COVID-19 vaccination perspectives among patients with Long COVID: A qualitative study

Individuals who have Long COVID may have unique perspectives about COVID-19 vaccination due to the significant impact that COVID-19 has had on their lives. However, little is known about the specific vaccination perspectives among this patient population. The goal of our study was to improve our understanding of perspectives about COVID-19 vaccines among individuals with Long COVID. Interviews were conducted with patients receiving care at a post-COVID recovery clinic. Deductive thematic analysis was used to characterize participant perspectives according to the vaccine acceptance continuum framework, which recognizes a spectrum from vaccine acceptance to refusal. From interviews with 21 patients, we identified perspectives across the continuum of vaccine acceptance. These perspectives included acceptance of vaccines to prevent future illness, concerns about vaccine side effects on Long COVID symptoms, and refusal of vaccines due to perceived natural immunity. A limitation of our study is that these perspectives are specific to individuals receiving care at one post-COVID recovery clinic. In conclusion, our study demonstrates that some patients with Long COVID are uncertain about COVID-19 vaccines and boosters but may also be amenable to conversations that impact future vaccination acceptance. Patient perspectives should be considered when communicating recommendations for COVID-19 vaccinations to this population.

When Infections Are Found: A Qualitative Study Characterizing Best Management Practices for Central Line-Associated Bloodstream Infection and Catheter-Associated Urinary Tract Infection Performance Monitoring and Feedback

Healthcare-associated infections (HAIs) remain a significant patient safety problem that can lead to illness and death, despite the implementation of clinical bundles to prevent HAIs. Management practices can support HAI prevention, but their role in HAI performance monitoring and feedback is not well understood. To address this knowledge gap, we previously conducted semi-structured interviews with staff at 18 hospitals to examine the role of management practices around the prevention of central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs). Interview transcripts were analyzed to identify themes related to HAI performance monitoring and feedback. The current analysis focuses on 10 higher-performing hospitals that were successful in preventing CLABSIs and CAUTIs. These institutions had robust practices including timely event analysis, leadership engagement, and multidisciplinary participation in HAI reviews. Across these sites, we found common goals including investigating HAIs without blame and identifying opportunities for improvement. Management practices such as timely analysis of HAIs, collaboration between facility leadership and multidisciplinary team members, and a focus on identifying the failure of a procedure or protocol, rather than the failure of staff members, are all approaches that can support infection prevention efforts. These management practices may be especially important as hospitals attempt to address increases in CLABSI and CAUTI rates that may have occurred during the coronavirus pandemic.

Creating a Palliative Care Clinic for Patients with Cancer Pain and Substance Use Disorder

BACKGROUND

Opioids are a first-line treatment for severe cancer pain. However, clinicians may be reluctant to prescribe opioids for patients with concurrent substance use disorders (SUD) or clinical concerns about non-prescribed substance use.

MEASURES

Patient volume, 60-day retention rate, and use of sublingual buprenorphine to treat opioid use disorder.

INTERVENTION

We created the Palliative Harm Reduction and Resiliency Clinic, a palliative care clinic founded on harm reduction principles and including formal collaboration with addiction psychiatry.

OUTCOMES

During the first 18 months, patient volume increased steadily; 70% of patients had at least one subsequent visit within 60 days of the initial appointment; and buprenorphine was prescribed for 55% of patients with opioid use disorder.

CONCLUSIONS/LESSONS LEARNED

The formal collaboration with addiction psychiatry and the integration of harm reduction principles and practices into ambulatory palliative care improved our ability to provide treatment to a previously underserved patient population with high symptom burden.

Reporting time toxicity in prospective cancer clinical trials: A scoping review

PURPOSE

This review aimed to assess the measurement and reporting of time toxicity (i.e., time spent receiving care) within prospective oncologic studies.

METHODS

On July 23, 2023, PubMed, Scopus, and Embase were queried for prospective or randomized controlled trials (RCT) from 1984 to 2023 that reported time toxicity as a primary or secondary outcome for oncologic treatments or interventions. Secondary analyses of RCTs were included if they reported time toxicity. The included studies were then evaluated for how they reported and defined time toxicity.

RESULTS

The initial query identified 883 records, with 10 studies (3 RCTs, 2 prospective cohort studies, and 5 secondary analyses of RCTs) meeting the final inclusion criteria. Treatment interventions included surgery (n = 5), systemic therapies (n = 4), and specialized palliative care (n = 1). The metric "days alive and out of the hospital" was used by 80% (n = 4) of the surgical studies. Three of the surgical studies did not include time spent receiving ambulatory care within the calculation of time toxicity. "Time spent at home" was assessed by three studies (30%), each using different definitions. The five secondary analyses from RCTs used more comprehensive metrics that included time spent receiving both inpatient and ambulatory care.

