Challenges and Solutions for Monitoring Alcohol Use in Patients With Alcohol-Related Liver Disease: Pilot Study of a Wearable Alcohol Biosensor.

OBJECTIVES: Early alcohol use identification can prevent morbidity/mortality for alcohol-associated liver disease (ALD). Innovative wearable alcohol biosensors (biosensors) that identify alcohol use through perspiration are an emerging technology with potential application for patients with ALD. Our primary aim was to determine biosensor acceptability and feasibility for patients with ALD. We describe participant acceptance and challenges using biosensor technology in a pilot study of biosensors with patients with ALD. DESIGN: Participants had a recent diagnosis or hospitalization for decompensated ALD, had to be drinking within the past 3 months, and had to be followed at our center. Participants wore the biosensor daily for 3 months. Quantitative data using the Technology Acceptance Model 2 (TAM2) measure were collected at intake and study conclusion. The TAM2's 13 items cover four scales: perceived usefulness, ease of use, attitude toward technology, and intention to use on a 7-point Likert scale. Lower scores indicate higher acceptance. Participants were asked open-ended questions about issues wearing the biosensor. RESULTS: Among 27 participants, 60% were women with an average age of 45 (10) years, and 89% were White. TAM2 subscales indicated initially high acceptance (mean scores = 1.2-2.2) and remained high (mean scores = 1.3-2.3) without a statistically significant decline at study conclusion. From open-ended questions, several themes regarding problems with device wear emerged a) uncomfortable or cumbersome to wear, b) problems with biosensor appearance, and c) issues with usability. Challenges to biosensor usage included data being lost when devices were damaged and devices being lost during the study. CONCLUSIONS: Alcohol biosensors seem to be acceptable to ALD participants. However, improving the appearance, comfort, durability, and functionality of biosensor devices is critical to clinical deployment.Trial Registration:Clinicaltrials.gov identifier NCT03533660: Alcohol biosensor monitoring for alcohol liver disease.

Promoting medication adherence from the perspective of adolescent and young adult kidney transplant recipients, parents, and health care professionals: A TAKE-IT TOO study.

Medication non-adherence is an important factor limiting allograft survival after kidney transplantation in AYA. Some interventions, including the TAKE-IT, showed some success in promoting adherence but the potential for scalability and use in routine clinical practice is limited. We applied user-centered design to gather the perspectives of recipients, parents, and health professionals concerning their needs, challenges, and potential intervention strategies to design an optimal, multi-component medication adherence intervention. The qualitative study was conducted at four Canadian and three American kidney transplant programs. Separate focus groups for recipients, parents, and health professionals were convened to explore these stakeholders' perspectives. Directed content analysis was employed to identify themes that were shared vs distinct across stakeholders. All stakeholder groups reported challenges related to taking medications on time in the midst of their busy schedules and the demands of transitioning toward independence during adolescence. The stakeholders also made suggestions for the multi-component behavioral intervention, including an expanded electronic pillbox and companion website, education materials, and customized digitized features to support shared responsibility and communication among recipients, parents, and health professionals. Several suggestions regarding the functionality and features of the potential intervention reported in this early stage will be explored in more depth as the iterative process unfolds. Our approach to actively involve all stakeholders in the process increases the likelihood of designing an adherence intervention that is truly user-informed and fit for the clinical setting.

The impact of a yoga-based physical therapy group for individuals with traumatic brain injury: results from a pilot study.

OBJECTIVE: To compare the impacts of yoga-based physical therapy versus a seated rest within the context of standard rehabilitation practice on sleep, heart rate variability (HRV), anxiety, and fatigue during acute traumatic brain injury (TBI) rehabilitation. METHODS: Eleven individuals participated in this crossover study involving the following interventions in a randomized order: group yoga-based physical therapy (YPT), conventional physical therapy (CPT), and group seated rest in a relaxing environment (SR). HRV and self-reported anxiety and fatigue were measured immediately before and after each group, and sleep after each condition and at baseline. Data was analyzed using generalized linear mixed models with repeated measures. RESULTS: The interaction between time and treatment was statistically significant (p = .0203). For the SR treatment, wake after sleep onset (WASO) rate was reduced from 14.99 to 10.60 (IRR = 0.71; p = .006). Time and treatment were not found to be statistically significantly associated with any of the secondary outcomes. CONCLUSION: Yoga-based physical therapy is feasible and safe in the inpatient rehabilitation setting following TBI. Sleep quality improved following the addition of a one-hour seated rest in a relaxing environment to a standard rehabilitation daily schedule, suggesting that structured rest time may be beneficial to sleep hygiene during inpatient rehabilitation following TBI. ClinicalTrials.Gov Registration Number: NCT03701594.

