Patient Risk-Benefit Preferences for Transcatheter Versus Surgical Mitral Valve Repair.

BACKGROUND: Transcatheter edge-to-edge repair (TEER) of mitral regurgitation is less invasive than surgery but has greater 5-year mortality and reintervention risks, and leads to smaller improvements in physical functioning. The study objective was to quantify patient preferences for risk-benefit trade-offs associated with TEER and surgery. METHODS AND RESULTS: A discrete choice experiment survey was administered to patients with mitral regurgitation. Attributes included procedure type; 30-day mortality risk; 5-year mortality risk and physical functioning for 5 years; number of hospitalizations in the next 5 years; and risk of additional surgery in the next 5 years. A mixed-logit regression model was fit to estimate preference weights. Two hundred one individuals completed the survey: 63% were female and mean age was 74 years. On average, respondents preferred TEER over surgery. To undergo a less invasive procedure (ie, TEER), respondents would accept up to a 13.3% (95% CI, 8.7%-18.5%) increase in reintervention risk above a baseline of 10%, 4.6 (95% CI, 3.1-6.2) more hospitalizations above a baseline of 1, a 10.7% (95% CI, 6.5%-14.5%) increase in 5-year mortality risk above a baseline of 20%, or more limited physical functioning representing nearly 1 New York Heart Association class (0.7 [95% CI, 0.4-1.1]) over 5 years. CONCLUSIONS: Patients in general preferred TEER over surgery. When holding constant all other factors, a functional improvement from New York Heart Association class III to class I maintained over 5 years would be needed, on average, for patients to prefer surgery over TEER.

Interventions to enhance the research productivity of academic staff in higher education schools of nursing: A systematic review.

AIM: Synthesize and present peer-reviewed evidence of interventions that enhance the research productivity of academics in Schools of Nursing in Higher Education Institutions. BACKGROUND: Pressures on academics in Schools of Nursing worldwide to increase or maintain high research productivity persist and numerous Higher Education Institutions across the world have developed interventions to increase productivity. Given evidence that the COVID-19 pandemic has resulted in a withdrawal from research, understanding which interventions best support and improve research productivity is urgent. Increasing research capacity is crucial but only one element in increasing productivity. No recent attempt has been made to synthesise the knowledge gained from these more wide-ranging initiatives. DESIGN: A mixed-methods systematic review, registered in PROSPERO, searching four academic databases (CINAHL, ERIC, MEDLINE, PsycINFO) from 1/01/2010-20/04/2022. All primary research studies of relevant interventions were included if they described the intervention, reported its outcomes and were published in the English language in peer-reviewed journals. RESULTS: 1637 studies were assessed against eligibility criteria, resulting in 20 included studies. No studies were excluded based on quality. Data pertaining to understandings of 'research productivity', barriers to research productivity, interventions and outcomes of interventions were extracted. The most often used measures were the frequency or staff-output ratio of funding, publications and presentations, while the less commonly used were the number of conference abstracts submitted/accepted and awards. Subjective measures were less commonly used. Barriers to research productivity fell into three broad categories: resource constraints, lack of priority for research and barriers related to the attitudes, knowledge and skills of School of Nursing academics. Interventions covered nine broad areas. Half of the interventions were multi-stranded, including a wide range of components to increase research productivity while the other half comprised one component only, such as writing groups and mentoring. All interventions had a positive impact on research productivity, however, heterogeneity in the measurement of impact, the duration of interventions, sources of comparative data and research design made comparison of interventions challenging. CONCLUSIONS: The review identified a need for future research to explore the barriers among under-represented groups of academics in Schools of Nursing across a broader geographical area; and what works for various sub-groups of academics. It also identified a need for a valid, standardised tool to assess the effectiveness of interventions to increase research productivity of academics in Schools of Nursing.

Participants' Evaluation and Outcomes following Integration of Self-Management Support into Outpatient Schizophrenia Case Management.

