Can screen-time help? An analysis of usage of patient engagement technology following colorectal surgery.

BACKGROUND: Patient engagement technologies (PETs) guide patients through the perioperative period. We aimed to investigate the levels of patient engagement with PETs through the peri-operative period and its impact on clinical outcomes. METHODS: Retrospective cohort study of patients undergoing elective colorectal surgery from 2018 to 2022. Outcomes were length of stay, readmissions, and complications within 30 days of index hospitalization. RESULTS: 359 (89.1%) patients activated the PET. Patients completed a median of 7 surveys, 2 in-hospital health-checks, and 1 post-discharge health-check. Median LOS was 3 days, 57 (14.1%) patients were readmitted, and 56 (13.9%) had a complication. Patients who completed no surveys had longer LOS than those who completed 2 or more. Patients who were readmitted and had post-operative complications completed significantly fewer surveys and post-discharge health-checks. Completion of surveys in more phases was associated with shorter LOS and lower readmission rates. Completion of more post-discharge health-checks was associated with lower complication rate. CONCLUSIONS: The use of PETs improves patient outcomes and experiences in the perioperative period. Patients who engage more frequently with PETs have shorter LOS with lower readmission and post-operative complication rates.

Use of statewide financial incentives to improve documentation of hernia and mesh characteristics in ventral hernia repair.

BACKGROUND: Documentation of intraoperative details is critical for understanding and advancing hernia care, but is inconsistent in practice. Therefore, to improve data capture on a statewide level, we implemented a financial incentive targeting documentation of hernia defect size and mesh use. METHODS: The Abdominal Hernia Care Pathway (AHCP), a voluntary pay for performance (P4P) initiative, was introduced in 2021 within the statewide Michigan Surgical Quality Collaborative (MSQC). This consisted of an organizational-level financial incentive for achieving 80% performance on eight specific process measures for ventral hernia surgery, including complete documentation of hernia defect size and location, as well as mesh characteristics and fixation technique. Comparisons were made between AHCP and non-AHCP sites in 2021. RESULTS: Of 69 eligible sites, 47 participated in the AHCP in 2021. There were N = 5362 operations (4169 at AHCP sites; 1193 at non-AHCP sites). At AHCP sites, 69.8% of operations had complete hernia documentation, compared to 50.5% at non-AHCP sites (p < 0.0001). At AHCP sites, 91.4% of operations had complete mesh documentation, compared to 86.5% at non-AHCP sites (p < 0.0001). The site-level hernia documentation goal of 80% was reached by 14 of 47 sites (range 14-100%). The mesh documentation goal was reached by 41 of 47 sites (range 4-100%). CONCLUSIONS: Addition of an organizational-level financial incentive produced marked gains in documentation of intra-operative details across a statewide surgical collaborative. The relatively large effect size-19.3% for hernia-is remarkable among P4P initiatives. This result may have been facilitated by surgeons' direct role in documenting hernia size and mesh use. These improvements in data capture will foster understanding of current hernia practices on a large scale and may serve as a model for improvement in collaboratives nationally.

Life after "no": barriers to behavior change for persons declined hernia repair due to high-risk features.

INTRODUCTION: Delaying an elective operation to mitigate risk factors improves patient outcomes. Elective ventral hernia repair is one such example. To address this issue, we developed a pre-operative optimization clinic to support high-risk patients seeking elective ventral hernia repair. Unfortunately, few patients progressed to surgery. Within this context, we sought to understand the barriers to behavior change among these patients with the goal of improving care for patients undergoing elective surgery. METHODS: We performed semi-structured, qualitative interviews with 20 patients who were declined ventral hernia repair due to either active tobacco use or obesity. Patients were recruited from a pre-operative optimization clinic at an academic hospital. Interviews sought to characterize patients' perceived barriers to behavior change. Interviews were concluded once thematic saturation was reached. We used an inductive thematic analysis to analyze the data. All data analysis was performed using MAXQDA software. RESULTS: Among 20 patients (mean age 50, 65% female, 65% White), none had yet undergone ventral hernia repair. While most patients had a positive experience in the clinic, among those who did not, we found three dominant themes around behavior change: (1) Patient's role in behavior change: how the patient perceived their role in making behavior changes optimize their health for surgery; (2) Obtainability of offered resources: the need for more support for patients to access the recommended healthcare; and (3) Patient-provider concordance: the extent to which patients and providers agree on the relative importance of different attributes of their care. CONCLUSION: Behavior change prior to elective surgery is complex and multifaceted. While improving access to tobacco cessation resources and obesity management may improve outcomes for some, patients may benefit from increased on-site facilitation to promote access to resources as well as the use of patient-facing decision support tools to promote patient-provider concordance.

Surgeon behaviors related to engaging patients in smoking cessation at the time of elective surgery.

BACKGROUND: Despite the abundance of evidence supporting smoking cessation before elective surgery, there is wide variation in surgeon adherence to these best practices. METHODS: This qualitative study used convenience sampling to recruit General Surgery trained surgeons. Surgeons participated in semi-structured interviews based on domains from the Theoretical Domains Framework (TDF). Content analysis was guided by the TDF. RESULTS: Of the 14 TDF domains, social or professional role/identity, memory, attention and decision processes, environmental context and resources, and beliefs about consequences emerged most frequently. Mapping these domains to the Behavior Change Wheel identified education, enablement, and incentivization as effective intervention functions. CONCLUSIONS: Using the TDF, this study identified a widespread sense of responsibility among surgeons to engage patients in perioperative smoking cessation despite workplace barriers and lacking resources. These findings provide valuable insight to facilitate surgeon participation in health promotion through targeted, theory-based interventions informed by surgeon identified barriers to perioperative smoking cessation.