Providing Level-of-Match Information to Perfectly Matched Unrelated Stem Cell Donors: Evaluating Acceptability and Potential Changes in Donor Availability.

Patients with blood-related diseases often cannot identify a matched related donor and must seek donors in unrelated donor registries. These registries face the challenge of ensuring that potential donors are available when contacted. Donor attrition is especially problematic when there is only a single perfectly matched potential donor. One way to improve donor availability might be to present perfectly matched donors (high-priority donors [HPDs]) with more precise information about their match status. This project evaluated the impact of providing such information to HPDs at the National Marrow Donor Program (NMDP)/Be The Match. Objectives were to determine the acceptability of the new messaging to both HPDs and the donor contact representatives (DCRs) who delivered the message, consistency of message delivery, and whether the new messaging was associated with improved donor availability. Mixed methods were used to collect telephone interview data from HPDs, matched samples of non-HPDs, and DCRs. Donor availability data came from NMDP records. Key findings were as follows: (1) the HPD message was acceptable to potential donors and did not seem to produce undue pressure, (2) the message was acceptable to DCRs who became more comfortable and consistent in delivering the message over time, but (3) the new messaging did not significantly increase availability. Despite the lack of evidence for increased availability, there may be ethical benefits and little harm to providing well-matched donors with more information about their degree of matching. Research should examine stronger match status messages and delivery of new messaging to additional highly-matched donor groups.

Knowledge, barriers and facilitators of exercise in dialysis patients: a qualitative study of patients, staff and nephrologists.

BACKGROUND: Despite growing evidence on benefits of increased physical activity in hemodialysis (HD) patients and safety of intra-dialytic exercise, it is not part of standard clinical care, resulting in a missed opportunity to improve clinical outcomes in these patients. To develop a successful exercise program for HD patients, it is critical to understand patients', staff and nephrologists' knowledge, barriers, motivators and preferences for patient exercise. METHODS: In-depth interviews were conducted with a purposive sample of HD patients, staff and nephrologists from 4 dialysis units. The data collection, analysis and interpretation followed Criteria for Reporting Qualitative Research guidelines. Using grounded theory, emergent themes were identified, discussed and organized into major themes and subthemes. RESULTS: We interviewed 16 in-center HD patients (mean age 60 years, 50% females, 63% blacks), 14 dialysis staff members (6 nurses, 3 technicians, 2 dietitians, 1 social worker, 2 unit administrators) and 6 nephrologists (50% females, 50% in private practice). Although majority of the participants viewed exercise as beneficial for overall health, most patients failed to recognize potential mental health benefits. Most commonly reported barriers to exercise were dialysis-related fatigue, comorbid health conditions and lack of motivation. Specifically for intra-dialytic exercise, participants expressed concern over safety and type of exercise, impact on staff workload and resistance to changing dialysis routine. One of the most important motivators identified was support from friends, family and health care providers. Specific recommendations for an intra-dialytic exercise program included building a culture of exercise in the dialysis unit, and providing an individualized engaging program that incorporates education and incentives for exercising. CONCLUSION: Patients, staff and nephrologists perceive a number of barriers to exercise, some of which may be modifiable. Participants desired an individualized intra-dialytic exercise program which incorporates education and motivation, and they provided a number of recommendations that should be considered when implementing such a program.

Reliability and construct validity of PROMIS® measures for patients with heart failure who undergo heart transplant.