CONCLUSIONS

Time toxicity is infrequently reported within oncologic clinical trials, with no standardized definition, metric, or methodology. Further research is needed to identify best practices in the measurement and reporting of time toxicity to develop strategies that can be implemented to reduce its burden on patients seeking cancer care.

Gaps in Patient-Centered Decision-Making Related to Complex Surgery: A Mixed-Methods Study

INTRODUCTION

We sought to understand the perceptions of surgeons around patient preferred roles in decision-making and their approaches to patient-centered decision-making (PCDM).

METHODS

A concurrent embedded mixed-methods design was utilized among a cohort of surgeons performing complex surgical procedures. Data were collected through online surveys. Associations between perceptions and PCDM approaches were examined.

RESULTS

Among 241 participants, most respondents were male (67.2%) with an average age of 47.6 y (standard deviation = 10.3); roughly half (52.4%) had practiced medicine for 10 or more years. Surgeons most frequently agreed (94.2%) with the statement, "Patients prefer to make health decisions on their own after seriously considering their physician's opinion." Conversely, surgeons most frequently disagreed (73.0%) with the statement, "Patients prefer that their physician make health decisions for them." Nearly one-third (30.4%) of surgeon qualitative responses (n = 115) indicated that clinical/biological information would help them tailor their approach to PCDM. Only 12.2% of respondents indicated that they assess patient preferences regarding both decision-making and information needs.

CONCLUSIONS

Surgeons most frequently agree that patients want to make their own health decisions after seriously considering their physicians opinion. A greater focus on what information surgeons should know before treatment decision-making may help optimize patient experience and outcomes related to complex surgical procedures.

Which factors influence the approach to shared decision-making among surgeons performing complex operations?

BACKGROUND

Shared decision-making (SDM) aims to create a context in which patients and surgeons work together to explore treatment options and goals of care. The objective of the current study was to characterize demographic factors, behaviors, and perceptions of patient involvement among surgeons relative to SDM.

METHODS

Using a cross-sectional survey methodology, surgeon demographics, behaviors, and perceptions of patient involvement were assessed. Surgeon approaches to SDM were measured using a 100-point scale ranging from 'patient-led' (0) to 'surgeon-led' (100).

RESULTS

Among 241 respondents, most were male (n = 123, 67.2%) and White (n = 124, 69.3%); roughly one-half of surgeons had been in practice ≥10 years (n = 120, 52.4%). Surgeon approaches to SDM ranged from 0 to 81.0, with a median rating of 50.0 (IQR: 35.5, 62.0). Reported approaches to SDM were associated with years in practice, sharing information, and perceptions of patient involvement. Surgeons in practice 10 + years most frequently utilized a 'Shared, Patient-led' approach to SDM (27.5%), while individuals with less experience more often employed a 'Shared, Surgeon-led' approach (33.3%, p = 0.031). Surgeons with a 'Patient-led' approach perceived patient involvement as most important (M = 3.82, SD = 0.16), while respondents who had a 'Surgeon-led' approach considered this less important (M = 3.57, SD = 0.38; p < 0.001).

CONCLUSION

Surgeon factors including demographics, behaviors, and perceptions of patient involvement influenced SDM approaches. SDM between patients and surgeons should strive to be more dynamic and tailored to each specific patient's needs to promote optimal patient-centered care.

Patient Experiences Navigating Care Coordination For Long COVID: A Qualitative Study

BACKGROUND

Little is known about how to best evaluate, diagnose, and treat long COVID, which presents challenges for patients as they seek care.

OBJECTIVE

Understand experiences of patients as they navigate care for long COVID.

DESIGN

Qualitative study involving interviews with patients about topics related to seeking and receiving care for long COVID.

PARTICIPANTS

Eligible patients were at least 18 years of age, spoke English, self-identified as functioning well prior to COVID infection, and reported long COVID symptoms continued to impact their lives at 3 months or more after a COVID infection.

APPROACH

Patients were recruited from a post-COVID recovery clinic at an academic medical center from August to September 2022. Interviews were audio-recorded, transcribed, and analyzed using thematic analysis.

