Telemedicine in urologic oncology care: Will telemedicine exacerbate disparities?

INTRODUCTION: Disparities in prostate, bladder, and kidney cancer outcomes are associated with access to care. Telemedicine can improve access but may be underutilized by certain patient populations. Our objective was to determine if the patient populations who suffer worse oncologic outcomes are the same as those who are less likely to use telemedicine. METHODS: Using an institutional database, we identified all prostate, bladder and kidney cancer encounters from March 14, 2020 to October 31, 2021 (n = 15,623; n = 4, 14; n = 3,830). Telemedicine was used in 13%, 8%, and 12% of these encounters, respectively. We performed random effects modeling analysis to examine patient and provider characteristics associated with telemedicine use. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were reported as measures of association. RESULTS: Among prostate, bladder, and kidney cancer patients, Black patients had lower odds of a telemedicine encounter (OR 0.51, 95% CI 0.37-0.69; OR 0.22, 95% CI 0.07-0.70; OR 0.46, 95% CI 0.24-0.86), and patients residing in small and isolated small rural towns areas had higher odds of a telemedicine encounter (OR 1.44, 95% CI 1.09-1.91; OR 2.12, 95% CI 1.14-3.94; OR 1.89, 95% CI 1.12-3.19). Compared to providers in practice ≤5 years, providers in practice for 6 to 15 years had significantly higher odds of a telemedicine encounter for prostate and bladder cancer patients (OR 4.10, 95% CI 1.4511.58; OR 3.42, 95% CI 1.09-10.77). CONCLUSION: The lower rates of telemedicine use among Black patients could exacerbate pre-existing disparities in prostate, bladder, and kidney cancer outcomes.

Intensive Care Unit Clinicians' Perspectives on Achieving Proactive Interprofessional Family Meetings.

BACKGROUND: Although proactive interprofessional family meetings are widely recommended as a best practice for patient- and family-centered care in intensive care units (ICUs), adherence to this recommendation is low. OBJECTIVES: To enhance understanding of practices, barriers, and facilitators related to the conduct of family meetings from the perspective of ICU clinicians and to elicit clinicians' ideas and opinions about strategies to achieve proactive interprofessional family meetings. METHODS: Semistructured telephone interviews were conducted with ICU clinicians who were purposively selected from among a national sample. Constant comparative analysis was used to generate a matrix of themes; enrollment ceased when no new ideas emerged. RESULTS: Interviews were conducted with 14 participants (10 nurses, 3 physicians, and 1 care manager). Rather than having a protocol for proactive family meetings, participants primarily held family meetings when physicians thought that it was time to discuss a transition to comfort-focused care. Other barriers included clinicians' discomfort with end-of-life conversations, physicians' time constraints, and nurses' competing clinical responsibilities. Facilitators included physicians' skill and comfort with difficult conversations, advocacy for family meetings from care managers/ social workers, and having full-time intensivists. Participants offered/endorsed multiple intervention ideas, including scheduling preemptively, monitoring unit performance, and adding discussion of a family meeting to daily rounds. CONCLUSIONS: A key barrier to proactive family meetings is the mindset that family meetings need occur only when a clinical decision must be made, rather than proactively to support and engage families. Clinicians suggested ways to make proactive family meetings routine.

Enhancing Implementation of Complex Critical Care Interventions through Interprofessional Education.

Background: Many critical care interventions that require teamwork are adopted slowly and variably despite strong evidence supporting their use. We hypothesize that educational interventions that target the entire interprofessional team (rather than professions in isolation) are one effective way to enhance implementation of complex interventions in the intensive care unit (ICU). Objective: As a first step toward testing this hypothesis, we sought to qualitatively solicit opinions about team dynamics, evidence translation, and interprofessional education as well as current knowledge, attitudes, and practices surrounding the use of one example of a team-based practice in the ICU-preventive postextubation noninvasive ventilation (NIV). Methods: We conducted a qualitative evaluation using semistructured interviews and focus groups with nurses, respiratory therapists, and physicians working in four ICUs in four hospitals within an integrated health system. ICUs were selected based on variation in academic versus community status. We iteratively analyzed transcripts using a thematic content analysis approach. Results: From December 2018 to January 2019, we conducted 32 interviews (34 people) and 3 focus groups (20 people). Participants included 31 nurses, 15 respiratory therapists, and 8 physicians. Participants had favorable views of how their teams work together but discussed ways team dynamics (e.g., leader inclusiveness) impact care coordination. Participants viewed interprofessional education favorably and shared suggestions regarding preferred content and delivery (e.g., include both profession-specific and team-oriented content). Though participants reported frequently using NIV as a treatment, they described rarely using NIV as a preventive strategy, and nurses and respiratory therapists described challenges to use such as perceived patient discomfort. There were ICU-specific differences in management of patients at a high risk for respiratory failure after extubation, with some preferring to delay extubation. Conclusion: Participants reported optimism that interprofessional education can be an acceptable and effective way to improve translation of evidence into practice. Participants also detailed patient-specific and ICU-wide barriers to the implementation of preventive postextubation NIV. This information about teamwork in the ICU, suggestions for interprofessional education, and barriers and facilitators to use of a target evidence-based practice can inform the development of novel educational strategies in ways that increase acceptability, appropriateness, and feasibility of the intervention.