PURPOSE: To evaluate the reliability and construct validity of measures from the Patient-Reported Outcomes Measurement Information System(®) (PROMIS(®)) for patients with heart failure before and after heart transplantation. METHODS: We assessed reliability of the PROMIS short forms using Cronbach's alpha and the average marginal reliability. To assess the construct validity of PROMIS computerized adaptive tests and short-form measures, we calculated Pearson product moment correlations between PROMIS measures of physical function, fatigue, depression, and social function and existing PRO measures of similar domains (i.e., convergent validity) as well as different domains (i.e., discriminate validity) in patients with heart failure awaiting heart transplant. We evaluated the responsiveness of these measures to change after heart transplant using effect sizes. RESULTS: Forty-eight patients were included in the analyses. Across the many domains examined, correlations between conceptually similar domains were larger than correlations between different domains of health, demonstrating construct validity. Health status improved substantially after heart transplant (standardized effect sizes, 0.63-1.24), demonstrating the responsiveness of the PROMIS measures. Scores from the computerized adaptive tests and the short forms were similar. CONCLUSIONS: This study provides evidence for the reliability and construct validity (including responsiveness to change) of four PROMIS domains in patients with heart failure before and after heart transplant. PROMIS measures are a reasonable choice in this context and will facilitate comparisons across studies and health conditions.

Prevention of poor psychosocial outcomes in living organ donors: from description to theory-driven intervention development and initial feasibility testing.

CONTEXT: Although some living donors experience psychological, somatic, and interpersonal difficulties after donation, interventions to prevent such outcomes have not been developed or evaluated. OBJECTIVE: To (1) summarize empirical evidence on psychosocial outcomes after donation, (2) describe a theoretical framework to guide development of an intervention to prevent poor outcomes, and (3) describe development and initial evaluation of feasibility and acceptability of the intervention. METHODS: Based on a narrative literature review suggesting that individuals ambivalent about donation are at risk for poor psychosocial outcomes after donation, the intervention targeted this risk factor. Intervention structure and content drew on motivational interviewing principles in order to assist prospective donors to resolve ambivalence. Data were collected on donors' characteristics at our institution to determine whether they constituted a representative population in which to evaluate the intervention. Study participants were then recruited to assess the feasibility and acceptability of the intervention. They were required to have scores greater than 0 on the Simmons Ambivalence Scale (indicating at least some ambivalence about donation). RESULTS: Our population was similar to the national living donor population on most demographic and donation-related characteristics. Eight individuals who had been approved to donate either a kidney or liver segment were enrolled for pilot testing of the intervention. All successfully completed the 2-session telephone-based intervention before scheduled donation surgery. Participants' ratings of acceptability and satisfaction were high. Open-ended comments indicated that the intervention addressed participants' thoughts and concerns about the decision to donate. CONCLUSIONS: The intervention is feasible, acceptable, and appears relevant to donor concerns. A clinical trial to evaluate the efficacy of the intervention is warranted.

An intervention fidelity framework for technology-based behavioral interventions.

BACKGROUND: Despite the proliferation of health technologies, descriptions of the unique considerations and practical guidance for evaluating the intervention fidelity of technology-based behavioral interventions are lacking. OBJECTIVES: The aims of this study were to (a) discuss how technology-based behavioral interventions challenge conventions about how intervention fidelity is conceptualized and evaluated, (b) propose an intervention fidelity framework that may be more appropriate for technology-based behavioral interventions, and (c) present a plan for operationalizing each concept in the framework using the intervention fidelity monitoring plan for Pocket PATH (Personal Assistant for Tracking Health), a mobile health technology designed to promote self-care behaviors after lung transplantation, as an exemplar. METHOD: The literature related to intervention fidelity and technology acceptance was used to identify the issues that are unique to the fidelity of technology-based behavioral interventions and thus important to include in a proposed intervention fidelity framework. An intervention fidelity monitoring plan for technology-based behavioral interventions was developed as an example. RESULTS: The intervention fidelity monitoring plan was deemed feasible and practical to implement and showed utility in operationalizing the concepts such as assessing interventionists' delivery and participants' acceptance of the technology-based behavioral intervention. DISCUSSION: The framework has the potential to guide the development of implementation fidelity monitoring tools for other technology-based behavioral interventions. Further application and testing of this framework will allow for a better understanding of the role that technology acceptance plays in the adoption and enactment of the behaviors that technology-based behavioral interventions are intended to promote.

Implementing Huddles Improves Care Coordination in an Academic Health Center.

