Applying User-Centered Design and Implementation Science to the Early-Stage Development of a Telehealth-Enhanced Hybrid Cardiac Rehabilitation Program: Quality Improvement Study.

BACKGROUND: Cardiac rehabilitation (CR) is an evidence-based intervention that improves event-free survival in patients with cardiac conditions, yet <27% of all eligible patients use CR in the United States. CR is traditionally delivered in clinic-based settings where implementation barriers abound. Innovative nontraditional program designs and strategies are needed to support widespread CR uptake. OBJECTIVE: This study aimed to demonstrate how user-centered design (UCD) and implementation science (IS) principles and methods can be integrated into the early-stage development of nontraditional CR interventions. METHODS: As part of a NewYork-Presbyterian Hospital (NYPH) quality improvement initiative (March 2020-February 2022), we combined UCD and IS principles and methods to design a novel home- and clinic-based telehealth-enhanced hybrid CR (THCR) program. We co-designed this program with multilevel stakeholders using an iterative 3-step UCD process to identify user and contextual barriers and facilitators to CR uptake (using semistructured interviews and contextual inquiry [step 1]), design an intervention prototype that targets contextual and user factors and emulates the evidence-based practice (through design workshops and journey mapping [step 2]), and review and refine the prototype (according to real-world usability testing and feedback [step 3]). The UCD process was informed by the Theoretical Domains Framework and Consolidated Framework for Implementation Research. RESULTS: At step 1, we conducted semistructured interviews with 9 provider- and system-level stakeholders (female: n=6, 67%) at 3 geographically diverse academic medical centers, which revealed behavioral (eg, self-efficacy and knowledge) and contextual (eg, social distancing guidelines, physical space, staffing, and reimbursement) barriers to uptake; hybrid delivery was a key facilitator. Step 2 involved conducting 20 design workshops and 3 journey-mapping sessions with multidisciplinary NYPH stakeholders (eg, digital health team, CR clinicians, and creative director) where we identified key design elements (eg, mix of clinic- and home-based CR and synchronous remote patient monitoring), yielding an initial THCR prototype that leveraged NYPH's telehealth infrastructure. At step 3, we conducted usability testing with 2 CR clinicians (both female) administering home-based sessions to 3 CR patients (female: n=1, 33%), which revealed usability themes (eg, ease of using remote patient monitoring devices or a telehealth platform, technology disruptions, and confidence in using the telehealth platform to safely monitor patients) and design solutions (eg, onboarding sessions, safety surveys, and fully supervised remote sessions) to be included in the final THCR prototype. CONCLUSIONS: Combining UCD and IS methods while engaging multidisciplinary stakeholders in an iterative process yielded a theory-informed THCR program targeting user and contextual barriers to real-world CR implementation. We provide a detailed summary of the process and guidance for incorporating UCD and IS principles and methods into the early-stage development of a nontraditional CR intervention. The feasibility, acceptability, appropriateness, and usability of the final THCR prototype is being evaluated in an ongoing study.

User-centered design of a telehealth-enhanced hybrid cardiac rehabilitation program as hospital quality improvement.

Background Innovative program designs and strategies are needed to support the widespread uptake of cardiac rehabilitation (CR) programs in the post-COVID19 era. We combined user-centered design (UCD) and implementation science (ImS) principles to design a novel telehealth-enhanced hybrid (home and clinic-based) CR (THCR) program. Methods As part of a New York Presbyterian Hospital (NYPH) quality improvement initiative (March 2020-February 2022), we designed a THCR program using an iterative 3 step UCD process informed by the Theoretical Domains Framework and Consolidated Framework for Implementation Research to: 1) identify user and contextual barriers to CR uptake (stakeholder interviews), 2) design an intervention prototype (design workshops and journey mapping), and 3) refine the prototype (usability testing). The process was optimized for usability and implementation outcomes. Results Step 1: Semi-structured interviews with stakeholders (n = 9) at 3 geographically diverse academic medical centers revealed behavioral (e.g., self-efficacy, knowledge) and contextual (e.g., social distancing guidelines, physical space, staffing, reimbursement) barriers to uptake. Step 2: Design workshops (n = 20) and journey-mapping sessions (n = 3) with multi-disciplinary NYPH stakeholders (e.g., digital health team, CR clinicians, creative director) yielded a THCR prototype that leveraged NYPH's investment in their remote patient monitoring (RPM) platform to optimize feasibility of home-based CR sessions. Step 3: Usability testing with CR clinicians (n = 2) administering and CR patients (n = 3) participating in home-based sessions revealed usability challenges (e.g., RPM devices/exercise equipment usability; Wi-Fi/Bluetooth connectivity/syncing; patient safety/knowledge and protocol flexibility). Design workshops (n = 24) and journey-mapping sessions (n = 3) yielded design solutions (e.g., onboarding sessions, safety surveys, fully supervised remote sessions) and a refined THCR prototype. Conclusion Combining UCD and ImS methods while engaging multi-disciplinary stakeholders in an iterative process yielded a theory-informed telehealth-enhanced hybrid CR program targeting user and contextual barriers to real-world CR implementation. We provide a detailed summary of the process, and guidance for incorporating UCD and ImS methods in early-stage intervention development. THCR may shrink the evidence-to-practice gap in CR implementation. A future hybrid type I effectiveness-implementation trial will determine its feasibility, acceptability, and effectiveness.

