Challenges and Opportunities in Data Visualization Education: A Call to Action.

This paper is a call to action for research and discussion on data visualization education. As visualization evolves and spreads through our professional and personal lives, we need to understand how to support and empower a broad and diverse community of learners in visualization. Data Visualization is a diverse and dynamic discipline that combines knowledge from different fields, is tailored to suit diverse audiences and contexts, and frequently incorporates tacit knowledge. This complex nature leads to a series of interrelated challenges for data visualization education. Driven by a lack of consolidated knowledge, overview, and orientation for visualization education, the 21 authors of this paper-educators and researchers in data visualization-identify and describe 19 challenges informed by our collective practical experience. We organize these challenges around seven themes People, Goals & Assessment, Environment, Motivation, Methods, Materials, and Change. Across these themes, we formulate 43 research questions to address these challenges. As part of our call to action, we then conclude with 5 cross-cutting opportunities and respective action items: embrace DIVERSITY+INCLUSION, build COMMUNITIES, conduct RESEARCH, act AGILE, and relish RESPONSIBILITY. We aim to inspire researchers, educators and learners to drive visualization education forward and discuss why, how, who and where we educate, as we learn to use visualization to address challenges across many scales and many domains in a rapidly changing world: viseducationchallenges.github.io.

Patients' experiences undergoing cancer surgery during the COVID-19 pandemic: a qualitative study.

PURPOSE: This study aimed to understand patients' experiences undergoing cancer surgery during the COVID-19 pandemic. In response to COVID-19, many elective cancer surgeries were delayed creating a massive backlog of cases. Patients' experiences with surgical delays may inform healthcare systems' responses to the backlog of cases and guide preparations for future healthcare emergencies. METHODS: This was a qualitative description study. Patients undergoing general surgery for cancer at two university-affiliated hospitals between March 2020 and January 2021 were invited to one-to-one interviews. Patients were purposefully selected using quota sampling until interviews produced no new information (i.e., thematic saturation). Interviews were conducted using a semi-structured guide and analyzed according to inductive thematic analysis. RESULTS: Twenty patients were included [mean age 64 ± 12.9; male (n = 10); surgical delay (n = 14); cancer sites: breast (n = 8), skin (n = 4), hepato-pancreato-biliary (n = 4), colorectal (n = 2), and gastro-esophageal (n = 2)]. When determining their willingness to undergo surgery, patients weighed the risk of COVID-19 infection against the urgency of their disease. Changes to the hospital environment (e.g., COVID-19 preventative measures) and deviations from expected treatment (e.g., alternative treatments, remote consultations, rescheduled care) caused diverse psychological responses, ranging from increased satisfaction to severe distress. Patients employed several coping strategies to mitigate distress, including eliciting reassurance from care providers, seeking information from unconventional sources, and reframing care interruptions. CONCLUSIONS: Changes in care during the pandemic elicited diverse psychological responses from patients undergoing cancer surgery. Coping was facilitated by consistent communication with providers, emphasizing the importance of patient-centered expectation setting as we prepare for the future within and beyond the pandemic.

S110-Opioid-free analgesia after outpatient general surgery: A qualitative study focused on the perspectives of patients and clinicians involved in a pilot trial.

