Improving patient safety through mandatory quality improvement (QI) education in a family medicine residency programme.

Although the American College of Graduate Medical Education (ACGME) requires that medical trainees acquire competencies in patient safety and quality improvement (QI), no standard curriculum exists. We envisaged that a sustainable QI curriculum would be a pragmatic way to improve residents' skills and competence in patient safety. Our aim was to develop and evaluate a patient safety-oriented QI curriculum in an established family medicine residency programme. A patient safety curriculum fulfilling ACGME requirements was developed and implemented in a family residency programme. The curriculum comprised didactics, self-paced online modules, experiential learning through individual QI projects, and mortality and morbidity conferences. The programme was evaluated using a survey at the end of its first year. We assessed knowledge on patient safety and QI, confidence in discussing safety concerns with peers, and ability to recognise safety gaps and initiate corrective actions. We also assessed the perception of the programme's relevance to the residents' training. All 36 residents participated, 19 completed the evaluation survey. Fifteen (79%) respondents reported learning more about the causes of medical errors, 42% could report safety concerns and 26% could recognise quality gaps. In addition, 58% felt the curriculum increased their confidence in discussing patient safety concerns with peers while 74% found the curriculum very relevant to their training. Some participants described the programme as 'very productive'. Embedding a QI curriculum into the ongoing residency training may be a realistic approach to training family medicine residents with no prior formal QI training.

Risk of Depression in a Suburban Primary Care Setting Before and During the COVID-19 Pandemic.

INTRODUCTION: Major depression is a common disorder affecting millions of adults each year. Many population-based surveys showed an increase in the number people with symptoms of depression at the onset of the COVID-19 pandemic. Our aim was to determine and compare the prevalence of depression risk in a primary care setting before and during the COVID-19 pandemic. METHODS: We conducted a cross-sectional study based on retrospective review of medical records from a large suburban primary care clinic. Records of adults 18 years and older, seen between January 1, 2019 and December 31, 2020 and who had also been screened for depression using the 9-item Patient Health Questionnaire (PHQ-9) were analyzed. RESULTS: Adults 18 years and older who completed the PHQ-9 assessment in 2019 and 2020 were 5078 and 4338, respectively. Risk of depression was 18.2% in 2019 and 14.8% in 2020 (P < .001). In adults under 50 years and those 50 years and older, depression risk was 20.7% versus 15.3% in 2019 (P < .001) and 17.3% versus 12.6% in 2020 (P < .001), respectively. In females, depression risk was 20.0% in 2019 and 16.8% in 2020 (P < .01), and in males, 14.1% in 2019 and 10.6% in 2020 (P < .01). CONCLUSION: Although our results did not reflect the published literature reporting a higher prevalence of depression during the COVID-19 pandemic, they were consistent with reports of increased risk in females and younger adults.

A randomized controlled trial evaluating the effects of social networking on chronic disease management in rheumatoid arthritis.

OBJECTIVE: Social networking has been shown to improve health outcomes in certain patient populations. While patients with rheumatoid arthritis (RA) increasingly use social networking to communicate with peers, the effects of these interactions are largely unknown. METHODS: In a randomized controlled trial, we compared RA patients who participated in a social networking group moderated by peer leaders and who had access to a static website offering RA materials with a control group, who only had access to the website. The primary outcomes were patients' RA knowledge, self-efficacy and empowerment. Secondary outcomes included participation in desired health behaviors, and satisfaction with peer support, among others. Follow-up assessments were conducted at 3 and 6 months. Participants who never signed in were excluded from the primary analysis. RESULTS: 105 participants were randomized to each group. Mean age was 52 (±12.4) and 92.4% were females. Knowledge scores improved in both groups, but only in the control group the differences observed at 3 and 6 months were significant (p≤0.02). Self-efficacy scores also improved in both groups, but only the differences observed at 6 months in the Facebook group were significant (p=0.02). When comparing groups, at 3 months the knowledge improvements observed in the control group were greater compared with those observed in the Facebook group (mean difference 0.4 versus 0.1; respectively, p=0.03). No other differences were observed in secondary outcomes between the 2 groups, except in peer support satisfaction. The Facebook® group reported greater peer support satisfaction in 3 out 5 subscales compared with the control group (p≤0.04). CONCLUSION: Peer support satisfaction was higher in participants using an online social network, but this was not translated into greater disease knowledge or empowerment.

