Telemedicine-based inspiratory muscle training and walking promotion with lung cancer survivors following curative intent therapy: a parallel-group pilot randomized trial.

PURPOSE: Following curative-intent therapy of lung cancer, many survivors experience dyspnea and physical inactivity. We investigated the feasibility, acceptability, safety, and potential efficacy of inspiratory muscle training (IMT) and walking promotion to disrupt a postulated "dyspnea-inactivity" spiral. METHODS: Between January and December 2022, we recruited lung cancer survivors from Kaiser Permanente Colorado who completed curative-intent therapy within 1-6 months into a phase-IIb, parallel-group, pilot randomized trial (1:1 allocation). The 12-week intervention, delivered via telemedicine, consisted of exercise training (IMT + walking), education, and behavior change support. Control participants received educational materials on general exercise. We determined feasibility a priori: enrollment of ≥ 20% eligible patients, ≥ 75% retention, study measure completion, and adherence. We assessed acceptability using the Telemedicine-Satisfaction-and-Usefulness-Questionnaire and safety events that included emergency department visits or hospitalizations. Patient-centered outcome measures (PCOMs) included dyspnea (University-of-California-San-Diego-Shortness-of-Breath-Questionnaire), physical activity (activPAL™ steps/day), functional exercise capacity (mobile-based-six-minute-walk-test), and health-related quality of life (HRQL, St.-George's-Respiratory-Questionnaire). We used linear mixed-effects models to assess potential efficacy. RESULTS: We screened 751 patients, identified 124 eligible, and consented 31 (25%) participants. Among 28 participants randomized (14/group), 22 (11/group) completed the study (79% retention). Intervention participants returned > 90% of self-reported activity logs, completed > 90% of PCOMs, and attended > 90% of tele-visits; 75% of participants performed IMT at the recommended dose. Participants had high satisfaction with tele-visits and found the intervention useful. There was no statistically significant difference in safety events between groups. Compared to control participants from baseline to follow-up, intervention participants had statistically significant and clinically meaningful improved HRQL (SGRQ total, symptom, and impact scores) (standardized effect size: -1.03 to -1.30). CONCLUSIONS: Among lung cancer survivors following curative-intent therapy, telemedicine-based IMT + walking was feasible, acceptable, safe, and had potential to disrupt the "dyspnea-inactivity" spiral. Future efficacy/effectiveness trials are warranted and should incorporate IMT and walking promotion to improve HRQL. TRIAL REGISTRATION: ClinicalTrials.gov NCT05059132.

Resident perspectives on the value of interdisciplinary conference calls for geriatric patients.

BACKGROUND: There are limited competency-based educational curricula for transitions of care education (TOC) for internal medicine (IM) residency programs. The University of Colorado implemented a virtual interdisciplinary conference call, TEAM (Transitions Expectation and Management), between providers on the inpatient Acute Care of the Elder (ACE) unit and the outpatient Seniors Clinic at the University of Colorado Hospital. Residents rotating on the ACE unit participated in weekly conferences discussing Seniors Clinic patients recently discharged, or currently hospitalized, to address clinical concerns pertaining to TOC. Our goals were to understand resident perceptions of the educational value of these conferences, and to determine if these experiences changed attitudes or practice related to care transitions. METHODS: We performed an Institutional Review Board-approved qualitative study of IM housestaff who rotated on the ACE unit during 2018-2019. Semi-structured interviews were conducted to understand perceptions of the value of TEAM calls for residents' own practice and the impact on patient care. Data was analyzed inductively, guided by thematic analysis. RESULTS: Of the 32 IM residents and interns who rotated on ACE and were invited to participate, 11 agreed to an interview. Three key themes emerged from interviews that highlighted residents' experiences identifying and navigating some of their educational 'blind spots:' 1) Awareness of patient social complexities, 2) Bridging gaps in communication across healthcare settings, 3) Recognizing the value of other disciplines during transitions. CONCLUSIONS: This study highlights learner perspectives of the benefit of interdisciplinary conference calls between inpatient and outpatient providers to enhance transitions of care, which provide meaningful feedback and serve as a vehicle for residents to recognize the impact of their care decisions in the broader spectrum of patients' experience during hospital discharge. Educators can maximize the value of these experiences by promoting reflective debriefs with residents and bringing to light previously unrecognized knowledge gaps around hospital discharge.

Understanding Experiences of Caregivers of Spouses With Dementia During Caregiver Health Care Emergencies.

BACKGROUND AND OBJECTIVES: Caregivers of persons with dementia are frequently spouses. Caregiver hospitalization causes disruption to caregiving. The goal of this research was to understand the preparedness and stress trajectory of peri-caregiver hospitalization. RESEARCH DESIGN AND METHODS: Mixed methods were used. Caregivers of spouses with dementia (n = 1,000) were surveyed to determine their perceived preparedness for their own hospitalization. Journey mapping interviews (n = 18) were used to map caregivers' experiences during 5 phases: (a) their spouse with dementia (SWD)'s dementia diagnosis; (b) their SWD's dementia progression; (c) their own health event; (d) their own hospitalization; and (e) their own return home from the hospital. RESULTS: Among the 452 (45%) eligible caregiver survey respondents, 75 (17%) had experienced hospitalization in the previous 12 months and 51 (68%) hospitalizations were unexpected. Twenty-three (31%) of hospitalized caregivers indicated they did not have prior plans in place for the care of the SWD. When asked about an unexpected hospitalization in the future, 233 (52%) felt somewhat prepared and 133 (29%) felt not at all prepared. Journey mapping revealed 3 groups of caregivers: Group 1 (n = 7) rated their stress lower during their hospitalization, Group 2 (n = 7) rated their stress highest during their hospitalization, and Group 3 (n = 4) were at a sustained high-stress level. DISCUSSION AND IMPLICATIONS: Many caregivers are not prepared for their own hospitalization. The stress trajectory through important phases of dementia caregiving and a caregiver's own hospitalization is not universal. Meeting the needs of caregivers' peri-hospitalization should be tailored to the individual caregiver.

