"Hypertension is such a difficult disease to manage": federally qualified health center staff- and leadership-perceived readiness to implement a technology-facilitated team-based hypertension model.

BACKGROUND: Despite decades of evidence demonstrating the efficacy of hypertension care delivery in reducing morbidity and mortality, a majority of hypertension cases remain uncontrolled. There is an urgent need to elucidate and address multilevel facilitators and barriers clinical staff face in delivering evidence-based hypertension care, patients face in accessing it, and clinical systems face in sustaining it. Through a rigorous pre-implementation evaluation, we aimed to identify facilitators and barriers bearing the potential to affect the planned implementation of a multilevel technology-facilitated hypertension management trial across six primary care sites in a large federally qualified health center (FQHC) in New York City. METHODS: During a dedicated pre-implementation period (3-9 months/site, 2021-2022), a capacity assessment was conducted by trained practice facilitators, including (1) online anonymous surveys (n = 124; 70.5% of eligible), (2) hypertension training analytics (n = 69; 94.5% of assigned), and (3) audio-recorded semi-structured interviews (n = 67; 48.6% of eligible) with FQHC leadership and staff. Surveys measured staff sociodemographic characteristics, adaptive reserve, evidence-based practice attitudes, and implementation leadership scores via validated scales. Training analytics, derived from end-of-course quizzes, included mean score and number attempts needed to pass. Interviews assessed staff-reported facilitators and barriers to current hypertension care delivery and uptake; following audio transcription, trained qualitative researchers employed a deductive coding approach, informed by the Consolidated Framework for Implementation Research (CFIR). RESULTS: Most survey respondents reported moderate adaptive reserve (mean = 0.7, range = 0-1), evidence-based practice attitudes (mean = 2.7, range = 0-4), and implementation leadership (mean = 2.5, range = 0-4). Most staff passed training courses on first attempt and demonstrated high scores (means > 80%). Findings from interviews identified potential facilitators and barriers to implementation; specifically, staff reported that complex barriers to hypertension care, control, and clinical communication exist; there is a recognized need to improve hypertension care; in-clinic challenges with digital tool access imposes workflow delays; and despite high patient loads, staff are motivated to provide high-quality cares. CONCLUSIONS: This study serves as one of the first to apply the CFIR to a rigorous pre-implementation evaluation within the understudied context of a FQHC and can serve as a model for similar trials seeking to identify and address contextual factors known to impact implementation success. TRIAL REGISTRATION: ClinicalTrials.gov NCT03713515 , date of registration: October 19, 2018.

Quantifying the impact of telemedicine and patient medical advice request messages on physicians' work-outside-work.

The COVID-19 pandemic has boosted digital health utilization, raising concerns about increased physicians' after-hours clinical work ("work-outside-work"). The surge in patients' digital messages and additional time spent on work-outside-work by telemedicine providers underscores the need to evaluate the connection between digital health utilization and physicians' after-hours commitments. We examined the impact on physicians' workload from two types of digital demands - patients' messages requesting medical advice (PMARs) sent to physicians' inbox (inbasket), and telemedicine. Our study included 1716 ambulatory-care physicians in New York City regularly practicing between November 2022 and March 2023. Regression analyses assessed primary and interaction effects of (PMARs) and telemedicine on work-outside-work. The study revealed a significant effect of PMARs on physicians' work-outside-work and that this relationship is moderated by physicians' specialties. Non-primary care physicians or specialists experienced a more pronounced effect than their primary care peers. Analysis of their telemedicine load revealed that primary care physicians received fewer PMARs and spent less time in work-outside-work with more telemedicine. Specialists faced increased PMARs and did more work-outside-work as telemedicine visits increased which could be due to the difference in patient panels. Reducing PMAR volumes and efficient inbasket management strategies needed to reduce physicians' work-outside-work. Policymakers need to be cognizant of potential disruptions in physicians carefully balanced workload caused by the digital health services.

Opening the Black Box of an mHealth Patient-Reported Outcome Tool for Diabetes Self-Management: Interview Study Among Patients With Type 2 Diabetes.

