Effects of the Communities that Heal (CTH) intervention on perceived opioid-related community stigma in the HEALing Communities Study: results of a multi-site, community-level, cluster-randomized trial

Background

Community stigma against people with opioid use disorder (OUD) and intervention stigma (e.g., toward naloxone) exacerbate the opioid overdose crisis. We examined the effects of the Communities that HEAL (CTH) intervention on perceived opioid-related community stigma by stakeholders in the HEALing Communities Study (HCS).

Methods

We collected three surveys from community coalition members in 66 communities across four states participating in HCS. Communities were randomized into Intervention (Wave 1) or Wait-list Control (Wave 2) arms. We conducted multilevel linear mixed models to compare changes in primary outcomes of community stigma toward people treated for OUD, naloxone, and medication for opioid use disorder (MOUD) by arm from time 1 (before the start of the intervention) to time 3 (end of the intervention period in the Intervention arm).

Findings

Intervention stakeholders reported a larger decrease in perceived community stigma toward people treated for OUD (adjusted mean change (AMC) -3.20 [95% C.I. -4.43, -1.98]) and toward MOUD (AMC -0.33 [95% C.I. -0.56, -0.09]) than stakeholders in Wait-list Control communities (AMC -0.18 [95% C.I. -1.38, 1.02], p = 0.0007 and AMC 0.11 [95% C.I. -0.09, 0.31], p = 0.0066). The relationship between intervention status and change in stigma toward MOUD was moderated by rural-urban status (urban AMC -0.59 [95% CI, -0.87, -0.32], rural AMC not sig.) and state. The difference in stigma toward naloxone between Intervention and Wait-list Control stakeholders was not statistically significant (p = 0.18).

Interpretation

The CTH intervention decreased stakeholder perceptions of community stigma toward people treated for OUD and stigma toward MOUD. Implementing the CTH intervention in other communities could decrease OUD stigma across diverse settings nationally.

Funding

US National Institute on Drug Abuse.

Differences by Race in Outcomes of an In-Person Training Intervention on Use of an Inpatient Portal: A Secondary Analysis of a Randomized Clinical Trial

Importance

Differences in patient use of health information technologies by race can adversely impact equitable access to health care services. While this digital divide is well documented, there is limited evidence of how health care systems have used interventions to narrow the gap.

Objective

To compare differences in the effectiveness of patient training and portal functionality interventions implemented to increase portal use among racial groups.

Design, Setting, and Participants

This secondary analysis used data from a randomized clinical trial conducted from December 15, 2016, to August 31, 2019. Data were from a single health care system and included 6 noncancer hospitals. Participants were 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. Data were analyzed from September 1, 2022, to October 31, 2023.

Interventions

A 2 × 2 factorial design was used to compare the inpatient portal training intervention (touch, in-person [high] vs built-in video tutorial [low]) and the portal functionality intervention (technology, full functionality [full] vs a limited subset of functions [lite]).

Main Outcomes and Measures

Primary outcomes were inpatient portal use, measured by frequency and comprehensiveness of use, and use of specific portal functions. A logistic regression model was used to test the association of the estimators with the comprehensiveness use measure. Outcomes are reported as incidence rate ratios (IRRs) for the frequency outcomes or odds ratios (ORs) for the comprehensiveness outcomes with corresponding 95% CIs.

Results

Of 2892 participants, 550 (19.0%) were Black individuals, 2221 (76.8%) were White individuals, and 121 (4.2%) were categorized as other race (including African, American Indian or Alaska Native, Asian or Asian American, multiple races or ethnicities, and unknown race or ethnicity). Black participants had a significantly lower frequency (IRR, 0.80 [95% CI, 0.72-0.89]) of inpatient portal use compared with White participants. Interaction effects were not observed between technology, touch, and race. Among participants who received the full technology intervention, Black participants had lower odds of being comprehensive users (OR, 0.76 [95% CI, 0.62-0.91), but interaction effects were not observed between touch and race.

Conclusions and Relevance

In this study, providing in-person training or robust portal functionality did not narrow the divide between Black participants and White participants with respect to their inpatient portal use. Health systems looking to narrow the digital divide may need to consider intentional interventions that address underlying issues contributing to this inequity.

Trial Registration

ClinicalTrials.gov Identifier: NCT02943109.

Differences in perceptions of community stigma towards opioid use disorder between community substance use coalition members and the general public

INTRODUCTION

To examine differences in perceptions about community stigma towards individuals with opioid use disorder (OUD) between community members involved in the opioid response (i.e., coalition members) and the general public, and how community geography may moderate this relationship.

METHODS

This study administered identical cross-sectional surveys about perceived community opioid-related stigma to two distinct populations in 66 communities participating in the HEALing Communities Study prior to the intervention period (i.e., coalition members, November 2019-January 2020; residents, March-April 2020). Linear-mixed models compared survey responses of populations, including the moderating effect of community rural/urban location.