BACKGROUND: Opioid-free analgesia (OFA) may mitigate opioid-related harms after outpatient general surgery; however, the comparative effectiveness of this approach should be assessed in robust randomized controlled trials (RCTs). Undertaking an RCT on OFA raises important practical concerns, including surgeon and patient hesitation regarding pain management without opioids. We conducted a qualitative study to explore patients' and clinicians' perspectives and experiences with a pilot trial focused on OFA after outpatient general surgery. METHODS: Patients undergoing outpatient abdominal and breast procedures were randomized to receive post-discharge opioid analgesia (OA) or OFA. Semi-structured interviews with patients and clinicians involved in the trial were conducted to elicit personal perspectives and experiences. Purposive sampling for maximum variation was used to recruit participants with diverse characteristics. Transcribed interviews were assessed using inductive thematic analysis. RESULTS: Ten patients (5 abdominal, 5 breast) and 10 clinicians (6 surgeons, 2 anesthesiologists, 2 nurses) were interviewed. Five major themes emerged: readiness for trial engagement, pre-trial thoughts about the interventions, postoperative pain experiences, intervention acceptability, and trial refinement. Most patients were open to OFA. Clinicians expressed willingness to prescribe OFA, particularly after less invasive procedures and when using peripheral nerve blocks (PNBs). Concerns were raised regarding the adequacy of pain control and side effects of non-opioid drugs (e.g., NSAID-induced bleeding, kidney injury). Overall, participants were enthusiastic about the trial and recognized its relevance; clinicians praised the study design and organization; and patients valued the use of electronic questionnaires. Suggestions for improvements included preventing potential bias arising from the use of PNBs (i.e., via standardization or stratification) and reducing patient burden (i.e., decreasing postoperative questionnaires). CONCLUSION: Patients and clinicians who participated in a pilot RCT generally accept the clinical equipoise between OA versus OFA after outpatient general surgery and recognize the need for methodologically robust trials to inform evidence-based analgesia prescribing.

Effectiveness of a personalized health profile on specificity of self-management goals among people living with HIV in Canada: findings from a blinded pragmatic randomized controlled trial.

PURPOSE: To estimate among people living with chronic HIV, to what extent providing feedback on their health outcomes will affect the number and specificity of patient-formulated self-management goals. METHODS: A personalized feedback profile was produced for individuals enrolled in a Canadian HIV Brain Health Now study. Goal specificity was measured by total number of specific words (matched to a domain-specific developed lexicon) per person-words using text mining techniques. RESULTS: Of 176 participants enrolled and randomly assigned to feedback and control groups, 110 responses were received. The average number of goals was similar for both groups (3.7 vs 3.9). The number of specific words used in the goals formulated by the feedback and control group were 642 and 739, respectively. Specific nouns and actionable verbs were present to some extent and "measurable" and "time-bound" words were mainly missing. Negative binomial regression showed no difference in goal specificity among groups (RR = 0.93, 95% CI 0.78-1.10). Goals set by both groups overlapped in 8 areas and had little difference in rank. CONCLUSION: Personalized feedback profile did not help with formulation of high-quality goals. Text mining has the potential to help with difficulties of goal evaluation outside of the face-to-face setting. With more data and use of learning models automated answers could be generated to provide a more dynamic platform.

Patient and surgeon preferences for early ileostomy closure following restorative proctectomy for rectal cancer: why aren't we doing it?

BACKGROUND: Early ileostomy closure (EIC), ≤ 2 weeks from creation, is a relatively new practice. Multiple studies have demonstrated that this approach is safe, feasible, and cost-effective. Despite the demonstrated benefits, this is neither routine practice, nor has it been studied, in North America. This study aimed to assess patient and surgeon perspectives about EIC. METHODS: A mixed-methods, cross-sectional study of patients and surgeons was performed. Rectal cancer survivors from a single institution who underwent restorative proctectomy with diverting loop ileostomy and subsequent closure within the last 5 years were contacted. North American surgeons with high rectal cancer volumes (> 20 cases/year) were included. Surveys (patients) and semi-structured interviews (surgeons) were conducted. Analysis employed descriptive statistics and thematic analysis, respectively. RESULTS: Forty-eight patients were surveyed (mean age 65.1 ± 11.8 years; 54.2% male). Stoma closure occurred after a median of 7.7 months (IQR 4.8-10.9) and 50.0% (24) found it "difficult" or "very difficult" to live with their stoma. Patients considered improvement in quality of life and quicker return to normal function the most important advantages of EIC, whereas the idea of two operations in two weeks being too taxing on the body was deemed the biggest disadvantage. Most patients (35, 72.9%) would have opted for EIC. Surgeon interviews (15) revealed 4 overarching themes: (1) there are many benefits to EIC; (2) specific patient characteristics would make EIC an appropriate option; (3) many barriers to implementing EIC exist; and (4) many logistical hurdles need to be addressed for successful implementation. Most surgeons (12, 80.0%) would "definitely want to participate" in a North American randomized-controlled trial (RCT) on EIC for rectal cancer patients. CONCLUSIONS: Implementing EIC poses many logistical challenges. Both patients and surgeons are interested in further exploring EIC and believe it warrants a North American RCT to motivate a change in practice.

