Providing Hearing Assistance to Veterans in the Emergency Department: A Qualitative Study.

INTRODUCTION: Effective communication is essential to good health care, and hearing loss disrupts patient-provider communication. For the more than 2 million veterans with severe hearing loss, communication is particularly challenging in noisy health care environments such as emergency departments. The purpose of this qualitative study was to describe patient and provider perspectives of feasibility and potential benefit of providing a hearing assistance device, a personal amplifier, during visits to an emergency department in an urban setting affiliated with the Department of Veterans Affairs. METHODS: This qualitative descriptive study was conducted in parallel with a randomized controlled study. We completed a semistructured interview with 11 veterans and 10 health care providers to elicit their previous experiences with patient-provider communication in the ED setting and their perspectives on hearing screening and using the personal amplifier in the emergency department. Interview data were analyzed using content analysis and Atlas.ti V8.4 software (Scientific Software Development GmbH, Berlin, Germany). RESULTS: The veteran sample (n = 11) had a mean age of 80.3 years (SD = 10.2). The provider sample included 7 nurses and 3 physicians. In the ED setting, hearing loss disrupts patient-provider communication. Screening for hearing loss in the emergency department was feasible except in urgent/emergent cases. The use of the personal amplifier made communication more effective and less effortful for both veterans and providers. DISCUSSION: Providing the personal amplifier improved the ED experience for veterans and offers a promising intervention that could improve health care quality and safety for ED patient populations.

Adult Protective Services Training: Insights from California Caseworkers.

Adult Protective Services (APS) training is critical to the mission of APS in supporting the workforce, but not much is known from caseworkers' perspectives. To learn more, 63 caseworkers in five California counties, from urban, suburban, and rural areas, participated in focus groups. Discussion was organized around three open-ended questions regarding implementation of the National Adult Protective Services Association (NAPSA) training content in practice: (1) What trainings have changed your practice and how? (2) How could training be changed to make it easier to implement? (3) What characteristics of your work environment interfere with implementation of learning? Through iterative reading and review of focus group transcripts, four themes emerged: (1) motivations, (2) barriers, (3) facilitators, and (4) impact. Caseworkers also made recommendations to improve training for better implementation of concepts and skills. Caseworkers involved in this study were quick to assert the need for increased access to training, more sophisticated content, and experiential learning. Moreover, expanding and enhancing safety training was recommended, as was aligning training with local needs and policies. Since the NAPSA approved APS core competencies and advanced topics are also offered and used in other counties and states, considering how to improve training could benefit caseworkers nationwide.

Collective intelligence in medical decision-making: a systematic scoping review.

BACKGROUND: Collective intelligence, facilitated by information technology or manual techniques, refers to the collective insight of groups working on a task and has the potential to generate more accurate information or decisions than individuals can make alone. This concept is gaining traction in healthcare and has potential in enhancing diagnostic accuracy. We aim to characterize the current state of research with respect to collective intelligence in medical decision-making and describe a framework for diverse studies in this topic. METHODS: For this systematic scoping review, we conducted a systematic search for published literature using PubMed, Embase, Web of Science, and CINAHL on August 8, 2017. We included studies that combined the insights of two or more medical experts to make decisions related to patient care. Studies that examined medical decisions such as diagnosis, treatment, and management in the context of an actual or theoretical patient case were included. We include studies of complex medical decision-making rather than identification of a visual finding, as in radiology or pathology. We differentiate between medical decisions, in which synthesis of multiple types of information is required over time, and studies of radiological scans or pathological specimens, in which objective identification of a visual finding is performed. Two reviewers performed article screening, data extraction, and final inclusion for analysis. RESULTS: Of 3303 original articles, 15 were included. Each study examined the medical decisions of two or more individuals; however, studies were heterogeneous in their methods and outcomes. We present a framework to characterize these diverse studies, and future investigations, based on how they operationalize collective intelligence for medical decision-making: 1) how the initial decision task was completed (group vs. individual), 2) how opinions were synthesized (information technology vs. manual vs. in-person), and 3) the availability of collective intelligence to participants. DISCUSSION: Collective intelligence in medical decision-making is gaining popularity to advance medical decision-making and holds promise to improve patient outcomes. However, heterogeneous methods and outcomes make it difficult to assess the utility of collective intelligence approaches across settings and studies. A better understanding of collective intelligence and its applications to medicine may improve medical decision-making.

Social Media as a Tool to Promote Health Awareness: Results from an Online Cervical Cancer Prevention Study.

