How to screen for at-risk alcohol use in transplant patients? From instrument selection to implementation of the AUDIT-C.

BACKGROUND: Given that drinking >2-3 units of alcohol daily might already have adverse health effects, regular screening of at-risk drinking is warranted. We aimed to select and pilot a short instrument to accurately screen for at-risk drinking in transplant patients. METHODOLOGY AND RESULTS: Five consecutive steps were completed: A comprehensive literature review identified 24 possible self-report instruments (step 1). These instruments were scored on six yes/no criteria (ie, length, concept measured, diagnostic accuracy, population, manual available, cost) (step 2). Four nurses piloted three instruments with the highest score and were interviewed on their experiences with using the AUDIT-C, TWEAK, and Five Shot. The AUDIT-C was the easiest to use and score, and items were clear. Cognitive debriefings with 16 patients were conducted to verify clarity of instructions and items, and suggestions were incorporated into a modified version of the AUDIT-C (step 4). A convenience sample of 130 Dutch-speaking heart transplant patients completed the modified AUDIT-C during a scheduled visit (Step 5), revealing that 27.6% of patients showed at-risk drinking. CONCLUSION: The AUDIT-C might be a suitable instrument to identify at-risk drinking in routine post-transplant follow-up. Further validation, however, is indicated.

Shedding light on an unknown reality in solid organ transplant patients' self-management: A contextual inquiry study.

Traditional quantitative and qualitative research methods inadequately capture the complexity of patients' daily self-management. Contextual inquiry methodology, using home visits, allows a more in-depth understanding of how patients integrate immunosuppressive medication intake, physical activity, and healthy eating in their daily lives, and which difficulties they experience when doing so. This mixed-method study comprised 2 home visits in 19 purposively selected adult heart, lung, liver, and kidney transplant patients, asking them to demonstrate how they implement the aforementioned health behaviors. Meanwhile, conversations were audio-taped and photographs were taken. Audio-visual materials were coded using directed content analysis. Difficulties and supportive strategies were identified via inductive thematic analysis. We learned that few patients understood what "sufficiently active" means. Physical discomforts and poor motivation created variation across activity levels observed. Health benefits of dietary guidelines were insufficiently understood, and their implementation into everyday life considered difficult. Many underestimated the strictness of immunosuppressive medication intake, and instructions on handling late doses were unclear. Interruptions in routine and busyness contributed to nonadherence. We also learned that professionals often recommend supportive strategies, which patients not always like or need. This contextual inquiry study revealed unique insights, providing a basis for patient-tailored self-management interventions.

Technology Experience of Solid Organ Transplant Patients and Their Overall Willingness to Use Interactive Health Technology.

BACKGROUND: The use of interactive health technology (IHT) is a promising pathway to tackle self-management problems experienced by many chronically ill patients, including solid organ transplant (Tx) patients. Yet, to ensure that the IHT is accepted and used, a human-centered design process is needed, actively involving end users in all steps of the development process. A first critical, predevelopment step involves understanding end users' characteristics. This study therefore aims to (a) select an IHT platform to deliver a self-management support intervention most closely related to Tx patients' current use of information and communication technologies (ICTs), (b) understand Tx patients' overall willingness to use IHT for self-management support, and investigate associations with relevant technology acceptance variables, and (c) explore Tx patients' views on potential IHT features. DESIGN AND METHODS: We performed a cross-sectional, descriptive study between October and December 2013, enrolling a convenience sample of adult heart, lung, liver, and kidney Tx patients from the University Hospitals Leuven, Belgium. Broad inclusion criteria were applied to ensure a representative patient sample. We used a 35-item newly designed interview questionnaire to measure Tx patients' use of ICTs, their overall willingness to use IHT, and their views on potential IHT features, as well as relevant technology acceptance variables derived from the Unified Theory of Acceptance and Use of Technology and a literature review. Descriptive statistics were used as appropriate, and an ordinal logistic regression model was built to determine the association between Tx patients' overall willingness to use IHT, the selected technology acceptance variables, and patient characteristics. FINDINGS: Out of 139 patients, 122 agreed to participate (32 heart, 30 lung, 30 liver, and 30 kidney Tx patients; participation rate: 88%). Most patients were male (57.4%), married or living together (68%), and had a mean age of 55.9 ± 13.4 years. Only 27.9% of Tx patients possessed a smartphone, yet 72.1% owned at least one desktop or laptop PC with wireless Internet at home. On a 10-point numeric scale, asking patients whether they think IHT development is important to support them personally in their self-management, patients gave a median score of 7 (25th percentile 5 points; 75th percentile 10 points). Patients who were single or married or living together were more likely to give a higher rating than divorced or widowed patients; patients who completed only secondary education gave a higher rating than higher educated patients; and patients with prior ICT use gave a higher rating than patients without prior ICT use. Tx patients also had clear preferences regarding IHT features, such as automatic data transfer, as much as possible, visual aids (e.g., graphs) over text messages, and personally deciding when to access the IHT. CONCLUSIONS: By investigating Tx patients' possession and use of ICTs, we learned that computers and the Internet, and not smartphones, are the most suitable IHT platforms to deliver self-management interventions for our Tx patients. Moreover, Tx patients generally are open to using IHT, yet patient acceptance variables and their preferences for certain IHT features should be taken into account in the next steps of IHT development. Designers intending to develop or use existing IHTs should never overlook this critical first step in a human-centered design. CLINICAL RELEVANCE: Before considering using eHealth technology in clinical practice, professionals should always check whether patients are familiar with using information and communication technology, and whether they are willing to use technology for health-related purposes.

Best practice recommendations on the application of seclusion and restraint in mental health services: An evidence, human rights and consensus-based approach.