Preferred Strategies for Delivering Health Information to Patients With Musculoskeletal Disorders: A Qualitative Study.

BACKGROUND: Patients' information needs may differ from what their care providers may perceive to be the patients' needs. This discordance needs to be recognized and addressed. OBJECTIVE: We conducted a qualitative study to explore the perceptions of patients with selected musculoskeletal disorders and those of rheumatologists, on their preferred strategies for delivery of disease management information. METHODS: Fifty-two patients diagnosed with either rheumatoid arthritis, knee osteoarthritis, or osteoporosis took part in 6 focus groups and 18 individual semistructured interviews. In addition, 11 rheumatologists participated in 2 focus groups and 4 semistructured individual interviews. Data were explored by thematic content analysis. Perceived preferences were identified and compared between patients and rheumatologists regarding (a) media, (b) setting, (c) messengers, and (d) key message content. RESULTS: Patients' preferred media for disease management information were electronic (television and videos delivered as digital optical discs or the Internet), group instruction, and printed material. Patients preferred the information to be delivered in the setting of their homes, doctor's offices, or clinic waiting areas by the rheumatologists and patients with disease experience, addressing healthy lifestyle changes, medication adherence, and consequences of noncompliance. For rheumatologists, the perceived preference for information delivery was through printed material (brochures, booklets, and pamphlets) delivered in waiting areas by nurses and physicians, addressing nature of the disease, complications, and treatment adverse effects. CONCLUSIONS: Provider perspectives on strategies for education may differ from those of patients. Our findings highlight the need for considering different stakeholder perspectives in designing educational tools and decision support materials for patients with chronic diseases. TAKEHOME MESSAGE: Rheumatologists' preferences on strategies for education (mode of delivery, delivery setting, messengers, and topics) differ from those of patients. For example, patients want to learn about lifestyle changes and consequences of compliance versus noncompliance, whereas rheumatologists considered more important for patients to understand their disease, treatment adverse effects, and consequences of noncompliance.

Serial frailty assessments following allogeneic stem cell transplant in older adults: A pilot study.

INTRODUCTION: Increasing numbers of older adults undergo allogeneic stem cell transplantation (SCT) as the only chance of meaningful survival for hematologic malignancies. However, toxicities in vulnerable patients may offset the benefits of SCT. Frailty and abnormal geriatric assessment (GA) prior to SCT have been associated with decreased overall survival in persons aged 60 and older. The purpose of this pilot study was to determine the prevalence of baseline GA deficits and frailty, the prevalence of frailty or death at three and six months after allogeneic SCT, and associations between baseline assessments and the presence of frailty or death post-SCT. METHODS: We enrolled 50 patients aged 60 years and older and completed a baseline GA including comorbidity, polypharmacy, nutrition, physical performance, functional status, social support, depression and anxiety, and cognition. Frailty was defined as three or more abnormalities of gait speed, grip strength, weight loss, physical activity, and exhaustion, and was assessed at baseline, three months, and six months after SCT. A composite outcome of frailty or death at three months and six months was analyzed. RESULTS: Frailty was present in 11/50 (22%) of patients at baseline. Ten patients did not complete three- month follow-up, and twelve patients did not complete six-month follow-up. Of those with follow-up data, 22 patients (55%) were frail or deceased three months after SCT, and 27 patients (71%) were frail or deceased six months after SCT. Frailty at baseline was not significantly associated with frailty or death at three or six months after SCT. However, the study's small enrollment limits conclusions on these associations. CONCLUSION: GA deficits and frailty are prevalent in older adult SCT recipients at baseline and after transplant. Future studies should aim for larger enrollment in order to validate associations between these deficits and outcomes, especially survival, functional status, and quality of life following SCT.

Quality of Life Assessment in Older Adults with Dementia: A Systematic Review.