RESULTS

A total of 826 coalition members and 1131 residents completed the surveys. The study found no differences between the coalition members and residents for general perceived community opioid-related stigma. In both urban and rural communities, coalition members reported greater perceived community stigma than residents reported towards medication for opioid use disorder (MOUD), naloxone, and drug treatment as an alternative to incarceration.

CONCLUSION

Our findings suggest similar perceived community opioid-related stigma between coalition members and residents, yet differences emerge related to evidence-based practices (i.e., MOUD, naloxone, and drug treatment as an alternative to incarceration) to reduce opioid overdose deaths.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04111939.

Association of Socioeconomic Status With Life's Essential 8 in the National Health and Nutrition Examination Survey: Effect Modification by Sex

BACKGROUND

Higher scores for the American Heart Association Life's Essential 8 (LE8) metrics, blood pressure, cholesterol, glucose, body mass index, physical activity, smoking, sleep, and diet, are associated with lower risk of chronic disease. Socioeconomic status (SES; employment, insurance, education, and income) is associated with LE8 scores, but there is limited understanding of potential differences by sex. This analysis quantifies the association of SES with LE8 for each sex, within Hispanic Americans, non-Hispanic Asian Americans, non-Hispanic Black Americans, and non-Hispanic White Americans.

METHODS AND RESULTS

Using cross-sectional data from the National Health and Nutrition Examination Survey, years 2011 to 2018, LE8 scores were calculated (range, 0-100). Age-adjusted linear regression quantified the association of SES with LE8 score. The interaction of sex with SES in the association with LE8 score was assessed in each racial and ethnic group. The US population representatively weighted sample (13 529 observations) was aged ≥20 years (median, 48 years). The association of education and income with LE8 scores was higher in women compared with men for non-Hispanic Black Americans and non-Hispanic White Americans (P for all interactions <0.05). Among non-Hispanic Asian Americans and Hispanic Americans, the association of SES with LE8 was not different between men and women, and women had greater LE8 scores than men at all SES levels (eg, high school or less, some college, and college degree or more).

CONCLUSIONS

The factors that explain the sex differences among non-Hispanic Black Americans and non-Hispanic White Americans, but not non-Hispanic Asian Americans and Hispanic Americans, are critical areas for further research to advance cardiovascular health equity.

Community-level determinants of stakeholder perceptions of community stigma toward people with opioid use disorders, harm reduction services and treatment in the HEALing Communities Study

BACKGROUND

Community stigma toward people with opioid use disorder (OUD) can impede access to harm reduction services and treatment with medications for opioid use disorder (MOUD). Such community OUD stigma is partially rooted in community-level social and economic conditions, yet there remains a paucity of large-scale quantitative data examining community-level factors associated with OUD stigma. We examined whether rurality, social inequity, and racialized segregation across communities from four states in the HEALing Communities Study (HCS) were associated with 1) greater perceived community stigma toward people treated for OUD, 2) greater perceived intervention stigma toward MOUD, and 3) greater perceived intervention stigma toward naloxone by community stakeholders in the HCS.

METHODS

From November 2019-January 2020, a cross-sectional survey about community OUD stigma was administered to 801 members of opioid overdose prevention coalitions across 66 communities in four states prior to the start of HCS intervention activities. Bivariate analyses assessed pairwise associations between community rural/urban status and each of the three stigma variables, using linear mixed effect modeling to account for response clustering within communities, state, and respondent sociodemographic characteristics. We conducted similar bivariate analyses to assess pairwise associations between racialized segregation and social inequity.

RESULTS

On average, the perceived community OUD stigma scale score of stakeholders from rural communities was 4% higher (β=1.57, SE=0.7, p≤0.05), stigma toward MOUD was 6% higher (β=0.28, SE=0.1, p≤0.05), and stigma toward naloxone was 10% higher (β=0.46, SE=0.1, p≤0.01) than among stakeholders from urban communities. No significant differences in the three stigma variables were found among communities based on racialized segregation or social inequity.

CONCLUSION

Perceived community stigma toward people treated for OUD, MOUD, and naloxone was higher among stakeholders in rural communities than in urban communities. Findings suggest that interventions and policies to reduce community-level stigma, particularly in rural areas, are warranted.

Development of a conceptual model of the capacity for patients to engage in their health care: a group concept mapping study

BACKGROUND

Patient engagement is seen as a necessary component in achieving the triple aim of improved population health, improved experience of care, and lower per capita health care costs. While there has been a substantial increase in the number of tools and patient-centered initiatives designed to help patients participate in health decisions, there remains a limited understanding of engagement from the perspective of patients and a lack of measures designed to capture the multi-faceted nature of the concept.