(1) Background: Self-management is advocated as a feasible, effective intervention to support individuals to actively manage the impact of illness and live healthier lives. We sought to evaluate a piloted self-management model, SET for Health, tailored for individuals living with schizophrenia embedded within ambulatory case management. (2) Methods: A mixed-methods design engaged 40 adults living with schizophrenia in the SET for Health protocol. Functional and symptomatic outcomes were measured by self-report and clinician ratings at baseline and completion of self-management plans, on average one year later. Semi-structured qualitative client interviews invited evaluations of personal experiences with the intervention. (3) Results: Significant improvements were found concerning client illness severity, social and occupational functioning, illness management and functional recovery with reductions in emergency visits and days in hospital. Clients endorsed the value of the intervention. Baseline clinical characteristics did not predict who benefited. Participation contributed to motivational gains and quality of life. (4) Conclusions: Results confirmed self-management support embedded within traditional case management improved clients' clinical and functional status, and contributed to quality of life. Clients engaged in their recovery and actively used self-management strategies. Self-management can be successfully adopted by clients with schizophrenia regardless of age, gender, education, illness severity or duration.

Preparing an integrated self-management support intervention for people living with schizophrenia: Creating collaborative spaces.

INTRODUCTION: This article describes the planning and development of a novel self-management support protocol, self-management engaging together (SET) for Health, purposefully designed and embedded within traditional case management services to be accessible to people living with schizophrenia and comorbidities. Drawing on established self-management principles, SET for Health was codesigned by researchers, healthcare providers and clients, to create a practical and meaningful intervention to support the target group to manage their own health and wellness. Decision making is described behind tailoring the self-management innovation to meet the needs of an at risk, disadvantaged group served by tertiary, public health care in Canada. METHOD: This integrated knowledge translation (IKT) study used a descriptive approach to document the process of planning and operationalizing the SET for Health intervention as a part of routine care in two community-based teams providing predominantly schizophrenia services. Diffusion of innovations literature informed planning. The setting was strategically prepared for organizational change. A situational assessment and theoretical frameworks identified contextual elements to be addressed. Existing established self-management approaches for mental illness were appraised. RESULTS: When a review of established approaches revealed incongruence with the aims and context of service delivery, common essential elements were distilled. To facilitate collaborative client-provider self-management conversations and self-management learning opportunities, core components were operationalized by the use of tailored interactive tools. The materials coproduced by clients and providers offered joint reference tools, foundational for capacity-building and recognition of progress. CONCLUSION: Planning and developing a model of self-management support for integration into traditional schizophrenia case management services required attention to the complex social ecological nature of the treatment approach and the workplace context. Demonstration of proof of concept is described in a separate paper.

Organisational change to integrate self-management into specialised mental health services: Creating collaborative spaces.

INTRODUCTION: Self-management support for schizophrenia has become expected practice leaving organisations to find ways for feasible implementation. Self-management support involves a foundational cultural shift for traditional disease-based services, new ways of clients-providers working together, coupled with delivering a portfolio of tools and techniques. A new model of self-management support embedded into traditional case management services, called SET for Health (Self-management Engaging Together for Health),  was designed and tailored to make such services meaningfully accessible to clients of a tertiary care centre. This paper describes the proof of concept demonstration efforts, the successes/challenges, and initial organisational changes. METHOD: An integrated knowledge translation approach was selected as a means to foster organisational change grounded in users' daily realities. Piloting the model in two community case management programmes, we asked two questions: Can a model of self-management support be embedded in existing case management and delivered within routine specialised mental health services? What organisational changes support implementation? RESULTS: Fifty-one clients were enroled. Indicators of feasible delivery included 72.5% completion of self-management plans in a diverse sample, exceeding the 44% set minimum; and an attrition rate of 21.6%, less than 51% set maximum. Through an iterative evaluation process, the innovation evolved to a targeted hybrid approach revolving around client goals and a core set of co-created reference tools, supplemental tools and resources. Operationalisation by use of tools was implemented to create spaces for client-provider collaborations. Monitoring of organisational changes identified realignment of practices. Changes were made to procedures and operations to further spread and sustain the model. CONCLUSION: This study demonstrated how self-management support can be implemented, within existing resources, for routine delivery of specialised services for individuals living with schizophrenia. The model holds promise as a hybrid option for supporting clients to manage their own health and wellness.

