Health insurance, perceived threat, and posttraumatic stress after suspected acute coronary syndrome.

OBJECTIVE: Threat perceptions during evaluation for acute coronary syndrome (ACS) in the emergency department (ED) predict posttraumatic stress symptoms (PSS). It is unknown how health insurance status affects threat perceptions. We tested whether lacking health insurance is associated with higher threat perceptions and PSS in patients with suspected ACS in the ED and whether threat perceptions mediate associations between lack of health insurance and subsequent PSS. METHOD: Patients in the Columbia University Irving Medical Center ED with suspected ACS enrolled in an observational cohort study of psychological and cardiovascular outcomes. A multivariable linear regression model tested health insurance status as the predictor of ED threat perceptions and PSS 1-month posthospitalization, adjusting for age, gender, education, Charlson Comorbidity Index, and Global Registry of Acute Coronary Events risk score. A bootstrapped mediation model tested health insurance status as the predictor, PSS 1-month posthospitalization as the outcome, and ED threat perceptions as the mediator, with the same covariates. RESULTS: Of 1,741 patients with suspected ACS in the ED (Mage = 61.01 years, SD = 13.27; 47.1% women), a plurality identified as "Other" race (36.1%), Black (23.9%), and White (22.4%), and 10.3% of patients were uninsured. Lack of health insurance was associated with greater threat perceptions, b = -0.16, 95% CI [-0.26, -0.06], p = .002. Threat perceptions mediated the association between lack of health insurance and higher 1-month PSS, indirect effect = -1.04, 95% CI [-1.98, -0.17]. CONCLUSIONS: Lacking health insurance may heighten threat perceptions during ACS evaluation, which may put patients at risk of developing PSS. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Linking measures to mechanisms of action: An expert opinion study.

OBJECTIVE: This study sought to integrate the NIH Science of Behaviour Change (SOBC) measures repository comprising measures of putative mechanisms with mechanisms of action (MoA) identified by the Human Behaviour-Change Project (HBCP). DESIGN: Participants were 30 international experts recruited from professional networks and societies. In three anonymous virtual rounds, experts established consensus on hypothesized links between 26 MoAs and 44 self-report measures. METHODS: In Round 1, experts completed a survey rating agreement with 84 pre-identified measure-MoA links and suggested new links. In Round 2, experts discussed 10 links in an online forum, including pre-identified links with <50% agreement and new links suggested by 20-50% of experts. In Round 3, experts completed a survey rating all links eligible for discussion in Round 2. RESULTS: Twenty-seven experts completed Round 1, 23 completed Round 2 and 18 completed Round 3. In Round 1, 82 of 84 pre-identified links reached >50% agreement and 14 new links were suggested by >50% of experts. In Round 2, experts discussed measure-MoA links and measurement quality. In Round 3, 71 of 96 links reached ≥50% agreement. A total of 167 links reached >50% expert agreement, 33 of which reached ≥90% agreement. CONCLUSION: By identifying putative mechanisms (HBCP) for the 44 self-report measures (SOBC), this study advances the cumulation of scientific results and interoperability of resources to facilitate process research.

Effect of cohabiting partners on the development of posttraumatic stress symptoms after emergency department visits for stroke and transient ischemic attack.

OBJECTIVE: Partners can be beneficial for patients experiencing stressful health events such as a stroke/transient ischemic attack (TIA). During such events, however, partners may exacerbate early distress. The present study tested whether having a cohabiting partner modified the association between patients' early perceptions of threat (e.g., feeling vulnerable, helpless) and longer-term posttraumatic stress symptoms (PTSS). METHODS: Participants (N = 328) were drawn from an observational cohort study of patients evaluated for stroke/TIA at an urban academic hospital between 2016 and 2019. Participants self-reported emergency department (ED) threat perceptions and PTSS secondary to the stroke/TIA at three days and one month post-event. RESULTS: Cohabiting partner status modified the association of ED threat with early PTSS. Patients with a cohabiting partner exhibited a positive association between ED threat and early PTSS, B = 0.12, p < .001; those without a cohabiting partner did not, B = 0.04, p = .067. A cohabiting partner was protective only for patients who initially reported low levels of ED threat, as patients with a cohabiting partner who reported low levels of ED threat also had lower early PTSS, B = -0.15, p = .016; at high levels of ED threat, a cohabiting partner was not protective, B = -0.02, p = .68. ED threat was associated with PTSS at one month, B = 0.42, p < .001, but cohabiting partner status did not modify the association. CONCLUSIONS: ED threat perceptions were positively associated with early PTSS only for patients with a cohabiting partner. For patients who do not initially experience a stroke/TIA event as threatening, cohabiting partners may help patients maintain psychological equanimity.