METHODS

Development of a concept map of patient engagement followed a five-step modified Group Concept Mapping (GCM) methodology of preparation, generation, structuring, analysis and interpretation. We engaged a Project Advisory Committee at each step, along with three rounds of survey collection from clinicians and patients for element generation (272 clinicians, 61 patients), statement sorting (30 clinicians, 15 patients), and ranking and rating of statements (159 clinicians, 67 patients). The survey of three separate samples, as opposed to focus groups of 'experts,' was an intentional decision to gain a broad perspective about the concept of patient engagement. We conducted the structure and analysis steps within the groupwisdom concept mapping software.

RESULTS

The final concept map comprised 47 elements organized into 5 clusters: Relationship with Provider, Patient Attitudes and Behaviors, Access, Internal Resources and External Resources. There was considerable agreement in the way elements in each cluster were rated by patients and clinicians. An analysis of the importance of the constitutive elements of patient engagement relative to their addressability highlighted actionable items in the domain of Relationship with Provider, aimed at building trust and enabling patients to ask questions. At the same time, the analysis also identified elements traditionally considered barriers to engagement, like personal access to the internet and the patient's level of digital literacy, as difficult to address by the healthcare system, but also relatively less important for patients.

CONCLUSIONS

Through our GCM approach, incorporating perspectives of both patients and clinicians, we identified items that can be used to assess patient engagement efforts by healthcare systems. As a result, our study offers specific insight into areas that can be targeted for intervention by healthcare systems to improve patient engagement.

Association of Living in a Food Desert and Poor Periconceptional Diet Quality in a Cohort of Nulliparous Pregnant Individuals

BACKGROUND

A poor diet can result from adverse social determinants of health and increases the risk of adverse pregnancy outcomes.

OBJECTIVE

We aimed to assess, using data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be prospective cohort, whether nulliparous pregnant individuals who lived in a food desert were more likely to experience poorer periconceptional diet quality compared with those who did not live in a food desert.

METHODS

The exposure was living in a food desert based on a spatial overview of food access indicators by income and supermarket access per the Food Access Research Atlas. The outcome was periconceptional diet quality per the Healthy Eating Index (HEI)-2010, analyzed by quartile (Q) from the highest or best (Q4, reference) to the lowest or worst dietary quality (Q1); and secondarily, nonadherence (yes or no) to 12 key aspects of dietary quality.

RESULTS

Among 7,956 assessed individuals, 24.9% lived in a food desert. The mean HEI-2010 score was 61.1 of 100 (SD: 12.5). Poorer periconceptional dietary quality was more common among those who lived in a food desert compared with those who did not live in a food desert (Q4: 19.8%, Q3: 23.6%, Q2: 26.5%, and Q1: 30.0% vs. Q4: 26.8%, Q3: 25.8%, Q2: 24.5%, and Q1: 22.9%; overall P < 0.001). Individuals living in a food desert were more likely to report a diet in lower quartiles of the HEI-2010 (i.e., poorer dietary quality) (aOR: 1.34 per quartile; 95% CI: 1.21, 1.49). They were more likely to be nonadherent to recommended standards for 5 adequacy components of the HEI-2010, including fruit, total vegetables, greens and beans, seafood and plant proteins, and fatty acids, and less likely to report excess intake of empty calories.

CONCLUSIONS

Nulliparous pregnant individuals living in a food desert were more likely to experience poorer periconceptional diet quality compared with those who did not live in a food desert.

A Qualitative Study of Health Equity's Role in Community Coalition Development

Opioid overdose deaths are dramatically increasing in the United States and disproportionately affecting minority communities, with the increasing presence of fentanyl exacerbating this crisis. Developing community coalitions is a long-standing strategy used to address public health issues. However, there is a limited understanding of how coalitions operate amid a serious public health crisis. To address this gap, we leveraged data from the HEALing Communities Study (HCS)-a multisite implementation study aiming to reduce opioid overdose deaths in 67 communities. Researchers analyzed transcripts of 321 qualitative interviews conducted with members of 56 coalitions in the four states participating in the HCS. There were no a priori interests in themes, and emergent themes were identified through inductive thematic analysis and then mapped to the constructs of the Community Coalition Action Theory (CCAT). Themes emerged related to coalition development and highlighted the role of health equity in the inner workings of coalitions addressing the opioid epidemic. Coalition members reported seeing the lack of racial and ethnic diversity within their coalitions as a barrier to their work. However, when coalitions focused on health equity, they noted that their effectiveness and ability to tailor their initiatives to their communities' needs were strengthened. Based on our findings, we suggest two additions to enhance the CCAT: (a) incorporating health equity as an overarching construct that affects all stages of development, and (b) ensuring that data about individuals served are included within the pooled resource construct to enable monitoring of health equity.

Rationale and design of the linking education, produce provision, and community referrals to improve diabetes care (LINK) study

BACKGROUND

Individuals with type 2 diabetes (T2D) experiencing food insecurity may have other non-medical, health-related social needs (e.g., transportation, housing instability) that decrease their ability to attain T2D control and impact other health outcomes.