What matters most to patients with severe aortic stenosis when choosing treatment? Framing the conversation for shared decision making.

BACKGROUND: Guidelines recommend including the patient's values and preferences when choosing treatment for severe aortic stenosis (sAS). However, little is known about what matters most to patients as they develop treatment preferences. Our objective was to identify, prioritize, and organize patient-reported goals and features of treatment for sAS. METHODS: This multi-center mixed-methods study conducted structured focus groups using the nominal group technique to identify patients' most important treatment goals and features. Patients separately rated and grouped those items using card sorting techniques. Multidimensional scaling and hierarchical cluster analyses generated a cognitive map and clusters. RESULTS: 51 adults with sAS and 3 caregivers with experience choosing treatment (age 36-92 years) were included. Participants were referred from multiple health centers across the U.S. and online. Eight nominal group meetings generated 32 unique treatment goals and 46 treatment features, which were grouped into 10 clusters of goals and 11 clusters of features. The most important clusters were: 1) trust in the healthcare team, 2) having good information about options, and 3) long-term outlook. Other clusters addressed the need for and urgency of treatment, being independent and active, overall health, quality of life, family and friends, recovery, homecare, and the process of decision-making. CONCLUSIONS: These patient-reported items addressed the impact of the treatment decision on the lives of patients and their families from the time of decision-making through recovery, homecare, and beyond. Many attributes had not been previously reported for sAS. The goals and features that patients' value, and the relative importance that they attach to them, differ from those reported in clinical trials and vary substantially from one individual to another. These findings are being used to design a shared decision-making tool to help patients and their clinicians choose a treatment that aligns with the patients' priorities. TRIAL REGISTRATION: ClinicalTrials.gov, Trial ID: NCT04755426, Trial URL https://clinicaltrials.gov/ct2/show/NCT04755426.

Anxiety and Depression Following Aortic Valve Replacement.

Background The aim of this study was to identify patients vulnerable for anxiety and/or depression following aortic valve replacement (AVR) and to evaluate factors that may mitigate this risk. Methods and Results This is a retrospective cohort study conducted using a claims database; 18 990 patients (1/2013-12/2018) ≥55 years of age with 6 months of pre-AVR data were identified. Anxiety and/or depression risk was compared at 3 months, 6 months, and 1 year following transcatheter aortic valve replacement or surgical AVR (SAVR) after risk adjustment using logistic regression and Cox proportional hazards models. Separate models were estimated for patients with and without surgical complications and discharge location. Patients with SAVR experienced a higher relative risk of anxiety and/or depression at 3 months (12.4% versus 8.8%; adjusted hazard ratio [HR] 1.39 [95% CI, 1.19-1.63]) and 6 months (15.6% versus 13.0%; adjusted HR, 1.24 [95% CI, 1.08-1.42]), with this difference narrowing by 12 months (20.1% versus 19.3%; adjusted HR, 1.14 [95% CI, 1.01-1.29]) after AVR. This association was most pronounced among patients discharged to home, with patients with SAVR having a higher relative risk of anxiety and/or depression. In patients who experienced operative complications, there was no difference between SAVR and transcatheter aortic valve replacement. However, among patients without operative complications, patients with SAVR had an increased risk of postoperative anxiety and/or depression at 3 months (adjusted HR, 1.47 [95% CI, 1.23-1.75]) and 6 months (adjusted HR 1.26 [95% CI, 1.08-1.46]), but not at 12 months. Conclusions There is an associated reduction in the risk of new-onset anxiety and/or depression among patients undergoing transcatheter aortic valve replacement (versus SAVR), particularly in the first 3 and 6 months following treatment.

Personal narratives of learning self-management: Lessons for practice based on experiences of people with serious mental illness.

