Telehealth Implementation Response to COVID-19 in the OneFlorida+ Clinical Research Network: Perspectives of Clinicians and Health Systems Leaders.

Introduction: The COVID-19 pandemic forced health systems worldwide to make rapid adjustments to patient care. Nationwide stay-at-home mandates and public health concerns increased demand for telehealth to maintain patients' continuity of care. These circumstances permitted observation of telehealth implementation in real-world settings at a large scale. This study aimed to understand clinician and health system leader (HSL) experiences in expanding, implementing, and sustaining telehealth during COVID-19 in the OneFlorida+ clinical research network. Methods: We conducted semistructured videoconference interviews with 5 primary care providers, 7 specialist providers, and 12 HSLs across 7 OneFlorida+ health systems and settings. Interviews were audiorecorded, transcribed, and summarized using deductive team-based template coding. We then used matrix analysis to organize the qualitative data and identify inductive themes. Results: Rapid telehealth implementation occurred even among sites with low readiness, facilitated by responsive planning, shifts in resource allocation, and training. Common hurdles in routine telehealth use, including technical and reimbursement issues, were also barriers to telehealth implementation. Acceptability of telehealth was influenced by benefits such as the providers' ability to view a patient's home environment and the availability of tools to enhance patient education. Lower acceptability stemmed from the inability to conduct physical examinations during the shutdown. Conclusions: This study identified a broad range of barriers, facilitators, and strategies for implementing telehealth within large clinical research networks. The findings can contribute to optimizing the effectiveness of telehealth implementation in similar settings, and point toward promising directions for telehealth provider training to improve acceptability and promote sustainability.

Pediatric primary care provider and staff perspectives on the implementation of electronic health record-based social needs interventions: A mixed-methods study.

Introduction: Interventions to address social needs in clinical settings can improve child and family health outcomes. Electronic health record (EHR) tools are available to support these interventions but are infrequently used. This mixed-methods study sought to identify approaches for implementing social needs interventions using an existing EHR module in pediatric primary care. Methods: We conducted focus groups and interviews with providers and staff (n = 30) and workflow assessments (n = 48) at four pediatric clinics. Providers and staff completed measures assessing the acceptability, appropriateness, and feasibility of social needs interventions. The Consolidated Framework for Implementation Research guided the study. A hybrid deductive-inductive approach was used to analyze qualitative data. Results: Median scores (range 1-5) for acceptability (4.9) and appropriateness (5.0) were higher than feasibility (3.9). Perceived barriers to implementation related to duplicative processes, parent disclosure, and staffing limitations. Facilitators included the relative advantage of the EHR module compared to existing documentation practices, importance of addressing social needs, and compatibility with clinic culture and workflow. Self-administered screening was seen as inappropriate for sensitive topics. Strategies identified included providing resource lists, integrating social needs assessments with existing screening questionnaires, and reducing duplicative documentation. Conclusions: This study offers insight into the implementation of EHR-based social needs interventions and identifies strategies to promote intervention uptake. Findings highlight the need to design interventions that are feasible to implement in real-world settings. Future work should focus on integrating multiple stakeholder perspectives to inform the development of EHR tools and clinical workflows to support social needs interventions.

Parent Perspectives on Electronic Health Record-Based Social Needs Screening and Documentation: A Qualitative Study.

OBJECTIVE: Social needs interventions in clinical settings can improve child health outcomes; however, they are not routinely delivered in routine pediatric care. The electronic health record (EHR) can support these interventions, but parent engagement in the development of EHR-based social needs interventions is lacking. The aim of this study was to assess parent perspectives on EHR-based social needs screening and documentation and identify family-centered approaches for screening design and implementation. METHODS: We enrolled 20 parents from four pediatric primary care clinics. Parents completed a social risk questionnaire from an existing EHR module and participated in qualitative interviews. Parents were asked about the acceptability of EHR-based social needs screening and documentation and preferences for screening administration. A hybrid deductive-inductive approach was used to analyze qualitative data. RESULTS: Parents identified the benefits of social needs screening and documentation but expressed concerns related to privacy, fear of negative outcomes, and use of outdated documentation. Some felt self-administered electronic questionnaires would mitigate parent discomfort and encourage disclosure of social needs, while others felt face-to-face screening would be more effective. Parents stressed the importance of transparency on the purpose of social needs screening and the use of data. CONCLUSIONS: This work can inform the design and implementation of EHR-based social needs interventions that are acceptable and feasible for parents. Findings suggest strategies such as clear communication and multi-modal delivery methods may enhance intervention uptake. Future work should integrate feedback from multiple stakeholders to design and evaluate interventions that are family-centered and feasible to implement in clinical settings.

