Frances K. Barg

Using crowdsourcing as a platform to evaluate lay perception of prophylactic mesh placement

BACKGROUNDnProphylactic mesh placement (PMP) at the time of open abdominal surgery has gained momentum over the last decade. However, there remains an identifiable gap in the literature regarding patient-reported outcomes and qualitative metrics. In effort to gauge the populations understanding or familiarity with PMP, this study provides an educational framework and uses crowdsourcing as a novel means to assess perception among the general population.nnnMETHODSnA cross-sectional survey study was conducted among the general public to elicit perspectives on PMP. An online crowdsourcing platform was used to capture responses to a questionnaire. Pearsons correlation coefficients, paired t-test, chi-square test, and Fishers exact tests were performed.nnnRESULTSnOf 433 respondents, 338 (78.1%) were included. Individuals who had previously undergone surgery and those who had prior hernia repair were more likely to choose PMP than surgically naïve patients (Pxa0=xa00.06).nnnCONCLUSIONSnThe majority of respondents support the use of PMP. This study contributes to the existing body of literature on PMP and serves as the first qualitative description to gauge the populations perception and understanding of this surgical technique. Within the evolving health care landscape, understanding quality-of-life measures have become increasingly important in defining successful surgical outcomes. Although the data-driven level-I evidence supports the clinical use of PMP, this study intends to establish a framework for future patient-reported outcome studies.

Health care access and quality for persons with disability: Patient and provider recommendations

BACKGROUNDnSignificant disparities in health care access and quality persist between persons with disabilities (PWD) and persons without disabilities (PWOD). Little research has examined recommendations of patients and providers to improve health care for PWD.nnnOBJECTIVEnWe sought to explore patient and health care provider recommendations to improve health care access and quality for PWD through focus groups in the physical world in a community center and in the virtual world in an online community.nnnMETHODSnIn all, 17 PWD, 4 PWOD, and 6 health care providers participated in 1 of 5 focus groups. Focus groups were conducted in the virtual world in Second Life® with Virtual Ability, an online community, and in the physical world at Agape Community Center in Milwaukee, WI. Focus group data were analyzed using a grounded theory methodology.nnnRESULTSnThemes that emerged in focus groups among PWD and PWOD as well as health care providers to improve health care access and quality for PWD were: promoting advocacy, increasing awareness and knowledge, improving communication, addressing assumptions, as well as modifying and creating policy. Many participants discussed political empowerment and engagement as central to health care reform.nnnCONCLUSIONSnBoth PWD and PWOD as well as health care providers identified common themes potentially important for improving health care for PWD. Patient and health care provider recommendations highlight a need for modification of current paradigms, practices, and approaches to improve the quality of health care provision for PWD. Participants emphasized the need for greater advocacy and political engagement.

Developing a Standard Handoff Process for Operating Room–to-ICU Transitions: Multidisciplinary Clinician Perspectives from the Handoffs and Transitions in Critical Care (HATRICC) Study

BACKGROUNDnOperating room (OR)-to-ICU handoffs place patients at risk for preventable harm. Numerous studies have described standardized handoff procedures following cardiac surgery, but no existing literature describes a general OR-to-ICU handoff system.nnnMETHODSnAs part of the Handoffs and Transitions in Critical Care (HATRICC) study, a postoperative handoff procedure was developed by conducting interviews and focus groups with staff routinely involved in OR-to-ICU patient transitions in two mixed surgical ICUs, which included nurses, house staff, and advanced practice providers. Transcripts were analyzed according to grounded theory. Surveys, attending physician interviews, and field notes further informed process development.nnnRESULTSnInterviews were conducted with 62 individuals, and three focus groups were held with 19 participants. Clinicians endorsed the importance of the OR-to-ICU handoff but identified several barriers to consistently achieving an ideal handoff-mainly, time pressure, unclear expectations, and confusion about other clinicians informational needs. Participants were receptive to a standardized handoff process, provided that it was not overly prescriptive. Surveys (nu2009=u2009132) revealed unreliable information transfer with current OR-to-ICU handoffs. These findings and preexisting OR-to-ICU handoff literature were used to develop a novel handoff process and information template suitable for standard use in a mixed surgical ICU.nnnCONCLUSIONnOR and ICU teams agreed on handoffs importance but expressed important barriers to consistently practicing ideal handoffs. Future work is needed to determine whether the handoff procedures developed by incorporating bedside provider perspectives improve patient outcomes.

