Ensuring fidelity: key elements to consider in disseminating a diabetes telemanagement program for underserved Hispanic/Latinos living with type 2 diabetes.

Background: The Hispanic/Latino population has greater risk (estimated >50%) of developing type 2 diabetes (T2D) and developing it at a younger age. The American Diabetes Association estimates costs of diagnosed diabetes in 2017 was $327 billion; with medical costs 2.3x higher than patients without diabetes. The purpose of this manuscript is to describe the methodology utilized in a randomized controlled trial aimed at evaluating the efficacy of a diabetes telemanagement (DTM) program for Hispanic/Latino patients with T2D. The intent is to provide information for future investigators to ensure that this study can be accurately replicated. Methods: This study was a randomized controlled trial with 240 participants. Eligible patients (Hispanic/Latino, aged 18+, living with T2D) were randomized to Comprehensive Outpatient Management (COM) or DTM. DTM was comprised of usual care, including routine clinic visits every three months, as well as: Biometrics (a tablet, blood glucose meter, blood pressure monitor, and scale); Weekly Video Visits (facilitated in the patient's preferred language); and Educational Videos (including culturally congruent diabetes self-management education and quizzes). COM consisted of usual care including routine clinic visits every three months. For this study, COM patients received a glucometer, glucose test strips, and lancets. Establishing a therapeutic nurse-patient relationship was a fundamental component of our study for both groups. First contact (post-enrollment) centered on ensuring that patients and caregivers understood the program, building trust and rapport, creating a non-judgmental environment, determining language preference, and establishing scheduling availability (including evenings and weekends). DTM were provided with a tablet which allowed for self-paced education through videos and weekly video visits. The research team and Community Advisory Board identified appropriate educational video content, which was incorporated in diabetes educational topics. Video visits allowed us to assess patient involvement, motivation, and nonverbal communication. Communicating in Spanish, and awareness of diverse Hispanic/Latino backgrounds was critical, as using relevant and commonly-used terms can increase adherence and improve outcomes. Shared decision-making was encouraged to make realistic health care choices. Conclusion: Key elements discussed above provide a framework for future dissemination of an evidence-based DTM intervention to meet the needs of underserved Hispanic/Latino people living with T2D.

Intersectionality and Its Impact on Microaggression in Female Physicians in Academic Medicine: A Cross-Sectional Study.

Introduction: The burden of microaggressions in the workplace is an ongoing stressor for female physicians in academic medicine. For female physicians of Color or of the Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual community, this burden is even heavier due to the concept of intersectionality. The goal of this study is to assess frequency of microaggressions experienced by participants. In addition, to explore the associations between microaggression and individual outcomes, patient care practices and attitudes, and perception of pay/promotion equity. Methods: This was a cross-sectional analysis of female residents, fellows and attendings conducted from December 2020-January 2021 at Northwell Health across all specialties. One hundred seventeen participants replied to the study in REDCap. They completed questionnaires related to the topics of imposter phenomenon, microaggressions, gender identity salience, patient safety, patient care, counterproductive work behavior and pay and promotion equity. Results: A majority of the respondents were white (49.6%) and 15+ years out of medical school (43.6%). Around 84.6% of female physicians endorsed experiencing microaggressions. There were positive associations between microaggressions and imposter phenomenon as well as microaggressions and counterproductive work behavior. There was a negative association between microaggressions and pay equity or promotion. The small sample size did not allow for us to examine differences by race. Discussion: Although the number of female physicians continues to rise due to an uptick in female medical school enrollees, female physicians still must deal with the burden of microaggressions in the workplace. Conclusions: As a result, academic medical institutions must seek to create more supportive workplace for female physicians.

COVID-19 stressors for Hispanic/Latino patients living with type 2 diabetes: a qualitative study.