An effectiveness-implementation hybrid trial of phone-based tobacco cessation interventions in the Lebanese primary healthcare system: protocol for project PHOENICS.

BACKGROUND: Tobacco use remains the leading cause of preventable disease, disability, and death in the world. Lebanon has an exceptionally high tobacco use burden. The World Health Organization endorses smoking cessation advice integrated into primary care settings as well as easily accessible and free phone-based counseling and low-cost pharmacotherapy as standard of practice for population-level tobacco dependence treatment. Although these interventions can increase access to tobacco treatment and are highly cost-effective compared with other interventions, their evidence base comes primarily from high-income countries, and they have rarely been evaluated in low- and middle-income countries. Recommended interventions are not integrated as a routine part of primary care in Lebanon, as in other low-resource settings. Addressing this evidence-to-practice gap requires research on multi-level interventions and contextual factors for implementing integrated, scalable, and sustainable cessation treatment within low-resource settings. METHODS: The objective of this study is to evaluate the comparative effectiveness of promising multi-component interventions for implementing evidence-based tobacco treatment in primary healthcare centers within the Lebanese National Primary Healthcare Network. We will adapt and tailor an existing in-person smoking cessation program to deliver phone-based counseling to smokers in Lebanon. We will then conduct a three-arm group-randomized trial of 1500 patients across 24 clinics comparing (1) ask about tobacco use; advise to quit; assist with brief counseling (AAA) as standard care; (2) ask; advise; connect to phone-based counseling (AAC); and (3) AAC + nicotine replacement therapy (NRT). We will also evaluate the implementation process to measure factors that influence implementation. Our central hypothesis is that connecting patients to phone-based counseling with NRT is the most effective alternative. This study will be guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, supported by Proctor's framework for implementation outcomes. DISCUSSION: The project addresses the evidence-to-practice gap in the provision of tobacco dependence treatment within low-resource settings by developing and testing contextually tailored multi-level interventions while optimizing implementation success and sustainability. This research is significant for its potential to guide the large-scale adoption of cost-effective strategies for implementing tobacco dependence treatment in low-resource settings, thereby reducing tobacco-related morbidity and mortality. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05628389, Registered 16 November 2022.

Comparative effectiveness of mobile health smoking cessation approaches among underserved patients in primary care: Study protocol for the PROMOTE-UP trial.

INTRODUCTION: Tobacco smoking is the leading cause of preventable disease, disability, and premature death in the United States. Recent advances have led to two efficacious mobile health (mHealth) treatments for smoking cessation: iCanQuit, an Acceptance and Commitment Therapy-based behavioral treatment promoting cessation through accepting triggers and committing to values; and Motiv8, a contingency management intervention promoting smoking cessation with financial incentives via biochemically verified abstinence. This study will evaluate the comparative effectiveness of the Florida Quitline, iCanQuit alone, and iCanQuit+Motiv8 in a pragmatic trial among patients who smoke in underserved primary care settings. METHODS: The study will be an individually-randomized controlled trial with three arms (Florida Quitline, iCanQuit alone, iCanQuit+Motiv8 combined) conducted in multiple primary care practices affiliated with the OneFlorida+ Clinical Research Consortium. Adult patients who smoke will be randomized to one of the 3 study arms (n = 444/arm), stratified by healthcare setting (academic vs. community). The primary outcome will be 7-day point prevalence smoking abstinence at 6 months post-randomization. Secondary outcomes will be 12-month smoking abstinence, patient satisfaction with the interventions, and changes in patient quality of life and self-efficacy. The study will also assess how and for whom the interventions help sub-group patients in achieving smoking abstinence by measuring theory-derived factors that mediate smoking outcome-specific baseline moderators. CONCLUSIONS: Results from this study will provide evidence for the comparative effectiveness of mHealth smoking cessation interventions in healthcare settings. Use of mHealth interventions can make smoking cessation resources more equitably accessible and have far-reaching impact on community and population health. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05415761, Registered 13 June 2022.