Using a multistakeholder collaboratory and patient surveys to inform the conduct of personalized (N-of-1) trials.

OBJECTIVE: Personalized trials have the potential to improve the precision of treatment selection and foster patient involvement in clinical decision making. Little is known about the attitudes of patients with multimorbidities. To address this, stakeholders designed and conducted a national survey that determined general attitudes and features of personalized trials that may increase their use among patients with multimorbidities in clinical and research practice. METHOD: A multistakeholder collaboratory of patients, clinicians, scientists, methodologists, statisticians, and research disseminators designed a survey to determine the conditions, symptoms, and design attributes most applicable to personalized trials according to patients. A sample of U.S. patients with two or more prespecified personalized-trial-amenable chronic conditions completed the online survey. RESULTS: Multimorbid participants (N = 501; M age = 56.1 years) showed that some conditions, symptoms or use cases for personalized trials include pain (57.6%), hypertension (38.8%), diabetes (28.8%), sleep problems (27.4%), and depression (23.0%). Overall, 82.0% of the participants with multimorbidities were interested in participating in personalized trials. The percentage that were interested varied by trial attributes, including physician involvement (86.4%), patient-driven treatment selection (88.0%), clinician blinding (59.2%), placebo treatment options (57.5%), and out-of-pocket costs (41.8%). CONCLUSION: Participants with multimorbidities identified prevalent use cases that are suited to personalized trials. Participants also identified design features of such trials, including patient-driven treatment selection, active comparators, and nonblinding. This study demonstrates that eliciting input from a collaboratory and patients with multimorbidities can inform research priorities for this rapidly growing patient population and increase adoption by researchers and clinicians alike. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Relationship between NIH stroke symptoms and post-traumatic stress disorder in patients evaluated for transient ischemic attack/stroke.

OBJECTIVE: Post-traumatic stress disorder (PTSD) can develop after a life-threatening medical event. According to the enduring somatic treat (EST) model, internal somatic cues (e.g., rapid heart rate) may contribute to symptoms of stroke/TIA-induced PTSD. To address this possibility, the present study tested the association of stroke-induced disability with PTSD symptoms in patients treated for stroke or transient ischemic attack (TIA). METHOD: Participants (n = 300) were drawn from an observational cohort study examining PTSD symptoms in patients admitted to the NewYork Presbyterian Hospital between 2015 and 2017 for a stroke/TIA. Patients self-reported acute stress symptoms in-person approximately 3 days post-stroke/TIA and PTSD symptoms via telephone one month later. Severity of stroke symptoms (i.e., stroke disability) was evaluated using the NIH Stroke Scale prior to hospital discharge. RESULTS: Stroke disability had a significant, positive association with acute stress symptoms early post-stroke/TIA, B = 0.46, se = 0.15, p = .002, and with PTSD symptoms one month later, B = 0.56, se = 0.19, p = .003. CONCLUSIONS: Stroke disability is positively associated with both acute distress and PTSD symptoms one month later following a stroke/TIA, supporting the hypothesis that internal somatic symptoms contribute to the development stroke/TIA-induced PTSD symptoms.

Personal preferences for Personalised Trials among patients with chronic diseases: an empirical Bayesian analysis of a conjoint survey.