METHODS

A pragmatic randomized controlled trial (pRCT) to test the effect of produce provision, diabetes and culinary skills training and education, and social needs screening, navigation, and resolution, on hemoglobin A1c (A1c) levels in individuals with T2D (A1c ≥7.5%) experiencing food insecurity; a cost-effectiveness evaluation of the interventions that comprise the pRCT; and a process evaluation to understand the contextual factors that impact the uptake, effectiveness, and sustainability of the interventions.

SETTING

Ambulatory care clinics (e.g., family medicine, general internal medicine, endocrinology) affiliated with an academic medical center in an urban environment in the Midwest.

DESIGN

2 × 2 factorial design.

INTERVENTIONS

Cooking Matters for Diabetes is a 6-week diabetes and culinary education intervention. The Health Impact Ohio Central Ohio Pathways Hub intervention is a community health worker model designed to evaluate and address participants' social needs. All participants will receive referral to the Mid-Ohio Farmacy to provide weekly access to fresh produce.

OUTCOMES

Primary outcome of the pRCT is change in A1c at 3 months; secondary outcomes include A1c at 6 months, and diabetes self-efficacy, food insecurity, and diet quality at 3 and 6 months.

DISCUSSION

Food insecurity, unmet social needs, diabetes education and self-efficacy are critical issues that must be addressed to improve T2D treatment, care, and health equity.

CLINICALTRIALS

gov: NCT05472441.

Diversity of Participation in Clinical Trials and Influencing Factors: Findings from the Health Information National Trends Survey 2020

BACKGROUND

Clinical trial diversity is critical to advance health and health equity. Research addressing the discrepancy between goals of achieving clinical trial diversity and realities of study enrollment remains underdeveloped.

OBJECTIVE

This study aims to examine the association between race/ethnicity and clinical trial invitation, participation, knowledge, and sources of influence on clinical trial participation.

DESIGN AND PARTICIPANTS

A cross-sectional, observational study using nationally representative data from 3689 US adults (≥ 18 years of age) who responded to the Health Information National Trends Survey fielded from February 24 to June 15, 2020.

MAIN MEASURES

Primary outcomes included clinical trial invitation, participation, knowledge, and sources of influence on participation. The independent variable of interest is self-reported race/ethnicity.

KEY RESULTS

Respondents identifying as non-Hispanic Black (relative to non-Hispanic White) had higher odds of being invited into a clinical trial (adjusted odds ratio: 2.0, 95% confidence interval (CI): 1.1, 3.7), but no differences in odds of participation were observed by race/ethnicity. Respondents from all races/ethnicities reported that personal healthcare providers were the most trusted source of clinical trial information. Hispanic (marginal effect (ME): - 0.09; 95% CI: - 0.16, - 0.03), non-Hispanic Black (ME: - 0.11; 95% CI: - 0.18, - 0.04), and non-Hispanic other (ME: - 0.11; 95% CI: - 0.19, - 0.02) respondents had lower odds than non-Hispanic White respondents of saying they would be influenced "a lot" by their doctor encouraging participation. Non-Hispanic Black respondents had significantly lower odds (relative to non-Hispanic White) of indicating family encouragement would influence their clinical trial participation decision "a lot" (ME: - 0.09; 95%: CI: - 0.14, - 0.03).

CONCLUSION

While personal healthcare providers were trusted sources of information, racial/ethnic minority populations noted lower odds of clinical trial participation influence from providers and family. Thus, it is imperative for the healthcare, government, and industry organizations to build trust in medicine and science.

Perspectives on Challenges and Opportunities for Interoperability: Findings From Key Informant Interviews With Stakeholders in Ohio

BACKGROUND

Interoperability-the exchange and integration of data across the health care system-remains a challenge despite ongoing policy efforts aimed at promoting interoperability.

OBJECTIVE

This study aimed to identify current challenges and opportunities to advancing interoperability across stakeholders.

METHODS

Primary data were collected through qualitative, semistructured interviews with stakeholders (n=24) in Ohio from July to October 2021. Interviewees were sampled using a stratified purposive sample of key informants from 4 representative groups as follows: acute care and children's hospital leaders, primary care providers, behavioral health providers, and regional health information exchange networks. Interviews focused on key informant perspectives on electronic health record implementation, the alignment of public policy with organizational strategy, interoperability implementation challenges, and opportunities for health information technology. The interviews were transcribed verbatim followed by rigorous qualitative analysis using directed content analysis.

RESULTS

The findings illuminate themes related to challenges and opportunities for interoperability that align with technological (ie, implementation challenges, mismatches in interoperability capabilities across stakeholders, and opportunities to leverage new technology and integrate social determinants of health data), organizational (ie, facilitators of interoperability and strategic alignment of participation in value-based payment programs with interoperability), and environmental (ie, policy) domains.