Mixed methods evaluation of vaping and tobacco product use prevention interventions among youth in the Florida 4-H program.

INTRODUCTION: Novel prevention programs are developed to address the increase in e-cigarette use (vaping) among children. However, it remains paramount to test their feasibility in rural settings. This pilot study implemented and evaluated the feasibility and outcomes of two innovative programs, CATCH My Breath and smokeSCREEN, among youth in rural settings in Florida. METHODS: We conducted four focus groups with youth aged 11-17 recruited from 4-H rural clubs in Florida. In a subsequent randomized trial, we recruited 82 youth participants and assigned them to one of three arms: CATCH My Breath, smokeSCREEN, or control. CATCH My Breath and smokeSCREEN participants attended online group intervention sessions while the control group received educational material. Pre- and post-surveys were administered to all participants to assess knowledge, susceptibility, perceived positive outcomes and risk perceptions related to tobacco and e-cigarette use. Other feasibility parameters were also assessed. RESULTS: Focus group discussions provided insights about feasibility and informed the implementation of both interventions in terms of delivery format, scheduling of sessions and incentives. After the intervention, CATCH My Breath participants significantly improved their general tobacco-related knowledge (post-pre = 16.21-12.92 = 3.3, p <.01) and risk perceptions towards other flavored tobacco products (post-pre = 19.29-17.71 = 1.6, p <.05). smokeSCREEN participants significantly improved their general tobacco knowledge (post-pre = 18.77-13.77 = 5.0, p <.01), knowledge about e-cigarettes (post-pre = 9.08-6.31 = 2.8, p <.01) and risk perception towards e-cigarettes (post-pre = 24.69-21.92 = 2.8, p <.05). CONCLUSIONS: This study demonstrated feasibility of delivering the interventions via participant engagement, participants' willingness to be randomized, assessment of outcome measures, and exploration of different recruitment methods. Despite the potential positive influence of CATCH My Breath and smokeSCREEN on youth participants, further evaluation with larger samples is needed.

The Association of Socioeconomic Vulnerability and Race and Ethnicity With Disease Burden Among Children in a Statewide Medicaid Population.

OBJECTIVE: Individuals enrolled in Medicaid have disproportionately worse health outcomes due to challenges related to Social Determinants of Health. We aim to examine the prevalence of 3 childhood conditions (asthma, type 2 diabetes, and attention deficit hyperactivity disorder [ADHD]) in children within the Texas Medicaid system. In order to recognize the layers of vulnerability, we examine prevalence at the intersection of socioeconomic status with race and ethnicity within this economically challenged population. METHODS: Children ages 0 to 17 were identified from claims and encounter data for all children enrolled in Texas Medicaid in 2017 for at least 6 months. All children were placed into one of 5 quintiles based on their census tract socioeconomic vulnerability. The Rate Ratio statistical test was employed to identify the statistical significance of the disparity in health outcomes related to higher neighborhood vulnerability within each racial or ethnic group. RESULTS: Asthma for each race and ethnicity group was significantly more prevalent in the higher vulnerability census tracts. Increased vulnerability related to significant increase in type 2 diabetes for Hispanic children, but not for other groups. Diagnosed ADHD prevalence was significantly higher in less vulnerable non-Hispanic white children compared to more vulnerable. CONCLUSIONS: This study found that even among children who receive Medicaid and are thus economically disadvantaged, socioeconomic vulnerability applies an additional burden within racial and ethnic groups to produce disparities in health-related burden. However, the trend of the relationship varied by race and ethnicity group and health condition.

Exploring paediatricians' experiences with performance improvement modules and quality improvement.

