How Does a Junior Faculty Development Program Affect Burnout? A Mixed Methods Assessment.

OBJECTIVES: Burnout is common among junior faculty. Professional development has been proposed as a method to improve engagement and reduce burnout among academic physicians. The Penn State College of Medicine Junior Faculty Development Program (JFDP) is a well-established, interdisciplinary program. However, an increase in burnout was noted among participants during the program. The authors sought to quantify the change in burnout seen among JFDP participants across 3 cohorts, and to explore sources of well-being and burnout among participants. METHODS: Through a sequential explanatory mixed methods approach, participants in the 2018/19, 2019/20, and 2020/21 cohorts took a survey assessing burnout (Copenhagen Burnout Inventory), quality of life (QoL), job satisfaction, and work-home conflict at the start and end of the course. Descriptive statistics were generated as well as Pearson χ2 test/Fisher exact test for categorical variables and Wilcoxon rank sum tests for continuous variables for group comparisons. To better understand the outcome, past participants were invited to interviews regarding their experience of burnout during the course. Inductive thematic analysis (kappa = 0.86) was used to derive themes. RESULTS: Start- and end-of-course surveys were completed by 84 and 75 participants, respectively (response rates: 95.5% and 85.2%). Burnout associated with patient/learner/client/colleague increased (P = .005) and QoL decreased (P = .02) at the end compared with the start. Nonsignificant trends toward worsening in other burnout categories, work-home conflict, and job satisfaction were also observed. Nineteen interviews yielded themes related to risks and protective factors for burnout including competing demands, benefits of networking, professional growth, and challenges related to diverse faculty roles. CONCLUSION: Junior Faculty Development Program participants demonstrated worsening of burnout and QoL during the program while benefiting from opportunities including skill building and networking. The impact of Junior Faculty Development Programs on the well-being of participants should be considered as an element of their design, evaluation, and refinement over time.

Placental pathology reports: A qualitative study in a US university hospital setting on perceived clinical utility and areas for improvement.

OBJECTIVE: To explore how placental pathology is currently used by clinicians and what placental information would be most useful in the immediate hours after delivery. STUDY DESIGN: We used a qualitative study design to conduct in-depth, semi-structured interviews with obstetric and neonatal clinicians who provide delivery or postpartum care at an academic medical center in the US (n = 19). Interviews were transcribed and analyzed using descriptive content analysis. RESULTS: Clinicians valued placental pathology information yet cited multiple barriers that prevent the consistent use of pathology. Four main themes were identified. First, the placenta is sent to pathology for consistent reasons, however, the pathology report is accessed by clinicians inconsistently due to key barriers: difficult to find in the electronic medical record, understand, and get quickly. Second, clinicians value placental pathology for explanatory capability as well as for contributions to current and future care, particularly when there is fetal growth restriction, stillbirth, or antibiotic use. Third, a rapid placental exam (specifically including placental weight, infection, infarction, and overall assessment) would be helpful in providing clinical care. Fourth, placental pathology reports that connect clinically relevant findings (similar to radiology) and that are written with plain, standardized language and that non-pathologists can more readily understand are preferred. CONCLUSION: Placental pathology is important to clinicians that care for mothers and newborns (particularly those that are critically ill) after birth, yet many problems stand in the way of its usefulness. Hospital administrators, perinatal pathologists, and clinicians should work together to improve access to and contents of reports. Support for new methods to provide quick placenta information is warranted.

The Opaque Language of Sexuality: Medical Students' and Providers' Beliefs About Virginity.