A Roadmap for Successful State Sepsis Regulations-Lessons From New York.

New York state implemented the first state-level sepsis regulations in 2013. These regulations were associated with improved mortality, leading other states to consider similar steps. Our objective was to provide insight into New York state's sepsis policy making process, creating a roadmap for policymakers in other states considering similar regulations. DESIGN: Qualitative study using semistructured interviews. SETTING: We recruited key stakeholders who had knowledge of the New York state sepsis regulations. SUBJECTS: Thirteen key stakeholders from three groups included four New York state policymakers and seven clinicians and hospital association leaders involved in the creation and implementation of the 2013 New York state sepsis regulations, as well as two members of patient advocacy groups engaged in sepsis advocacy. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We used iterative, inductive thematic analysis to identify themes related to participant perceptions of the New York state sepsis policy, factors that influenced the policy's perceived successes, and opportunities for improvement. We identified several factors that facilitated success. Among these were that policymakers engaged a diverse array of stakeholders in development, allowing them to address potential barriers to implementation and create early buy-in. Policymakers also paid specific attention to the balance between the desire for comprehensive reporting and the burden of data collection, narrowly focusing on "essential" sepsis-related data elements to reduce the burden on hospitals. In addition, the regulations touched on all three major domains of sepsis quality-structure, process, and outcomes-going beyond a data collection to give hospitals tools to improve sepsis care. CONCLUSIONS: We identified factors that distinguish the New York sepsis regulations from less successful sepsis polices at the federal level. Ultimately, lessons from New York state provide valuable guidance to policymakers and hospital officials seeking to develop and implement policies that will improve sepsis quality.

US Hospital Capacity Managers' Experiences and Concerns Regarding Preparedness for Seasonal Influenza and Influenza-like Illness.

Importance: The 2017-2018 influenza season in the US was marked by a high severity of illness, wide geographic spread, and prolonged duration compared with recent previous seasons, resulting in increased strain throughout acute care hospital systems. Objective: To characterize self-reported experiences and views of hospital capacity managers regarding the 2017-2018 influenza season in the US. Design, Setting, and Participants: In this qualitative study, semistructured telephone interviews were conducted between April 2018 and January 2019 with a random sample of capacity management administrators responsible for throughput and hospital capacity at short-term, acute care hospitals throughout the US. Main Outcomes and Measures: Each participant's self-reported experiences and views regarding high patient volumes during the 2017-2018 influenza season, lessons learned, and the extent of hospitals' preparedness planning for future pandemic events. Interviews were recorded and transcribed and then analyzed using thematic content analysis. Outcomes included themes and subthemes. Results: A total of 53 key hospital capacity personnel at 53 hospitals throughout the US were interviewed; 39 (73.6%) were women, 48 (90.6%) had a nursing background, and 29 (54.7%) had been in the occupational role for more than 4 years. Participants' experiences were categorized into several domains: (1) perception of strain, (2) effects of influenza and influenza-like illness on staff and patient care, (3) immediate staffing and capacity responses to influenza and influenza-like illness, and (4) future staffing and capacity preparedness for influenza and influenza-like illness. Participants reported experiencing perceived strain associated with concerns about preparedness for seasonal influenza and influenza-like illness as well as concerns about staffing, patient care, and capacity, but future pandemic planning within hospitals was not reported as being a high priority. Conclusions and Relevance: The findings of this qualitative study suggest that during the 2017-2018 influenza season, there were systemic vulnerabilities as well as a lack of hospital preparedness planning for future pandemics at US hospitals. These issues should be addressed given the current coronavirus disease 2019 pandemic.