CONCLUSIONS

Interoperability, although technically feasible for most providers, remains challenging for technological, organizational, and environmental reasons. Our findings suggest that the incorporation of end user considerations into health information technology development, implementation, policy, and standard deployment may support interoperability advancement.

Community engagement and clinical trial diversity: Navigating barriers and co-designing solutions-A report from the "Health Equity through Diversity" seminar series

INTRODUCTION

In recent years, there has been increasing awareness of the lack of diversity among clinical trial participants. Equitable representation is key when testing novel therapeutic and non-therapeutic interventions to ensure safety and efficacy across populations. Unfortunately, in the United States (US), racial and ethnic minority populations continue to be underrepresented in clinical trials compared to their White counterparts.

METHODS

Two webinars in a four-part series, titled "Health Equity through Diversity," were held to discuss solutions for advancing health equity through diversifying clinical trials and addressing medical mistrust in communities. Each webinar was 1.5 hours long, beginning with panelist discussions followed by breakout rooms where moderators led discussions related to health equity and scribes recorded each room's conversations. The diverse groups of panelists included community members, civic representatives, clinician-scientists, and biopharmaceutical representatives. Scribe notes from discussions were collected and thematically analyzed to uncover the central themes.

RESULTS

The first two webinars were attended by 242 and 205 individuals, respectively. The attendees represented 25 US states, four countries outside the US, and shared various backgrounds including community members, clinician/researchers, government organizations, biotechnology/biopharmaceutical professionals, and others. Barriers to clinical trial participation are broadly grouped into the themes of access, awareness, discrimination and racism, and workforce diversity. Participants noted that innovative, community-engaged, co-designed solutions are essential.

CONCLUSIONS

Despite racial and ethnic minority groups making up nearly half of the US population, underrepresentation in clinical trials remains a critical challenge. The community engaged co-developed solutions detailed in this report to address access, awareness, discrimination and racism, and workforce diversity are critical to advancing clinical trial diversity.

Association of community-level food insecurity and glycemic control among pregnant individuals with pregestational diabetes

AIM

To evaluate whether pregnant individuals with pregestational diabetes who live in a food-insecure community have worse glycemic control compared to those who do not live in a food-insecure community.

METHODS

A retrospective analysis of pregnant individuals with pregestational diabetes enrolled in a multidisciplinary prenatal and diabetes care program. The exposure was community-level food insecurity per the Food Access Research Atlas. The outcomes were hemoglobin A1c (A1c) < 6.0 % in early and late pregnancy, and an absolute decrease in A1c ≥ 2.0 % and mean change in A1c across pregnancy.

RESULTS

Among 418 assessed pregnant individuals with pregestational diabetes, those living in a food-insecure community were less likely to have an A1c < 6.0 % in early pregnancy compared to those living in a community without food insecurity [16 % vs. 30 %; adjusted risk ratio (aRR): 0.55; 95 % CI: 0.33-0.92]. Individuals living in a food-insecure community were more likely to achieve a decrease in A1c ≥ 2.0 % [35 % vs. 21 %; aRR: 1.55; 95 % CI: 1.06-2.28] and a larger mean decrease in A1c across pregnancy [mean: 1.46 vs. 1.00; adjusted beta: 0.47; 95 % CI: 0.06-0.87)].

CONCLUSIONS

Pregnant individuals with pregestational diabetes who lived in a food-insecure community were less likely to enter pregnancy with glycemic control, but were more likely to have a reduction in A1c and achieve similar A1c status compared to those who lived in a community without food insecurity. Whether interventions that address food insecurity improve glycemic control and consequent perinatal outcomes remains to be studied.

Embedding Big Qual and Team Science into Qualitative Research: Lessons from a Large-scale, Cross-site Research Study

Background

A major part of the HEALing Communities Study (HCS), launched in 2019 to address the growing opioid epidemic, is evaluating the study's intervention implementation process through an implementation science (IS) approach. One component of the IS approach involves teams with more than 20 researchers collaborating across four research sites to conduct in-depth qualitative interviews with over 300 participants at four time points. After completion of the first two rounds of data collection, we reflect upon our qualitative data collection and analysis approach. We aim to share our lessons learned about designing and applying qualitative methods within an implementation science framework.

Methods

The HCS evaluation is based on the RE-AIM/PRISM framework and incorporates interviews at four timepoints. At each timepoint, the core qualitative team of the Intervention Work Group drafts an interview guide based on the framework and insights from previous round(s) of data collection. Researchers then conduct interviews with key informants and coalition members within their respective states. Data analysis involves drafting, iteratively refining, and finalizing a codebook in a cross-site and within-site consensus processes. Interview transcripts are then individually coded by researchers within their respective states.