BACKGROUND: Mobile health (mHealth) tools are used to collect data on patient-reported outcomes (PROs) and facilitate the assessment of patients' self-management behaviors outside the clinic environment. Despite the high availability of mHealth diabetes tools, there is a lack of understanding regarding the underlying reasons why these mHealth PRO tools succeed or fail in terms of changing patients' self-management behaviors. OBJECTIVE: This study aims to identify the factors that drive engagement with an mHealth PRO tool and facilitate patients' adoption of self-management behaviors, as well as elicit suggestions for improvement. METHODS: This qualitative study was conducted within the context of a randomized controlled trial designed to evaluate the efficacy of an mHealth PRO tool (known as i-Matter) versus usual care regarding reduction in glycated hemoglobin (HbA1c) levels and adherence to self-management behaviors at 12 months among patients with uncontrolled type 2 diabetes. Patients randomized to i-Matter participated in semistructured interviews about their experiences at the 3-, 6-, 9-, and 12-month study visits. A qualitative analysis of the interviews was conducted by 2 experienced qualitative researchers using conventional qualitative content analysis. RESULTS: The sample comprised 71 patients, of whom 67 (94%) completed at least one interview (n=48, 72% female patients; n=25, 37% identified as African American or Black; mean age 56.65 [SD 9.79] years). We identified 4 overarching themes and 6 subthemes. Theme 1 showed that the patients' reasons for engagement with i-Matter were multifactorial. Patients were driven by internal motivating factors that bolstered their engagement and helped them feel accountable for their diabetes (subtheme 1) and external motivating factors that helped to serve as reminders to be consistent with their self-management behaviors (subtheme 2). Theme 2 revealed that the use of i-Matter changed patients' attitudes toward their disease and their health behaviors in 2 ways: patients developed more positive attitudes about their condition and their ability to effectively self-manage it (subtheme 3), and they also developed a better awareness of their current behaviors, which motivated them to adopt healthier lifestyle behaviors (subtheme 4). Theme 3 showed that patients felt more committed to their health as a result of using i-Matter. Theme 4 highlighted the limitations of i-Matter, which included its technical design (subtheme 5) and the need for more resources to support the PRO data collected and shared through the tool (subtheme 6). CONCLUSIONS: This study isolated internal and external factors that prompted patients to change their views about their diabetes, become more engaged with the intervention and their health, and adopt healthy behaviors. These behavioral mechanisms provide important insights to drive future development of mHealth interventions that could lead to sustained behavior change.

Operational Implementation of Remote Patient Monitoring Within a Large Ambulatory Health System: Multimethod Qualitative Case Study.

BACKGROUND: Remote patient monitoring (RPM) technologies can support patients living with chronic conditions through self-monitoring of physiological measures and enhance clinicians' diagnostic and treatment decisions. However, to date, large-scale pragmatic RPM implementation within health systems has been limited, and understanding of the impacts of RPM technologies on clinical workflows and care experience is lacking. OBJECTIVE: In this study, we evaluate the early implementation of operational RPM initiatives for chronic disease management within the ambulatory network of an academic medical center in New York City, focusing on the experiences of "early adopter" clinicians and patients. METHODS: Using a multimethod qualitative approach, we conducted (1) interviews with 13 clinicians across 9 specialties considered as early adopters and supporters of RPM and (2) speculative design sessions exploring the future of RPM in clinical care with 21 patients and patient representatives, to better understand experiences, preferences, and expectations of pragmatic RPM use for health care delivery. RESULTS: We identified themes relevant to RPM implementation within the following areas: (1) data collection and practices, including impacts of taking real-world measures and issues of data sharing, security, and privacy; (2) proactive and preventive care, including proactive and preventive monitoring, and proactive interventions and support; and (3) health disparities and equity, including tailored and flexible care and implicit bias. We also identified evidence for mitigation and support to address challenges in each of these areas. CONCLUSIONS: This study highlights the unique contexts, perceptions, and challenges regarding the deployment of RPM in clinical practice, including its potential implications for clinical workflows and work experiences. Based on these findings, we offer implementation and design recommendations for health systems interested in deploying RPM-enabled health care.

Analyzing User Engagement Within a Patient-Reported Outcomes Texting Tool for Diabetes Management: Engagement Phenotype Study.