Mobile App Prototype in Older Adults for Postfracture Acute Pain Management: User-Centered Design Approach.

BACKGROUND: Postfracture acute pain is often inadequately managed in older adults. Mobile health (mHealth) technologies can offer opportunities for self-management of pain; however, insufficient apps exist for acute pain management after a fracture, and none are designed for an older adult population. OBJECTIVE: This study aims to design, develop, and evaluate an mHealth app prototype using a human-centered design approach to support older adults in the self-management of postfracture acute pain. METHODS: This study used a multidisciplinary and user-centered design approach. Overall, 7 stakeholders (ie, 1 clinician-researcher specialized in internal medicine, 2 user experience designers, 1 computer science researcher, 1 clinical research assistant researcher, and 2 pharmacists) from the project team, together with 355 external stakeholders, were involved throughout our user-centered development process that included surveys, requirement elicitation, participatory design workshops, mobile app design and development, mobile app content development, and usability testing. We completed this study in 3 phases. We analyzed data from prior surveys administered to 305 members of the Canadian Osteoporosis Patient Network and 34 health care professionals to identify requirements for designing a low-fidelity prototype. Next, we facilitated 4 participatory design workshops with 6 participants for feedback on content, presentation, and interaction with our proposed low-fidelity prototype. After analyzing the collected data using thematic analysis, we designed a medium-fidelity prototype. Finally, to evaluate our medium-fidelity prototype, we conducted usability tests with 10 participants. The results informed the design of our high-fidelity prototype. Throughout all the phases of this development study, we incorporated inputs from health professionals to ensure the accuracy and validity of the medical content in our prototypes. RESULTS: We identified 3 categories of functionalities necessary to include in the design of our initial low-fidelity prototype: the need for support resources, diary entries, and access to educational materials. We then conducted a thematic analysis of the data collected in the design workshops, which revealed 4 themes: feedback on the user interface design and usability, requests for additional functionalities, feedback on medical guides and educational materials, and suggestions for additional medical content. On the basis of these results, we designed a medium-fidelity prototype. All the participants in the usability evaluation tests found the medium-fidelity prototype useful and easy to use. On the basis of the feedback and difficulties experienced by participants, we adjusted our design in preparation for the high-fidelity prototype. CONCLUSIONS: We designed, developed, and evaluated an mHealth app to support older adults in the self-management of pain after a fracture. The participants found our proposed prototype useful for managing acute pain and easy to interact with and navigate. Assessment of the clinical outcomes and long-term effects of our proposed mHealth app will be evaluated in the future.

Feasibility of Prospectively Comparing Opioid Analgesia With Opioid-Free Analgesia After Outpatient General Surgery: A Pilot Randomized Clinical Trial.