Increasing Uptake of Depression Screening and Treatment Guidelines in Cardiac Patients: A Behavioral and Implementation Science Approach to Developing a Theory-Informed, Multilevel Implementation Strategy.

BACKGROUND: Depression leads to poor health outcomes in patients with coronary heart disease (CHD). Despite guidelines recommending screening and treatment of depressed patients with CHD, few patients receive optimal care. We applied behavioral and implementation science methods to (1) identify generalizable, multilevel barriers to depression screening and treatment in patients with CHD and (2) develop a theory-informed, multilevel implementation strategy for promoting guideline adoption. METHODS: We conducted a narrative review of barriers to depression screening and treatment in patients with CHD (ie, medications, exercise, cardiac rehabilitation, or therapy) comprising data from 748 study participants. Informed by the behavior change wheel framework and Expert Recommendations for Implementing Change, we defined multilevel target behaviors, characterized determinants (capability, opportunity, motivation), and mapped barriers to feasible, acceptable, and equitable intervention functions and behavior change techniques to develop a multilevel implementation strategy, targeting health care systems/providers and patients. RESULTS: We identified implementation barriers at the system/provider level (eg, Capability: knowledge; Opportunity: workflow integration; Motivation: ownership) and patient level (eg, Capability: knowledge; Opportunity: mobility; Motivation: symptom denial). Acceptable, feasible, and equitable intervention functions included education, persuasion, environmental restructuring, and enablement. Expert Recommendations for Implementing Change strategies included learning collaborative, audit, feedback, and educational materials. The final multicomponent strategy (iHeart DepCare) for promoting depression screening/treatment included problem-solving meetings with clinic staff (system); educational/motivational videos, electronic health record reminders/decisional support (provider); and a shared decision-making (electronic shared decision-making) tool with several functions for patients, for example, patient activation, patient treatment selection support. CONCLUSIONS: We applied implementation and behavioral science methods to identify implementation barriers and to develop a multilevel implementation strategy for increasing uptake of depression screening and treatment in patients with CHD as a use case. The multilevel implementation strategy will be evaluated in a future hybrid II effectiveness-implementation trial.

The association between sleep and psychological distress among New York City healthcare workers during the COVID-19 pandemic.

BACKGROUND: Healthcare workers (HCWs) treating patients with COVID-19 report psychological distress. We examined whether disturbed sleep was associated with psychological distress in New York City (NYC) HCWs during the initial peak of the COVID-19 pandemic (April-May 2020). METHODS: HCWs completed a survey screening for acute stress (4-item Primary Care PTSD screen), depressive (Patient Health Questionaire-2), and anxiety (2-item Generalized Anxiety Disorder scale) symptoms. Insomnia symptoms (modified item from the Insomnia Severity Index) and short sleep (SS, sleep duration <6 h/day) were assessed. Poisson regression analyses predicting psychological distress from SS and insomnia symptoms, adjusting for demographics, clinical role/setting, redeployment status, shifts worked, and multiple comparisons were performed. RESULTS: Among 813 HCWs (80.6% female, 59.0% white) mean sleep duration was 5.8 ± 1.2 h/night. Prevalence of SS, insomnia, acute stress, depressive, and anxiety symptoms were 38.8%, 72.8%, 57.9%, 33.8%, and 48.2%, respectively. Insomnia symptoms was associated with acute stress (adjusted prevalence ratio [PR]: 1.51, 95% CI: 1.35, 1.69), depressive (PR: 2.04, 95% CI: 1.78, 2.33), and anxiety (PR: 1.74, 95% CI: 1.55, 1.94) symptoms. SS was also associated with acute stress (PR: 1.17, 95% CI: 1.07, 1.29), depressive (PR: 1.36, 95% CI: 1.233, 1.51), and anxiety (PR: 1.38, 95% CI: 1.26, 1.50) symptoms. LIMITATIONS: Our cross-sectional analysis may preclude the identification of temporal associations and limit causal claims. CONCLUSIONS: In our study, SS and insomnia were associated with psychological distress symptoms in NYC HCWs during the COVID-19 pandemic. Sleep may be a target for interventions to decrease psychological distress among HCWs.