INTRODUCTION: In the absence of a cure, dementia is often managed by minimizing risk factors contributing to quality of life (QOL). Attitudes to dementia in older adults may differ from those in relatively younger adults. The aim was to conduct a systematic review of the literature to determine how QOL was assessed in adults, 65 years and older with dementia, and identify factors that influence the reported scores. METHODS: A systematic review of full-text articles addressing QOL in older adults with dementia, published in English from January 1995 to September 2020, was conducted using PubMed and PsycINFO. We included studies that assessed QOL and involved participants 65 years and older. Studies were evaluated for inclusion by 2 independent pairs of reviewers. We assessed the quality of the studies using the Joanna Briggs Institute's Critical Appraisal Checklist. Study characteristics and findings were summarized. Analysis was by narrative synthesis. We identified social and clinical factors influencing QOL scores. RESULTS: Of the 1,010 articles identified, 19 met the inclusion criteria. These 19 studies involved 6,279 persons with dementia, with sample sizes from 32 to 1,366. Mean age of participants ranged from 77.1 to 86.6 years. Five measurement tools were identified; Quality of Life in Alzheimer Disease (QOL-AD), Alzheimer Disease-Related Quality of Life (ADRQL), Quality of Life in Late-Stage Dementia (QUALID), QUALIDEM (a dementia-specific QOL tool), and DEMQOL (health-related QOL for people with dementia). Self-ratings of QOL were higher than proxy ratings. Factors commonly influencing self-ratings of QOL included depression, functional impairment, and polypharmacy. Common factors that influenced proxy ratings included functional impairment, presence of neuropsychiatric symptoms, cognitive impairment, and caregiver burden. CONCLUSION: In evaluating QOL in dementia, self- and proxy reports may complement each other to ensure that all perspectives are addressed.

Quality appraisal of educational websites about osteoporosis and bone health.

PURPOSE/INTRODUCTION: Bone health education publicly available through the Internet, if evidence-based and unbiased, could help patients deal with issues such as decision-making, maintaining healthy lifestyles, using medications correctly, and improving their communication with health professionals. METHODS: We performed an environmental scan and quality assessment of the currently available osteoporosis and bone health patient education information on the World Wide Web. The sample websites were identified by using three separate search tools: Google Advanced, Bing, and Ask.com . Two independent investigators collected data and appraised the quality of selected websites. RESULTS: We identified 48 websites. Most websites were focused on risks factors of osteoporosis, preventive measures, screening recommendations, and topics to discuss with the physician. All websites provided adequate information describing treatment options; however, only 36% had information addressing duration of treatment, what happens when treatment stops, and the benefits and risks of various treatments. A total of 55% of the websites had their content updated to 2019 and 68% cited their sources of information to support their content. Reading levels ranged from 7.5 to 15.2 (higher than the recommended 6-grade level). CONCLUSIONS: Websites with information about bone health and osteoporosis commonly present information about initial treatment choices, but most fail to address risk-benefit issues, and common barriers than can occur throughout the course of the disease. In addition, many websites did not update their content, did not cite their sources of information, or were written at a 9-grade level or above (rendering them unsuitable for low-literacy populations).

Randomized Controlled Trial of Patient Education Tools for Patients With Rheumatoid Arthritis.

OBJECTIVE: The present study was undertaken to evaluate the efficacy of 2 educational tools for patients with rheumatoid arthritis (RA) by comparing a newly developed video tool, including storylines and testimonials, combined with a written booklet to the same written booklet alone. METHODS: We conducted a randomized controlled trial. Our primary outcome was disease knowledge. Secondary outcomes were decisional conflict, self-efficacy, effective health care management, and satisfaction. Outcomes were measured before and after reviewing the materials, and 3 and 6 months later. Linear mixed-effects models were performed to evaluate changes over time. RESULTS: In total, 221 participants received an educational video and booklet (n = 111) or a booklet alone (n = 110). The mean age was 50.8 years, mean disease duration was 4.8 years, 85% were female, and 24% had limited health literacy levels. Within groups, most outcomes improved between baseline and follow-up, but there were no statistically significant differences across groups. Patients receiving the video and booklet were more likely than those receiving the booklet alone to rate the presentation as excellent for providing information about the impact of RA, medication options, evidence about medications, benefits of medication, and self-care options. Factors significantly associated with greater improvements in knowledge and decisional conflict from baseline to 6 months included limited health literacy, lower educational level, and shorter disease duration. CONCLUSION: Regardless of the delivery method, outcomes were improved up to 6 months after educational materials were delivered. Our findings support the implementation of self-administered educational materials in clinical settings, as they can result in sustained improvements in disease knowledge and decisional conflict.