OBJECTIVE: The American Board of Pediatrics' (ABP) maintenance of certification (MOC) programme seeks to continue educating paediatricians throughout their careers by encouraging lifelong learning and continued improvement. The programme includes four parts, each centring on a different aspect of medical practice. Part 4 MOC centres on quality improvement (QI). Surveys by the ABP suggest that paediatricians are dissatisfied with aspects of part 4, but their reasons are unclear. This study sought to explore factors contributing to dissatisfaction with part 4 by focusing on performance improvement modules (PIMs), a popular means of achieving part 4 credit. METHODS: The study used cross-sectional purposive sampling drawing from US physicians working in a range of practice settings: private outpatient, hospital, academic and low-income clinics. The sampling frame was divided by practice characteristics and satisfaction level, derived from a five-point Likert item asking about physician satisfaction regarding a recent PIM. In-depth interviews were conducted with 21 physicians, and the interview data were coded, categorised into themes and analysed using a framework analysis approach. RESULTS: Paediatricians expressed nuanced views of PIMs and remain globally dissatisfied with part 4, although reasons for dissatisfaction varied. Concerns with PIMs included: (1) excessive time and effort; (2) limited improvement and (3) lack of clinically relevant topics. While most agreed that QI is important, participants felt persistently dissatisfied with the mechanics of doing PIMs, especially when QI tasks fell outside of their typical work regimen. CONCLUSIONS: Paediatricians agreed that part 4, PIMs, and QI efforts in general still lack clinical relevance and need to be more easily incorporated into practice workflow. Clinicians specifically felt that PIMs must be directly integrated with physicians' practice settings in terms of topic, data quality and metrics, and must address practice differences in time and monetary resources for completing large or complex projects.

Implementation strategies for integrating tobacco cessation treatment in cancer care: A qualitative study.

Purpose: The objective of this study was to determine how to optimize implementation of tobacco cessation treatment interventions in cancer care by (1) investigating the feasibility and acceptability of a multi-level approach to tobacco cessation treatment intervention, (2) identifying barriers and facilitators to implementation, and (3) eliciting additional strategies to improve implementation of the intervention. Methods: We conducted qualitative interviews with oncologists (n = 15) from one large academic health center in the Southeastern United States. We asked about their knowledge, attitudes, and current practices regarding tobacco use screening and treatment. We also asked about two proposed strategies to support implementation of tobacco cessation treatment: (1) developing a registry of tobacco users in collaboration with the state-run tobacco cessation program, and (2) providing on-site tobacco cessation counseling from trained professionals. Results: Oncologists saw addressing tobacco use as valuable; however, they felt restricted from consistently addressing tobacco use by multi-level barriers such as workload, electronic health record (EHR) design, patient anxiety, and low self-efficacy for treating tobacco dependence. Oncologists responded positively to on-site treatment and felt this strategy would increase treatment accessibility and enhance engagement. Reaction to developing a registry of tobacco users was mixed, with concerns regarding lack of oncologist involvement and patient privacy expressed. Other suggested strategies for supporting implementation of tobacco cessation treatment included reducing referral complexity, establishing financial or quality incentives for oncologists, and leveraging existing EHR tools to facilitate integration of cessation interventions into clinic workflows. Conclusion: We identified several challenges to implementing tobacco use treatment in cancer care; however, we considered strategies to overcome these barriers that were viewed as feasible and acceptable. Our work highlights the importance of engaging stakeholders in implementation efforts. Future work should explore the impact of the implementation strategies identified in this study.

Implementation of a High-Sensitivity Troponin-I Assay in an Academic Medical Center: A Qualitative and Quantitative Assessment.

OBJECTIVES: To describe the clinical impact and lessons learned through implementation of a high sensitivity troponin (hsTn) assay. BACKGROUND: hsTn assays have received regulatory approval for use in the United States, and healthcare facilities are beginning to adopt these new assays. Questions remain about how to implement them and what effect they may have on demand for cardiovascular services. METHODS: We conducted a mixed-methods implementation science-based investigation of hsTn adoption at a single academic medical center. We designed the investigation based on the Consolidated Framework for Implementation Research, exploring clinicians' perspectives on intervention characteristics, inner setting, individual characteristics, and process of implementation domains. Focus groups were conducted with clinicians from multiple service lines. RESULTS: Participants reported that the new hsTn assay did not fundamentally change processes of care such as cardiology consultations or inpatient admissions. Implementation was facilitated by leveraging the electronic medical record to provide useful suggestions for hsTn management at the point-of-care. The use of case-based teaching was considered most effective. Areas of ongoing concern included management of high-risk patients, outpatient follow-up, and feasibility of accelerated diagnostic protocols for early discharge from the emergency department. A decrease in the number of hsTn assays ordered was observed; no change was noted for admissions, cardiology consultations, or noninvasive cardiac imaging. CONCLUSIONS: A comprehensive educational campaign, based on multidisciplinary collaboration can effectively prepare clinicians for implementation of hsTn. New hsTn assays may not have any substantial effect on acute management of patients with cardiac complaints.