Although virginity is not a medical term and is instead socially constructed, it remains unknown what medical providers believe about the biological basis of virginity. This study explored providers' and medical students' beliefs about virginity and the potential impact of such beliefs on healthcare. This was a concurrent mixed-method survey study of 124 medical students and 216 healthcare providers (Registered Nurse, Physician Assistant, Nurse Practitioner, and Doctor of Medicine) at Penn State Health and The Pennsylvania State University College of Medicine. Participants rated their level of agreement with common misconceptions about virginity on a six-point Likert scale. Open-ended questions gave respondents the opportunity to define virginity and to describe terms like virgin and virginal in the context of sexual experience and the medical lexicon. We identified common themes in the qualitative data using thematic analysis. Frequencies of misconceptions and statistically significant demographic associations were identified in the quantitative data. Definitions of virginity were varied and vague, most with negative connotations. A majority of respondents said that virginity has no biological basis. Many participants identified downsides to use of terms like virgin, virginity, and virginal in medicine. The most prevalent misconceptions about virginity were related to the hymen. Seventeen percent of students and 26% of providers at least somewhat agreed that it was possible to determine whether a person has engaged in vaginal intercourse through a gynecological exam. Misconceptions about virginity persist in medicine and bias, even if unintended, may impact the quality-of-care people with vaginas receive. Language around sexual health should be specific, inclusive, clinically relevant, and free from judgment. Medical education must continue to work to eliminate the concept of a biological basis to virginity.

'Didn't See the Need': Misperceptions about glucagon from the perspectives of people with diabetes and their caregivers.

AIMS: Severe hypoglycaemia among people with diabetes who use insulin can be a life-threatening complication if left untreated. Although glucagon has been approved for treatment of hypoglycaemia since the 1960s, it has been underutilized. We aimed to understand the perceptions of people with diabetes and their caregivers about glucagon. METHODS: We conducted in-depth, one-on-one telephone interviews with people with diabetes and their caregivers in the United States. The interviews included questions around general awareness of glucagon, reasons for owning or not owning glucagon, and suggestions for improving understanding of glucagon as treatment for severe hypoglycaemia. Initial synopsis and inductive codebook schema were used to analyse the responses by two independent researchers. Themes were developed from the codes, and codes were re-mapped back to the themes. RESULTS: There were 60 dyads of people with diabetes and their caregivers (N = 120). Four themes developed from the interviews: (1) for most participants, the stated reasons for not owning or renewing a prescription for glucagon included unawareness of the medication, its advantages and its value; (2) misperceptions about glucagon occurred frequently; (3) caregivers often lacked confidence in administering reconstituted injectable glucagon; and (4) education and training from healthcare providers about glucagon would be welcomed. CONCLUSIONS: This study emphasizes the need for healthcare providers to discuss hypoglycaemia prevention and events at each clinical visit, including the use of glucagon in the case of severe hypoglycaemia. Healthcare providers are encouraged to assess the knowledge of people with diabetes and their caregivers regarding treatment and prevention of hypoglycaemia.

Factors Driving Resistance to Clinical Decision Support: Finding Inspiration in Radiology 3.0.

PURPOSE: The effectiveness of evidence-based guidelines (EBGs) and clinical decision support (CDS) is significantly hampered by widespread clinician resistance to it. Our study was designed to better understand the reasons for this resistance to CDS and explore the factors that drive it. METHODS: We used a mixed-methods approach to explore and identify the drivers of resistance for CDS among clinicians, including a web-based multispecialty survey exploring clinicians' impressions of the strengths and weaknesses of CDS, two clinician focus groups, and several one-on-one focused clinician interviews in which individual participants were asked to comment on their rationale for choosing imaging utilization that might not be supported by EBGs. Additionally, a unique electronic learning and assessment module known as Amplifire was used to probe clinician knowledge gaps regarding EBGs and CDS. RESULTS: In both the quantitative and qualitative portions of the study, the primary factor driving resistance to CDS was a desire to order studies not supported by EBGs, primarily for the purpose of reducing the clinician's diagnostic uncertainty. CONCLUSIONS: Our results suggest that to enhance the effectiveness of CDS, we must first address the issue of clinician discomfort with diagnostic uncertainty and the role of imaging via educational outreach and ongoing radiologist consultation.

The experience of a severe hypoglycaemic event from the perspective of people with diabetes and their caregivers: "What am I going to do?"