KEY RESULTS

Participants (n=21) reported experiences related to elements of care coordination: access to care, evaluation, treatment, and ongoing care concerns. Some patients noted access to care was facilitated by having providers that listened to and validated their symptoms; other patients reported feeling their access to care was hindered by providers who did not believe or understand their symptoms. Patients reported confusion around how to communicate their symptoms when being evaluated for long COVID, and they expressed frustration with receiving test results that were normal or diagnoses that were not directly attributed to long COVID. Patients acknowledged that clinicians are still learning how to treat long COVID, and they voiced appreciation for providers who are willing to try new treatment approaches. Patients expressed ongoing care concerns, including feeling there is nothing more that can be done, and questioned long-term impacts on their aging and life expectancy.

CONCLUSIONS

Our findings shed light on challenges faced by patients with long COVID as they seek care. Healthcare systems and providers should consider these challenges when developing strategies to improve care coordination for patients with long COVID.

Identifying beliefs driving COVID-19 vaccination: Lessons for effective messaging

Increasing vaccination acceptance has been essential during the COVID-19 pandemic and in preparation for future public health emergencies. This study aimed to identify messaging strategies to encourage vaccine uptake by measuring the drivers of COVID-19 vaccination among the general public. A survey to assess COVID-19 vaccination acceptance and hesitancy was advertised on Facebook in February-April 2022. The survey included items asking about COVID-19 vaccination status and participant demographics, and three scales assessing medical mistrust, perceived COVID-19 risk, and COVID-19 vaccine confidence (adapted from the Oxford COVID-19 vaccine confidence and complacency scale). The main outcome was vaccination, predicted by patient demographics and survey scale scores. Of 1,915 survey responses, 1,450 (75.7%) were included, with 1,048 (72.3%) respondents reporting they had been vaccinated. In a multivariable regression model, the COVID-19 vaccine confidence scale was the strongest predictor of vaccination, along with education level and perceived COVID-19 risk. Among the items on this scale, not all were equally important in predicting COVID-19 vaccination. The items that best predicted vaccination, at a given score on the COVID-19 vaccine confidence scale, included confidence that vaccine side effects are minimal, that the vaccine will work, that the vaccine will help the community, and that the vaccine provides freedom to move on with life. This study improved our understanding of perceptions most strongly associated with vaccine acceptance, allowing us to consider how to develop messages that may be particularly effective in encouraging vaccination among the general public for both the COVID-19 pandemic and future public health emergencies.

Short-term and long-term financial toxicity from breast cancer treatment: a qualitative study

PURPOSE

The rising cost of breast cancer treatment has increased patients' financial burden, intensifying an already stressful treatment process. Although researchers increasingly recognize the harmful impact of medical and nonmedical costs associated with cancer treatment, understanding patients' perspectives of financial toxicity is limited. We aimed to explore the topic of financial toxicity through the lived experiences of patients with breast cancer from groups at risk of social and economic marginalization.

METHODS

We conducted semi-structured interviews with 50 women with breast cancer from four specific groups: Black women, Medicaid enrollees, rural residents, and women age ≤ 40. We transcribed, coded, and analyzed the data using deductive and inductive approaches.

RESULTS

Two overarching themes captured patients' experiences of financial toxicity: short-term and long-term impacts. Short-term stressors included direct medical (e.g., co-pays, premiums), nonmedical (e.g., transportation, lodging), and indirect (e.g., job loss, reduced work hours) costs. Early in their treatments, patients' focus on survival took precedence over financial concerns. However, as the treatment course progressed, fear of consequences from compounding costs of care and financial distress negatively impacted patients' lifestyles and outlooks for the future.

CONCLUSION

Programs addressing financial toxicity that look beyond early-phase interventions are needed. Specifically, patients struggling with the accumulation of treatment costs and the resultant stress require ongoing support. Long-term support is especially needed for groups vulnerable to financial instability and social marginalization.

The Role of Palliative Care in Heart Failure, Part 3: Facilitators and Barriers to Cardiac Palliative Care Clinic Development

Background: Patients with heart failure frequently have significant disease burden and complex psychosocial needs. The integration of palliative care into the management of these patients can decrease symptom burden throughout their course of illness. Therefore, in 2009, we established a cardiac palliative care clinic colocated with heart failure providers in a large academic heart hospital. Objective: To better understand the facilitators and barriers to integrating palliative care into our heart failure management service. Design: Qualitative study using a semistructured interview guide. Setting, Subjects: Between October 2020 and January 2021, we invited all 25 primary cardiac providers at our academic medical center in the midwestern United States to participate in semistructured qualitative interviews to discuss their experiences with the cardiac palliative care clinic. Measurements: Interview transcripts were analyzed using a deductive-dominant thematic analysis approach to reveal emerging themes. Results: Providers noted that the integration of palliative care into the treatment of patients with heart failure was helped and hindered primarily by issues related to operations and communications. Operational themes about clinic proximity and the use of telehealth as well as communication themes around provider-provider communication and the understanding of palliative care were particularly salient. Conclusions: The facilitators and barriers identified have broad applicability that are independent of the etiological nature (e.g., cancer, pulmonary, neurological) of any specialty or palliative care clinic. Moreover, the strategies we used to implement improvements in our clinic may be of benefit to other practice models such as independent and embedded clinics.