Mixed-methods economic evaluation of the implementation of tobacco treatment programs in National Cancer Institute-designated cancer centers.

BACKGROUND: The Cancer Center Cessation Initiative (C3I) was launched in 2017 as a part of the NCI Cancer Moonshot program to assist NCI-designated cancer centers in developing tobacco treatment programs for oncology patients. Participating centers have implemented varied evidence-based programs that fit their institutional resources and needs, offering a wide range of services including in-person and telephone-based counseling, point of care, interactive voice response systems, referral to the quitline, text- and web-based services, and medications. METHODS: We used a mixed methods comparative case study design to evaluate system-level implementation costs across 15 C3I-funded cancer centers that reported for at least one 6-month period between July 2018 and June 2020. We analyzed operating costs by resource category (e.g., personnel, medications) concurrently with transcripts from semi-structured key-informant interviews conducted during site visits. Personnel salary costs were estimated using Bureau of Labor Statistics wage data adjusted for area and occupation, and non-wage benefits. Qualitative findings provided additional information on intangible resources and contextual factors related to implementation costs. RESULTS: Median total monthly operating costs across funded centers were $11,045 (range: $5129-$20,751). The largest median operating cost category was personnel ($10,307; range: $4122-$19,794), with the highest personnel costs attributable to the provision of in-person program services. Monthly (non-zero) cost ranges for other categories were medications ($17-$573), materials ($6-$435), training ($96-$516), technology ($171-$2759), and equipment ($10-$620). Median cost-per-participant was $466 (range: $70-$2093) and cost-per-quit was $2688 (range: $330-$9628), with sites offering different combinations of program components, ranging from individually-delivered in-person counseling only to one program that offered all components. Site interviews provided context for understanding variations in program components and their cost implications. CONCLUSIONS: Among most centers that have progressed in tobacco treatment program implementation, cost-per-quit was modest relative to other prevention interventions. Although select centers have achieved similar average costs by offering program components of various levels of intensity, they have varied widely in program reach and effectiveness. Evaluating implementation costs of such programs alongside reach and effectiveness is necessary to provide decision makers in oncology settings with the important additional information needed to optimize resource allocation when establishing tobacco treatment programs.

Behavioral Weight Loss Intervention Preferences of Adolescents with Overweight/Obesity.

Background: Behavioral lifestyle interventions are the foundation of adolescent obesity treatment. Tailoring an intervention using adolescent stakeholder engagement during the development process could improve intervention effectiveness. Methods: Adolescents with overweight/obesity ages 14-19 (n = 41) participated in 11 sex-specific focus groups (girls = 6, boys = 5) and were asked their preferences regarding who should lead the intervention and be involved, what the messaging of the program should be, how to make the program engaging and maintain participation, and how to best measure nutrition intake and activity. Transcripts were coded and analyzed for emergent themes. Results: Mean age was 16.0 ± 1.8 years and participants were racially/ethnically diverse. Adolescents preferred interventions that avoid a focus on "weight loss," and instead emphasize "healthy lifestyle," which represents a more comprehensive goal of targeting physical and mental well-being. Most participants indicated preferences for a relatable instructor with prior weight loss experience. Both sexes preferred optional parental involvement, as some parents were described as helpful, while others were perceived as a hindrance to success. Boys and girls identified incentives, engaging activities, and electronic communication as core components for engagement and retention, with girls emphasizing socialization and building relationships. Sex differences in preferences were observed. Girls had more concerns about intervention participation and preferred interventions to be sex stratified. Conclusions: Behavioral interventions to treat adolescent obesity should focus messaging/content on healthy lifestyles, rather than weight loss, and be sex stratified. Development and implementation of future behavioral interventions for adolescent obesity should consider tailoring to adolescent preferences when possible to improve feasibility, acceptability, and effectiveness.

Perspectives of pregnant and breastfeeding women on longitudinal clinical studies that require non-invasive biospecimen collection - a qualitative study.

BACKGROUND: Investigation of the microbiome during early life has stimulated an increasing number of cohort studies in pregnant and breastfeeding women that require non-invasive biospecimen collection. The objective of this study was to explore pregnant and breastfeeding women's perspectives on longitudinal clinical studies that require non-invasive biospecimen collection and how they relate to study logistics and research participation. METHODS: We completed in-depth semi-structured interviews with 40 women who were either pregnant (n = 20) or breastfeeding (n = 20) to identify their understanding of longitudinal clinical research, the motivations and barriers to their participation in such research, and their preferences for providing non-invasive biospecimen samples. RESULTS: Perspectives on research participation were focused on breastfeeding and perinatal education. Participants cited direct benefits of research participation that included flexible childcare, lactation support, and incentives and compensation. Healthcare providers, physician offices, and social media were cited as credible sources and channels for recruitment. Participants viewed lengthy study visits and child protection as the primary barriers to research participation. The barriers to biospecimen collection were centered on stool sampling, inadequate instructions, and drop-off convenience. CONCLUSION: Women in this study were interested in participating in clinical studies that require non-invasive biospecimen collection, and motivations to participate center on breastfeeding and the potential to make a scientific contribution that helps others. Effectively recruiting pregnant or breastfeeding participants for longitudinal microbiome studies requires protocols that account for participant interests and consideration for their time.

Implementation context for addressing social needs in a learning health system: a qualitative study.

INTRODUCTION: Unmet social needs contribute to growing health disparities and rising health care costs. Strategies to collect and integrate information on social needs into patients' electronic health records (EHRs) show promise for connecting patients with community resources. However, gaps remain in understanding the contextual factors that impact implementing these interventions in clinical settings. METHODS: We conducted qualitative interviews with patients and focus groups with providers (January-September 2020) in two primary care clinics to inform the implementation of a module that collects and integrates patient-reported social needs information into the EHR. Questions addressed constructs within the Theoretical Framework for Acceptability and the Consolidated Framework for Implementation Research. Data were coded deductively using team-based framework analysis, followed by inductive coding and matrix analyses. RESULTS: Forty patients participated in interviews, with 20 recruited at the clinics and 20 from home. Two focus groups were conducted with a total of 12 providers. Factors salient to acceptability and feasibility included patients' discomfort answering sensitive questions, concerns about privacy, difficulty reading/understanding module content, and technological literacy. Rapport with providers was a facilitator for patients to discuss social needs. Providers stressed that limited time with patients would be a barrier, and expressed concerns about the lack of available community resources. CONCLUSION: Findings highlight the need for flexible approaches to assessing and discussing social needs with patients. Feasibility of the intervention is contingent upon support from the health system to facilitate social needs assessment and discussion. Further study of availability of community resources is needed to ensure intervention effectiveness.

Perceived barriers/facilitators to a healthy lifestyle among diverse adolescents with overweight/obesity: A qualitative study.

Objective: Effectiveness of behavioural obesity treatments in adolescents is modest. Thus, incorporating participant feedback may lead to improvement of intervention acceptability. This qualitative study's objective was to assess perceived barriers/facilitators to weight loss and healthy lifestyles among diverse adolescents with overweight/obesity (OW/OB). Methods: Adolescents ages 14-19 with BMI ≥ 85th percentile participated in focus groups and identified perceived barriers/facilitators to weight loss and healthy lifestyles. Results: Ten sex-stratified focus groups (n = 41; n = 13 males, n = 28 females) were conducted in 2018 and 2019. Females reported experiencing weight struggles, whereas males often stated no struggles with weight, despite all participants meeting criterion for OW/OB. Barriers included eating behaviours, family members and internal motivation, with additional barriers of physical activity, friends, time and support cited in females. Facilitators included parental, familial and peer support of healthy eating and exercise, modelling behaviours, internal motivation and organized sports. Two additional findings regarding adolescents' perceived barriers/facilitators include substantial overlap and sex differences of perceived barriers/facilitators. Conclusions: Adolescent males and females with OW/OB experience weight status differently, affecting their perceived barriers/facilitators to weight loss and healthy lifestyles. Tailoring weight management interventions to the unique needs of adolescent females versus adolescent males has the potential to improve intervention quality and effectiveness.

An Implementation Trial to Improve Tobacco Treatment for Cancer Patients: Patient Preferences, Treatment Acceptability and Effectiveness.

Continued smoking after a cancer diagnosis increases mortality, risk of recurrence, and negatively impacts treatment effectiveness. However, utilization of tobacco use cessation treatment among cancer patients remains low. We conducted a clinical trial assessing patient preferences, treatment acceptability, and preliminary effectiveness (7-day point prevalence at 12 weeks) of three tobacco treatment options among cancer patients at an academic health center. Implementation strategies included electronic referral and offering the choice of three treatment options: referral to external services, including the quitline (PhoneQuit) and in-person group counseling (GroupQuit), or an internal service consisting of 6-week cognitive behavioral therapy delivered via smartphone video conferencing by a tobacco treatment specialist (SmartQuit). Of 545 eligible patients, 90 (16.5%) agreed to enroll. Of the enrolled patients, 39 (43.3%) chose PhoneQuit, 37 (41.1%) SmartQuit, and 14 (15.6%) GroupQuit. Of patients reached for 12-week follow-up (n = 35), 19 (54.3%) reported receiving tobacco treatment. Of all patients referred, 3 (7.7%) PhoneQuit, 2 (5.4%) SmartQuit, and 2 (14.3%) GroupQuit patients reported 7-day point prevalence abstinence from smoking at 12 weeks. Participants rated the SmartQuit intervention highly in terms of treatment acceptability. Results indicate that more intensive interventions may be needed for this population, and opportunities remain for improving reach and utilization.

"I can be the Judge of What's Serious": A Qualitative Pilot Study of Parents' Responses to Messaging About Side Effects of the HPV Vaccine.

OBJECTIVE: Parents' concerns about vaccine safety and side effects likely contribute to low rates of human papillomavirus (HPV) vaccination among adolescents. To facilitate parent-provider discussions about the HPV vaccine, we developed and tested the content of a clinical decision support application for implementation in pediatric clinical settings. This study sought to elicit perspectives of parents and providers on the best way to communicate information on vaccine side effects. METHODS: To understand the acceptability of the application's content, we conducted focus groups with parents (n = 11) and providers (n = 9) at three primary care clinics. Focus groups transcriptions were analyzed using iterations of deductive and inductive coding, with independent coding by two trained reviewers to improve inter-rater reliability. RESULTS: Surprisingly, when parents reviewed screen shots of HPV vaccine safety and side effect messages, parents took exception to the expression "no evidence of serious side effects". Parents wanted side effects listed explicitly so they could decide for themselves which side effects were "serious". Parents also felt that the HPV vaccine did have serious side effects, and the wording undermined their trust in the vaccine messaging overall. Providers accepted the phrasing of side effects and did not express concerns that parents would object to the messaging. CONCLUSIONS: Further research is needed to confirm parents' concerns with the phrasing "no serious side effects" for the HPV vaccine and to assess the impact on HPV vaccination deferral or delay.

Tobacco-Related Counseling and Documentation in Adolescent Primary Care Practice: Challenges and Opportunities.

INTRODUCTION: Primary care visits present an opportunity to reduce tobacco use and tobacco smoke exposure (TSE) among adolescents. To date, few studies have examined tobacco-related electronic health record (EHR) documentation in adolescent visits. The purpose of this study was to (1) describe tobacco-related EHR documentation practices in adolescent care clinics, including whether alternative tobacco products, parental use, and TSE were addressed; and (2) identify aspects of adolescent tobacco use that may inform EHR updates and counseling and documentation practices. METHODS: Following a convergent mixed-methods design, we conducted an EHR review of 508 adolescent well-child visits, performed focus groups with pediatric providers and staff, and conducted in-depth interviews with adolescent patients. Record review data and interview transcripts were analyzed and interpreted concurrently. RESULTS: In the EHR review, cigarette screening was documented in 92.3% of visits, smokeless tobacco screening in 51.4%, parental tobacco use in 23.2%, and home TSE in 33.1% of visits. Smoking status options were not mutually exclusive and did not include noncigarette products. No records documented assessment of e-cigarette use, despite nearly half of adolescent interview respondents citing these as the most popular products among adolescents. In interviews, adolescents discussed their experiences with alternative tobacco/nicotine products more than cigarettes. CONCLUSIONS: Tobacco use status prompts should be revised for clarity and include noncigarette tobacco products and TSE. Provider education on noncigarette products and TSE assessment is needed. Improvements in EHR systems, resources, and tools can lead to better tobacco screening, prevention, and treatment practices among primary care providers. IMPLICATIONS: Clinical guidelines call for pediatricians to assess and treat adolescent and parental tobacco use during primary care visits. The use of electronic health records (EHRs) can improve screening and counseling practices; however, few studies have examined tobacco-related EHR documentation practices in adolescent care settings. This mixed-methods study found low rates of EHR documentation related to noncigarette nicotine/tobacco products, parental tobacco use, and tobacco smoke exposure. These results demonstrate the need for increased provider training and EHR modifications to facilitate comprehensive tobacco control efforts in the adolescent population.