INTRODUCTION: Clinicians are challenged to deliver self-management interventions in recovery-oriented services for individuals living with serious mental illnesses. Little is known about how people learn self-management skills and questions remain about how best to deliver support. To offer insights for delivery, this research describes the lived experiences of learning self-management and the meaning of those experiences within recovery journeys and the context of health-care delivery. METHODS: Design followed van Manen's approach of phenomenology through an occupational therapist's lens. Using purposeful criterion sampling until saturation, 25 adults with psychosis experiences (8-40 years) from six community-based specialised mental health programs were interviewed. Conceptual maps were cocreated depicting key learning experiences, intersections with services, and recommendations. Data reduction, reconstruction and explication of meaning occurred concurrently, and multiple strategies were used to transparently support an open, iterative, reflexive process. FINDINGS: Participants described eight essential tasks to live well, learned often serendipitously, taking up to 15-30 years to find the right combination of supports and self-management strategies to achieve what they felt was a life of quality. Self-management needs were not routinely addressed by services and extended beyond illness or crisis management while participants grappled with emotions, self-concept, relationships, and occupational issues. Participants asked providers to "teach us to teach ourselves"; "invite clients" to the decision table; and deal directly with emotions of fear, shame, and trust with respect to self and relationships. Findings challenge conventional conceptualisations of self-management to consider clients living interdependent lives with tasks performed in context, dynamically influenced by complex personal, socio-ecological relationships. CONCLUSIONS: Participants' narratives compel increasing access to strategic personalised self-management learning opportunities as an effort to shorten the prolonged recovery paths. Findings offer ways providers can understand and address eight self-management learning tasks from the perspective of lived experiences. Self-management was enmeshed with recovery, health, and building a life.

Predicting Quality of Life at 1 Year After Transcatheter Aortic Valve Replacement in a Real-World Population.

Background Among clinical trial patients at high surgical risk, a model has been developed and externally validated to estimate patient risk for poor outcomes after transcatheter aortic valve replacement (TAVR). How this model performs in lower risk and unselected patients is not known. We sought to examine and optimize the performance of the TAVR poor outcome risk model among patients in the US Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Methods and Results Among 13 351 patients who underwent TAVR at 252 US sites between November 9, 2011 and June 30, 2015, the rate of poor outcome at 1 year after TAVR was 38.9%, which was because of death in 20.7% and poor quality of life or quality of life decline in 18.2%. The rate of poor outcome has decreased slightly over time, from 42.0% in 2012 to 37.8% in 2015 ( P for trend=0.076). The original TAVR poor outcome risk model did not calibrate well on this population. We then reestimated the intercept and coefficients in the model and retested model performance, after which it performed well (both overall and in subgroups), with a C index 0.65 and excellent calibration. Conclusions In a large cohort of unselected patients in the United States, we found that while a substantial minority of patients continue to have a poor outcome after TAVR, outcomes have slowly improved over time. After recalibration, the TAVR poor outcome risk model performed well. This model could potentially be used before TAVR to help patients have appropriate expectations of recovery.

Transcatheter Versus Surgical Aortic Valve Replacement: Propensity-Matched Comparison.

BACKGROUND: Randomized trials support the use of transcatheter aortic valve replacement (TAVR) for the treatment of aortic stenosis in high- and intermediate-risk patients, but the generalizability of those results in clinical practice has been challenged. OBJECTIVES: The aim of this study was to determine the safety and effectiveness of TAVR versus surgical aortic valve replacement (SAVR), particularly in intermediate- and high-risk patients, in a nationally representative real-world cohort. METHODS: Using data from the Transcatheter Valve Therapy Registry and Society of Thoracic Surgeons National Database linked to Medicare administrative claims for follow-up, 9,464 propensity-matched intermediate- and high-risk (Society of Thoracic Surgeons Predicted Risk of Mortality score ≥3%) U.S. patients who underwent commercial TAVR or SAVR were examined. Death, stroke, and days alive and out of the hospital to 1 year were compared, as well as discharge home, with subgroup analyses by surgical risk, demographics, and comorbidities. RESULTS: In a propensity-matched cohort (median age 82 years, 48% women, median Society of Thoracic Surgeons Predicted Risk of Mortality score 5.6%), TAVR and SAVR patients experienced no difference in 1-year rates of death (17.3% vs. 17.9%; hazard ratio: 0.93; 95% confidence interval [CI]: 0.83 to 1.04) and stroke (4.2% vs. 3.3%; hazard ratio: 1.18; 95% CI: 0.95 to 1.47), and no difference was observed in the proportion of days alive and out of the hospital to 1 year (rate ratio: 1.00; 95% CI: 0.98 to 1.02). However, TAVR patients were more likely to be discharged home after treatment (69.9% vs. 41.2%; odds ratio: 3.19; 95% CI: 2.84 to 3.58). Results were consistent across most subgroups, including among intermediate- and high-risk patients. CONCLUSIONS: Among unselected intermediate- and high-risk patients, TAVR and SAVR resulted in similar rates of death, stroke, and DAOH to 1 year, but TAVR patients were more likely to be discharged home.