Interactions and perceptions of patients with rheumatoid arthritis participating in an online support group.

OBJECTIVE: Peer support is important for psychosocial well-being in patients with rheumatoid arthritis (RA). Our objective was to assess the interactions, engagement, and perceptions of participants in an online support group for patients with RA. METHODS: Participants were 18 years or older, diagnosed with RA within 10 years, and residing in the USA or Canada. All participated in a closed Facebook online support group. Membership was by invitation only, and discussions were visible only to members, moderators, and two research staff. Each week, participants discussed a topic posted by a moderator. They also shared other disease-relevant information beside the topics posted. We assessed participants' engagement and qualitatively analyzed the content of their postings in the first 5 weeks of participation. RESULTS: The group had 90 participants: 94% were female and 83% white. Median age was 54 (24-84) years. Mean number of contributors per week was 50 (range, 42-62); 10% of participants never contributed to the discussions. Participation in discussions declined over time. Over three-quarters of participant posting were about information sharing. Participants shared information on disease experiences, medications, social lives (including pictures of themselves, families, and pets), online resources on RA, frustrations, messages of encouragement, and satirical depictions of their disease experience. Many expressed gratitude for the social support provided. CONCLUSION: Participants were generally enthusiastic and shared disease-related information and personal experiences. Social media groups may provide alternative means of providing education and peer support often lacking in traditional models of care.Key Points• The study examines how patients with rheumatoid arthritis engage in an online support group and the nature of their interactions.• This study reveals that social media platforms could provide viable options or complements to the traditional face-to-face small group patient support system.• It may be necessary to pay special attention to how to ensure a sustained participant interest in online social support group among patients with rheumatoid arthritis.

Association between frailty syndrome and survival in patients with pancreatic adenocarcinoma.

BACKGROUND: Frailty is a syndrome characterized by weakness, slow gait, weight loss, exhaustion, and low activity. We sought to determine whether frailty was associated with age or stage in newly diagnosed patients with pancreatic ductal adenocarcinoma (PDAC), and determine its association with survival. METHODS: Consecutive patients with newly diagnosed PDAC of all stages underwent baseline assessment. Frailty (per Fried criteria) was defined as having three or more abnormalities in: grip strength, gait speed, weight loss, self-reported exhaustion, or self-reported physical activity. Baseline clinicodemographic characteristics, anatomic stage, performance status, and laboratory markers of prognosis were included. The association between baseline characteristics, frailty, and survival was determined. The associations of individual frailty measures with age, stage, comorbidities, and performance status were examined. Body composition was measured from computed tomographic images using SliceOMatic software. RESULTS: Of 150 patients enrolled, 8 were excluded because they did not have PDAC on final diagnosis. The median age was 65 years (range, 32-89). Seventy-nine patients (55.6%) were sarcopenic, and 36 (25.4%) were frail. Frailty was associated with increasing comorbidities (P = 0.03) and worse performance status (P < 0.01). During follow-up, 79 patients (56%) died. Frailty was significantly associated with death during the follow-up period (P < 0.001) for the entire cohort, including patients with curative (P = 0.038) and palliative (P = 0.003) treatment plans. CONCLUSIONS: Frailty was seen frequently in patients with newly diagnosed PDAC and was not associated with increasing age or more advanced stage. Frailty was a predictor of survival, including patients treated with curative intent.

Assessing information needs and use of online resources for disease self-management in patients with rheumatoid arthritis: a qualitative study.

To explore the information needs of patients with rheumatoid arthritis (RA) and their acceptance of online resources and Facebook in particular, as a source of information, interaction, and support among peers. Participants were adults with RA of ≤ 10 years duration, had ongoing or prior treatment with disease-modifying anti-rheumatic drugs or biologic agents, and internet access. We conducted 20 in-depth interviews using semi-structured interview guide to explore: (1) RA information needs, (2) use of self-management health behaviors, (3) use of internet resources for disease management, (4) role of peer support in health self-management, and (5) use of social networking sites (SNS) such as Facebook in disease management. Data were analyzed using content analysis and constant comparative methods. Participants were mainly female (85%), White (70%), and over 50 years old (70%). Specific information needs included knowledge regarding medications, disease course, pain control, diet, and exercise. Most participants had a narrow perception of SNS as a tool for disease management. However, they found SNS acceptable and were open to participating in a support group on Facebook with reasonable assurance of privacy. Although the overarching theme was RA information needs, the other themes contribute in supporting the robust emergence of Internet media in informing patients about their health and support systems. Our findings can inform the choice and format of materials to be considered for online education on self-management and social networking for RA patients.