BACKGROUND: Patient-reported outcomes (PROs) capture patients' views on their health conditions and its management, and are increasingly used in clinical trials, including those targeting type 2 diabetes (T2D). Mobile health (mHealth) tools offer novel solutions for collecting PRO data in real time. Although patients are at the center of any PRO-based intervention, few studies have examined user engagement with PRO mHealth tools. OBJECTIVE: This study aimed to evaluate user engagement with a PRO mHealth tool for T2D management, identify patterns of user engagement and similarities and differences between the patients, and identify the characteristics of patients who are likely to drop out or be less engaged with a PRO mHealth tool. METHODS: We extracted user engagement data from an ongoing clinical trial that tested the efficacy of a PRO mHealth tool designed to improve hemoglobin A1c levels in patients with uncontrolled T2D. To date, 61 patients have been randomized to the intervention, where they are sent 6 PRO text messages a day that are relevant to T2D self-management (healthy eating and medication adherence) over the 12-month study. To analyze user engagement, we first compared the response rate (RR) and response time between patients who completed the 12-month intervention and those who dropped out early (noncompleters). Next, we leveraged latent class trajectory modeling to classify patients from the completer group into 3 subgroups based on similarity in the longitudinal engagement data. Finally, we investigated the differences between the subgroups of completers from various cross-sections (time of the day and day of the week) and PRO types. We also explored the patient demographics and their distribution among the subgroups. RESULTS: Overall, 19 noncompleters had a lower RR to PRO questions and took longer to respond to PRO questions than 42 completers. Among completers, the longitudinal RRs demonstrated differences in engagement patterns over time. The completers with the lowest engagement showed peak engagement during month 5, almost at the midstage of the program. The remaining subgroups showed peak engagement at the beginning of the intervention, followed by either a steady decline or sustained high engagement. Comparisons of the demographic characteristics showed significant differences between the high engaged and low engaged subgroups. The high engaged completers were predominantly older, of Hispanic descent, bilingual, and had a graduate degree. In comparison, the low engaged subgroup was composed mostly of African American patients who reported the lowest annual income, with one of every 3 patients earning less than US $20,000 annually. CONCLUSIONS: There are discernible engagement phenotypes based on individual PRO responses, and their patterns vary in the timing of peak engagement and demographics. Future studies could use these findings to predict engagement categories and tailor interventions to promote longitudinal engagement. TRIAL REGISTRATION: Clinicaltrials.gov NCT03652389; https://clinicaltrials.gov/ct2/show/NCT03652389. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/18554.

Evidence for Telemedicine's Ongoing Transformation of Health Care Delivery Since the Onset of COVID-19: Retrospective Observational Study.

BACKGROUND: The surge of telemedicine use during the early stages of the COVID-19 pandemic has been well documented. However, scarce evidence considers the use of telemedicine in the subsequent period. OBJECTIVE: This study aims to evaluate use patterns of video-based telemedicine visits for ambulatory care and urgent care provision over the course of recurring pandemic waves in 1 large health system in New York City (NYC) and what this means for health care delivery. METHODS: Retrospective electronic health record (EHR) data of patients from January 1, 2020, to February 28, 2022, were used to longitudinally track and analyze telemedicine and in-person visit volumes across ambulatory care specialties and urgent care, as well as compare them to a prepandemic baseline (June-November 2019). Diagnosis codes to differentiate suspected COVID-19 visits from non-COVID-19 visits, as well as evaluating COVID-19-based telemedicine use over time, were compared to the total number of COVID-19-positive cases in the same geographic region (city level). The time series data were segmented based on change-point analysis, and variances in visit trends were compared between the segments. RESULTS: The emergence of COVID-19 prompted an early increase in the number of telemedicine visits across the urgent care and ambulatory care settings. This use continued throughout the pandemic at a much higher level than the prepandemic baseline for both COVID-19 and non-COVID-19 suspected visits, despite the fluctuation in COVID-19 cases throughout the pandemic and the resumption of in-person clinical services. The use of telemedicine-based urgent care services for COVID-19 suspected visits showed more variance in response to each pandemic wave, but telemedicine visits for ambulatory care have remained relatively steady after the initial crisis period. During the Omicron wave, the use of all visit types, including in-person activities, decreased. Patients between 25 and 34 years of age were the largest users of telemedicine-based urgent care. Patient satisfaction with telemedicine-based urgent care remained high despite the rapid scaling of services to meet increased demand. CONCLUSIONS: The trend of the increased use of telemedicine as a means of health care delivery relative to the pre-COVID-19 baseline has been maintained throughout the later pandemic periods despite fluctuating COVID-19 cases and the resumption of in-person care delivery. Overall satisfaction with telemedicine-based care is also high. The trends in telemedicine use suggest that telemedicine-based health care delivery has become a mainstream and sustained supplement to in-person-based ambulatory care, particularly for younger patients, for both urgent and nonurgent care needs. These findings have implications for the health care delivery system, including practice leaders, insurers, and policymakers. Further investigation is needed to evaluate telemedicine adoption by key demographics, identify ongoing barriers to adoption, and explore the impacts of sustained use of telemedicine on health care outcomes and experience.