Factors that shape preference for acupuncture or cognitive behavioral therapy for the treatment of insomnia in cancer patients

PurposePatient preference is an essential component of patient-centered supportive cancerxa0care; however, little is known about the factors that shape preference for treatment. This study sought to understand what factors may contribute to patient preference for two non-pharmacological interventions, acupuncture or cognitive behavioral therapy for insomnia (CBT-I).MethodsWe conducted individual, open-ended, semi-structured interviews among cancer survivors who had completed active treatment and met the diagnostic criteria for insomnia disorder. Two forms of codes were used for analysis: a priori set of codes derived from the key ideas and a set of codes that emerged from the data.ResultsAmong 53 participants, the median age was 60.7 (range 27–83), 30 participants (56.6%) were female, and 18 (34%) were non-white. We identified three themes that contributed to an individual’s treatment preference: perception of the treatment’s evidence base, experience with the treatment, and consideration of personal factors. Participants gave preference to the treatment perceived as having stronger evidence. Participants also reflected on positive or negative experiences with both of the interventions, counting their own experiences, as well as those of trusted sources. Lastly, participants considered their own unique circumstances and factors such as the amount of work involved, fit with personality, or fit with their “type” of insomnia.ConclusionsKnowledge of the evidence base, past experience, and personal factors shaped patient preference regardless of whether they accurately represent the evidence. Acknowledging these salient factors may help inform patient-centered decision-making and care.

A Qualitative Exploration of Co-location as an Intervention to Strengthen Home Visiting Implementation in Addressing Maternal Child Health

Objectives The aim of this paper is to explore the process and impact of co-locating evidence-based maternal and child service models to inform future implementation efforts. Methods As part of a state-wide evaluation of maternal and child home visiting programs, we conducted semi-structured interviews with administrators and home visitors from home visiting agencies across Pennsylvania. We collected 33 interviews from 4 co-located agencies. We used the Consolidated Framework for Implementation Research (CFIR) to describe the key elements mitigating implementation of multiple home visiting models. Results A primary advantage of co-location described by participants was the ability to increase the agency’s base of eligible clients through the implementation of a model with different program eligibility (e.g. income, child age) than the existing agency offering. Model differences related to curriculum (e.g. content or intensity/meeting frequency) enabled programs to more selectively match clients to models. To recruit eligible clients, new models were able to build upon the existing service networks of the initial program. Co-location provided organizational opportunities for shared trainings, enabling administrative efficiencies and collaborative staff learning. Programs implemented strategies to build synergies with complementary model features, for instance using the additional program option to serve waitlisted clients and to transition services after one model is completed. Conclusions for Practice Considerable benefits are experienced when home visiting models co-locate. This research builds on literature encouraging collaboration among community agencies and provides insight on a specific facilitative approach. This implementation strategy informs policy across the social services spectrum and competitive funding contexts.

Heart Failure Home Management Challenges and Reasons for Readmission: a Qualitative Study to Understand the Patient’s Perspective

BackgroundHeart failure patients have high 30-day hospital readmission rates. Interventions designed to prevent readmissions have had mixed success. Understanding heart failure home management through the patient’s experience may reframe the readmission “problem” and, ultimately, inform alternative strategies.ObjectiveTo understand patient and caregiver challenges to heart failure home management and perceived reasons for readmission.DesignObservational qualitative study.ParticipantsHeart failure patients were recruited from two hospitals and included those who were hospitalized for heart failure at least twice within 30xa0days and those who had been recently discharged after their first heart failure admission.ApproachOpen-ended, semi-structured interviews. Conclusions vetted using focus groups.Key ResultsSemi-structured interviews with 31 patients revealed a combination of physical and socio-emotional influences on patients’ home heart failure management. Major themes identified were home management as a struggle between adherence and adaptation, and hospital readmission as a rational choice in response to distressing symptoms. Patients identified uncertainty regarding recommendations, caused by unclear instructions and temporal incongruence between behavior and symptom onset. This uncertainty impaired their competence in making routine management decisions, resulting in a cycle of limit testing and decreasing adherence. Patients reported experiencing hopelessness and frustration in response to perceiving a deteriorating functional status. This led some to a cycle of despair characterized by worsening adherence and negative emotions. As these cycles progressed and distressing symptoms worsened, patients viewed the hospital as the safest place for recovery and not a “negative” outcome.ConclusionCycles of limit testing and despair represent important patient-centered struggles in managing heart failure. The resulting distress and fear make readmission a rational choice for patients rather than a negative outcome. Interventions (e.g., palliative care) that focus on methods to address these patient-centered factors should be further studied rather than methods to reduce hospital readmissions.

Deployment communication: Underlying processes and outcomes.