Online social media platforms represent a promising opportunity for public health promotion. Research is limited, however, on the effectiveness of social media at improving knowledge and awareness of health topics and motivating healthy behavior change. Therefore, we investigated whether participation in an online social media platform and receipt of brief, tailored messages is effective at increasing knowledge, awareness, and prevention behaviors related to human papillomavirus (HPV) and cervical cancer. We conducted an online study in which 782 recruited participants were consecutively assigned to nine-person groups on a social media platform. Participants were shown a unique random set of 20 tailored messages per day over five days. Participants completed a baseline and post survey to assess their knowledge, awareness, and prevention behaviors related to HPV and cervical cancer. There were no statistically significant changes in knowledge and prevention behaviors from the baseline to the post survey among study participants. There was a modest, statistically significant change in response to whether participants had ever heard of HPV, increasing from 90 to 94% (p = 0.003). Our findings suggest that most study participants had substantial knowledge, awareness, and engagement in positive behaviors related to cervical cancer prevention at the start of the study. Nevertheless, we found that HPV awareness can be increased through brief participation in an online social media platform and receipt of tailored health messages. Further investigation that explores how social media can be used to improve knowledge and adoption of healthy behaviors related to cervical cancer is warranted.

Care Setting Transitions for People With Dementia: Qualitative Perspectives of Current and Former Care Partners.

Care partners (CP) of people with dementia (PWD) report that decisions about care setting are aided by the support of healthcare providers. However, providers are often underprepared to offer adequate counseling. This qualitative study aimed to identify what support from providers will assist CPs in making decisions related to care setting throughout the dementia journey. We conducted semi-structured interviews with current CPs of PWD and former CPs of decedents. We utilized the constant comparative method to identify themes regarding preferences around care setting as the PWD progressed from diagnosis to end-of-life. Participants were 31 CPs, including 16 current and 15 former CPs. CPs had a mean age of 67 and were primarily white (n = 23/31), female (n = 21/31), and spouses (n = 24/31). Theme 1: Current CPs discussed overwhelming uncertainty pertaining to care setting, expressing "I don't know when I need to plan on more care," and a desire to understand "what stage we are at." Theme 2: Later in the disease, former CPs wanted guidance from healthcare providers on institutional placement ("I sure would've loved some help finding better places") or support to stay in the home ("a doctor had to come to the house"). CPs want early, specific guidance from healthcare providers related to transitions between home and long-term care. Early in the disease course, counseling geared toward prognosis and expected disease course helps CPs make plans. Later, caregivers want help identifying locations or institutionalization or finding home care resources.

The HEAR-VA Pilot Study: Hearing Assistance Provided to Older Adults in the Emergency Department.

BACKGROUND/OBJECTIVES: Poor communication is a barrier to care for people with hearing loss. We assessed the feasibility and potential benefit of providing a simple hearing assistance device during an emergency department (ED) visit, for people who reported difficulty hearing. DESIGN: Randomized controlled pilot study. SETTING: The ED of New York Harbor Manhattan Veterans Administration Medical Center. PARTICIPANTS: One hundred and thirty-three Veterans aged 60 and older, presenting to the ED, likely to be discharged to home, who either (1) said that they had difficulty hearing, or (2) scored 10 or greater (range 0-40) on the Hearing Handicap Inventory-Survey (HHI-S). INTERVENTION: Subjects were randomized (1:1), and intervention subjects received a personal amplifier (PA; Williams Sound Pocketalker 2.0) for use during their ED visit. MEASUREMENTS: Three survey instruments: (1) six-item Hearing and Understanding Questionnaire (HUQ); (2) three-item Care Transitions Measure; and (3) three-item Patient Understanding of Discharge Information. Post-ED visit phone calls to assess ED returns. RESULTS: Of the 133 subjects, 98.3% were male; mean age was 76.4 years (standard deviation (SD) = 9.2). Mean HHI-S score was 19.2 (SD = 8.3). Across all HUQ items, intervention subjects reported better in-ED experience than controls. Seventy-five percent of intervention subjects agreed or strongly agreed that ability to understand what was said was without effort versus 56% for controls. Seventy-five percent of intervention subjects versus 36% of controls said clinicians provided them with an explanation about presenting problems. Three percent of intervention subjects had an ED revisit within 3 days compared with 9.0% controls. CONCLUSION: Veterans with hearing difficulties reported improved in-ED experiences with use of PAs, and were less likely to return to the ED within 3 days. PAs may be an important adjunct to older patient ED care but require validation in a larger more definitive randomized controlled trial.

Evaluation of a Health Information Technology-Enabled Collective Intelligence Platform to Improve Diagnosis in Primary Care and Urgent Care Settings: Protocol for a Pragmatic Randomized Controlled Trial.