The Role of Palliative Care in Heart Failure, Part 4: A Framework for Collaboration in Advance Care Planning

Background: Palliative care integration into cardiology is growing, allowing primary cardiology care teams increasing opportunities to utilize palliative care to support processes such as advance care planning (ACP). Objective: The aim of the study is to understand perspectives of cardiac care team members about the involvement and impact of palliative care on ACP in heart failure. Design: A qualitative study using a semistructured interview guide was performed. Settings/Subjects: Interviews were conducted with cardiac care team members, including cardiologists, cardiac surgeons, and nurse practitioners, at a large academic medical center in the United States with an integrated cardiac palliative care team. Measurements: Deductive and inductive thematic analysis of interview transcripts enabled characterization of themes around the role of palliative care in ACP. Results: Two themes were identified with regard to providers' perspectives about ACP: (1) different levels of comfort with initiating and conducting ACP conversations and (2) different opinions about the desired role of palliative care in the ACP process. In exploring these themes, we characterized four distinct approaches to ACP with palliative care as a novel framework for planning consultation. Conclusions: The different approaches to ACP and the implications for how cardiac providers interact with the palliative care team present an important opportunity to guide ACP consultation in practice. Adoption of this framework may help cardiac providers enhance the process of care delivery and ACP in important ways that improve care for their patients.

The Role of Palliative Care in Heart Failure, Part 2: Characteristics of Patients Undergoing Outpatient Palliative Care Evaluation for Advanced Cardiac Therapies

Background: Characteristics of patients undergoing outpatient evaluation for advanced cardiac therapies are largely unknown. Objective: To describe demographics, baseline quality of life, and frailty of patients undergoing evaluation for advanced therapies at the time of presentation for evaluation in an outpatient cardiac palliative care clinic and examine key quality of life differences across patients. Design: Retrospective chart review to report baseline demographics and quality of life. Settings/Subjects: Patients at a large academic medical center in the United States referred for advanced cardiac therapies in 2021. Measurements: Depression and anxiety were measured using the Hospital Anxiety and Depression Scale; quality of life was measured using the Functional Assessment of Chronic Illness Therapy-Palliative care (FACIT-Pal) tool; and frailty was measured using the Fried Frailty Phenotype. Differences in quality of life by disease etiology, demographic characteristics, and frailty were assessed. Results: Fifty-four patients were seen in the outpatient cardiac palliative care clinic for advanced therapy evaluation. Most were Caucasian (80%) and male (74%). Patients traveled an average of 61 minutes to the clinic. All but five lived in a rural, medically underserved, or health professional shortage area. Forty percent scored abnormal or borderline abnormal for anxiety; 22% scored abnormal or borderline abnormal for depression. The FACIT-Pal mean score was 129 (standard deviation 23), with emotional and functional well-being domains contributing most to poor quality of life. Seventy-one percent were frail. Patients with a nonischemic etiology had a 3.32 times higher rate of anxiety than nonischemic patients (95% confidence interval = 1.05-10.54, p = 0.041). Conclusion: As patients undergoing transplant evaluation have high levels of depression, anxiety, and frailty, interdisciplinary care teams will be needed to properly manage the needs of this complex population. These results can inform efforts to integrate palliative care into advanced cardiac therapy and improve patients' experiences.

The Role of Palliative Care in Heart Failure, Part 1: Referring Provider Perspectives About Opportunities in Advanced Cardiac Therapies