Background and aim: During the early stages of the COVID-19 pandemic, nationwide lockdowns caused disruption in the diets, physical activities, and lifestyles of patients with type 2 diabetes. Previous reports on the possible association between race/ethnicity, COVID-19, and mortality have shown that Hispanic/Latino patients with type 2 diabetes who are socioeconomically disadvantaged are disproportionately affected by this novel virus. The aim of this study was to explore stressors associated with changes in diabetes self-management behaviors. Our goal was to highlight the health disparities in these vulnerable racial/ethnic minority communities and underscore the need for effective interventions. Methods and participants: Participants were enrolled in part of a larger randomized controlled trial to compare diabetes telehealth management (DTM) with comprehensive outpatient management (COM) in terms of critical patient-centered outcomes among Hispanic/Latino patients with type 2 diabetes. We conducted a thematic analysis using patient notes collected from two research nurses between March 2020 and March 2021. Two authors read through the transcripts independently to identify overarching themes. Once the themes had been identified, both authors convened to compare themes and ensure that similar themes were identified within the transcripts. Any discrepancies were discussed by the larger study team until a consensus was reached. Results: Six themes emerged, each of which can be categorized as either a source or an outcome of stress. Sources of stress associated with the COVID-19 pandemic were (1) fear of contracting COVID-19, (2) disruptions from lockdowns, and (3) financial stressors (e.g., loss of income). Outcomes of COVID-19 stressors were (1) reduced diabetes management (e.g., reduced diabetes monitoring and physical activity), (2) suboptimal mental health outcomes (e.g., anxiety and depression), and (3) outcomes of financial stressors. Conclusion: The findings indicated that underserved Hispanic/Latino patients with type 2 diabetes encountered a number of stressors that led to the deterioration of diabetes self-management behaviors during the pandemic.

Black Physicians' Experiences with Anti-Black Racism in Healthcare Systems Explored Through An Attraction-Selection-Attrition Lens.

Anti-Black racism is a specific form of racism directed at Black people. In healthcare, there are poignant examples of anti-Black racism in the recruitment, selection, and retention stages of the job cycle. Research shows that anti-Black racism is associated with inequitable work outcomes and the under-representation of Black physicians. However, empirical findings are scattered with no organizing framework to consolidate these findings. To add to the literature, in this paper we present the attraction-selection-attrition (ASA) model (Schneider, 1987) as an organizing framework to discuss Black physicians' experiences with anti-Black racism and discrimination throughout their careers. We draw from previous literature to highlight specific experiences of Black physicians at each stage of the job cycle (i.e., attraction, selection, retention), and we offer considerations on how practitioners can mitigate anti-Black racism throughout the job cycle. In the wake of COVID-19 and highly publicized social justice movements, healthcare systems are seeking ways to increase the recruitment, selection, and retention of Black physicians to ensure health equity. We believe this guide will be valuable to practitioners, leaders, researchers, and program directions seeking to advance diversity, equity, and inclusion of Black physicians in their healthcare systems. We conclude by providing practical implications and directions for future research.

Who Am I and Where Do I Belong? The Impact of Heritage Cultural Identity Salience on Immigrant Workers Acculturation Strategies.

There has been growing interest among organizational researchers in the relationship between acculturation strategies and organizational outcomes of immigrant employees. However, what is noticeably missing from the literature on acculturation strategies is how cultural values such as heritage cultural identity salience affect an immigrant employee's acculturation strategy and subsequent work attitude and behaviors. Drawing on Berry's (1997) acculturation strategy and framework, we examined heritage cultural identity salience, harmony enhancement, integration and marginalization acculturation strategy, turnover intention, and affective commitment among immigrant employees in the USA. In this time-lagged study, we found that heritage cultural identity salience was negatively related to marginalization and positively related to integration. Harmony enhancement significantly buffered the relationship between heritage cultural identity salience and marginalization and integration, respectively. Heritage cultural identity salience had significant indirect effects on affective commitment via marginalization and both affective commitment and turnover intention via integration. Lastly, results from the moderated mediated analysis showed that the indirect effect of heritage identity salience on affective commitment and turnover intention via integration was significantly different at varying levels of harmony enhancement. Our study affirms existing research on acculturation strategy and extends the literature by introducing harmony enhancement as a moderator. The use of Berry's (1997) framework and the results of this study provide useful insights into the inclusion and retention of immigrant employees in the US workforce. Practical implications, as well as theoretical contributions, are discussed.

Physician challenges and supports during the first wave of the COVID-19 pandemic: A mixed methods study.