Perceptions of Hyperoxemia and Conservative Oxygen Therapy in the Management of Acute Respiratory Failure.

Rationale: Mechanically ventilated patients in the intensive care unit (ICU) are often managed to maximize oxygenation, yet hyperoxemia may be deleterious to some. Little is known about how ICU providers weigh tradeoffs between hypoxemia and hyperoxemia when managing acute respiratory failure. Objectives: To define ICU providers' mental models for managing oxygenation for patients with acute respiratory failure and identify barriers and facilitators to conservative oxygen therapy. Methods: In two large U.S. tertiary care hospitals, we performed semistructured interviews with a purposive sample of ICU nurses, respiratory therapists, and physicians. We assessed perceptions of oxygenation management, hyperoxemia, and conservative oxygen therapies through interviews, which we audio recorded and transcribed verbatim. We analyzed transcripts for representative themes using an iterative thematic-analysis approach. Results: We interviewed 10 nurses, 10 respiratory therapists, 4 fellows, and 5 attending physicians before reaching thematic saturation. Major themes included perceptions of hyperoxemia, attitudes toward conservative oxygen therapy, and aspects of titrated-oxygen-therapy implementation. Many providers did not recognize the term "hyperoxemia," whereas others described a poor understanding; several stated they never encounter hyperoxemia clinically. Concerns about hyperoxemia varied: some providers believed that typical ventilation strategies emphasizing progressive lowering of the fraction of inspired oxygen mitigated worries about excess oxygen administration, whereas others maintained that hyperoxemia is harmful only to patients with chronic lung disease. Almost all interviewees expressed familiarity with lower oxygen saturations in chronic obstructive pulmonary disease. Cited barriers to conservative oxygen therapy included concerns about hypoxemia, particularly among nurses and respiratory therapists; perceptions that hyperoxemia is not harmful; and a lack of clear evidence supporting conservative oxygen therapy. Interviewees suggested that interprofessional education and convincing clinical trial evidence could facilitate uptake of conservative oxygenation. Conclusions: This study describes attitudes toward hyperoxemia and conservative oxygen therapy. These preferences and uncertain benefits and risks of conservative oxygen therapy should be considered during future implementation efforts. Successful oxygen therapy implementation most likely will require 1) improving awareness of hyperoxemia's effects, 2) normalizing lower saturations in patients without chronic lung disease, 3) addressing ingrained beliefs regarding oxygen management and oxygen's safety, and 4) using interprofessional education to obtain buy-in across providers and inform the ICU team.

Psychological Safety in Intensive Care Unit Rounding Teams.

Rationale: Psychological safety is the condition by which members of an organization feel safe to voice concerns and take risks. Although psychological safety is an important determinant of team performance, little is known about its role in the intensive care unit (ICU). Objectives: To identify the factors associated with psychological safety and the potential influence of psychological safety on team performance in critical care. Methods: We performed daily surveys of healthcare providers in 12 ICUs within an integrated health system over a 2-week period. Survey domains included psychological safety, leader familiarity, leader inclusiveness, role clarity, job strain, and teamwork. These data were linked to daily performance on lung-protective ventilation and spontaneous breathing trials. We used regression models to examine the antecedents of psychological safety as well as the influence of psychological safety on both perceived teamwork and actual performance. Results: We received 553 responses from 270 unique providers. At the individual provider level, higher leader inclusiveness (adjusted ß = 0.32; 95% confidence interval [CI], 0.24 to 0.41) and lower job strain (adjusted ß = -0.07, 95% CI, -0.13 to -0.02) were independently associated with greater psychological safety. Higher psychological safety was independently associated with greater perception of teamwork (adjusted ß = 0.30; 95% CI, 0.25 to 0.36). There was no association between team psychological safety and performance on either spontaneous breathing trials (incident rate ratio for each 1-unit change in team psychological safety, 0.85; 95% CI, 0.81 to 1.10) or lung-protective ventilation (incident rate ratio, 0.77; 95% CI, 0.57 to 1.04). Conclusions: Psychological safety is associated with several modifiable factors in the ICU but is not associated with actual use of evidence-based practices.

Patient-centered and efficacious advance care planning in cancer: Protocol and key design considerations for the PEACe-compare trial.