Background: There are many ways that palliative care can support patients with heart failure, but the role of palliative care in supporting patients who are considering or are already using advanced cardiac therapies is less clear. Objective: To understand referring providers' perspectives about the role of palliative care in the treatment of patients with heart failure considering or using advanced cardiac therapies. Design: Qualitative study using a semistructured interview guide. Setting/Subjects: This study was conducted at an academic medical center in the United States with an integrated cardiac palliative care program. Interviews were conducted with cardiology providers, including cardiologists, cardiac surgeons, and nurse practitioners who care for patients with heart failure and who are considering or receiving advanced cardiac therapies. Measurements: Interview transcripts were analyzed deductively and inductively to reveal themes in providers' perspectives. Results: Five themes were identified about the role of palliative care when advanced therapies were considered or being used: (1) educating patients; (2) supporting goal-concordant care; (3) managing symptoms; (4) addressing psychosocial needs; and (5) managing end-of-life care. Providers suggested palliative care could be a facilitator of advanced therapies, rather than merely something to add to end-of-life care. Conclusions: Cardiology providers recognize the value of integrating palliative care across the heart failure disease trajectory to provide therapy options, support decision-making processes, and provide goal-concordant care for patients considering or receiving advanced therapies. Increasing awareness of opportunities to integrate palliative care throughout the treatment of these patients may help cardiology providers better coordinate with palliative care specialists to improve patient care.

Impact of early vs late palliative care referrals on healthcare utilization in patients with pancreatic cancer

PURPOSE

The purpose of this study was to examine the impact of early versus late palliative care referral (PCR) following pancreatic cancer diagnosis.

METHODS

Patients diagnosed with PDAC who received a PCR between 2014 and 2020 at a major academic institution were identified. PCR was classified as early (< 30 days) or late (≥ 30 days) based on time from definitive diagnosis. Data were obtained on number of emergency department (ED) visits, intensive care unit (ICU) admissions, and hospital admissions.

RESULTS

Among 1458 patients with PDAC, 419 (28.7%) received PCR, among which 67.3% (n = 282) received a late PCR. Of those who received PCR, the majority were White (85%) and male (54.8%), with a median age of 62 years at time of diagnosis. Patients who received an early PCR more commonly presented with stage 4 disease at diagnosis (early: n = 91, 69% vs. late: n = 132, 47%), whereas patients who received a late PCR more commonly presented with stage 1, 2, or 3 disease (early: n = 40, 30.5% vs. late: n = 150, 53.2%) (p < 0.001). Patients who received early PCR had fewer median ED visits (1 vs. 2, p < 0.001) and hospital admissions (1 vs. 2, p < 0.001) compared with patients who received late PCR. However, after performing recurrent-event Cox-proportional hazards models, the timing of PCR did not impact hospital admission (HR 0.88, 95% CI 0.68, 1.14; p = 0.3).

CONCLUSION

Timing of PCR for patients with PDAC was not associated with healthcare utilization. Further prospective trials are needed to study the patient-centered impact of early integration of palliative care services into multidisciplinary pancreatic cancer teams.

Perspectives of patients undergoing neoadjuvant chemotherapy for breast cancer during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic resulted in a lapse in routine health care and cancer screenings for many individuals. This study sought to improve our understanding of the impact of the COVID-19 pandemic on women being treated for breast cancer, both in general, and specifically related to their diagnosis.

METHODS

Semi-structured interviews were conducted between August 2021 and February 2022 with women who were receiving neoadjuvant chemotherapy for early-stage breast cancer at the Stefanie Spielman Comprehensive Breast Center in Columbus, Ohio. Interviews were recorded and transcribed verbatim. Transcripts were coded using deductive dominant thematic analysis and inductive coding that allowed for categorization of data as well as identification of emergent themes.

RESULTS

Data collected from our 19 interviews revealed that the COVID-19 pandemic posed important challenges for breast cancer patients including fear of COVID-19 infection and feelings of isolation. Most interviewees noted they had been vaccinated against COVID-19 because of a desire to protect themselves and others from getting sick. Some women also expressed concerns about having delayed their screening mammograms due to the pandemic. Several patients described unexpected positive aspects of the pandemic such as being able to spend more time with family and having the ability to continue working because of the option to work from home during their cancer treatment.

CONCLUSIONS

Our findings provide important insight about the impact of COVID-19 on breast cancer patients. We highlight the positives that have been reported because of the pandemic, as well as the need to address delayed breast cancer screening.

Understanding Concerns about COVID-19 and Vaccination: Perspectives from Kidney Transplant Recipients