Importance: The overprescription of opioids to surgical patients is recognized as an important factor contributing to the opioid crisis. However, the value of prescribing opioid analgesia (OA) vs opioid-free analgesia (OFA) after postoperative discharge remains uncertain. Objective: To investigate the feasibility of conducting a full-scale randomized clinical trial (RCT) to assess the comparative effectiveness of OA vs OFA after outpatient general surgery. Design, Setting, and Participants: This parallel, 2-group, assessor-blind, pragmatic pilot RCT was conducted from January 29 to September 3, 2020 (last follow-up on October 2, 2020). at 2 university-affiliated hospitals in Montreal, Quebec, Canada. Participants were adult patients (aged ≥18 years) undergoing outpatient abdominal (ie, cholecystectomy, appendectomy, or hernia repair) or breast (ie, partial or total mastectomy) general surgical procedures. Exclusion criteria were contraindications to drugs used in the trial, preoperative opioid use, conditions that could affect assessment of outcomes, and intraoperative or early complications requiring hospitalization. Interventions: Patients were randomized 1:1 to receive OA (around-the-clock nonopioids and opioids for breakthrough pain) or OFA (around-the-clock nonopioids with increasing doses and/or addition of nonopioid medications for breakthrough pain) after postoperative discharge. Main Outcomes and Measures: Main outcomes were a priori RCT feasibility criteria (ie, rates of surgeon agreement, patient eligibility, patient consent, treatment adherence, loss to follow-up, and missing follow-up data). Secondary outcomes included pain intensity and interference, analgesic intake, 30-day unplanned health care use, and adverse events. Between-group comparison of outcomes followed the intention-to-treat principle. Results: A total of 15 surgeons were approached; all (100%; 95% CI, 78%-100%) agreed to have patients recruited and adhered to the study procedures. Rates of patient eligibility and consent were 73% (95% CI, 66%-78%) and 57% (95% CI, 49%-65%), respectively. Seventy-six patients were randomized (39 [51%] to OA and 37 [49%] to OFA) and included in the intention-to-treat analysis (mean [SD] age, 55.5 [14.5] years; 50 [66%] female); 40 (53%) underwent abdominal surgery, and 36 (47%) underwent breast surgery. Seventy-five patients (99%; 95% CI, 93%-100%) adhered to the allocated treatment; 1 patient randomly assigned to OFA received an opioid prescription. Seventeen patients (44%) randomly assigned to OA consumed opioids after discharge. Seventy-three patients (96%; 95% CI, 89%-99%) completed the 30-day follow-up. The rate of missing questionnaires was 37 of 3724 (1%; 95% CI, 0.7%-1.4%). All the a priori RCT feasibility criteria were fulfilled. Conclusions and Relevance: The findings of this pilot RCT support the feasibility of conducting a robust, full-scale RCT to inform evidence-based prescribing of analgesia after outpatient general surgery. Trial Registration: ClinicalTrials.gov Identifier: NCT04254679.

Opioid versus opioid-free analgesia after surgical discharge: a systematic review and meta-analysis of randomised trials.

BACKGROUND: Excessive opioid prescribing after surgery has contributed to the current opioid crisis; however, the value of prescribing opioids at surgical discharge remains uncertain. We aimed to estimate the extent to which opioid prescribing after discharge affects self-reported pain intensity and adverse events in comparison with an opioid-free analgesic regimen. METHODS: In this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Library, Scopus, AMED, Biosis, and CINAHL from Jan 1, 1990, until July 8, 2021. We included multidose randomised controlled trials comparing opioid versus opioid-free analgesia in patients aged 15 years or older, discharged after undergoing a surgical procedure according to the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity definition (minor, moderate, major, and major complex). We screened articles, extracted data, and assessed risk of bias (Cochrane's risk-of-bias tool for randomised trials) in duplicate. The primary outcomes of interest were self-reported pain intensity on day 1 after discharge (standardised to 0-10 cm visual analogue scale) and vomiting up to 30 days. Pain intensity at further timepoints, pain interference, other adverse events, risk of dissatisfaction, and health-care reutilisation were also assessed. We did random-effects meta-analyses and appraised evidence certainty using the Grading of Recommendations, Assessment, Development, and Evaluations scoring system. The review was registered with PROSPERO (ID CRD42020153050). FINDINGS: 47 trials (n=6607 patients) were included. 30 (64%) trials involved elective minor procedures (63% dental procedures) and 17 (36%) trials involved procedures of moderate extent (47% orthopaedic and 29% general surgery procedures). Compared with opioid-free analgesia, opioid prescribing did not reduce pain on the first day after discharge (weighted mean difference 0·01cm, 95% CI -0·26 to 0·27; moderate certainty) or at other postoperative timepoints (moderate-to-very-low certainty). Opioid prescribing was associated with increased risk of vomiting (relative risk 4·50, 95% CI 1·93 to 10·51; high certainty) and other adverse events, including nausea, constipation, dizziness, and drowsiness (high-to-moderate certainty). Opioids did not affect other outcomes. INTERPRETATION: Findings from this meta-analysis support that opioid prescribing at surgical discharge does not reduce pain intensity but does increase adverse events. Evidence relied on trials focused on elective surgeries of minor and moderate extent, suggesting that clinicians can consider prescribing opioid-free analgesia in these surgical settings. Data were largely derived from low-quality trials, and none involved patients having major or major-complex procedures. Given these limitations, there is a great need to advance the quality and scope of research in this field. FUNDING: The Canadian Institutes of Health Research.