PURPOSE OF THE STUDY: To determine whether routinely scheduled, organized interdisciplinary huddles result in decreased length of stay and readmissions. PRIMARY PRACTICE SETTING: The study was conducted in an academic health center (AHC) that also fills a community hospital need for a diverse inner-city population. Results are applicable in other care settings. METHODOLOGY AND SAMPLE: Daily interdisciplinary huddles were piloted on 5 medical/surgical units. The 2015 readmission and length of stay data were compared with the 2013 baseline. RESULTS: There was a mean readmission reduction of 0.56%. A paired t test comparing the 2013 and 2015 readmission rates of the 5 units was significant (p < .05). There was a 0.42-day increase in the mean LOS between the 2013 baseline and the 2015 follow-up. A paired t test comparing 2013 and 2015 readmission rates of the 5 units was not significant at the .05 level. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Daily interdisciplinary sessions can result in reduced readmissions. Long-lasting positive outcomes related to enhanced communication are possible. Requirements for success include consistency in the standard huddle content reviewed. Data should be followed closely throughout an extended period of time to identify trends and support sustainment. Creative means to obtain input from services that cover multiple units and not be able to attend huddles may be necessary. Staff turnover will impact success. Variation in physician engagement can be addressed by frequent communication on the "why" behind the significance of the huddles, as well as sharing of change data highlighting success stories.

Personality characteristics among cardiothoracic transplant recipients.

Personality characteristics are clinically believed to predict posttransplant adherence and outcome; however, data, as to the prevalence and type of personality disorders (PDs) and distribution of personality traits among transplant (txp) populations, are sparse and inconclusive. This paper reports on the prevalence and type of PD and range of personality traits, according to the Five-Factor model, among 73 adult cardiothoracic txp recipients. It represents the first systematic assessment of PDs and traits in a sample of txp recipients. Personality disorders were assessed with a semistructured diagnostic interview; personality traits were assessed with a self-report instrument. Thirty-three percent of the sample met diagnostic criteria for a PD, approximately three times higher than prevalence of PD previously reported among nonpsychiatric populations. Mean values of personality traits for the sample were in the normative range but with wide variability; extreme values on four of the five traits were scored by subjects with a PD. This unexpectedly high prevalence of PD and the wide variability in traits among heart and lung recipients alert clinicians to consider personality characteristics when planning interventions to increase compliance and maximize quality of life after cardiothoracic transplantation.

Quality of life and coping strategies among lung transplant candidates and their family caregivers.

Although numerous studies have examined coping strategies and quality of life (QOL) among patients with chronic diseases and their family caregivers, no studies have examined the reciprocal effects of patient and caregiver coping strategies on their dyad partner's QOL. Because most people who cope with stressful health experiences do so within the context of interpersonal relationships, it is important to understand the ways in which the two partners' coping strategies may reciprocally affect each other's QOL. Adult lung transplant candidates and their caregivers (N=114 pairs) participated in semi-structured interviews that included measures of QOL and coping with patients' health-related problems. Multivariate, canonical correlation analyses were performed to examine unique patterns of associations between coping and QOL in patient-caregiver dyads. Better patient QOL, across multiple domains, was associated with better caregiver QOL. Multiple elements of patients' coping, including greater use of active coping and emotionally oriented coping were related to generally poorer patient QOL in psychosocial and physical domains. Similarly, caregivers who used more emotionally oriented coping had poorer QOL. There was no statistically reliable relationship between either (a) patient and caregiver use of coping strategies, or (b) caregiver coping and patient QOL. However, patients' coping strategies were important correlates of caregivers' QOL. These findings belie common clinical beliefs that family members' coping responses to patients' health are likely to affect patient well-being. Instead, patients' coping and QOL may be critical for understanding caregiver well-being, especially in the current era in which caregivers are assuming increased responsibility for providing patient care.

Participant satisfaction methods and outcomes in Medicaid managed care.

Participant satisfaction is an important outcome in evaluating the effectiveness of healthcare programs and benefits. With vulnerable populations, such as Medicaid beneficiaries, determining participant satisfaction poses unique challenges. The purpose of this article is to discuss participant satisfaction methods and outcomes from a multi-year experience of surveying Medicaid Managed Care (MMC) participants in Nebraska (2000-2005). Using a variety of survey methods, the foci were to measure satisfaction with MMC enrollment, understanding of MMC guidelines, and satisfaction with education services provided. Results illustrate response rate patterns and outcome trends that contribute to quality improvement knowledge useful for others surveying Medicaid populations.