Comparing two durations of medically tailored meals posthospitalization: A randomized clinical trial.

BACKGROUND: Medically tailored meals (MTM) may be beneficial to patients after hospital discharge. OBJECTIVE: To determine if 2 versus 4 weeks of MTM posthospitalization will improve patient outcomes. DESIGN: Randomized unblinded trial. SETTINGS AND PARTICIPANTS: Six hundred and fifty patients pending hospital discharge with at least one chronic condition. INTERVENTION: One MTM a day for 2 versus 4 weeks. MAIN OUTCOME AND MEASURES: The primary outcome was a change from baseline to 60 days in the Hospital Anxiety Depression Scale (HADS). Secondary outcomes measured change in the Katz activities of daily living (ADLs), DETERMINE nutritional risk, and all-cause emergency department (ED) visits and rehospitalizations. RESULTS: From baseline to 60 days the HADS anxiety subscale changed 5.4-4.9 in the 2-week group (p = .03) and 5.4-5.3 in the 4-week group (p = .49); the difference in change between groups 0.4 (p = .25). HADS changed 5.4-4.8 in the 2-week group (p = .005) and 5.3-5.1 in the 4-week group (p = .34); the difference in change between groups 0.4 (p = .18). ADL score changed from 5.3 to 5.6 in the 2-week group (p ≤ .0001) and 5.2-5.5 in the 4-week group (p ≤ .0001); the difference in change between groups -0.01 (p = .90). The DETERMINE changed in the 2-week group from 7.2 to 6.4 (p = .0006) and from 7 to 6.7 in the 4-week group (p = .19); the difference in change between groups 0.5 (p = .13). There was no difference in ED visits and rehospitalizations between groups or time to rehospitalization. CONCLUSIONS: Different durations of short-term MTM did not affect patient-centered or utilization outcomes.

Caregiver Experiences of Care Coordination for Recently Discharged Patients: A Qualitative Metasynthesis.

Caregivers of patients often provide key support for patients after hospitalization. This qualitative metasynthesis describes caregiver perspectives about care coordination for patients discharged from the hospital. A literature search of Ovid Medline and CINAHL completed on May 23, 2018, identified 1,546 studies. Twelve articles were included in the final metasynthesis. Caregiver perspectives about care coordination were compiled into overall themes. A subanalysis of studies in which patients were discharged with home health services was completed. Five main themes emerged related to caregiver perspectives on care coordination after hospitalization: (a) Suboptimal access to clinicians after discharge, (b) Feeling disregarded by clinicians, (c) Need for information and training at discharge, (d) Overwhelming responsibilities to manage appointments and medications, and (e) Need for emotional support.Findings from this metasynthesis suggest the need for clinicians to engage with caregivers to provide support, training, and communication after hospital discharge.

Identifying Patient Readmissions: Are Our Data Sources Misleading?

BACKGROUND: The accuracy of data is vital to identifying hospitalization outcomes for clinical trials. Patient attrition and recall bias affects the validity of patient-reported outcomes, and the growing prevalence of Medicare Advantage (MA) could mean Fee-for-Service (FFS) claims are less reliable for ascertaining hospital utilization. Statewide health information exchanges (HIEs) may be a more complete data source but have not been frequently used for research. DESIGN: Secondary analysis comparing identification of readmissions using 3 different acquisition approaches. SETTING: Randomized controlled trial of heart failure (HF) disease management in 37 skilled nursing facilities (SNFs). PARTICIPANTS: Patients with HF discharged from the hospital to SNF. MEASURES: Readmissions up to 60 days post-SNF admission collected by patient self-report, recorded by nursing home (NH) staff during the SNF stay, or recorded in the state HIE. RESULTS: Among 657 participants (mean age 79 ± 10 years, 49% with FFS), 295 unique readmissions within 60 days of SNF admission were identified. These readmissions occurred among 221 patients. Twenty percent of all readmissions were found using only patient self-report, 28% were only recorded by NH staff during the SNF stay, and 52% were identified only using the HIE. The readmission rate (first readmission only) based only on patient self-report and direct observation was 18% rather than 34% with the addition of the enhanced HIE method. CONCLUSIONS AND IMPLICATIONS: More than one-quarter (34%) of HF patients were rehospitalized within 60 days post SNF admission. Use of a statewide HIE resulted in identifying an additional 153 admissions, 52% of all the readmissions seen in this study. Without use of an HIE, nearly half of readmissions would have been missed as a result of incomplete patient self-report or loss to follow-up. Thus, HIEs serve as an important resource for researchers to ensure accurate outcomes data.