Communicating Patient Health Data: A Wicked Problem.

Designing patient-collected health data visualizations to support communicating patient data during clinical visits is a challenging problem due to the heterogeneity of the parties involved: patients, healthcare providers, and healthcare systems. Designers must ensure that all parties' needs are met. This complexity makes it challenging to find a definitive solution that can work for every individual. We have approached this research problem-communicating patient data during clinical visits-as a wicked problem. In this article, we outline how wicked problem characteristics apply to our research problem. We then describe the research methodologies we employed to explore the design space of individualized patient data visualization solutions. Lastly, we reflect on the insights and experiences we gained through this exploratory design process. We conclude with a call to action for researchers and visualization designers to consider patients' and healthcare providers' individualities when designing patient data visualizations.

Prognostic value of the Duke Activity Status Index (DASI) in patients undergoing colorectal surgery.

BACKGROUND: Complications are common after colorectal surgery and remain a target for quality improvement. Lower preoperative physical functioning is associated with poor postoperative outcomes, but assessment often relies on subjective judgment or resource-intensive tests. Recent literature suggests that self-reported functional capacity, measured using the Duke Activity Status Index (DASI), is a strong predictor of postoperative outcomes. This study aimed to estimate the extent to which DASI predicts 30-day complications after colorectal surgery. METHODS: In this observational study, 100 patients undergoing colorectal resection [median age 63, 57% men, 81% laparoscopic, 37% rectal surgery] responded to DASI two weeks preoperatively. Complications were classified according to Clavien-Dindo and quantified using the comprehensive complication index (CCI). Our primary analysis targeted the relationship between preoperative DASI and odds of complications. Secondary analyses focused on 30-day severe complications, CCI, readmissions, and length of stay (LOS). We also explored the predictive ability of DASI with scores dichotomized based on a previously validated threshold (≤ 34). RESULTS: Mean preoperative DASI was 48 ± 12. Forty-six patients (46%) experienced 30-day complications (8% severe, CCI 9.6 ± 15). Lower DASI scores were associated with higher odds of complications (OR 1.08, 95%CI 1.03-1.14; p = 0.001). Preoperative DASI was also an independent predictor of severe complications, CCI, and readmissions. The predictive ability was supported when scores were dichotomized at ≤ 34. CONCLUSION: DASI is a significant predictor of postoperative complications after colorectal surgery. This questionnaire can be easily implemented in clinical practice to identify patients with low preoperative functional capacity and target interventions to those at higher risk.

Understanding the Meaning of Recovery to Patients Undergoing Abdominal Surgery.

Importance: Postoperative recovery is difficult to define or measure. Research addressing interventions aimed to improve recovery after abdominal surgery often focuses on measures such as duration of hospital stay and complication rates. Although these clinical parameters are relevant, understanding patients' perspectives regarding postoperative recovery is fundamental to guiding patient-centered care. Objective: To elucidate the meaning of recovery from the perspective of patients undergoing abdominal surgery. Design, Setting, and Participants: This international qualitative study involved semistructured interviews with patients recovering from abdominal surgery from October 2016 to November 2018 in tertiary hospitals in 4 countries (Canada, Italy, Brazil, and Japan). A purposive maximal variation sampling method was used to ensure the recruitment of patients with varying demographic, clinical, and surgical characteristics. Data on race were not collected. Each interview lasted between 1 and 2 hours. Interviews were recorded and then transcribed verbatim. Transcripts were then analyzed using an inductive thematic analysis approach. Data analysis was conducted from July 2019 to September 2019. Main Outcomes and Measures: The qualitative analysis revealed themes reflecting the meaning of recovery from the perspective of patients undergoing abdominal surgery. Results: Thirty patients recovering from abdominal surgery were interviewed (15 [50%] female; mean [SD] age, 57 [18] years; 10 [33%] underwent major surgery; 16 [53%] underwent laparoscopic surgery). The interviews revealed that for patients undergoing abdominal surgery, the meaning of recovery embodied 5 overarching themes: (1) returning to habits and routines, (2) resolution of symptoms, (3) overcoming mental strains, (4) regaining independence, and (5) enjoying life. Themes associating the meaning of recovery to traditional parameters, such as earlier hospital discharge or absence of complications, were not identified in the interviews. Conclusions and Relevance: This qualitative study suggests that the meaning of recovery from the perspective of patients undergoing abdominal surgery goes beyond traditional clinical parameters. The elements of recovery identified in this study should be taken into account in patient-surgeon discussions about recovery and when developing patient-centered strategies to improve postoperative outcomes.