The Impact of Telemedicine on Physicians' After-hours Electronic Health Record "Work Outside Work" During the COVID-19 Pandemic: Retrospective Cohort Study.

BACKGROUND: Telemedicine as a mode of health care work has grown dramatically during the COVID-19 pandemic; the impact of this transition on clinicians' after-hours electronic health record (EHR)-based clinical and administrative work is unclear. OBJECTIVE: This study assesses the impact of the transition to telemedicine during the COVID-19 pandemic on physicians' EHR-based after-hours workload (ie, "work outside work") at a large academic medical center in New York City. METHODS: We conducted an EHR-based retrospective cohort study of ambulatory care physicians providing telemedicine services before the pandemic, during the acute pandemic, and after the acute pandemic, relating EHR-based after-hours work to telemedicine intensity (ie, percentage of care provided via telemedicine) and clinical load (ie, patient load per provider). RESULTS: A total of 2129 physicians were included in this study. During the acute pandemic, the volume of care provided via telemedicine significantly increased for all physicians, whereas patient volume decreased. When normalized by clinical load (ie, average appointments per day by average clinical days per week), telemedicine intensity was positively associated with work outside work across time periods. This association was strongest after the acute pandemic. CONCLUSIONS: Taking physicians' clinical load into account, physicians who devoted a higher proportion of their clinical time to telemedicine throughout various stages of the pandemic engaged in higher levels of EHR-based after-hours work compared to those who used telemedicine less intensively. This suggests that telemedicine, as currently delivered, may be less efficient than in-person-based care and may increase the after-hours work burden of physicians.

Intergenerational Technology Transfer: Enhancing African American Older Adults' Self-Efficacy for Diabetes Self-Management.

BACKGROUND: African American older adults are twice as likely to have diabetes than White older adults. Little is understood of African American older adults' self-efficacy in using technology to support recommended chronic disease self-management. OBJECTIVES: Our objective was to describe the feasibility of using a community-based health education session that used intergenerational technology transfer to promote use of technology to support self-management. The team designed a health and technology education session then measured its impact on African American older adults' self-efficacy for using technology to support self-management. METHODS: The community-based participatory research approach informed the study design which duplicated the sessions at the two study sites, in Detroit and Flint. We conducted a health education seminar in which older adults with diabetes shared insights on living with diabetes with younger adults they selected from their personal networks. The younger adults showed older adults how to access health information on smartphones. RESULTS: The sample included African American older adults (aged ≥50 years; n = 39) and younger adults (aged 18-49 years; n = 26). All participants showed improvements in self-efficacy for following recommendations for diet (i.e., preparing healthy meals [p = 0.0179]) and healthy diet behavior [p = 0.0044]) and physical activity (i.e., decrease in effort to exercise [p = 0.0185]), and for six of seven items, which measured confidence in using technology for self-management (e.g., using technology for health [p = 0.0002]). CONCLUSIONS: Findings provide foundational observations to inform evidence-based healthy aging interventions that use technology. Future research should explore the efficacy of community-based health education sessions with intergenerational technology transfer designed to support self-management.