AIMS: Among people with diabetes using insulin, severe hypoglycaemia (SH) can be a life-threatening complication, if untreated. The personal experiences during an SH event from the perspectives of people with diabetes and their caregivers are not well-characterized. This study assessed the perceptions of the event and the decision making processes of people with diabetes (T1D n = 36; T2D n = 24) and their caregivers during SH events. METHODS: In-depth one-on-one telephone interviews were conducted with dyads of people with diabetes and caregivers in the United States (n = 120). An initial synopsis and inductive codebook schema were used to analyse the data with two independent coders (kappa = 0.87-0.89). Themes were developed from the codes, and codes were re-mapped to the themes. RESULTS: Four themes were formed: (1) Caregivers scramble to do the right thing and support people with diabetes in treating SH; (2) Decision making capacity is impaired during an SH event, often a panicked time; (3) People learn to manage SH events through their own experiences and frequently make lifestyle changes to prevent and treat future events; and (4) Discussion with healthcare providers about SH, and particularly SH treatment, is limited. CONCLUSIONS: SH events are stressful and often evoke emotional reactions that can impair decision making. Thus, advance treatment planning of SH events needs to occur. Much of the knowledge about SH treatment derives from prior experience rather than healthcare provider guidance, suggesting a need for healthcare providers to initiate proactive discussions about SH treatment.

Examining medication adherence and preferences for a lifestyle intervention among Black and Latinx adults with hypertension: a feasibility study.

BACKGROUND: Approximately 116.4 million adults in the USA have hypertension, and the rates of uncontrolled hypertension remain higher among racial and ethnic minorities. There is a need for effective interventions that promote healthy behaviors and long-term behavioral change in the management of hypertension. The primary objective of this study was to determine the feasibility of developing a lifestyle intervention that would assess hypertension management and the use of technology among Blacks and Latinx with hypertension. The secondary objective is to explore perceptions of community-based resources for hypertension and preferences for a lifestyle intervention for hypertension among Blacks and Latinx with hypertension. METHODS: In this explanatory mixed-methods study, quantitative data were collected using surveys, participants reported their use of technology and adherence to antihypertensive medication. Participants were Black and Latinx adults with hypertension living in Central Pennsylvania, USA. Qualitative data were obtained from semi-structured interviews and focus groups, and participants were asked about managing hypertension, local resources, and preferences for a behavioral intervention. Data were examined using summary statistics for quantitative data and thematic analysis for qualitative data. RESULTS: Black and Latinx participants (n=30) completed surveys for the quantitative study. The majority (75%) of participants self-reported being confident in managing their medication without help and remembering to take their medication as prescribed. Fewer participants (54.2%) reported using technology to help manage medication. There were 12 participants in the qualitative phase of the study. The qualitative findings indicated that participants felt confident in their ability to manage hypertension and were interested in participating in a lifestyle intervention or program based online. Some participants reported a lack of resources in their community, while others highlighted local and national resources that were helpful in managing high blood pressure. CONCLUSION: This study provides important insights on barriers and facilitators for managing hypertension, current use of technology and interest in using technology to manage hypertension, and preferences for future lifestyle interventions among racial and ethnic minorities. This study also provides insights to the health needs and resources available in this community and how future behavioral interventions could be tailored to meet the needs of this community. The findings of this study will be used to inform the tailoring of future lifestyle interventions; specifically, we will include text messaging reminders for medication and to disseminate educational materials related to hypertension and provide resources to connect study participants with local and national resources.

Working to Increase Stability through Exercise (WISE): screening, recruitment, and baseline characteristics.

BACKGROUND: The aim of this paper is to describe the utility of various recruitment modalities utilized in the Working to Increase Stability through Exercise (WISE) study. WISE is a pragmatic randomized trial that is testing the impact of a 3-year, multicomponent (strength, balance, aerobic) physical activity program led by trained volunteers or delivered via DVD on the rate of serious fall-related injuries among adults 65 and older with a past history of fragility fractures (e.g., vertebral, fall-related). The modified goal was to recruit 1130 participants over 2 years in three regions of Pennsylvania. METHODS: The at-risk population was identified primarily using letters mailed to patients of three health systems and those over 65 in each region, as well as using provider alerts in the health record, proactive recruitment phone calls, radio advertisements, and presentations at community meetings. RESULTS: Over 24 months of recruitment, 209,301 recruitment letters were mailed, resulting in 6818 telephone interviews. The two most productive recruitment methods were letters (72% of randomized participants) and the research registries at the University of Pittsburgh (11%). An average of 211 letters were required to be mailed for each participant enrolled. Of those interviewed, 2854 were ineligible, 2,825 declined to enroll and 1139 were enrolled and randomized. Most participants were female (84.4%), under age 75 (64.2%), and 50% took an osteoporosis medication. Not having a prior fragility fracture was the most common reason for not being eligible (87.5%). The most common reason provided for declining enrollment was not feeling healthy enough to participate (12.6%). CONCLUSIONS: The WISE study achieved its overall recruitment goal. Bulk mailing was the most productive method for recruiting community-dwelling older adults at risk of serious fall-related injury into this long-term physical activity intervention trial, and electronic registries are important sources and should be considered.

