, and flawed individual-level clinical decision-making. Given the empirical evidence of DIF and RS, we aim to review clinical implications and solutions for addressing DIF and RS by providing vignettes from collaborative examinations with workshop participants, as well as the literature. By making these methodological concepts accessible and relevant, for practice, clinicians may feel more confident to ask clarifying questions of patients when PROM scores and the contextual patient information do not align. PROM scores need to be interpreted via dialogue with the patient to avoid misinterpretation due to DIF and RS, which could diminish patient-clinician communication and impede shared decision-making. This work is part of an interdisciplinary knowledge translation initiative focused on the interpretation of PROM scores by clinically-oriented audiences.

Avoidance of urinary catheterization to minimize in-hospital complications after transcatheter aortic valve implantation: An observational study.

BACKGROUND: Contemporary transcatheter aortic valve implantation (TAVI) devices and approach present opportunities to review historical practices initially informed by early treatment development and cardiac surgery. The avoidance of urinary catheterization in the older TAVI population is a strategy to minimize in-hospital complications. The purpose of the study was to explore elimination-related complications following the phased implementation of a default strategy of avoiding urinary catheterization in patients undergoing transfemoral (TF) TAVI. METHODS: We conducted an observational study using a retrospective chart review of patients treated between 2011 and 2013 to identify patient characteristics, peri-procedure details, in-hospital outcomes and elimination-related complications in patients who did or did not receive a peri-procedure indwelling catheter. Descriptive analyses were used to report differences between the groups; we conducted a regression analysis to explore the relationship between the practice of urinary catheterization and total procedure time. RESULTS: Of the 408 patients who underwent TF TAVR, 188 (46.1%) received a peri-procedure indwelling urinary catheter and 220 (53.9%) did not. There was no difference in in-hospital mortality (2.2%), disabling stroke (0.5%), or other major cardiac adverse events. The avoidance of a urinary catheter resulted in significantly lower rates of urinary tract infection requiring a new antibiotic regimen (1.4% versus 6.1%, p = 0.014), haematuria documented by medicine or nursing (3.7% versus 17.6%, p = 0.001), and the need for continuous bladder irrigation (2.7% versus 0%, p = 0.027). CONCLUSION: The avoidance of a urinary catheter may contribute to improved outcomes in patients undergoing TAVI. The intervention should be further evaluated within the broader study of minimalist TAVI.

Workplace continuing education for nurses caring for hospitalised older people.

AIMS AND OBJECTIVES: To develop, implement and evaluate a workplace continuing education programme about nursing care of hospitalised older people. BACKGROUND: The healthcare system cannot rely solely upon nurses' prelicensure education to prepare them to meet the evolving needs of hospitalised older patients. Over the past decade, there has been a dramatic rise in the proportion of older people in hospitals, yet many nurses do not have specialised knowledge about the unique care needs of this population. DESIGN: A multimethod pre-to post-design was employed. METHODS: Between September 2013 and April 2014, data were collected via surveys, focus groups and interviews. Thirty-two Registered Nurses initially enrolled in the programme of which 22 completed all data points. Three managers also participated in interviews. One-way repeated-measures ANOVAs were conducted to evaluate the effect of the programme and change over time. Qualitative data were analysed using thematic analysis. RESULTS: Survey results indicated improvements in perceptions about nursing care of older people but no changes in knowledge. Themes generated from the qualitative data focused on participants' experiences of taking part in the programme and included: (i) relevance of content and delivery mode, (ii) value of participating in the programme and (iii) continuing education in the context of acute care. CONCLUSIONS: This study illustrated the potential role of workplace continuing education in improving care for hospitalised older people, particularly the potential to change nurses' perceptions about this population. Nurses prefer learning opportunities that are varied in delivery of educational elder-focused content and accessible at work. Organisational leaders need to consider strategies that minimise potential barriers to workplace continuing education. IMPLICATIONS FOR PRACTICE: Workplace continuing education can play a key role in improving quality of care for hospitalized older adults and ought to be a priority for employers planning education for nurses.

Vancouver Transcatheter Aortic Valve Replacement Clinical Pathway: Minimalist Approach, Standardized Care, and Discharge Criteria to Reduce Length of Stay.

We describe the development, implementation, and evaluation of a standardized clinical pathway to facilitate safe discharge home at the earliest time after transfemoral transcatheter aortic valve replacement. Between May 2012 and October 2014, the Heart Team developed a clinical pathway suited to the unique requirements of transfemoral transcatheter aortic valve replacement in contemporary practice. The components included risk-stratified minimalist periprocedure approach, standardized postprocedure care with early mobilization and reconditioning, and criteria-driven discharge home. Our aim was to reduce variation in care, identify a subgroup of patients suitable for early discharge (≤48 hours), and decrease length of stay for all patients. We addressed barriers related to historical practices, complex multidisciplinary stakeholder engagement, and adoption of length of stay as a quality indicator. We retrospectively reviewed the experiences of 393 consecutive patients; 150 (38.2%) were discharged early. At baseline, early discharge patients had experienced less previous balloon aortic valvuloplasty, had higher left ventricular ejection fraction, better cognitive function, and were less frail than the standard discharge group (>48 hours). Early discharge was associated with the use of local anesthesia, implantation of balloon expandable device, avoidance of urinary catheter, and early removal of temporary pacemaker. Median length of stay was 1 day for early discharge and 3 days for other patients; 97.7% were discharged home. There were no differences in 30-day mortality (1.3%), disabling stroke (0.8%), or readmission (10.7%). The implementation of a transcatheter aortic valve replacement clinical pathway shifted the program's approach to combine standardized processes and individual risk stratification. The Vancouver transcatheter aortic valve replacement clinical pathway requires a rigorous assessment to determine its efficacy, safety, and reproducibility.

Masculinity and Fatherhood: New Fathers' Perceptions of Their Female Partners' Efforts to Assist Them to Reduce or Quit Smoking.

Health promotion initiatives to reduce smoking among parents have focused almost exclusively on women to support their cessation during pregnancy and postpartum, while overlooking the importance of fathers' smoking cessation. This study was a secondary analysis of in-depth interviews with 20 new and expectant fathers to identify how they perceived their female partners' efforts to assist them to reduce or quit smoking. Social constructionist gender frameworks were used to theorize and develop the findings. Three key themes were identified: support and autonomy in men's smoking cessation, perception of challenging men's freedom to smoke, and contempt for men's continued smoking. The findings suggest that shifts in masculinities as men take up fathering should be considered in designing smoking cessation interventions for fathers.

Appreciating the Persona paradox: lessons from participatory design sessions with HIV+ gay men.

Eliciting user requirements from HIV-positive gay men who smoke can be challenging. This is because of the complex relationship between social stigma and gender identities (e.g., gay, masculine, HIV+, and smoking status). Inspired to engage HIV-positive gay men in the development of a web-assisted tobacco intervention, we used personas as a main communication tool in our participatory design sessions. Personas are characters created by users that embody part of their own behaviours, thoughts, and motivations. In an apparent paradox, this article is a description of how the use of personas to ensure less realistic self-representation provided an impetus for more self-disclosure. Findings and feedbacks from this study reveal that personas are an effective design tool to engage users in sensitive topics. Implications for future work are also discussed.