A socioecological qualitative analysis of barriers to care in colorectal surgery.

BACKGROUND: Although specific social determinants of health have been associated with disparities in surgical outcomes, there exists a gap in knowledge regarding the mechanisms of these associations. Gaining perspectives from multiple socioecological levels can help elucidate these mechanisms. Our study aims to identify social determinants of health that act as barriers or facilitators to surgical care among colorectal surgery stakeholders. METHODS: We recruited participants representing 5 socioecological levels: patients (individual); caregivers/surgeons (interpersonal); and leaders in hospitals (organizational), communities (community), and government (policy). Patients participated in focus groups, and the remaining participants underwent individual interviews. Semistructured interview guides were used to explore barriers and facilitators to surgical care at each socioecological level. Transcripts were analyzed by 3 coders in an inductive thematic approach with content analyses. The intercoder agreement was 93%. RESULTS: Six patient focus groups (total n = 18) and 12 key stakeholder interviews were conducted. The mean age of patients was 54.7 years, 66% were Black, and 61% were female. The most common diseases were colorectal cancer (28%), inflammatory bowel disease (28%), and diverticulitis (22%). Key social determinants of health impacting surgical care emerged at each level: individual (clear communication, mental stress), interpersonal (provider communication and trust, COVID-related visitation restrictions), organizational (multiple forms of contact, quality educational materials, scheduling systems, discrimination), community (community and family support and transportation), and policy (charity care, patient advocacy organizations, insurance coverage). CONCLUSION: Key social determinants of health-impacting care among colorectal surgery patients emerged at each socioecological level and may provide targets for interventions to reduce surgical disparities.

Validity and Reliability of the Modified Attitudes About Drug Use in Pregnancy Scale.

OBJECTIVE: To contemporize the Attitudes About Drug Abuse in Pregnancy questionnaire, keep the length of the modified scale brief to promote use, and test the psychometric properties of the modified scale among perinatal nurses. DESIGN: Cross-sectional survey. SETTING: Four hospitals in the Midwestern United States. PARTICIPANTS: Registered nurses who worked in perinatal units (N = 440). METHODS: We collected data from participants using survey methods. Seven experts in perinatal substance use research and clinical care informed scale modifications. We used a split-sample design involving maternal-newborn units (labor, postpartum) and newborn-focused units (NICU, pediatrics). We evaluated construct validity using factor analysis and reliability using Cronbach's alpha. We tested for differences between units using analysis of variance and Tukey's post hoc honest significant difference test of pairwise differences. RESULTS: The final modified scale included 13 items that loaded on one factor and showed internal consistency reliability in both samples (α = .88-.91). We found a statistically significant difference in mean score between NICU and pediatric units; however, the absolute difference was small and likely not clinically significant. CONCLUSIONS: The Modified Attitudes About Drug Use in Pregnancy scale has initial evidence for validity and reliability, was updated to reflect current terminology in the field, and is a pragmatic tool for use in research.

A conceptual framework for clinical and translational virtual community engagement research.

Introduction: The COVID-19 pandemic accelerated a trend for clinical and translational community-engaged research in adapting to an increasingly virtual landscape. This requires a framework for engagement distinct from in-person research and program activities. We reflect on four case studies of community engagement activities that inform a conceptual framework to better integrate the virtual format into community-engaged research reflecting key tenets of health equity and antiracist praxis. Methods: Four projects were selected by community-engaged research stakeholders for an in-depth review based on how much the virtual transition impacted activities such as planning, recruitment, and data collection for each project. Transitions to virtual engagement were assessed across ten areas in which community engagement has been demonstrated to make a positive impact. Results: Our analysis suggests a conceptual evaluation framework in which the ten community engagement areas cluster into four interrelated domains: (1) development, design, and delivery; (2) partnership and trust building; (3) implementation and change; and (4) ethics and equity. Conclusions: The domains in this conceptual framework describe critical elements of community engaged research and programs consistent with recommendations for health equity informed meaningful community engagement from the National Academy of Medicine. The conceptual framework and case studies can be used for evaluation and to develop guidelines for clinical and translational researchers utilizing the virtual format in community-engaged research.

Use of Storytelling to Increase Navigation Capacity Around the Affordable Care Act in Communities of Color.

BACKGROUND: Improving health insurance coverage and retention in communities of color is a national priority and new approaches are needed. OBJECTIVES: To describe 1) the formation of Insure Detroit, a community-based participatory research (CBPR) partnership aimed at addressing health insurance and Affordable Care Act (ACA) literacy challenges in economically disadvantaged areas, 2) the development of Insuring Good Health, a novel, multimedia, health information technology-focused intervention to address the health aims of the partnership, and 3) the evaluation plan for the intervention. METHODS: Insure Detroit, a partnership between researchers and community-based organizations, was established. Principles of CBPR were followed closely in the conduct of this project. The Insure Detroit partnership developed the intervention and evaluation plan through an iterative process. The Insuring Good Health intervention is multilingual and composed of a responsive website. It includes nine short, animated videos informed by storytelling techniques that communicate key learning points pertaining to health insurance navigation and use. LESSONS LEARNED: Lessons learned included narrowing learning points for the intervention, balancing the volume of work to comply with the study timeline, and balancing the political climate with the development of the intervention. CONCLUSIONS: The Insure Detroit partnership demonstrates that a CBPR approach can develop media-based health communications to address health insurance literacy. Our experiences highlight that CBPR principles that encourage shared decision making and co-learning can result in high-quality, innovative interventions that have the potential to resonate well with communities of color.