Results

Successes in the evaluation process includes having structured procedures for communication, data collection, and analysis, all of which are critical for ensuring consistent data collection and for achieving consensus during data analysis. Challenges include recognizing and accommodating the diversity of training and knowledge between researchers, and establishing reliable ways to securely store, manage, and share the large volumes of data.

Conclusion

Qualitative methods using a team science approach have been limited in their application in large, multi-site randomized controlled trials of health interventions. Our experience provides practical guidance for future studies with large, experientially and disciplinarily diverse teams, and teams seeking to incorporate qualitative or mixed-methods components for their evaluations.

Addressing non-medical health-related social needs through a community-based lifestyle intervention during the COVID-19 pandemic: The Black Impact program

BACKGROUND

Non-medical health-related social needs (social needs) are major contributors to worse health outcomes and may have an adverse impact on cardiovascular risk factors and cardiovascular disease. The present study evaluated the effect of a closed-loop community-based pathway in reducing social needs among Black men in a lifestyle change program.

METHODS

Black men (n = 70) from a large Midwestern city participated in Black Impact, a 24-week community-based team lifestyle change single-arm pilot trial adapted from the Diabetes Prevention Program and American Heart Association's (AHA) Check, Change, Control Blood Pressure Self-Management Program, which incorporates AHA's Life's Simple 7 (LS7) framework. Participants were screened using the Centers for Medicare and Medicaid Services (CMS) Accountable Health Communities Health-Related Social Needs Screening Tool. Participants with affirmative responses were referred to a community hub pathway to address social needs. The primary outcome for this analysis is change in social needs based on the CMS social needs survey at 12 and 24 weeks using mixed effect logistic regressions with random intercepts for each participant. Change in a LS7 score (range 0-14) from baseline to 12 and 24 weeks was evaluated using a linear mixed-effects model stratified by baseline social needs.

RESULTS

Among 70 participants, the mean age of participants was 52 ±10.5 years. The men were sociodemographically diverse, with annual income ranging from <$20,000 (6%) to ≥$75,000 (23%). Forty-three percent had a college degree or higher level of education, 73% had private insurance, and 84% were employed. At baseline 57% of participants had at least one social need. Over 12 and 24 weeks, this was reduced to 37% (OR 0.33, 95%CI: 0.13, 0.85) and 44% (OR 0.50, 95%CI: 0.21, 1.16), respectively. There was no association of baseline social needs status with baseline LS7 score, and LS7 score improved over 12 and 24 weeks among men with and without social needs, with no evidence of a differential effect.

CONCLUSIONS

The Black Impact lifestyle change single-arm pilot program showed that a referral to a closed-loop community-based hub reduced social needs in Black men. We found no association of social needs with baseline or change in LS7 scores. Further evaluation of community-based strategies to advance the attainment of LS7 and address social needs among Black men in larger trials is warranted.

Barriers to and recommendations for integrating the age‐friendly 4‐Ms framework into electronic health records

BACKGROUND

The Institute for Healthcare Improvement's 4-Ms framework of care for older adults recommends a multidisciplinary assessment of a patient's Medications, Mentation, Mobility, and What Matters Most. Electronic health record (EHR) systems were developed prior to this emphasis on the 4-Ms. We sought to understand how healthcare providers across the healthcare system perceive their EHRs and to identify any current best practices and ideas for improvement regarding integration of the 4-Ms.

METHODS

Anonymous survey of healthcare providers who care for older adults. The survey aimed to evaluate efficiency, error tolerance, and satisfaction (usefulness and likeability). The survey was distributed through organizational list serves that focus on the care of older adults and through social media.

RESULTS

Sixty-six respondents from all geographic segments of the U.S. (n = 62) and non-U.S. practices (n = 4) responded. Most (82%) were physicians. Respondents used a range of EHRs and 82% had >5 years of experience with their current EHR. Over half of respondents agreed that their EHR had easy to find contact information (56%) and advance directives. Finding a patient's prior cognitive status (26% agreement), goals of care (24%), functional status (14%), and multidisciplinary geriatric assessments (27%) was more difficult. Only 3% were satisfied with how their EHR handles geriatric syndromes. In free text responses, respondents (79%) described three areas that the EHR assists in the care of older adults: screening tied to actions or orders; advance care planning, and medication alerts or review. Common suggestions on how to improve the EHR included incorporating geriatric assessments in notes, establishing a unified place to review the 4-Ms, and creating age-specific best practice alerts.

CONCLUSIONS

The majority of healthcare providers were not satisfied with how their EHR handles multidisciplinary geriatric assessment and geriatric care. EHR modifications would aide in reporting, communicating, and tracking the 4-Ms in EHRs.