The COVID-19 pandemic poses a significant risk for immunosuppressed groups such as transplant patients. The purpose of this study was to improve our understanding of the impact of the COVID-19 pandemic on kidney transplant recipients, including their views on COVID-19 vaccination. Semi-structured interviews were conducted from December 2021 to August 2022 with 38 kidney transplant recipients who had an appointment with their transplant care team within the previous 6 months. We used qualitative thematic analysis to characterize the perspectives of interviewees. Regardless of COVID-19 vaccination status, most interviewees reported utilizing public health measures such as masking, hand washing, and avoiding crowds to protect themselves against COVID-19. Vaccinated interviewees (n = 31) noted that they chose to receive a COVID-19 vaccine because of their increased risk due to their immunocompromised state. For unvaccinated interviewees (n = 7), reasons for not receiving a COVID-19 vaccine included concerns about the safety and efficacy of the vaccine. Both vaccinated and unvaccinated interviewees expressed concerns about the lack of adequate testing of the vaccine in transplant patients and questioned if the vaccine might have unknown side effects for transplant recipients. Regardless of the vaccination status, most interviewees noted having trust in their healthcare team. Interviewees also described interpersonal tensions that arose during the pandemic, many of which surrounded vaccination and other preventive measures that were important to participants to protect their health. Together, these data demonstrate differing concerns and experiences related to the COVID-19 pandemic for vaccinated and unvaccinated transplant recipients. These findings highlight the unique needs of transplant recipients and reveal opportunities to support this vulnerable patient population in efforts to protect their health as the COVID-19 pandemic evolves.

Utilization of Palliative and Hospice Care Among Pancreatic Cancer Patients at an Academic Center

INTRODUCTION

Pancreatic ductal adenocarcinoma has the lowest 5-y relative survival of all solid tumor malignancies. Palliative care can improve the quality of life of both patients and their caregivers. However, the utilization patterns of palliative care in patients with pancreatic cancer are unclear.

METHODS

Pancreatic cancer patients who were diagnosed between October 2014 and December 2020 at the Ohio State University were identified. Palliative care and hospice utilization and referral patterns were assessed.

RESULTS

Of the 1458 pancreatic cancer patients, 55% (n = 799) were male, median age at diagnosis was 65 y (interquartile range [IQR]: 58, 73), and most were Caucasian (n = 1302, 89%). Palliative care was utilized by 29% (n = 424) of the cohort, with the initial consultation obtained after an average of 6 ± 9 mo from diagnosis. Patients who received palliative care were younger (62 y, IQR: 55, 70 versus 67 y, IQR: 59, 73; P < 0.001) and more frequently members of racial and ethnic minorities (15% versus 9%; P < 0.001) versus those who did not receive palliative care. Among the 344 (24%) patients who received hospice care, 153 (44%) had no prior palliative care consultation. Patients referred to hospice care survived a median of 14 d (95% CI, 12-16) after hospice referral.

CONCLUSIONS

Only 3 out of 10 patients with pancreatic cancer received palliative care at an average of 6 mo from initial diagnosis. More than two out of every five patients referred to hospice had no previous palliative care consultation. Efforts to understand the impact of improved integration of palliative care into pancreatic cancer programs are needed.

Total artificial heart implantation: supportive care preparedness planning framework

BACKGROUND

The total artificial heart (TAH) is an implanted device approved as a modality to stabilize patients with severe biventricular heart failure or persistent ventricular arrhythmias for evaluation and bridge to transplantation. According to the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS), about 450 patients received a TAH between 2006 and 2018. Patients being evaluated for a TAH are often critically ill and a TAH offers the best chance at survival. Given the prognostic uncertainty of these patients, there is a crucial need for preparedness planning to help patients and their caregivers plan for living and supporting a loved one with a TAH.

AIM

To describe an approach to preparedness planning and highlight the importance of palliative care.

METHODS

We reviewed the current needs and approaches to preparedness planning for a TAH. We categorized our findings and suggest a guide to maximize conversations with patients and their decision makers.

RESULTS

We identified four critical areas to address: the decision maker, minimal acceptable outcome/maximal acceptable burden, living with the device, and dying with the device. We suggest using a framework of mental and physical outcomes and locations of care as a way to identify minimal acceptable outcome and maximal acceptable burden.

CONCLUSION

Decision making for a TAH is complex. There is an urgency and patients do not always have capacity. Identifying legal decision makers and social support is critical. The surrogate decision makers should be included in preparedness planning including discussions about end-of-life care and treatment discontinuation. Having palliative care as members of the interdisciplinary mechanical circulatory support team can assist in these preparedness conversations.

Prevalence of Violence against Providers in Heart and Lung Transplant Programs

Workplace violence in healthcare institutions is becoming more frequent. The objective of this study was to better understand the nature of threat and physical acts of violence from heart and lung transplant patients and families toward healthcare providers and suggest programmatic mitigation strategies. We administered a brief survey to attendees at the 2022 International Society of Heart and Lung Transplantation Conference in Boston, Massachusetts. A total of 108 participants responded. Threats of physical violence were reported by forty-five participants (42%), were more frequently reported by nurses and advanced practice providers than physicians (67% and 75% vs. 34%; p < 0.001) and were more prevalent in the United States than abroad (49% vs. 21%; p = 0.026). Acts of physical violence were reported by one out of every eight providers. Violence against providers in transplant programs warrants closer review by health systems in order to ensure the safety of team members.