In Their Own Words: Resources Needed by School Nurses to Facilitate Student Immunization Compliance.

BACKGROUND: All 50 states have school-entry immunization requirements, and many also allow exemptions based on medical and non-medical reasons. School nurses are responsible for managing student immunization compliance based on state policies, but lack standardized resources and guidance. METHODS: Pennsylvania school nurses (N = 21) participated in semi-structured interviews regarding their strategies for communication and management of student immunization information, along with resources needed for practice improvement. Data were analyzed using descriptive content analysis. RESULTS: Nurses reported similarities in timelines used for communication of immunization requirements, but differences in mechanisms used to secure and manage immunization records. Nurses reported a need for clarity regarding exclusions and exemption policy implementation and requested standardized resources and guidance for navigating immunization compliance. CONCLUSIONS: A need exists for standardized processes that support immunization compliance. Furthermore, nurses highlighted a need for additional training and enhanced networks to develop creative strategies for promoting immunization uptake among families.

New insights into diabetes burnout and its distinction from diabetes distress and depressive symptoms: A qualitative study.

AIMS: This study aimed to corroborate the main hypotetized dimensions of diabetes burnout, and its distinction from diabetes distress and depressive symptoms among adults with type 1 diabetes (T1D). METHODS: A qualitative descriptive study was employed to collect data from 31 eligible participants using semi-structured individual phone interviews. Participants were recruited through purposive sampling among a larger sample of adults with T1D in a previous study. Data was analyzed using qualitative content analysis including immersion, reduction, and interpretation. RESULTS: Exhaustion and detachment were frequent manifestations of diabetes burnout that often accompanied by instances during which participants experienced a loss of control over diabetes. Whereas individuals' support systems could either help or hinder diabetes burnout. Participants saw burnout as separate but closely related to distress and depressive symptoms, with some suggesting correlations among burnout, distress, and depressive symptoms, while others expressed that distress caused their burnout and depressive symptoms. CONCLUSIONS: Diabetes burnout reflects a significant yet unexplored concept which might explain the complexities of suboptimal self-management and poor diabetes outcomes. Emerging evidence suggesting diabetes burnout as a distinct concept calls for more studies to mitigate diabetes burnout as an obstacle to optimal diabetes care.

"Not Today, Diabetes": Using Blog Analysis to Understand Emotional Interactions and Support Among People With Type 1 Diabetes.

The goal of this study is to understand how internet blogs are used by people with type 1 diabetes (T1D) to provide or exchange social support. A stratified, clustered proportionate probability sample of entries from 10 Internet blogs focusing on T1D was obtained. A random sample of 100 days generated 200 blogger posts and 1,606 commenter responses. Entries were coded using qualitative analysis software and analyzed thematically. Blogs were used as a dynamic, interactional form of emotional support from others who understood diabetes from personal experience; and as a source of sharing lived user experience of having diabetes, more often than as a way of communicating medical knowledge or facts about diabetes. Blog participation contributed to a sense of belonging for participants in the "Diabetes Online Community" where there was a shared culture. In conclusion, blogs provide unobtrusive access to the experiences of people with T1D that are driven by their interests rather than those of qualitative research interviewers or healthcare providers. In addition to permitting analysis of the way that participants use blogs to address their own personal wants and needs, blog data can serve as an inexpensive and unobtrusive method for studying topics of interests to researchers and healthcare providers.

Social Experiences of Adults Using Online Support Forums to Lose Weight: A Qualitative Content Analysis.