BACKGROUND: Diagnostic error in ambulatory care, a frequent cause of preventable harm, may be mitigated using the collective intelligence of multiple clinicians. The National Academy of Medicine has identified enhanced clinician collaboration and digital tools as a means to improve the diagnostic process. OBJECTIVE: This study aims to assess the efficacy of a collective intelligence output to improve diagnostic confidence and accuracy in ambulatory care cases (from primary care and urgent care clinic visits) with diagnostic uncertainty. METHODS: This is a pragmatic randomized controlled trial of using collective intelligence in cases with diagnostic uncertainty from clinicians at primary care and urgent care clinics in 2 health care systems in San Francisco. Real-life cases, identified for having an element of diagnostic uncertainty, will be entered into a collective intelligence digital platform to acquire collective intelligence from at least 5 clinician contributors on the platform. Cases will be randomized to an intervention group (where clinicians will view the collective intelligence output) or control (where clinicians will not view the collective intelligence output). Clinicians will complete a postvisit questionnaire that assesses their diagnostic confidence for each case; in the intervention cases, clinicians will complete the questionnaire after reviewing the collective intelligence output for the case. Using logistic regression accounting for clinician clustering, we will compare the primary outcome of diagnostic confidence and the secondary outcome of time with diagnosis (the time it takes for a clinician to reach a diagnosis), for intervention versus control cases. We will also assess the usability and satisfaction with the digital tool using measures adapted from the Technology Acceptance Model and Net Promoter Score. RESULTS: We have recruited 32 out of our recruitment goal of 33 participants. This study is funded until May 2020 and is approved by the University of California San Francisco Institutional Review Board until January 2020. We have completed data collection as of June 2019 and will complete our proposed analysis by December 2019. CONCLUSIONS: This study will determine if the use of a digital platform for collective intelligence is acceptable, useful, and efficacious in improving diagnostic confidence and accuracy in outpatient cases with diagnostic uncertainty. If shown to be valuable in improving clinicians' diagnostic process, this type of digital tool may be one of the first innovations used for reducing diagnostic errors in outpatient care. The findings of this study may provide a path forward for improving the diagnostic process. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/13151.

Perceptions of cervical cancer prevention on Twitter uncovered by different sampling strategies.

INTRODUCTION: Cervical cancer prevention is possible through use of the HPV vaccine and Pap tests, yet the vaccine remains underutilized. METHODS: We obtained publicly-available Twitter data from 2014 using three sampling strategies (top-ranked, simple random sample, and topic model) based on key words related to cervical cancer prevention. We conducted a content analysis of 100 tweets from each of the three samples and examined the extent to which the narratives and frequency of themes differed across samples. RESULTS: Advocacy-related tweets constituted the most prevalent theme to emerge across all three sample types, and were most frequently found in the top-ranked sample. A random sample detected the same themes as topic modeling, but the relative frequency of themes identified from topic modeling fell in-between top-ranked and random samples. DISCUSSION: Variations in themes uncovered by different sampling methods suggest it is useful to qualitatively assess the relative frequency of themes to better understand the breadth and depth of social media conversations about health. CONCLUSIONS: Future studies using social media data should consider sampling methods to uncover a wider breadth of conversations about health on social media.

Testing and improving the acceptability of a web-based platform for collective intelligence to improve diagnostic accuracy in primary care clinics.

OBJECTIVES: Usable tools to support individual primary care clinicians in their diagnostic processes could help to reduce preventable harm from diagnostic errors. We conducted a formative study with primary care providers to identify key requisites to optimize the acceptability of 1 online collective intelligence platform (Human Diagnosis Project; Human Dx). MATERIALS AND METHODS: We conducted semistructured interviews with practicing primary care clinicians in a sample of the US community-based clinics to examine the acceptability and early usability of the collective intelligence online platform using standardized clinical cases and real-world clinical cases from the participants' own practice. We used an integrated inductive-deductive qualitative analysis approach to analyze the interview transcripts. RESULTS AND DISCUSSION: Perceived usefulness, perceived accuracy, quality assurance, trust, and ease of use emerged as essential domains of acceptability required for providers to use a collective intelligence tool in clinical practice. Participants conveyed that the collective opinion should: (1) contribute to their clinical reasoning, (2) boost their confidence, (3) be generated in a timely manner, and (4) be relevant to their clinical settings and use cases. Trust in the technology platform and the clinical accuracy of its collective intelligence output emerged as an incontrovertible requirement for user acceptance and engagement. CONCLUSION: We documented key requisites to building a collective intelligence technology platform that is trustworthy, useful, and acceptable to target end users for assistance in the diagnostic process. These key lessons may be applicable to other provider-facing decision support platforms.