Community Coalitions' Perspectives on Engaging with Hospitals in Ohio to Address the Opioid Crisis

Community coalitions have been leading the multisector response to the opioid epidemic in the Unites States. However, with the medicalization of opioid use disorder and changing health care policies, hospitals have moved to the forefront, becoming more active in collaborating with community coalitions. Little is currently known about how community coalitions view and approach collaborating with hospitals despite its importance for understanding and advancing interorganizational approaches to combating the opioid epidemic. Using data from semistructured interviews (n = 119) conducted from November 2019 to January 2020 as part of the HEALing Communities Study (ClinicalTrials.gov: NCT04111939), the authors examined how community coalition members perceive hospital collaborations and explored the opportunities and challenges of these partnerships. They characterized 3 emergent themes: coalition approaches to collaborating with hospitals, barriers to collaboration, and opportunities for sustainable relationships. This new evidence highlights the value that coalitions place on hospital collaborations, as well as mechanisms that may help support ongoing partnerships.

Interoperability in a Post-Roe Era: Sustaining Progress While Protecting Reproductive Health Information

This Viewpoint proposes a solution to better safeguard reproductive health information in patient records that are now more complete owing to the interoperability of health information exchange networks.

Multi-stakeholder perspectives on the implementation of a clinic-based food referral program for patients with chronic conditions: a qualitative examination

Clinic-based food referral programs (FRPs) may help alleviate food insecurity and improve access to nutritious foods by systematically identifying and referring food-insecure primary care patients to community-based food resources. The purpose of this study was to examine the barriers to and facilitators of implementation of an FRP offered to primary care patients who screen positive for food insecurity and have a qualifying chronic condition. we used a multi-stakeholder approach to conduct semi-structured interviews with healthcare providers and administrators from an academic medical center (AMC) (n = 20), representatives of a regional foodbank and its affiliated pantries (n = 11), and patients referred to the FRP (n = 20), during the initial phase of FRP implementation from April to September 2020. Interviews were audio-recorded, transcribed verbatim, and coded using a deductive dominant approach that allowed for the identification of emergent themes. Seven major themes emerged across the two domains of analysis: barriers to and facilitators of FRP implementation. Key barriers were (a) provider time constraints and competing demands; (b) inadequate physician feedback regarding patient use of the program; (c) patient transportation barriers; and (d) stigma associated with food pantry use. Key facilitators of implementation included (a) program champions; (b) screening and referral coordination; and (c) addressing food pantry-related stigma. This study identifies factors that deter and facilitate the implementation of an AMC-based FRP. Our findings highlight opportunities for healthcare and community-based organizations to refine and optimize FRP models toward the ultimate aim of advancing health equity for food-insecure patients.

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.

Examining the Relationship between Health Literacy, Health Numeracy, and Patient Portal Use

OBJECTIVES

The objective of this study is to investigate the relationships between health literacy and numeracy (HLN) and patient portal use, measured in inpatient and outpatient settings.

METHODS

Using data collected as part of a pragmatic randomized controlled trial conducted across the inpatient population of a U.S.-based academic medical center, the present study evaluated the relationships between patients' perceptions of health literacy and their skills, interpreting medical information with metrics of engagement with patient portals.

RESULTS

Self-reported levels of HLN for patients in the study sample (n = 654) were not significantly associated with inpatient portal use as measured by frequency of use or the number of different inpatient portal functions used. Use of the outpatient version of the portal over the course of 6 months following hospital discharge was also not associated with HLN. A subsequent assessment of patients after 6 months of portal use postdischarge (response rate 40%) did not reveal any differences with respect to portal use and health numeracy; however, a significant increase in self-reported levels of health literacy was found at this point.

CONCLUSION

While previous studies have suggested that low HLN might represent a barrier to inpatient portal adoption and might limit engagement with outpatient portals, we did not find these associations to hold. Our findings, however, suggest that the inpatient setting may be effective in facilitating technology acceptance. Specifically, the introduction of an inpatient portal made available on hospital-provided tablets may have practical implications and contribute to increased adoption of patient-facing health information technology tools.

Improving Provisioning of an Inpatient Portal: Perspectives from Nursing Staff

BACKGROUND

 Inpatient portals are recognized to provide benefits for both patients and providers, yet the process of provisioning tablets to patients by staff has been difficult for many hospitals.

OBJECTIVE

 Our study aimed to identify and describe practices important for provisioning an inpatient portal from the perspectives of nursing staff and provide insight to enable hospitals to address challenges related to provisioning workflow for the inpatient portal accessible on a tablet.

METHODS

 Qualitative interviews were conducted with 210 nursing staff members across 26 inpatient units in six hospitals within The Ohio State University Wexner Medical Center (OSUWMC) following the introduction of tablets providing access to an inpatient portal, MyChart Bedside (MCB). Interviews asked questions focused on nursing staffs' experiences relative to MCB tablet provisioning. Verbatim interview transcripts were coded using thematic analysis to identify factors associated with tablet provisioning. Unit provisioning performance was established using data stored in the OSUWMC electronic health record about provisioning status. Provisioning rates were divided into tertiles to create three levels of provisioning performance: (1) higher; (2) average; and (3) lower.