Studies have shown social support can promote weight loss, specifically when support is received online through forums on weight loss websites. The goal of this study was to explore the experiences of individuals using support forums on weight loss websites. We conducted a content analysis on web-administered survey responses from members of two weight loss websites (N = 340). The findings revealed three major themes: (1) receiving advice, strategies, and mantras are helpful with weight loss; (2) support forums provide a nonjudgmental environment for losing weight; and (3) receiving social support and inspiration from someone similar is helpful with weight loss. These findings suggest online support forums can benefit individuals attempting to lose weight by offering a place to receive nonjudgmental social support from other similar users.

Glycated Hemoglobin Differences Among Blog-Reading Adults With Type 1 Diabetes Compared With Those Who Do Not Read Blogs: Cross-Sectional Study.

BACKGROUND: Of the estimated 23.1 million individuals diagnosed with diabetes, approximately 5% have type 1 diabetes (T1D). It has been proposed that this number will triple by 2050. With increases in technology use and resources available, many individuals are using insulin pumps and continuous glucose monitors (CGMs) to help manage their T1D. They are also using online resources such as social media to find more information and advice based on real-life experiences from peers. Blogs are a particular social media modality often used by people with T1D but have not been widely investigated. OBJECTIVE: The purpose of this study was to assess glycated hemoglobin (HbA1c) differences between blog readers and blog nonusers in a population of adults with T1D. This study also looked at differences in technology use in these two groups, as well as HbA1c differences in blog use and technology subgroups. METHODS: Participants were recruited both by mail and by online T1D-themed blog postings. Respondents completed a secure online eligibility assessment and were asked questions related to their T1D, blog and internet use, and insulin pump and CGM use. Demographics were also collected. Differences between blog readers and blog nonusers were tested via chi-square and t tests. Mann-Whitney U tests, Fisher exact tests, and analyses of variance (ANOVA) were used to test for differences in self-reported HbA1c between groups and subgroups. RESULTS: A total of 282 eligible participants completed the survey (214 blog readers, 68 blog nonusers). Average duration of diabetes was 21.2 years, 77.7% (219/282) were female, 81.2% (229/282) used an insulin pump, 66.3% (187/282) used a CGM, and 95.7% (270/282) were white. HbA1c was lower for blog readers (7.0%) than blog nonusers (7.5%), P=.006; for insulin pump users (7.0%) than multiple daily injections (7.7%), P=.001; and for CGM users (7.0%) than CGM nonusers (7.5%), P=.001. After adjusting for significant covariates, the association between blog use and HbA1c remained significant (P=.04). ANOVA modeling also demonstrated significant differences in HbA1c between blog users and nonusers among subgroups by pump use and CGM use (P<.001). CONCLUSIONS: These results suggest that reading blogs is associated with lower HbA1c values. While association does not prove causation, blog readers have the benefit of learning information from peers and having 24/7 access to a community of individuals with similar daily life struggles, where they are able to ask questions and seek advice.

Working to Increase Stability through Exercise (WISE): Study protocol for a pragmatic randomized controlled trial of a coached exercise program to reduce serious fall-related injuries.

Approximately one-third of older adults fall each year and fall-related injuries are a leading cause of death and disability among this rapidly expanding age group. Despite the availability of bisphosphonates to reduce fractures, concerns over side effects have dramatically reduced use, suggesting that other treatment options are needed. Though many smaller studies have shown that physical activity programs can reduce falls, no study has been adequately powered to detect a reduction in fall-related injuries. We present the design of a three-year randomized controlled clinical trial of 1130 adults age 65 and older with a past history of fragility fractures (e.g., vertebral, fall-related). The main aim is to determine the impact of a community-based multicomponent (strength, balance, aerobic) physical activity program led by trained volunteers (or delivered via DVD) and accompanied by coaching and oversight, by telephone and in-person, by a fitness professional. The main outcome measure is serious fall-related injuries. Secondary outcomes include health care utilization, bone and muscle mass, loneliness, health-related quality of life and mood. The study represents the first large clinical trial of a comprehensive physical activity program to reduce secondary injuries among patients with a history of fragility fracture.

US ethnic group differences in self-management in the 2nd diabetes attitudes, wishes and needs (DAWN2) study.