WHAT IS KNOWN ON THE SUBJECT?: Seclusion and restraint still regularly occur within inpatient mental health services. The Council of Europe requires the development of a policy on for instance age limits, techniques and time limits. However, they only define the outer limits of such a policy by indicating when rights are violated. Within these limits, many choices remain open. Staff and service managers lack clarity on safe and humane procedures. Research literature provides limited and contradictory insights on these matters. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The study resulted in 77 best practice recommendations on the practical application of restraint and seclusion as last resort intervention in inpatient youth and adult mental health services, including forensic facilities. To our knowledge, this is the first study in which the development of recommendations on this topic is not only based on scientific evidence, but also on an analysis of European human rights standards and consensus within and between expert-professionals and experts-by-experience. This approach allowed to develop for the first time recommendations on time limits, asking for second opinion, and registration of seclusion and restraint. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The 77 recommendations encourage staff to focus on teamwork, safety measures, humane treatment, age and time limits, asking for second opinion, observation, evaluation and registration when applying seclusion and restraint as last resort intervention. The implementation of the best practice recommendations is feasible provided that they are combined with a broad preventive approach and with collaboration between service managers, staff (educators) and experts-by-experience. Under these conditions, the recommendations will improve safety and humane treatment, and reduce harm to both service users and staff. ABSTRACT: INTRODUCTION: Seclusion and restraint still regularly occur within inpatient mental health services. Professionals lack clarity on safe and humane procedures. Nevertheless, a detailed policy on for instance age limits, techniques and time limits is required. AIM: We developed recommendations on the humane and safe application of seclusion, physical intervention and mechanical restraint in inpatient youth and adult mental health services, including forensic facilities. METHOD: After developing a questionnaire based on a rapid scientific literature review and an analysis of human rights sources stemming from the Council of Europe, 60 expert-professionals and 18 experts-by-experience were consulted in Flanders (Belgium) through a Delphi-study. RESULTS: After two rounds, all but one statement reached the consensus-level of 65% in both panels. The study resulted in 77 recommendations on teamwork, communication, materials and techniques, maximum duration, observation, evaluation, registration, second opinion and age limits. DISCUSSION: Combining an evidence, human rights and consensus-based approach allowed for the first time to develop recommendations on time limits, asking for second opinion and registration. IMPLICATIONS FOR PRACTICE: When combined with a preventive approach and collaboration between service managers, staff (educators) and experts-by-experience, the recommendations will improve safety and humane treatment, and reduce harm to service users and staff.

Clinicians and patients perspectives on follow-up care and eHealth support after allogeneic hematopoietic stem cell transplantation: A mixed-methods contextual analysis as part of the SMILe study.

PURPOSE: We report on our contextual analysis's methodology, as a first step of an implementation science project aiming to develop, implement, and test the effectiveness of an integrated model of care in SteM-cell transplantatIon faciLitated by eHealth (SMILe). METHODS: We applied an explanatory sequential mixed-methods design including clinicians and patients of the University Hospital Freiburg, Germany. Data were collected from 3/2017 to 1/2018 via surveys in 5 clinicians and 60 adult allogeneic stem-cell transplantation patients. Subsequently, we conducted 3 clinician focus groups and 10 patient interviews. Data analysis followed a 3-step process: (1) creating narrative descriptions, tables, and maps; (2) mapping key observational findings per dimension of the eHealth-enhanced Chronic-Care Model; (3) reflecting on how findings affect our choice of implementation strategies. RESULTS: Current clinical practice is mostly acute care driven, with no interdisciplinarity and weak chronic illness management. Gaps were apparent in the dimensions of self-management support and delivery-system design. Health behaviors that would profit from support include medication adherence, physical activity and infection prevention. The theme "being alone and becoming an expert" underpinned patients need to increase support in hospital-to-home transitions. Patients reported insecurity about recognizing, judging and acting upon symptoms. The theme "eHealth as connection not replacement" underscores the importance of eHealth augmenting, not supplanting human contact. Synthesis of our key observational findings informed eight implementation strategies. CONCLUSION: Stakeholders are willing towards a chronic care-focused approach and open for eHealth support. The contextual information provides a basis for the SMILe model's development and implementation.

Emotional symptoms and quality of life in patients with pulmonary arterial hypertension.

BACKGROUND: Limited evidence exists on the nature and degree of emotional problems in pulmonary arterial hypertension (PAH) and their association with patients' health-related quality of life (HRQOL). METHODS: This cross-sectional study examined the presence of depression, anxiety, and stress symptoms, and their association with disease-specific and generic HRQOL. A total of 101 patients (73% women) with PAH (age, 55.4 ± 16.4 years; 42.6% in New York Heart Association [NYHA] class II) completed the Depression, Anxiety, and Stress Scale, the generic Medical Outcomes Study Short-Form 36-Item (SF-36) Health Survey, and the disease-specific Minnesota Living With Heart Failure Questionnaire (MLHFQ) HRQOL instrument. The association between emotional problems and HRQOL was determined using multivariable linear regression analyses, controlling for demographic and disease-related characteristics. RESULTS: Of the patients, 32.6%, 48%, and 27.6% experienced depressive, anxiety or stress symptoms, respectively. HRQOL was >1 standard deviation below population norms for the SF-36 Physical Component Summary. Depressive symptoms, NYHA class, and being disabled explained 46% of the total variance of the MLHFQ. Emotional problems did not contribute to the SF-36 Physical Component Summary but explained part of the variance of the physical sub-scales of the SF-36 role limitations due to physical problems, bodily pain, and general health. CONCLUSIONS: The high presence of emotional problems warrants regular screening and appropriate psychotherapeutic and/or pharmacological treatment. Which strategies could improve PAH patients' HRQOL remains to be investigated.