RESULTS

 Three themes emerged as critical strategies contributing to MCB tablet provisioning success on higher-performing units: (1) establishing a feasible process for MCB provisioning; (2) having persistent unit-level MCB tablet champions; and (3) having unit managers actively promote MCB tablets. These strategies were described differently by staff from the higher-performing units when compared with characterizations of the provisioning process by staff from lower-performing units.

CONCLUSION

 As inpatient portals are recognized as a powerful tool that can increase patients' access to information and enhance their care experience, implementing the strategies we identified may help hospitals' efforts to improve provisioning and increase their patients' engagement in their health care.

Exploring perspectives on changing opioid prescribing practices: A qualitative study of community stakeholders in the HEALing Communities Study

BACKGROUND

Community-based perspectives are needed to more broadly inform policy-makers, public health practitioners, prescribers, and pharmacists about community-led and broader efforts to reduce opioid overprescribing, and ultimately reduce prescription opioid use disorder, overdoses and fatalities. The aim of this study is to explore community-based perspectives on efforts to change opioid prescribing practices in their communities.

METHODS

Semi-structured interviews were conducted with 388 community stakeholders across four states (Kentucky, Massachusetts, New York, Ohio) from November 2019 to January 2020 about community approaches and goals of community-led responses to the opioid crisis. Data analysis combined deductive and inductive approaches to identify themes and sub-themes related to improving opioid prescribing practices.

RESULTS

Three major themes and different subthemes were characterized: (1) acknowledging progress (i.e., healthcare providers being part of the solution, provider education, and prescription drug monitoring programs); (2) emergent challenges (i.e., physician nonadherence with safer opioid prescribing guidelines, difficulty identifying appropriate use of opioids, and concerns about accelerating the progression from opioid misuse to drug abuse); and (3) opportunities for change (i.e., educating patients about safer use and proper disposal of opioids, expanding prescriber and pharmacist education, changing unrealistic expectations around eliminating pain, expanding and increasing insurance coverage for alternative treatment options).

CONCLUSIONS

Community stakeholders appeared to support specific opportunities to reduce prescription opioid misuse and improve safer prescribing. The opportunities included culture change around pain expectations, awareness of safe disposal, additional provider education, and increased coverage and acceptability of non-opioid treatments.

Approaches for overcoming barriers to cross-sector data sharing

OBJECTIVES

To characterize factors influencing the development and sustainability of data sharing in the Mid-Ohio Farmacy (MOF), a produce referral program implemented in partnership between a community-based organization (the Mid-Ohio Food Collective ["Food Collective"]) and an academic medical center (The Ohio State University Wexner Medical Center [OSUWMC]).

STUDY DESIGN

We used an in-depth case study approach to identify challenges that arose during implementation of the MOF and related solutions via semistructured interviews with representatives of both organizations (May-September 2020).

METHODS

Key informants from OSUWMC (n = 20) and the Food Collective (n = 11) were identified using a combination of purposive and convenience sampling; they included administrators, project champions, clinical providers, and food pantry representatives. Interview transcripts were coded using a deductive dominant approach guided by a logic model aimed at determining the resources and activities relevant to the development of the partnership.

RESULTS

Challenges of cross-sector data sharing fit into 3 themes: data sharing regulations, data exchange capabilities, and cross-sector data integration. Overcoming these challenges required creative workarounds-for example, linking patients across organizations was done via establishment of a unique, partnership-specific patient identifier, which was incorporated into the health system's electronic health record for continuity.

CONCLUSIONS

Our findings suggest that current regulatory frameworks are misspecified to the growing interest in cross-sector partnerships between health care and community-based organizations. Future efforts to support these relationships should consider clarifying rules around data sharing and increasing Medicaid support for nonmedical, health-related social needs.

Characterization of Electronic Health Record Use Outside Scheduled Clinic Hours among Primary Care Pediatricians: A Retrospective Descriptive Task Analysis of Electronic Health Record Access Log Data (Preprint)

Background

Many of the benefits of electronic health records (EHRs) have not been achieved at expected levels because of a variety of unintended negative consequences such as documentation burden. Previous studies have characterized EHR use during and outside work hours, with many reporting that physicians spend considerable time on documentation-related tasks. These studies characterized EHR use during and outside work hours using clock time versus actual physician clinic schedules to define the outside work time.

Objective

This study aimed to characterize EHR work outside scheduled clinic hours among primary care pediatricians using a retrospective descriptive task analysis of EHR access log data and actual physician clinic schedules to define work time.

Methods

We conducted a retrospective, exploratory, descriptive task analysis of EHR access log data from primary care pediatricians in September 2019 at a large Midwestern pediatric health center to quantify and identify actions completed outside scheduled clinic hours. