Applying the Behaviour Change Wheel to support deprescribing in long-term care: Qualitative interviews with stakeholder participants.

Background: Implementation and behavioural science are increasingly being used to support development and translation of evidence-based interventions into practice. We used the Behaviour Change Wheel (BCW) approach in two stakeholder forums to identify target behaviours and supporting actions to inform the development of a framework to support deprescribing in long-term care homes. During our planning for these forums, we found many applications of the BCW approach used in healthcare. However, we found no accounts of stakeholders' experiences when the BCW approach was used with large groups of people who were mostly unfamiliar with behavioural science. Objective: The goal of this research was to gain insight into the use of the BCW approach in the context of developing a framework to support deprescribing in long-term care. Methods: This descriptive qualitative study employed one-on-one semi-structured interviews with Ontario long-term care stakeholders who had participated in one or both of two in-person forums that we hosted. Interviews were transcribed verbatim and an inductive content-analysis approach was used to code data and determine themes. Results: Fifteen interviews were conducted. Four themes were identified. First, the BCW was new and made sense, but people found it hard to identify target behaviours before planning solutions. Second, participants varied in their opinions as to whether the 'right' people were participating. Third, participants found that the forum activities, worksheets and facilitators helped people use the approach. Fourth, stakeholder perspectives about potential implementation challenges and strategies to maximize success were identified. Conclusions: Overall, participants were positive about the use of the BCW approach, however, its usefulness could be optimized by enhancing explanations, facilitation and logistics to ensure an initial focus on targeting behaviours. Making stakeholder perspectives transparent and ensuring mechanisms are present to ensure all views are sought and considered are also important to optimizing participant experience.

Antibiotic use among admitted pediatric patients in the United States with status asthmaticus before and during the COVID-19 pandemic.

OBJECTIVE: Hospital admission trends of children with status asthmaticus diminished during the Coronavirus-19 (COVID-19) pandemic of 2020, possibly secondary to several factors such as school closures and use of face masks. What effect this had on antibiotic prescribing practices has yet to be described. The objective of our study was to evaluate the use of antibiotics in hospitalized children with a diagnosis of status asthmaticus before and during the COVID pandemic.Methods: A retrospective cross-sectional analysis was conducted using the TriNetX® cloud-based program with a national and institutional database. Each database was queried for all inpatient pediatric encounters from 3 to 18 years old, admitted with a diagnosis of status asthmaticus in the spring seasons of 2017-2019. Admission data and antibiotic usage were queried during the COVID-19 pandemic year of 2020 from both databases and compared amongst all study years.Results: In 2020, there was an overall decrease in the number of admissions as compared to the average number from 2017-2019, by 76.9% in the national database (p < 0.05) and 91.2% in the institutional database. The rates of antibiotic prescriptions significantly dropped among the national database (p < 0.001, z = 3.39) and remained non-significantly changed among the institutional database (p = 0.944 and z = 0.073).Conclusions: Our study demonstrates that the COVID-19 pandemic year of 2020 coincided with a significant decrease in hospital admissions and antibiotic prescribing prevalence among children with status asthmaticus on a national level. Nonetheless, our reported trends in antibiotic prescribing are still grossly similar to that of pre-pandemic times and may demonstrate a continued need for antimicrobial stewardship.

Persistent Clostridium difficile Colitis Mimicking A Fatal Case Of Strongyloides Hyperinfection Syndrome.

Strongyloidiasis, a disease caused by the helminth Strongyloides stercoralis, has been identified as a life-threatening parasitic infection among immunocompromised patients. In the most severe cases, which include hyperinfection syndrome and dissemination of larvae throughout multiple organ sites, there is typically a history of immunosuppression among the infected. Herein, we describe a fatal case of S. stercoralis hyperinfection in an immigrant from rural Ecuador presenting with diarrhea along with Clostridium difficile colitis after the use of a prolonged course of steroids. Despite the appropriate administration of ivermectin, living Strongyloides larvae were discovered in a tracheal lavage. The patient ultimately developed a multiorgan failure requiring life-supporting measures in the intensive care unit and later succumbed to his condition. This case of S. stercoralis hyperinfection emphasizes the importance of screening for this parasite in the appropriate clinical scenarios. The diagnosis of S. stercoralis can be made more accessible to practitioners through the use of methods such as the modified Baermann technique, agar-plate culture, and serologic antibody testing.

Pharmacists report lack of reinforcement and the work environment as the biggest barriers to routine monitoring and follow-up for people with diabetes: A survey of community pharmacists.

BACKGROUND: Medications with lifestyle are the cornerstone of diabetes management and routine monitoring and follow-up are essential to the delivery of quality care. Documented follow-up rates by pharmacists for people with diabetes are low despite good uptake of initial medication assessments in medication review programs. OBJECTIVES: Identify the barriers and facilitators to routine monitoring and follow-up for people with diabetes by community pharmacists. METHODS: Pharmacists were invited to complete a survey designed using the Theoretical Domains Framework Version 2 TDF (v2) consisting of 39 questions based on the 14 domains of the TDFv2 with quantitative response options using a 7 point Likert scale and 2 open-ended questions. Baseline information about the respondents and their practice sites were summarized using descriptive statistics. Mean scores and standard deviations were calculated for each of the Likert scale responses. Responses to open-ended questions were analyzed and coded using an inductive thematic approach. RESULTS: 346 pharmacists completed the survey (4.76% response rate). The TDF domains found to be positively influencing the delivery of routine monitoring and follow-up activities were beliefs about consequences for people with diabetes (6.08 ± 1.13), pharmacist knowledge (5.93 ± 0.99), pharmacist skills (5.44 ± 1.44), social influences (5.36 ± 1.32) and optimism (5.20 ± 1.58). The domains found to be negatively influencing were reinforcement (3.0 ± 1.89) and environmental context and resources (3.30 ± 1.81). Themes emerging from the thematic analysis included time and competing priorities, reimbursement, patient engagement, workflow and human resources, access to labs and clinical information, information technology and support from the owner/manager. CONCLUSIONS: Our research concludes that pharmacists report that their knowledge, skills, and beliefs about their role and responsibility, social influences and optimism are positive influences on routine monitoring and follow-up while reinforcement and the environmental context/resources are the greatest negative influences. Strategies to improve follow-up should be focused in these areas.

Factors associated with withdrawal from insulin pump therapy: A large-population-based study.

BACKGROUND: Although, number of diabetic patients received insulin pump (IP) therapy is increasing; there are limited data regarding factors associated with IP withdrawal. METHODS: We conducted a cross-sectional study using data from an Israeli health maintenance organization. All patients, 21 or older, with type 1 (T1DM) or type 2 (T2DM) diabetes, who received IP therapy for a 7-year period were identified. Patients who did not purchase IP maintenance supplies for at least six consecutive months were defined as withdrawn (N = 355). Patients who purchased supplies were defined as adherent (N = 352). RESULTS: In both T1DM and T2DM patients, withdrawal from IP therapy was positively associated with duration of diabetes longer than 5 years (odds ratio [OR] = 13.26 [CI, 7.16-23.34; P < .001] and OR = 10.92 [CI, 5.64-21.14; P < .001], respectively), nonadherence to dietician follow-up (OR = 5.78 [CI, 3.65-9.14; P < .001] and OR = 3.41 [CI, 1.99-5.85; P < .001], respectively), and poor glycaemic control prior to IP treatment (OR = 4.04 [CI, 2.18-7.48; P < .001] and OR = 4.59 [CI, 2.71-7.81; P < .001], respectively]. Co-morbid neuro-psychiatric disorders were also risk factors for IP withdrawal: diagnosis of depression (OR = 2.22 [CI, 1.16-4.27; P = .017] and Attention Deficit Hyperactivity Disorder (ADHD) OR = 2.45 [CI, 1.003-5.087; P = .043]) among T1DM patients; and diagnosis of depression (OR = 1.85 [CI, 1.05-5.27; P = .046] and dementia OR = 4.03 [CI, 1.03-19.77; P = .048]) among T2DM patients. CONCLUSION: In our large real-world population-based study, we found that smoking, obesity, poor glycaemic control, and co-morbid neuro-psychiatric disorders were associated with a high rate of withdrawal from IP therapy. Health care providers ought to familiarize themselves with patient characteristics predictive of nonadherence and should intensify patient follow-up when incorporating this new, costly, and challenging technology.

Views of Cohort Study Participants about Returning Research Results in the Context of Precision Medicine.

BACKGROUND: The practice of biorepository-based genetics research raises questions related to what ethical obligations researchers have to their participants. It is important to explore and include the thoughts of current biorepository participants as we move forward with this type of research. METHODS: Thirty participants (17 cancer patients, 7 cancer-free controls, and 6 relatives) were drawn from the Northwest Cancer Genetics Registry and participated in qualitative interviews lasting between 45 and 90 min. Topics explored in this study include which types of genetic test results participants of large biorepositories expect and would like to receive from research analyzing their samples, as well as thoughts on best practice for conducting this type of research. RESULTS: Cancer cases, controls, and first-degree relatives have differing views on what results they would like to receive from biorepository-based research. Participants across all groups attempted to balance the costs and benefits of returning individual research results. DISCUSSION: In the wake of precision medicine, it is important to describe the range of ways participants in large biorepositories both think and talk about the utilization of their specimens for genetics research.