Introduction: During the COVID-19 pandemic, physicians encountered significant COVID-19-related negative experiences and psychological distress in both their personal and professional lives. To understand the factors that negatively impact physician well-being, a number of studies have pointed to multiple work system factors such as excessive workload and workflow interruptions. In addition, studies have shown that positive interpersonal relationships that provide social support may also serve as a buffering role against psychological distress. The aim of our study explores the challenges and sources of support for physicians relative to mental health symptoms. Methods: In this study, We used a cross-sectional study design with a convergent parallel mixed method approach combining both qualitative and quantitative data collected in parallel from a self-report questionnaire immediately following the first wave of COVID-19. The aim of our study explores the challenges and sources of support for physicians relative to mental health symptoms. Results: Of the 457 physicians in the study, the most frequently potential negative occupational experiences were, "Being at risk of contracting COVID-19 from patients/co-workers" (90.5%) and "Contact with distressed family members who cannot be with a loved one" (69.5%). We identified five common themes for main sources of social support (e.g. emotional support from family/friends) and six themes for challenges (e.g., work-related demands exacerbated by the pandemic). Discussion: Our study highlights COVID-19 and other pandemic-related challenges that negatively impacted the mental health of physicians. Interventions that provide targeted organizational supports (e.g. sufficient PPE and child support), as well as specific sources of support (e.g. family and emotional), can attenuate those challenges and stressors experienced during a pandemic.

Health care consequences of hospitalization with Clostrioides difficile infection: a propensity score matching study.

BACKGROUND: Clostridiodies difficile infection (CDI) has been characterized by the Center for Disease Control and Prevention (CDC) as an urgent public health threat and a major concern in hospital, outpatient and extended-care facilities worldwide. METHODS: A retrospective cohort study of patients aged ≥ 18 hospitalized with CDI in New York State (NYS) between January 1, 2014-December 31, 2016. Data were extracted from NY Statewide Planning and Research Cooperative (SPARCS) and propensity score matching was performed to achieve comparability of the CDI (exposure) and non-CDI (non-exposure) groups. Of the 3,714,486 hospitalizations, 28,874 incidence CDI cases were successfully matched to 28,874 non-exposures. RESULTS: The matched pairs comparison demonstrated that CDI cases were more likely to be readmitted to the hospital at 30 (28.26% vs. 19.46%), 60 (37.65% vs. 26.02%), 90 (42.93% vs. 30.43) and 120 days (46.47% vs. 33.74), had greater mortality rates at 7 (3.68% vs. 2.0%) and 180 days (20.54% vs. 11.96%), with significant increases in length of stay and total hospital charges (p < .001, respectively). CONCLUSIONS: CDI is associated with a large burden on patients and health care systems, significantly increasing hospital utilization, costs and mortality.

Understanding Mental Health Needs and Gathering Feedback on Transcutaneous Auricular Vagus Nerve Stimulation as a Potential PTSD Treatment among 9/11 Responders Living with PTSD Symptoms 20 Years Later: A Qualitative Approach.

Posttraumatic stress disorder (PTSD) remains one of the most prevalent diagnoses of World Trade Center (WTC) 9/11 responders. Transcutaneous auricular vagus nerve stimulation (taVNS) is a potential treatment for PTSD, as it can downregulate activity in the brain, which is known to be related to stress responses and hyperarousal. To understand barriers and facilitators to engagement in mental health care and the feasibility and acceptability of using the taVNS device as a treatment for PTSD symptoms, a focus group was conducted among patients from the Queens WTC Health Program who had elevated symptoms of PTSD. The focus group discussion was recorded, transcribed, and analyzed. Three themes and subthemes emerged: (1) the continued prevalence of mental health difficulties and systematic challenges to accessing care; (2) positive reception toward the taVNS device as a potential treatment option, including a discussion of how to increase usability; and (3) feedback on increasing the feasibility and acceptance of the research methodology associated with testing the device in a pilot clinical trial. The findings highlight the need for additional treatment options to reduce PTSD symptoms in this population and provide key formative phase input for the pilot clinical trial of taVNS.

Electrocardiogram Monitoring Practices for Hospitalized Adults Receiving Antipsychotics: A Retrospective Cohort Study.