BACKGROUND: Failure to deliver care near the end of life that reflects the needs, values and preferences of patients with advanced cancer remains a major shortcoming of our cancer care delivery system. METHODS: A mixed-methods comparative effectiveness trial of in-person advance care planning (ACP) discussions versus web-based ACP is currently underway at oncology practices in Western Pennsylvania. Patients with advanced cancer and their caregivers are invited to enroll. Participants are randomized to either (1) in-person ACP discussions via face-to-face visits with a nurse facilitator following the Respecting Choices® Conversation Guide or (2) web-based ACP using the PREPARE for your care™ web-based ACP tool. The trial compares the effect of these two interventions on patient and family caregiver outcomes (engagement in ACP, primary outcome; ACP discussions; advance directive (AD) completion; quality of end-of-life (EOL) care; EOL goal attainment; caregiver psychological symptoms; healthcare utilization at EOL) and assesses implementation costs. Factors influencing ACP effectiveness are assessed via in-depth interviews with patients, caregivers and clinicians. DISCUSSION: This trial will provide new and much-needed empirical evidence about two patient-facing ACP approaches that successfully overcome limitations of traditional written advance directives but entail very different investments of time and resources. It is innovative in using mixed methods to evaluate not only the comparative effectiveness of these approaches, but also the contexts and mechanisms influencing effectiveness. Data from this study will inform clinicians, payers and health systems seeking to adopt and scale the most effective and efficient ACP strategy in real-world oncology settings.

Effective Care Practices in Patients Receiving Prolonged Mechanical Ventilation. An Ethnographic Study.

Rationale: Patients receiving prolonged mechanical ventilation experience low survival rates and incur high healthcare costs. However, little is known about how to optimally organize and manage their care.Objectives: To identify a set of effective care practices for patients receiving prolonged mechanical ventilation.Methods: We performed a focused ethnographic evaluation at eight long-term acute care hospitals in the United States ranking in either the lowest or highest quartile of risk-adjusted mortality in at least four of the five years between 2007 and 2011.Measurements and Main Results: We conducted 329 hours of direct observation, 196 interviews, and 39 episodes of job shadowing. Data were analyzed using thematic content analysis and a positive-negative deviance approach. We found that high- and low-performing hospitals differed substantially in their approach to care. High-performing hospitals actively promoted interdisciplinary communication and coordination using a range of organizational practices, including factors related to leadership (e.g., leaders who communicate a culture of quality improvement), staffing (e.g., lower nurse-to-patient ratios and ready availability of psychologists and spiritual care providers), care protocols (e.g., specific yet flexible respiratory therapy-driven weaning protocols), team meetings (e.g., interdisciplinary meetings that include direct care providers), and the physical plant (e.g., large workstations that allow groups to interact). These practices were believed to facilitate care that is simultaneously goal directed and responsive to individual patient needs, leading to more successful liberation from mechanical ventilation and improved survival.Conclusions: High-performing long-term acute care hospitals employ several organizational practices that may be helpful in improving care for patients receiving prolonged mechanical ventilation.

Determinants of Intensive Care Unit Telemedicine Effectiveness. An Ethnographic Study.

RATIONALE: Telemedicine is an increasingly common care delivery strategy in the ICU. However, ICU telemedicine programs vary widely in their clinical effectiveness, with some studies showing a large mortality benefit and others showing no benefit or even harm. OBJECTIVES: To identify the organizational factors associated with ICU telemedicine effectiveness. METHODS: We performed a focused ethnographic evaluation of 10 ICU telemedicine programs using site visits, interviews, and focus groups in both facilities providing remote care and the target ICUs. Programs were selected based on their change in risk-adjusted mortality after adoption (decreased mortality, no change in mortality, and increased mortality). We used a constant comparative approach to guide data collection and analysis. MEASUREMENTS AND MAIN RESULTS: We conducted 460 hours of direct observation, 222 interviews, and 18 focus groups across six telemedicine facilities and 10 target ICUs. Data analysis revealed three domains that influence ICU telemedicine effectiveness: 1) leadership (i.e., the decisions related to the role of the telemedicine, conflict resolution, and relationship building), 2) perceived value (i.e., expectations of availability and impact, staff satisfaction, and understanding of operations), and 3) organizational characteristics (i.e., staffing models, allowed involvement of the telemedicine unit, and new hire orientation). In the most effective telemedicine programs these factors led to services that are viewed as appropriate, integrated, responsive, and consistent. CONCLUSIONS: The effectiveness of ICU telemedicine programs may be influenced by several potentially modifiable factors within the domains of leadership, perceived value, and organizational structure.