OBJECTIVE: To describe individual patient preferences for Personalised Trials and to identify factors and conditions associated with patient preferences. DESIGN: Each participant was presented with 18 conjoint questions via an online survey. Each question provided two choices of Personalised Trials that were defined by up to eight attributes, including treatment types, clinician involvement, study logistics and trial burden on a patient. SETTING: Online survey of adults with at least two common chronic conditions in the USA. PARTICIPANTS: A nationally representative sample of 501 individuals were recruited from the Chronic Illness Panel by Harris Poll Online. Participants were recruited from several sources, including emails, social media and telephone recruitment of the target population. MAIN OUTCOME MEASURES: The choice of Personalised Trial design that the participant preferred with each conjoint question. RESULTS: There was large variability in participants' preferences for the design of Personalised Trials. On average, they preferred certain attributes, such as a short time commitment and no cost. Notably, a population-level analysis correctly predicted 62% of the conjoint responses. An empirical Bayesian analysis of the conjoint data, which supported the estimation of individual-level preferences, improved the accuracy to 86%. Based on estimates of individual-level preferences, patients with chronic pain preferred a long study duration (p≤0.001). Asthma patients were less averse to participation burden in terms of data-collection frequency than patients with other conditions (p=0.002). Patients with hypertension were more cost-sensitive (p<0.001). CONCLUSION: These analyses provide a framework for elucidating individual-level preferences when implementing novel patient-centred interventions. The data showed that patient preference in Personalised Trials is highly variable, suggesting that individual differences must be accounted for when marketing Personalised Trials. These results have implications for advancing precise interventions in Personalised Trials by indicating when rigorous scientific principles, such as frequent monitoring, is feasible in a substantial subset of patients.

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.

Interventions to improve adherence to antenatal and postnatal care regimens among pregnant women in sub-Saharan Africa: a systematic review.

BACKGROUND: Pregnant women in sub-Saharan Africa tend to have low adherence to antenatal and postnatal care regimens, contributing to high infant and child mortality rates. Despite low adherence figures and the high returns from attending antenatal and postnatal care visits, research on interventions to improve adherence is in its infancy. Our aim was to determine the effectiveness of existing interventions to improve adherence to antenatal and postnatal care regimens among pregnant women in sub-Saharan Africa. METHODS: Full text, peer-reviewed articles, published in English and listed in PubMed or PsycINFO through January 2018 were identified in a systematic review. Studies were restricted to randomized controlled trials only and had to assess intervention impact on antenatal and postnatal care adherence, operationalized as the frequency of visits attended. Two reviewers independently screened papers for inclusion and evaluated the risk of systematic error in each study using the Cochrane risk of bias tool. Any discrepancies were reconciled by a third independent reviewer. RESULTS: The initial search generated 186 articles, of which, five met our inclusion criteria. Due to the small sample size and methodological variation across studies, a pooled effect size estimate could not be obtained. Therefore, effects on antenatal and postnatal care adherence were examined and reported at the individual study level. None of the interventions were directly aimed at improving adherence, but two of the five, both behavioral interventions, demonstrated effectiveness in increasing antenatal care (rate ratio 5.86, 95% CI 2.6-13.0, p<0.0001) and postnatal care adherence (31.3%, 95% CI 15.4-47.2, p=0.0009), respectively. Three home visit interventions had no effect on antenatal care adherence. Although the risk of bias was unclear or high in some cases, it remained low in most categories across studies. CONCLUSIONS: Results point to a large gap in the literature on interventions to address antenatal and postnatal care adherence in sub-Saharan Africa. Interventions drawing upon the executive function literature and the promising results of the behavioral interventions reviewed here are urgently needed to address these gaps. TRIAL REGISTRATION: The review was prospectively registered with PROSPERO, id number https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=88152, on February 7, 2018.

The impact of support provided by close others in the emergency department on threat perceptions.

Objective: Having close others present in the emergency department (ED) can cause patients significant distress. The present study tested the hypothesis that close others provide more negative support than non-close others as a potential explanation for this effect.Design: Participants were 493 patients evaluated for an acute coronary syndrome (ACS) in the ED (MAge = 62.01, SDAge = 13.55; 49.49% male) and who arrived with close others (i.e. spouse/partner, child) or non-close others (e.g. neighbour). Patients self-reported support from companions and threat perceptions (in-ED and at recall approximately three days later).Main outcome measures: Positive support (comfort, responsiveness); negative support (made patients anxious, required comforting); threat perceptions (feeling helpless, vulnerable).Results: Close (vs non-close) others provided patients with marginally more positive support, but also required more comfort, B = 0.32, p = .050, and caused patients more anxiety, B = 0.24, p = .009. Anxiety was associated with patients' Threat Perceptions: in-ED, B = 0.11, p = .002; recall, B = 0.14, p < .001; as was provision of comfort to support partners: recall, B = .06, p = .005.Conclusion: Negative support may be one mechanism underlying the association between close others and patient distress in the ED.