Sociodemographic Disparities in Cure-Intended Treatment in Localized Prostate Cancer.

PURPOSE: Disparities in prostate cancer (PCa) morbidity and mortality occur across various populations. We investigated the sociodemographic correlates of treatment and disparities in the application of cure-intended (i.e., radical prostatectomy [RP], radiation therapy [RT]) treatment strategies in localized PCa among Texas residents diagnosed with PCa. METHODS: We analyzed data from the Texas Cancer Registry on men diagnosed with stage T1 or T2 PCa between 2004 and 2009. Multinomial logistic regression analysis was used to explore independent associations between cure-intended treatment modalities and sociodemographic characteristics (age, race/ethnicity, socioeconomic status [SES], and geographic location (rural versus urban)) using patients who did not receive definitive treatment as comparison group. RESULTS: Of 46,971 patients with available treatment data, age-adjusted treatment rates were 39.1% RP, 30.7% RT, and 30.2% for all other non-curative modalities. Compared to patients under 60 years, those ≥60 were less likely to receive RP, patients between 60 and 80 years were more likely to undergo RT, while those 80 years or older were less likely. Non-Hispanic blacks (OR =0.55, 95% CI, 0.50-0.59) and Hispanics (OR = 0.68, 95%CI, 0.62-0.74) were less likely to receive RP compared with whites. Hispanics were significantly less likely to receive RT (OR = 0.78, 95%CI, 0.72-0.85) than blacks and whites. People of low SES were 35% (OR = 0.65, 95%CI, 0.60-0.69) and 15% (OR = 0.85, 95%CI, 0.79-0.90) less likely to receive RP and RT, respectively, compared with those of high SES. Rural-urban status was not associated with cure-intended treatment. CONCLUSION: Potential sociodemographic disparities exist in the application of cure-intended treatment in localized prostate cancer in Texas particularly in race/ethnicity and SES.

Online Educational Tool to Promote Bone Health in Cancer Survivors.

Osteoporosis burden is significant in cancer survivors. Websites providing health information abound, but their development, quality, and source of information remain unclear. Our aim was to use a systematic and transparent approach to create an educational website on bone health, and to evaluate its potential to improve knowledge, self-management, and awareness in prostate cancer (PCa) and breast cancer (BCa) survivors. Guided by the Health Belief Model, we created a website using international standards and evaluated it in 10 PCa and 10 BCa survivors with self-administered questionnaire before, after, and 1 month after navigating the website. The mean scores on the knowledge questionnaire at baseline, postintervention and 1 month were, respectively, 5.1 (±2.0), 6.9 (±2.5), and 6.7 (±2.4), p < .008, in PCa and 3.4 (±2.7), 7.6 (±3.0), and 6.5 (±3.8), p  = .016, in BCa survivors. Acceptability ratings ranged from 60% to 100%. Participants found the website useful, helpful, and able to raise bone health awareness. Our website improved bone health knowledge in both PCa and BCa survivors. A systematic and transparent approach to the development of online educational websites could result in a tool capable of meeting the educational needs of targeted consumers. Cancer survivors could benefit from proven online educational tools.

Assessing information needs on bone health in cancer survivors.