OBJECTIVE: Antipsychotics are frequently used for managing both acute and chronic neuropsychiatric disorders. While antipsychotics are known to be associated with increased mortality due to cardiac arrhythmia, there is a lack of consensus on the timing and frequency of electrocardiogram (ECG) monitoring.  The goal of this study was to examine current ECG monitoring practices for adults receiving antipsychotics, specifically during hospital admission. METHODS: The study involved a multisite retrospective chart review of adults admitted across 8 hospitals between January 2010 and December 2015 who received antipsychotics during hospitalization. The primary outcome was the presence of an ECG after receiving an antipsychotic. RESULTS: During the study period, there were 26,353 hospitalizations during which adults received antipsychotic medication; the average age of the patients was 61.4 years, 50.1% were female, and 64.8% were white. The average comorbidity score was 1.4 with a median length of stay of 8.3 days. Of the 26,353 patients who were hospitalized, 60.6% (n=15,977) of patients in the sample had an ECG during their hospitalization, and 41.2% (n=10,865) had the ECG following antipsychotic administration. Patients who received a follow-up ECG had a longer length of stay (median: 11.3 d) compared with those who did not receive a follow-up ECG (median: 7.0 d). Follow-up ECGs were more likely among patients who had a history of heart failure [odds ratio (OR)=1.17, 95% confidence interval (CI): 1.06-1.30, P=0.002], who were receiving multiple antipsychotics (OR=1.3, 95% CI: 1.24-1.36, P<0.001) or other QT-prolonging medications (OR=1.09, 95% CI: 1.07-1.1, P<0.001), who were receiving risperidone (OR=1.12, 95% CI: 1.004-1.25, P=0.04), and who showed an increase in QTc duration (OR per 10 ms increase=1.02, 95% CI: 1.01-1.04, P=0.003). Follow-up ECGs were less likely to be administered to patients who were receiving antipsychotics before admission (OR=0.93, 95% CI: 0.87-0.997, P=0.04). CONCLUSIONS: This study demonstrated that, in a large health system, ECG monitoring is not routinely practiced for hospitalized patients receiving antipsychotics. Further studies are needed to identify patients who would most benefit from ECG monitoring in the acute care setting.

COVID-19 Conversations Within Black/Brown Minority Communities: A Stakeholder and Psychoeducation Approach Using Zoom/Facebook Live.

As communities of color are disproportionately affected by COVID-19, there is an urgent need for dissemination of timely and accurate information to community members. In this article, we describe a stakeholder approach for the implementation, evaluation, and lessons learned from COVID-19 Conversations, a program developed and delivered virtually by researchers and academics at Northwell Health. The goal of the program was to address the mental, physical, and psychosocial needs of community members. The program used Zoom/Facebook Live to deliver interactive discussions on topics ranging from health education on COVID-19 and mental health to resources for unmet social needs. This interprofessional, cross-sector collaboration highlights the importance of public health interventions aimed at reducing the spread of COVID-19 through easy online access and culturally relevant community education and outreach.

Qualitative program evaluation of social determinants of health screening and referral program.

Although the integration of social determinants of health (SDH) screening and referral programs in clinical settings has rapidly grown, the voice and experience of participants within SDH programs has not been well understood in program evaluations. To qualitatively evaluate a comprehensive SDH screening and referral program based in an academic primary care setting, we conducted a qualitative analysis of a semi-structured, focus group interview of 7 caregivers. We performed inductive coding representing emerging ideas from each transcript using focus group transcripts from families who participated in the SDH screening and referral program. A thematic model was created describing caregivers' experiences with respect to screening, intake, and referral phases of the program. Caregivers reported satisfaction with structural and process-related components of screening, intake, and referral. They expressed a preference for trained patient navigators over physicians for screening and intake for they were perceived to have time to prioritize caregivers' social needs. Caregivers reported disappointment with legal services screening, intake, and referral, citing lack of timely contact from the legal resource team and prematurity of provided legal resources. Overall, caregivers recommend the program, citing that the program provided social support, an environment where expression is encouraged, motivation to address their own health needs, and a convenient location. Overall, caregivers would recommend the program because they feel socially supported. The use of trained patient navigators appears to be instrumental to the successful implementation of the program in clinics, for navigators can provide caregivers with the appropriate time and personal attention they need to complete the survey and discuss their needs. Streamlining the referral process for evaluation of health-harming needs by the medical legal partnership was highlighted as an area for improvement.

Adapting a home telemonitoring intervention for underserved Hispanic/Latino patients with type 2 diabetes: an acceptability and feasibility study.