Reconciling modern machine-learning practice and the classical bias-variance trade-off.

Breakthroughs in machine learning are rapidly changing science and society, yet our fundamental understanding of this technology has lagged far behind. Indeed, one of the central tenets of the field, the bias-variance trade-off, appears to be at odds with the observed behavior of methods used in modern machine-learning practice. The bias-variance trade-off implies that a model should balance underfitting and overfitting: Rich enough to express underlying structure in data and simple enough to avoid fitting spurious patterns. However, in modern practice, very rich models such as neural networks are trained to exactly fit (i.e., interpolate) the data. Classically, such models would be considered overfitted, and yet they often obtain high accuracy on test data. This apparent contradiction has raised questions about the mathematical foundations of machine learning and their relevance to practitioners. In this paper, we reconcile the classical understanding and the modern practice within a unified performance curve. This "double-descent" curve subsumes the textbook U-shaped bias-variance trade-off curve by showing how increasing model capacity beyond the point of interpolation results in improved performance. We provide evidence for the existence and ubiquity of double descent for a wide spectrum of models and datasets, and we posit a mechanism for its emergence. This connection between the performance and the structure of machine-learning models delineates the limits of classical analyses and has implications for both the theory and the practice of machine learning.

Cyclometalated rhodium and iridium complexes with imidazole containing Schiff bases: Synthesis, structure and cellular imaging.

Cyclometalated rhodium(III) and iridium(III) complexes (1-4) of two Schiff base ligands L1 and L2 with the general formula [M(ppy)2(Ln)]Cl {M = Rh, Ir; ppy = 2-phenylpyridine; n = 1, 2; L = Schiff base ligand} have been synthesized. The new ligands and the complexes have been characterized with spectroscopic techniques. Electrochemistry of the complexes revealed anodic behavior, corresponding to an M(III) to M(IV) oxidation. The X-ray crystal structures of complexes 2 and 4 have also been determined to interpret the coordination behavior of the complexes. Photophysical study shows that all the complexes display fluorescence at room temperature with quantum yield of about 3 × 10-2 to 5 × 10-2. The electronic absorption spectra of all the complexes fit well with the computational studies. Cellular imaging studies were done with the newly synthesized complexes. To the best of our knowledge, this is the first report of organometallic complexes of rhodium(III) and iridium(III) with Schiff base ligands explored for cellular imaging. Emphasis of this work lies on the structural features, photophysical behavior, cellular uptake and imaging of the fluorescent transition metal complexes.

A Kamikaze Approach for Capturing Hg(2+) Ions through the Formation of a One-Dimensional Metal-Organometallic Polymer.

Efficient uptake of Hg(2+) ions in mercury-resistant bacteria is attributed to the presence of cysteine thiolates in the Mer proteins. In this work, a pyridine-appended pyridine-fused imidazolyl-2-thione scaffold was used as a mimic for the cysteinyl residues for efficient binding of the Hg(2+) ions. In the presence of Hg(2+) ions, an aryl C-H bond of the ligand is activated. The sulfur and nitrogen donors on the other end of the ligand coordinate with a second Hg(2+) ion. This motif in the presence of acetate ions forms a one-dimensional polymeric crystalline network characterized by singal-crystal X-ray diffraction studies. The formation of this polymeric structure leads to efficient removal (∼99%) of Hg(2+) ions from aqueous solutions through an underexplored "kamikaze" approach involving a small-molecule ligand as a sacrificial agent for trapping the ion.

Development of a cyclometalated iridium complex with specific intramolecular hydrogen-bonding that acts as a fluorescent marker for the endoplasmic reticulum and causes photoinduced cell death.

Cyclometalated iridium complexes have important applications as phosphorescent probes for cellular imaging due to their photophysical properties. Moreover, these properties also make them potential candidates as photosensitizers for photodynamic therapy (PDT) of tumors and skin diseases. Treatment of MCF7 breast carcinoma cells with a heteroleptic phosphorescent cyclometalated iridium(III) complex C2 followed by confocal imaging indicates that the complex selectively localizes and exhibits high fluorescence in the endoplasmic reticulum. In an unprecedented approach, systematic alteration of functional groups or the metal core in C2 to synthesize a series of iridium(III) complexes (C1­C10) and an organometallic rhenium complex C11 with an imidazolyl modified phenanthroline ligand has indicated the functional groups and their interactions that are responsible for this selective localization. Remarkably, the exposure of the cells treated with C2 to irradiation at 405 nm for one hour led to membrane blebbing and cell death, demonstrating a photosensitizing property of the compound.