AIMS: Understanding the relationship between ethnicity and self-management is important due to disparities in healthcare access, utilization, and outcomes among adults with type 2 diabetes from different ethnic groups in the US. METHODS: Self-reports of self-management and interest in improving self-management from US people with diabetes (PWD) in the 2nd Diabetes Attitudes, Wishes and Needs (DAWN2) study, a multinational, multi-stakeholder survey, were analyzed, including 447 non-Hispanic White, 241 African American, 194 Hispanic American, and 173 Chinese American PWD (>18 years). RESULTS: Overall, self-management behavior was highest for medication taking and lowest for physical activity. Non-Hispanic Whites had lowest physical activity and highest adherence to insulin therapy. Chinese Americans had lowest foot care and highest healthy eating. Overall, interest was highest for improving healthy eating and physical activity. Chinese Americans and Hispanic Americans were more interested than non-Hispanic Whites in improving most self-management behaviors. Chinese Americans were more interested than African Americans in improving most self-management behaviors. Healthcare providers telling PWD that their A1c needs improvement was associated with lower self-rated glucose control, which was associated with higher PWD interest in improving self-management behaviors. CONCLUSIONS: Diabetes care providers should use patient-centered approaches and consider ethnicity in tailoring self-management support.

Opportunities and challenges in screening for childhood sexual abuse.

Retrospective studies suggest 1 in 4 girls and 1 in 6 boys will experience sexual abuse before 18 years of age, resulting in future morbidity. Successful interventions exist, however, victims are reluctant to disclose. Screening for childhood sexual abuse (CSA) may provide an opportunity to overcome this barrier, yet no current model for universal CSA screening exists. We sought to understand the perspective of key stakeholders on CSA screening through qualitative research. Eight focus groups of 7-10 participants each (n=62) were conducted from April-September 2016. Stakeholders included school nurses, school teachers, counselors and administrators, pediatric providers, and parents. The interview guide focused on reporting suspected CSA and impressions of a CSA screening tool. Sessions were audiotaped and transcribed. Researchers used qualitative content analysis to develop conceptual categories that related to CSA screening and reporting. Two research team members independently open-coded 20% of the data for interrater reliability (kappa=0.98) prior to completing the coding process. Three major categories emerged to inform CSA screening. First, early screening (e.g. kindergarten) was preferred. Confidentiality was a concern, specifically privacy in the school-setting. As CSA perpetrators are often known to the child, parental presence in the medical office was also a concern. Finally, refinement of the screening process was discussed starting with routine education on safe touch and defining "normal." Rather than direct questioning, consistent and repeated offering of opportunities to disclose CSA and identification of a trusted adult were suggested. Next steps should involve partnering with evidence-based CSA prevention programs to incorporate and evaluate the aforementioned elements.

Exploring challenges in the patient's discharge process from the internal medicine service: A qualitative study of patients' and providers' perceptions.

In hospital-based medicine units, patients have a wide range of complex medical conditions, requiring timely and accurate communication between multiple interprofessional providers at the time of discharge. Limited work has investigated the challenges in interprofessional collaboration and communication during the patient discharge process. In this study, authors qualitatively assessed the experiences of internal medicine providers and patients about roles, challenges, and potential solutions in the discharge process, with a phenomenological focus on the process of collaboration. Authors conducted interviews with 87 providers and patients-41 providers in eight focus-groups, 39 providers in individual interviews, and seven individual patient interviews. Provider roles included physicians, nurses, therapists, pharmacists, care coordinators, and social workers. Interviews were audio-recorded and transcribed verbatim, followed by iterative review of transcripts using qualitative coding and content analysis. Participants identified several barriers related to interprofessional collaboration during the discharge process, including systems insufficiencies (e.g., medication reconciliation process, staffing challenges); lack of understanding others' roles (e.g., unclear which provider should be completing the discharge summary); information-communication breakdowns (e.g., inaccurate information communicated to the primary medical team); patient issues (e.g., patient preferences misaligned with recommendations); and poor collaboration processes (e.g., lack of structured interprofessional rounds). These results provide context for targeting improvement in interprofessional collaboration in medicine units during patient discharges. Implementing changes in care delivery processes may increase potential for accurate and timely coordination, thereby improving the quality of care transitions.