BACKGROUND: Home telemonitoring is a promising approach to optimizing outcomes for patients with Type 2 Diabetes; however, this care strategy has not been adapted for use with understudied and underserved Hispanic/Latinos (H/L) patients with Type 2 Diabetes. METHODS: A formative, Community-Based Participatory Research approach was used to adapt a home telemonitoring intervention to facilitate acceptability and feasibility for vulnerable H/L patients. Utilizing the ADAPT-ITT framework, key stakeholders were engaged over an 8-month iterative process using a combination of strategies, including focus groups and structured interviews. Nine Community Advisory Board, Patient Advisory, and Provider Panel Committee focus group discussions were conducted, in English and Spanish, to garner stakeholder input before intervention implementation. Focus groups and structured interviews were also conducted with 12 patients enrolled in a 1-month pilot study, to obtain feedback from patients in the home to further adapt the intervention. Focus groups and structured interviews were approximately 2 hours and 30 min, respectively. All focus groups and structured interviews were audio-recorded and professionally transcribed. Structural coding was used to mark responses to topical questions in the moderator and interview guides. RESULTS: Two major themes emerged from qualitative analyses of Community Advisory Board/subcommittee focus group data. The first major theme involved intervention components to maximize acceptance/usability. Subthemes included tablet screens (e.g., privacy/identity concerns; enlarging font sizes; lighter tablet to facilitate portability); cultural incongruence (e.g., language translation/literacy, foods, actors "who look like me"); nursing staff (e.g., ensuring accessibility; appointment flexibility); and, educational videos (e.g., the importance of information repetition). A second major theme involved suggested changes to the randomized control trial study structure to maximize participation, including a major restructuring of the consenting process and changes designed to optimize recruitment strategies. Themes from pilot participant focus group/structured interviews were similar to those of the Community Advisory Board such as the need to address and simplify a burdensome consenting process, the importance of assuring privacy, and an accessible, culturally congruent nurse. CONCLUSIONS: These findings identify important adaptation recommendations from the stakeholder and potential user perspective that should be considered when implementing home telemonitoring for underserved patients with Type 2 Diabetes. TRIAL REGISTRATION: NCT03960424; ClinicalTrials.gov (US National Institutes of Health). Registered 23 May 2019. Registered prior to data collection. https://www.clinicaltrials.gov/ct2/show/NCT03960424?term=NCT03960424&draw=2&rank=1.

Percutaneous Feeding Tubes in Individuals with Advanced Dementia: Are Physicians "Choosing Wisely"?

OBJECTIVES: To evaluate physician knowledge and perceptions about the American Board of Internal Medicine/American Geriatrics Society (ABIM/AGS) Choosing Wisely recommendations regarding percutaneous endoscopic gastrostomy (PEG) in individuals with advanced dementia. DESIGN: Multicenter, mixed-mode, anonymous questionnaire. SETTING: Three tertiary and four community hospitals in New York. PARTICIPANTS: Internal medicine physicians (N = 168). MEASUREMENTS: Physician knowledge and perceptions regarding PEG tubes in individuals with advanced dementia. RESULTS: Ninety-nine percent of physicians reported having cared for someone with advanced dementia; 95% had been involved in the PEG decision-making process; 38% were unsure whether the ABIM/AGSChoosing Wisely recommendations advise for or against PEG tubes in advanced dementia. Physicians who agreed that there is enough evidence to recommend against PEG placement for individuals with advanced dementia were more likely to know the ABIM/AGSChoosing Wisely recommendations (71% vs 28%, P < .001). Fifty-two percent felt in control of the PEG placement decision, and 27% expressed concerns about potential litigation. The most common factor influencing physicians was patient or decision-maker request (70%); 63% stated that families request PEG placement even when physician would not recommend it. Only 4% of the physicians would choose to have a PEG tube if they had advanced dementia. CONCLUSION: Despite the scientific evidence supporting the ABIM/AGSChoosing Wisely recommendations against the use of PEG tubes in individuals with advanced dementia, numerous incentives for placement complicate the decision for PEG placement. In today's healthcare environment, it is incumbent upon healthcare practitioners to be aware of the available evidence and to provide leadership to guide this complex decision-making process to promote true person-centered care.