Perspectives of Volunteer Firefighters during the COVID-19 Pandemic: Stumbling Blocks and Silver Linings

The COVID-19 pandemic has profoundly affected the lives of almost every individual in every nation, with numbers of infections continuing to grow. Across these nations, first responders are essential in their roles addressing emergencies, despite their risk of exposure to COVID-19 in the course of their work. We sought to understand the impacts of the COVID-19 pandemic on the lives of volunteer firefighters in the United States, an understudied group of these first responders. Interviews were conducted with volunteer firefighters between September and November 2021. Interviews were analyzed using deductive dominant thematic analysis. Thirty-three firefighters were interviewed who had an average of 22 years of service and a mean age of 52 years. Interviewees described pandemic-related challenges including the fear of COVID exposure and frustrations with work and personal relationships. They also identified unexpected work-related benefits including a deepened commitment to serve and improvements to training and safety. Further, some volunteers noted personal benefits such as developing stronger connections with others, having a new outlook on life, and observing goodwill. Our findings provide insight into the multifaceted and complex impact of the COVID-19 pandemic on volunteer firefighters.

Effect of In-Person vs Video Training and Access to All Functions vs a Limited Subset of Functions on Portal Use Among Inpatients: A Randomized Clinical Trial

Importance

Inpatient portals provide patients with clinical data and information about their care and have the potential to influence patient engagement and experience. Although significant resources have been devoted to implementing these portals, evaluation of their effects has been limited.

Objective

To assess the effects of patient training and portal functionality on use of an inpatient portal and on patient satisfaction and involvement with care.

Design, Setting, and Participants

This randomized clinical trial was conducted from December 15, 2016, to August 31, 2019, at 6 noncancer hospitals that were part of a single health care system. Patients who were at least 18 years of age, identified English as their preferred language, were not involuntarily confined or detained, and agreed to be provided a tablet to access the inpatient portal during their stay were eligible for participation. Data were analyzed from May 1, 2019, to March 15, 2021.

Interventions

A 2 × 2 factorial intervention design was used to compare 2 levels of a training intervention (touch intervention, consisting of in-person training vs built-in video tutorial) and 2 levels of portal function availability (tech intervention) within an inpatient portal (all functions operational vs a limited subset of functions).

Main Outcomes and Measures

The primary outcomes were inpatient portal use, measured by frequency and comprehensiveness of use, and patients' satisfaction and involvement with their care.

Results

Of 2892 participants, 1641 were women (56.7%) with a median age of 47.0 (95% CI, 46.0-48.0) years. Most patients were White (2221 [76.8%]). The median Charlson Comorbidity Index was 1 (95% CI, 1-1) and the median length of stay was 6 (95% CI, 6-7) days. Notably, the in-person training intervention was found to significantly increase inpatient portal use (incidence rate ratio, 1.34 [95% CI, 1.25-1.44]) compared with the video tutorial. Patients who received in-person training had significantly higher odds of being comprehensive portal users than those who received the video tutorial (odds ratio, 20.75 [95% CI, 16.49-26.10]). Among patients who received the full-tech intervention, those who also received the in-person intervention used the portal more frequently (incidence rate ratio, 1.36 [95% CI, 1.25-1.48]) and more comprehensively (odds ratio, 22.52; [95% CI, 17.13-29.62]) than those who received the video tutorial. Patients who received in-person training had higher odds (OR, 2.01 [95% CI, 1.16-3.50]) of reporting being satisfied in the 6-month postdischarge survey. Similarly, patients who received the full-tech intervention had higher odds (OR, 2.06 [95%CI, 1.42-2.99]) of reporting being satisfied in the 6-month postdischarge survey.

Conclusions and Relevance

Providing in-person training or robust portal functionality increased inpatient engagement with the portal during the hospital stay. The effects of the training intervention suggest that providing personalized training to support use of this health information technology can be a powerful approach to increase patient engagement via portals.

Trial Registration

ClinicalTrials.gov Identifier: NCT02943109.