Factors Associated with Insomnia Symptoms in a Longitudinal Study among New York City Healthcare Workers during the COVID-19 Pandemic.

BACKGROUND: Few studies have examined the longer-term psychological impact of COVID-19 in healthcare workers (HCWs). PURPOSE: We examined the 10-week trajectory of insomnia symptoms in HCWs during the COVID-19 pandemic. METHODS: HCWs completed a web-based survey at baseline (9 April-11 May 2020) and every 2 weeks for 10 weeks. The main outcome was the severity of insomnia symptoms in the past week. Multivariable-adjusted generalized estimating equation analyses examined factors associated with insomnia symptoms. RESULTS: n = 230 completed surveys at baseline. n = 155, n = 130, n = 118, n = 95, and n = 89 completed follow-ups at weeks 2, 4, 6, 8, and 10, respectively. Prevalence of insomnia symptoms of at least moderate severity was 72.6% at baseline, and 63.2%, 44.6%, 40.7%, 34.7%, and 39.3% at weeks 2, 4, 6, 8, and 10, respectively. In multivariable analyses, factors significantly associated with increased odds of insomnia symptoms were younger age (OR: 0.98, 95% CI: 0.96-1.00), working in a COVID-facing environment (OR: 1.75, 95% CI: 1.15-2.67) and hours worked (OR: 1.16, 95% CI: 1.06-1.27). CONCLUSIONS: The initial high rates of insomnia symptoms improved as time passed from the peak of local COVID-19 cases but four out of ten HCWs still had moderate-to-severe insomnia symptoms ten weeks after baseline.

Prevalence, Incidence, and Factors Associated with Posttraumatic Stress at Three-Month Follow-Up among New York City Healthcare Workers after the First Wave of the COVID-19 Pandemic.

BACKGROUND: Prevalence, incidence, and factors associated with posttraumatic stress disorder (PTSD) symptoms at follow-up among healthcare workers after the first wave of the COVID-19 pandemic are unknown. METHODS: A web survey invitation was sent to healthcare worker listservs at a NYC medical center (April, 2020). The Primary Care (PC)-PTSD questionnaire was used to screen for PTSD symptoms at baseline and then every 2 weeks for 10 weeks. Incidence and prevalence of PTSD symptoms were determined at each time point. Multivariable generalized estimating equation models were performed to investigate the factors associated with a positive PC-PTSD screen at follow-up. RESULTS: Median age (interquartile range) of N = 230 participants was 36 (31-48) years; 79.6% were women; 82.6% worked in COVID-19-focused settings. The prevalence of PTSD symptoms decreased from 55.2% at baseline to 25.0% at 10 weeks (p < 0.001). Among participants who had a baseline negative screen for PTSD symptoms, the incidence of PTSD at 10 weeks was 12.2% (p-trend 0.034). In multivariable-adjusted analyses, being a nurse (odds ratio [OR]: 1.70, 95% confidence interval [CI]: 1.06-2.71), female (OR: 3.00, 95% CI: 1.59, 5.72), and working in a COVID-19-focused location (OR: 1.51, 95% CI: 1.02, 2.21) were associated with increased odds of PTSD symptoms at 10-weeks. CONCLUSIONS: PTSD symptoms improved over 3 months following the first wave of the COVID-19 pandemic. However, one out of four NYC healthcare workers still had an increased risk for PTSD at 10-weeks. Screening healthcare workers for PTSD symptoms should be considered during the COVID-19 pandemic.

Psychological distress, coping behaviors, and preferences for support among New York healthcare workers during the COVID-19 pandemic.

OBJECTIVE: The mental health toll of COVID-19 on healthcare workers (HCW) is not yet fully described. We characterized distress, coping, and preferences for support among NYC HCWs during the COVID-19 pandemic. METHODS: This was a cross-sectional web survey of physicians, advanced practice providers, residents/fellows, and nurses, conducted during a peak of inpatient admissions for COVID-19 in NYC (April 9th-April 24th 2020) at a large medical center in NYC (n = 657). RESULTS: Positive screens for psychological symptoms were common; 57% for acute stress, 48% for depressive, and 33% for anxiety symptoms. For each, a higher percent of nurses/advanced practice providers screened positive vs. attending physicians, though housestaff's rates for acute stress and depression did not differ from either. Sixty-one percent of participants reported increased sense of meaning/purpose since the COVID-19 outbreak. Physical activity/exercise was the most common coping behavior (59%), and access to an individual therapist with online self-guided counseling (33%) garnered the most interest. CONCLUSIONS: NYC HCWs, especially nurses and advanced practice providers, are experiencing COVID-19-related psychological distress. Participants reported using empirically-supported coping behaviors, and endorsed indicators of resilience, but they also reported interest in additional wellness resources. Programs developed to mitigate stress among HCWs during the COVID-19 pandemic should integrate HCW preferences.