Hospital Perceptions of Medicare's Sepsis Quality Reporting Initiative.

BACKGROUND: In October 2015, the Centers for Medicare and Medicaid Services (CMS) implemented the Sepsis CMS Core Measure (SEP-1) program, requiring hospitals to report data on the quality of care for their patients with sepsis. OBJECTIVE: We sought to understand hospital perceptions of and responses to the SEP-1 program. DESIGN: A thematic content analysis of semistructured interviews with hospital quality officials. SETTING: A stratified random sample of short-stay, nonfederal, general acute care hospitals in the United States. PATIENTS: Hospital quality officers, including nurses and physicians. MEASUREMENTS: We completed 29 interviews before reaching content saturation. RESULTS: Hospitals reported a variety of actions in response to SEP-1, including new efforts to collect data, improve sepsis diagnosis and treatment, and manage clinicians' attitudes toward SEP-1. These efforts frequently required dedicated resources to meet the program's requirements for treatment and documentation, which were thought to be complex and not consistently linked to patient-centered outcomes. Most respondents felt that SEP-1 was likely to improve sepsis outcomes. At the same time, they described specific changes that could improve its effectiveness, including allowing hospitals to focus on the treatment processes most directly associated with improved patient outcomes and better aligning the measure's sepsis definitions with current clinical definitions. CONCLUSIONS: Hospitals are responding to the SEP-1 program across a number of domains and in ways that consistently require dedicated resources. Hospitals are interested in further revisions to the program to alleviate the burden of the reporting requirements and help them optimize the effectiveness of their investments in quality-improvement efforts.

Identifying Strategies for Effective Telemedicine Use in Intensive Care Units: The ConnECCT Study Protocol.

Telemedicine, the use of audiovisual technology to provide health care from a remote location, is increasingly used in intensive care units (ICUs). However, studies evaluating the impact of ICU telemedicine show mixed results, with some studies demonstrating improved patient outcomes, while others show limited benefit or even harm. Little is known about the mechanisms that influence variation in ICU telemedicine effectiveness, leaving providers without guidance on how to best use this potentially transformative technology. The Contributors to Effective Critical Care Telemedicine (ConnECCT) study aims to fill this knowledge gap by identifying the clinical and organizational factors associated with variation in ICU telemedicine effectiveness, as well as exploring the clinical contexts and provider perceptions of ICU telemedicine use and its impact on patient outcomes, using a range of qualitative methods. In this report, we describe the study protocol, data collection methods, and planned future analyses of the ConnECCT study. Over the course of 1 year, the study team visited purposefully sampled health systems across the United States that have adopted telemedicine. Data collection methods included direct observations, interviews, focus groups, and artifact collection. Data were collected at the ICUs that provide in-person critical care as well as at the supporting telemedicine units. Iterative thematic content analysis will be used to identify and define key constructs related to telemedicine effectiveness and describe the relationship between them. Ultimately, the study results will provide a framework for more effective implementation of ICU telemedicine, leading to improved clinical outcomes for critically ill patients.

Key stakeholders' perspectives on a Web-based advance care planning tool for advanced lung disease.

PURPOSE: There is a paucity of scalable advance care planning strategies that achieve the diverse goals of patients, families, and clinicians. We convened key stakeholders to gain their perspectives on developing a Web-based advance care planning tool for lung disease. MATERIALS AND METHODS: We conducted semistructured interviews with 50 stakeholders: 21 patients with lung disease, 18 surrogates, and 11 clinicians. Interviews explored stakeholders' desired content and design features of a Web-based advance care planning tool. Participants also rated the tool's acceptability and potential usefulness. We analyzed the interviews with modified grounded theory and validated themes through member checking. RESULTS: Stakeholders highly rated the acceptability (median, 5; interquartile range, 5-5) and potential usefulness (median, 5; interquartile range, 4-5) of a Web-based tool. Interviewees offered several suggestions: (1) use videos of medical scenarios and patient narratives rather than text, (2) include interactive content, and (3) allow the user control over how much they complete in 1 sitting. Participants identified challenges and potential solutions, such as how to manage the emotional difficulty of thinking about death and accommodate low computer literacy users. CONCLUSIONS: There is strong stakeholder support for the development of a Web-based advance care planning tool for lung disease.