An Opportunity to Understand Concerns about COVID-19 Vaccination: Perspectives from EMS Professionals

Some healthcare professionals, including emergency medical service (EMS) professionals, remain hesitant about receiving COVID-19 vaccines. This study sought to understand EMS professionals’ perspectives regarding COVID-19 vaccination. Using open-ended comments from a national survey deployed electronically to over 19,000 EMS professionals in April of 2021, we examined perspectives about acceptance of and hesitancy toward COVID-19 vaccines. Survey comments revealed differences in perspectives between vaccinated and unvaccinated EMS professionals regarding their personal role in improving public health through COVID-19 vaccination as well as vaccine benefits and the protection conferred by vaccination. Unvaccinated individuals also expressed concerns over the research and development of the COVID-19 vaccines that led to their decision not to get vaccinated. Individuals who were vaccinated suggested ways to increase uptake of the vaccine including having healthcare professionals serve as leaders for vaccination and educating individuals about COVID-19 vaccination through credible resources. Vaccine hesitancy remains a challenge to achieving herd immunity to COVID-19 through vaccination, even among healthcare professionals. Understanding the perspectives of those who have chosen not to be vaccinated can help direct strategies to reduce confusion and concerns. The perspectives of vaccinated individuals may also be valuable in identifying opportunities to promote vaccination in the professional setting.

Closing the Gap on COVID-19 Vaccinations in First Responders and Beyond: Increasing Trust

Although COVID-19 vaccines are widely available in the U.S. and much of the world, many have chosen to forgo this vaccination. Emergency medical services (EMS) professionals, despite their role on the frontlines and interactions with COVID-positive patients, are not immune to vaccine hesitancy. Via a survey conducted in April 2021, we investigated the extent to which first responders in the U.S. trusted various information sources to provide reliable information about COVID-19 vaccines. Those vaccinated generally trusted healthcare providers as a source of information, but unvaccinated first responders had fairly low trust in this information source-a group to which they, themselves, belong. Additionally, regardless of vaccination status, trust in all levels of government, employers, and their community as sources of information was low. Free-response explanations provided some context to these findings, such as preference for other COVID-19 management options, including drugs proven ineffective. A trusted source of COVID-19 vaccination information is not readily apparent. Individuals expressed a strong desire for the autonomy to make vaccination decisions for themselves, as opposed to mandates. Potential reasons for low trust, possible solutions to address them, generalizability to the broader public, and implications of low trust in official institutions are discussed.

Premedical Students' Attitudes Toward Primary Care Medicine

BACKGROUND

Expanded insurance coverage will likely increase the demand for primary care physicians in the United States. Despite this demand, the number of medical students planning to specialize in primary care is decreasing.

OBJECTIVE

To explore premedical students' attitudes toward the primary care specialty.

METHODS

Students enrolled in premedicine at a large Midwestern university were invited to complete the Primary Care Attitudes Survey (Cronbach α=.76). This 25-item survey measures attitudes about primary care on a 5-point Likert scale, ranging from 1, "strongly disagree" to 5, "strongly agree." Basic sociodemographic characteristics were assessed using descriptive statistics, and frequencies of individual survey responses were calculated using SPSS statistical software version 21.0.

RESULTS

A total of 100 premedical students (mean [SD] age, 19.8 [1.5] years; 59 female, 82 white non-Hispanic, and 33 freshman) completed the survey. Of 100 students, 33 planned to pursue primary care; 66 thought that primary care physicians would always have a job; 25 thought that primary care may become obsolete as medicine becomes more specialized; 48 thought that physician assistants and nurse practitioners would take over many primary care duties in the future; 91 thought that primary care physicians make important contributions to medicine; and 84 agreed that primary care focuses on the whole patient.

CONCLUSIONS

Premedical students held positive views about the importance of primary care; however, many expressed uncertainty about the stability of primary care careers in the future. Further, a substantial number of students believed common misconceptions about the scope and practice of primary care, such as primary care doctors are gatekeepers and mostly diagnose colds and ear infections.

Immunoglobulin Crystals in Reactive Plasma Cells in a Dog

Intracellular crystalline deposits of immunoglobulin are occasionally seen in human B-cell lymphoproliferative disorders such as multiple myeloma, chronic lymphocytic leukemia, and various forms of lymphoma. Even more uncommon is the occurrence of immunoglobulin crystals in benign plasma cells or reactive lymphocytes. Here we describe the histologic, immunohistochemical, and ultrastructural features of intracellular immunoglobulin crystals in nonneoplastic plasma cells in a chronic inflammatory lesion in a dog. Microscopically, the intracellular, nonbirefringent eosinophilic crystals were square to rectangular, 2–20 μgm long, and caused nuclear displacement to the periphery. The crystal-containing cells, as well as some of the crystals themselves, were positive for lambda light chain. Ultrastructural findings were consistent with a lattice network of protein-molecule alignment. The cause and significance of the crystals is unknown.