Drivers of preventable high health care utilization: a qualitative study of patient, physician and health system leader perspectives.

OBJECTIVES: A small percentage of patients account for the bulk of population health care utilization and costs in many countries including the United States (US). In the US, 5% of the population has high health care utilization accounting for nearly 50% of health care costs. A subset of this utilization is deemed preventable, and thus potentially cost saving to patients as well as to the health care system. This study sought to identify drivers of preventable utilization from the perspectives of three stakeholder groups in the US: health system leaders; high-need, high-cost (HNHC) patients or their primary caregivers; and physicians. METHODS: We performed a qualitative study using interviews of health system leaders and focus groups of HNHC patients, caregivers and physicians. We used a mixed inductive deductive approach to analyse transcripts and identify themes. RESULTS: We identified three key drivers of preventable high health care utilization: (1) unmet behavioural health needs, (2) socio-economic determinants of health and (3) challenges associated with accessing health care delivery systems. CONCLUSIONS: To be potentially more effective, interventions to reduce preventable high health care utilization should incorporate the perspectives of patients, health system leaders and physicians. Particularly important to stakeholders is increased access to mental-health resources, support for patients with low socio-economic resources and systemic changes that reduce wait times for primary care visits and allow providers more time during patient visits.

Considerations of Privacy and Confidentiality in Developing a Clinical Support Tool for Adolescent Tobacco Prevention: Qualitative Study.

BACKGROUND: Electronic clinical support tools show promise for facilitating tobacco screening and counseling in adolescent well-care. However, the application of support tools in pediatric settings has not been thoroughly studied. Successfully implementing support tools in local settings requires an understanding of barriers and facilitators from the perspective of both patients and providers. OBJECTIVE: This paper aimed to present the findings of a qualitative study conducted to inform the development and implementation of a support tool for adolescent tobacco screening and counseling in 3 pediatric clinics in North Florida. The primary objective of the study was to test and collect information needed to refine a tablet-based support tool with input from patients and providers in the study clinics. METHODS: A tablet prototype was designed to collect information from adolescents on tobacco susceptibility and use before their well-care visit and to present tobacco prevention videos based on their responses. Information collected from adolescents by the support tool would be available to providers during the visit to facilitate and streamline tobacco use assessment and counseling components of well-care. Focus groups with providers and staff from 3 pediatric clinics (n=24) identified barriers and facilitators to implementation of the support tool. In-depth interviews with racially and ethnically diverse adolescent patients who screened as susceptible to tobacco use (n=16) focused on acceptability and usability of the tool. All focus groups and interviews were audio-recorded and transcribed for team-based coding using thematic analysis. RESULTS: Privacy and confidentiality of information was a salient theme. Both groups expressed concerns that the tool's audio and visual components would impede privacy and that parents may read their child's responses or exert control over the process. Nearly all adolescents stated they would be comfortable with the option to complete the tool at home via a Web portal. Most adolescents stated they would feel comfortable discussing tobacco with their doctor. Adolescent interviews elicited 3 emergent themes that added context to perspectives on confidentiality and had practical implications for implementation: (1) purity: an expressed lack of concern for confidentiality among adolescents with no reported history of tobacco use; (2) steadfast honesty: a commitment to being honest with parents and providers about tobacco use, regardless of the situation; and (3) indifference: a perceived lack of relevance of confidentiality, based on the premise that others will "find out anyway" if adolescents are using tobacco. CONCLUSIONS: This study informed several modifications to the intervention to address confidentiality and introduce efficiency to well-care visits. The support tool was integrated into the electronic health record system used by the study clinics and modified to offer videos to all adolescents regardless of their tobacco use or susceptibility. Future studies will further test the acceptability of the intervention in practice.