This concurrent embedded mixed methods study explored important aspects of communication occurring between military service members and their intimate partners during a combat deployment to Iraq or Afghanistan. Fifty-eight participants (32 military veterans and 26 non-veteran partners) participated in an interview using standardized self-report measures assessing the current level of relationship satisfaction, trauma symptoms of the veteran, and the veterans’ trauma exposure. Participants also participated in a semistructured interview focused on combat deployment and reintegration experiences. The findings suggested that communication between service members and their intimate partners during deployment is important to maintaining an emotional connection, preventing distancing to ease the transition back, obtaining assurance regarding the safety of the deployed partner, and meeting current needs to be emotionally engaged with their partner. Access to the methods of deployment communication, however, was reported to be highly variable within and across deployments. Planned withholding of unpleasant or distressing information from one’s partner appeared to be common and may represent a choice by participants to improve their well-being and outcomes. Recommendations for clinical interventions include preventive programs to help couples discuss their expectations for communication during the deployment. Future research might focus on the development of measures of preferences in deployment communication, as well as the degree of impact of communication on service member duty performance, individual psychological outcomes, and couple-based outcomes.

Reducing Blindness from Retinopathy of Prematurity (ROP) in Argentina Through Collaboration, Advocacy and Policy Implementation

Retinopathy of prematurity (ROP) is a largely avoidable cause of blindness in children worldwide, requiring high-quality neonatal care, early detection and treatment. In middle-income countries throughout Latin America, Eastern Europe and South Asia, there has been a rise in ROP blindness due to a combination of increased survival of preterm infants, resource-scarce medical environments and lack of policies, training and human resources. However, Argentina is an example of country where rates of ROP blindness have declined and ROP programmes have been successfully and effectively embedded within the health and legal system. The purpose of this study is to describe the activities and stakeholders, including Ministry of Health (MoH) and UNICEF, involved in the process, from recognition of an epidemic of ROP blindness to the development of national guidelines, policies and legislation for control. Using a retrospective mixed methods case study design, data on rates of severe ROP was collected from 13 neonatal intensive care units from 1999 to 2012, and on the proportion of children blind from ROP in nine blind schools in seven provinces. Legislative document review, focus group discussions and key informant interviews were conducted with neonatologists, ophthalmologists, neonatal nurses, parents, MoH officials, clinical societies, legislators and UNICEF officials in seven provinces. Results are presented combining the stages heuristic policy framework and Shiffman including: agenda setting, policy formulation, implementation and evaluation. By 2012, ROP had declined as a cause of blindness in children in schools for the blind as had rates of severe ROP needing treatment in the NICUs visited. Multiple factors played a role in reducing blindness from ROP in Argentina and successfully coordinating its control including national advocacy, leadership, legislation and international collaboration. Lessons learned in Argentina can potentially be scaled to other LMICs in Latin America and beyond with further context-specific research.

Incorporating patient-centered factors into heart failure readmission risk prediction: A mixed-methods study

Background: Capturing and incorporating patient‐centered factors into 30‐day readmission risk prediction after hospitalized heart failure (HF) could improve the modest performance of current models. Methods: Using a mixed‐methods approach, we developed a patient‐centered survey and evaluated the additional predictive utility of the survey compared to a traditional readmission risk model (the Krumholz et al. model). Area under the receiver operating characteristic curve (AUC) and the Hosmer‐Lemeshow goodness‐of‐fit statistic quantified the performance of both models. We measured the amount of model improvement with the addition of patient‐centered factors to the Krumholz et al. model with the integrated discrimination improvement (IDI). In an exploratory analysis, we used hierarchical clustering algorithms to identify groups with similar survey responses and tested for differences between clusters using standard descriptive statistics. Results: From 3/24/2014 to 3/12/2015, 183 patients hospitalized with HF were enrolled from an urban, academic health system and followed for 30 days after discharge. The Krumholz et al. plus patient‐centered factors model had similar‐to‐slightly lower performance (AUC [95%CI]:0.62 [0.52, 0.71]; goodness‐of‐fit P = .10) than the Krumholz et al. model (AUC [95%CI]:0.66 [0.57, 0.76]; goodness‐of‐fit P = .19). The IDI (95%CI) was 0.003 (−0.014,0.020). We identified three patient clusters based on patient‐centered survey responses. The clusters differed with respect to gender, self‐rated health, employment status, and prior hospitalization frequency (all P < .05). Conclusions: The addition of patient‐centered factors did not improve 30‐day readmission model performance. Rather than designing interventions based on predicted readmission risk, tailoring interventions to all patients, based on their characteristics, could inform the design of targeted, readmission reduction strategies.