PURPOSE: Bone health education and implementation of preventive measures are key to effective management of osteoporosis. We assessed areas of knowledge deficits with respect to bone health in breast and prostate cancer survivors and the preferred source of health information METHODS: We used a mixed methods approach. We conducted 20 semi-structured interviews in breast or prostate cancer survivors receiving hormonal therapy. Responses were independently coded by 2 researchers and explored under 3 content areas: osteoporosis knowledge, behaviors for self-management, and preferred learning tools. Another 20 participants responded to a structured questionnaire that comprised modified versions of the Osteoporosis Knowledge Questionnaire (OPQ) and Osteoporosis Knowledge Assessment Tool (OKAT). The OPQ and OKAT were analyzed as summary scores, and areas of knowledge deficits (i.e., where ≥60 % of participants failed to give the right response) were identified. RESULTS: Median age of participants was 67 (range 48-92) and 78 % were White. Awareness of osteoporosis was high, but detailed knowledge was low. Bone healthy behaviors perceived by participants as most important include good nutrition, exercising, calcium and vitamin D supplementation and avoidance of falls. The Internet was the most preferred source of information. Areas of knowledge deficit revealed by the OPQ and OKAT included general information, risk factors, prevention, and treatment of osteoporosis. CONCLUSION: There is a desire for information on osteoporosis, specifically tailored for cancer survivors. Good nutrition, supplement intake, exercise, and avoidance of falls were perceived as key behaviors for self-management. The Internet was an important source of information for breast and prostate cancer patients. Implication for Cancer Survivors An educational website addressing the bone health information needs of cancer survivors could effectively improve behaviors for self-management.

Optimal screening for geriatric assessment in older allogeneic hematopoietic cell transplantation candidates.

OBJECTIVE: Older patients who receive hematopoietic cell transplantation (HCT) may be at risk for adverse outcomes due to age-related conditions or frailty. Geriatric assessment (GA) has been used to evaluate HCT candidates but can be time-consuming. We therefore sought to determine the predictive ability of two screening tools, the Vulnerable Elders Survey (VES-13) and the G8, for abnormal GA or frailty. MATERIALS AND METHODS: We enrolled 50 allogeneic HCT candidates age ≥60 years. The GA included measures of medical, physical, functional, and social health. Frailty was defined as 3 or more abnormalities on grip strength, gait speed, weight loss, exhaustion, and activity. We associated baseline characteristics and abnormal GA or frailty. We determined the sensitivity and predictive ability of the VES-13 and G8 for GA and frailty. RESULTS: Overall, 33 (66%) patients (mean age 65.4 years) had an abnormal GA, and 11 patients (22%) were frail. The G8 screening tool had a higher sensitivity for an abnormal GA (69.7%), and the VES-13 had a higher specificity (100%). Both tools had similar discriminatory ability. CONCLUSIONS: Older HCT candidates had a significant number of deficits on baseline GA and a high prevalence of frailty. Existing screening tools may not be able to replace a full GA.

Role of neoadjuvant therapy in the multimodality treatment of older patients with pancreatic cancer.

BACKGROUND: A well-defined treatment strategy for elderly patients with resectable pancreatic cancer is lacking. Multiple reports have described highly selected older cancer patients who have successfully undergone pancreatectomy. However, multimodality therapy is essential for long-term survival, and elderly patients are at high risk for not receiving adjuvant therapy postoperatively. We sought to describe the treatment patterns and outcomes of a series of elderly patients with pancreatic cancer who were treated with a multimodality strategy that liberally used neoadjuvant therapy. STUDY DESIGN: We retrospectively reviewed treatment plans, short-term outcomes, and overall survival of all patients 70 years old and older, presenting to our institution over a 9-year period, who were treated for potentially resectable or borderline resectable pancreatic cancer. RESULTS: There were 179 (76%) of 236 patients treated with curative intent. Of these patients, 153 (85%) initiated neoadjuvant therapy: 74 (48%) subsequently underwent pancreatectomy and 79 did not due to disease progression (n = 46), insufficient performance status (n = 23), or other reasons (n = 10). Eleven (42%) of 26 patients who underwent surgery first received postoperative therapy. Among patients treated with curative intent, the median overall survival of all patients initiating neoadjuvant therapy (16.6 months [range 2.1 to 142.7 months]) was similar to that of patients undergoing resection primarily (15.1 months [range 5.4 to 100.8 months]), p = 0.53. After pancreatectomy, patients had a 2% in-hospital mortality rate and 91% were discharged home. CONCLUSIONS: Eighty-five percent of all patients 70 years old and older, who underwent pancreatectomy for potentially resectable or borderline resectable pancreatic cancer, received multimodality therapy. More than 90% were discharged home. These data demonstrate a potential role for neoadjuvant therapy in selecting elderly patients for surgery, and support further studies to refine individualized treatment protocols for this high-risk population.