"Extra stabilisation" of a pyrene based molecular couple by γ-cyclodextrin in the excited electronic state.

Two thiosemicarbazide and semicarbazide functionalized pyrene labeled Schiff base compounds have been synthesized. The pyrene moieties in the compounds result in formation of π-π coupled complexes in aqueous medium in the excited electronic state. Added γ-cyclodextrin allows incorporation of the pyrene head inside its less polar core and promotes hydrogen bonding of the thio and oxo groups of the compounds with its rim hydroxyl groups to "stabilise" the monomers. This is confirmed by FT-IR and absorption spectroscopy. The stabilised monomers lead to formation of stabilised excimers as monitored by steady state and time-resolved fluorescence spectroscopy through varying the experimental conditions. The proposed model for the stabilisation of the Schiff base monomers has been evidenced by comparing with the fluorescence spectroscopic changes of two control compounds. The present work reports a step ahead toward proposing a simple host-guest method to extra stabilise the pyrene based excimers that can be biologically utilised.

Interaction of a "nido"-ruthenium terpyridylamine complex with charged elongated micellar scaffolds.

Influence on ionic surfactants by a specially designed terpyridylamine ligand and the ruthenium(II) complex formed with it has been studied in aqueous solution. The ligand coordinates to Ru(2+) into an octahedral geometry in such a way that the final form takes a "nido" or nest-like structure. The substitution on the pyridinyl moiety is kept at the ortho position to acquire the specified geometry. Similar complexes have been reported to have anti-tumor properties and thus the ruthenium complexes can effectively replace platinum complexes that serve the same purpose but with certain drawbacks. The "nido" geometry was chosen to minimize the cytotoxicity that creeps in when para substituents of the pyridinyl moiety are used. The latter variety forms a dendridic scaffold. In presence of both the ligand and the complex, ionic surfactants form elongated aggregates. The surface charge of those aggregates decides the nature of interaction of the ligand and the complex formed therefore. Interaction with anionic surfactant scaffold is found to be stronger than the cationic one.

Organoiridium complexes: efficient catalysts for the formation of sugar acetals and ketals.

[Cp(∗)IrCl(2)](2) is used as an efficient promoter for the synthesis of sugar acetals and ketals with good to excellent yields. The catalyst is found to be general for a wide range of sugars.

Bis{µ-(E)-methyl 4-[(2-carbamothio-ylhydrazinyl-idene)meth-yl]benzoate-κS:S}bis-[iodido(triphenyl-phosphane-κP)copper(I)].

The title complex, [Cu(2)I(2)(C(10)H(11)N(3)O(2)S)(2)(C(18)H(15)P)(2)], is a centrosymmetric sulfur-bridged dimer of Cu(I) with PPh(3) and iodine. The Cu(I) atom shows a distorted tetra-hedral geometry, with bite angles ranging from 98.61 (2) to 120.16 (3)°. The intra-molecular Cu⋯Cu distance is 2.8228 (12) Å. The thio-semicarbazone ligand is coordinated only through the S atom. In the crystal, the complex mol-ecules are linked via inter-molecular N-H⋯O hydrogen bonds, resulting in a hydrogen-bonded chain along the b axis.

Methyl 4-(1H-benzimidazol-2-yl)benzoate trihydrate.

The title compound, C(15)H(12)N(2)O(2)·3H(2)O, has been prepared from the reaction of a Schiff base of benzene-1,2-diamine and iron perchlorate at room temperature. The dihedral angle between the benzimidazole ring and the 4-substituted benzene ring is 0.47 (3)°. Hydrogen bonding involving water mol-ecules, imidazole N, imidazole imine H and ester O atoms stabilizes the crystal structure.