Use of functional capacity evaluations in workplaces and the compensation system: a report on workers' and report users' perceptions.

Until recently, little was documented about how functional capacity evaluations (FCEs) are used by employers and workers' compensation organizations. Such information was one focus of a comprehensive research study on FCEs carried out in southern Ontario, Canada, which involved representatives from the full range of groups involved in FCEs: referral sources, assessors, return-to-work specialists, third party payers and injured workers [1]. This paper shares findings from a cohort of injured workers undergoing FCEs, and explored how their FCE results were perceived and utilized by those receiving the reports. Based on study findings, we provide recommendations as to how FCEs should be requested, undertaken, reported and particularly applied to reduce work disability among injured workers.

Functional assessment of injured workers: a profile of assessor practices.

BACKGROUND: Considerable controversy and limited information surrounds the use of performance-based functional assessments for determining an injured worker's ability to function at work. PURPOSE: Amidst a variety of protocols, philosophies and tools, the key aspects of different assessment approaches are described and compared across a range of assessment provider organizations. METHOD: Qualitative and quantitative strategies were used to generate an in-depth understanding of the different assessment practices among 23 Southern Ontario assessment providers. RESULTS: Assessment approaches share common elements and variations that can be described along the continua of five dimensions: nature of assessor-evaluee interactions, fixed or flexible protocol delivery, efforts to contextualize, perceptions and use of evidence, and provider organizational environment. These approach dimensions are offered as a focus for appraising practices. PRACTICE IMPLICATIONS: Assessors need to reflect upon to what extent they are using a whole person, client-centred approach directed by clinical reasoning amidst a market driven industry.

Learning from today's clinicians in vocational practice to educate tomorrow's therapists.

BACKGROUND: In response to the demand for therapists and changes in vocational practice, a needs assessment was conducted to update an occupational therapy educational program. METHOD: Employing focus groups, interviews and questionnaires, 66 therapists from a wide range of graduating institutions working in vocational practice were asked to: a) identify the essential knowledge, skills and professional behaviours required for vocational practice; b) determine to what extent training is preparing students for vocational practice; and c) make recommendations for curriculum revision and/or for additional curriculum development. Participants and their jobs were profiled together with the challenges and issues of vocational practice. RESULTS: There was strong agreement among participants regarding what is required to practice effectively but disparate views concerning the extent they were prepared for practice. CLINICAL IMPLICATIONS: Recommendations were given for entry and postgraduate level curricula. Findings were compared to a past community practice survey. Implications for practicums, professional integrity and ethical issues were discussed.

Perspectives on work (re)entry for persons with disabilities: implications for clinicians.

Despite the prevalence of government funding to support employment opportunities for persons with disabilities, real jobs for this population still appear to be elusive. McMaster University researchers examined how six stakeholder groups defined workplace (re)entry success for persons with disabilities. Focus groups and individual interviews were conducted with representation from employers, unions, persons with disabilities, co-workers, supervisors and human resource departments. Participants numbered 86 and the average age was 42. Participant comments provided the researchers with rich data related to the study objectives. Success was perceived as not only a match between the employee and the job but also a win-win for employer and employer, a uniquely defined set of circumstances based on the specific individual and their environment as well as respect for the individual's dignity and quality of life. This article discusses the study and its outcomes and highlights implications for clinicians.