Impact of online patient reminders to improve asthma care: A randomized controlled trial.

IMPORTANCE: Asthma is one of the most burdensome chronic illnesses in the US. Despite widespread dissemination of evidence-based guidelines, more than half of the adults with asthma have uncontrolled symptoms. OBJECTIVE: To examine the efficacy of an online tool designed to improve asthma control. DESIGN: 12-month single blind randomized controlled trial of the online tool (Intervention condition, IC) versus an active control tool (CC). SETTING: Patients enrolled in an insurance plan. PARTICIPANTS: Participants were 408 adults (21-60 years of age) with persistent asthma. INTERVENTION: At least once each month and before provider visits, participants in the IC answered questions online about their asthma symptoms, asthma medications and asthma care received from providers, such as an asthma management plan. The tool then provided tailored feedback to remind patients 1) to ask health care providers specific questions that may improve asthma control (e.g., additional controller medications) and 2) to consistently perform specific self-care behaviors (e.g., proper inhaler technique). Participants in the CC received similar questions and feedback, yet focused instead on preventive services unrelated to asthma control (e.g., cancer screening). MAIN OUTCOME MEASURES: The main outcome measure was asthma control, as assessed by the 5-question Asthma Control Test (ACT). Secondary outcomes included quality of life, medication use and healthcare utilization (e.g., emergency department visits). RESULTS: After 12 months, 323 participants completed follow-up measures (79.2%). Participants in the IC reported a greater mean improvement in the ACT score than participants in the CC (2.3 vs. 1.2; p = 0.02) and 9 of 11 individual asthma control survey items showed non-significant improvements favoring the IC. No differences were observed in medication adherence, number of asthma controller medications or health care utilization. CONCLUSION AND RELEVANCE: Simple and brief online patient reminders improved asthma control among insured patients. Although future studies are needed to understand the mechanism of the improvement, the magnitude of the effect on asthma control was similar to the addition of an additional controller medication. Given the widespread use of the Internet, simple tools such as this may be useful for improving the control of other chronic diseases as well. TRIAL REGISTRATION: This study is registered at clinicaltrials.gov, NCT00921401, "Improving the Quality of Asthma Care Using the Internet".

A Novel Approach to Identifying Barriers and Facilitators in Raising a Child With Type 1 Diabetes: Qualitative Analysis of Caregiver Blogs.

BACKGROUND: With rising incidence of type 1 diabetes (T1D) diagnoses among children and the high levels of distress experienced by the caregivers of these children, caregiver support is becoming increasingly important. Historically, relatively few support resources have existed. Increasing use of the Internet, and blogs in particular, has seen a growth of peer support between caregivers of children with T1D. However, little is known about the type and quality of information shared on T1D caregiver blogs. At the same time, the information on such blogs offers a new window into what challenges and successes caregivers experience in helping to manage their children's T1D. OBJECTIVE: The purpose of this study was to (1) analyze blogs of caregivers to children with T1D to better understand the challenges and successes they face in raising a child with T1D, and (2) assess the blogs for the presence of unsafe or inaccurate clinical information or advice. METHODS: An inductive thematic qualitative study was conducted of three blogs authored by caregivers of children living with T1D, which included 140 unique blog posts and 663 associated comments. Two physician investigators evaluated the blogs for presence of clinical or medical misinformation. RESULTS: Five major themes emerged: (1) the impact of the child's diagnosis, (2) the burden of intense self-management experienced in caring for a child with T1D, (3) caregivers' use of technology to ease their fear of hypoglycemia and impacts that device alarms associated with this technology have on caregiver burden, (4) caregivers' perceptions of frequently missed or delayed diagnosis of T1D and the frustration this causes, and (5) the resilience that caregivers develop despite the burdens they experience. Misinformation was exceedingly rare and benign when it did occur. CONCLUSIONS: Blog analysis represents a novel approach to understand the T1D caregiver's experience. This qualitative study found many challenges that caregivers face in raising a child with T1D. Despite the many barriers caregivers face in managing their children's T1D, they find support through advocacy efforts and peer-to-peer blogging. Blogs provide a unique avenue for support, with only rare and benign findings of medical misinformation, and may be a resource that diabetes care providers can consider offering to families for support.