Development and usability of a feedback tool, "My Personal Brain Health Dashboard", to improve setting of self-management goals among people living with HIV in Canada.

OBJECTIVE: (1) To develop a personalized health outcome profile as a feedback tool to improve self-management in people living with chronic conditions such as HIV and (2) to evaluate the interpretability and usefulness of the feedback tool for setting specific goals. METHODS: The development of "My Personal Brain Health Dashboard" was inspired by the knowledge-to-action framework. A health outcome profile was computer generated in SAS from the outcome measures, at first and last recorded visits, of each person enrolled in the +BHN cohort from five sites in Canada. The Wilson-Cleary model framed the outcome measurement strategy. Single actionable items with evidence of life impact were chosen. The response option from the original item was the person's value and the optimal level was provided to help persons compare their results to an optimal target. Cognitive interviews were conducted with members of HIV community. Appropriateness of the Dashboard for goal-setting was tested by asking participants to write specific goals according to the Dashboard they were given. RESULTS: Fifteen respondents were recruited from Montreal and Vancouver. Items most endorsed to be changed were cognition, pain, and body mass index. 80% found the Dashboard useful for setting health-related goals. A total of 85 goals were set, the text of which was mined to create a lexicon for scoring goal quality in future endeavours. CONCLUSION: This study was the preparatory phase for a future trial on a method to stimulate setting specific goals. The future trial would provide a thorough understanding of the quality of person-defined goals.

Opioid versus opioid-free analgesia after surgical discharge: protocol for a systematic review and meta-analysis.

INTRODUCTION: Excessive prescribing after surgery has contributed to a public health crisis of opioid addiction and overdose in North America. However, the value of prescribing opioids to manage postoperative pain after surgical discharge remains unclear. We propose a systematic review and meta-analysis to assess the extent to which opioid analgesia impact postoperative pain intensity and adverse events in comparison to opioid-free analgesia in patients discharged after surgery. METHODS AND ANALYSIS: Major electronic databases (MEDLINE, Embase, Cochrane Library, Scopus, AMED, BIOSIS, CINAHL and PsycINFO) will be searched for multi-dose randomised-trials examining the comparative effectiveness of opioid versus opioid-free analgesia after surgical discharge. Studies published from January 1990 to July 2019 will be targeted, with no language restrictions. The search will be re-run before manuscript submission to include most recent literature. We will consider studies involving patients undergoing minor and major surgery. Teams of reviewers will, independently and in duplicate, assess eligibility, extract data and evaluate risk of bias. Our main outcomes of interest are pain intensity and postoperative vomiting. Study results will be pooled using random effects models. When trials report outcomes for a common domain (eg, pain intensity) using different scales, we will convert effect sizes to a common standard metric (eg, Visual Analogue Scale). Minimally important clinical differences reported in previous literature will be considered when interpreting results. Subgroup analyses defined a priori will be conducted to explore heterogeneity. Risk of bias will be assessed according to the Cochrane Collaboration's Risk of Bias Tool 2.0. The quality of evidence for all outcomes will be evaluated using the GRADE rating system. ETHICS AND DISSEMINATION: Ethical approval is not required since this is a systematic review of published studies. Our results will be published in a peer-reviewed journal and presented at relevant conferences. Further knowledge dissemination will be sought via public and patient organisations focussed on pain and opioid-related harms.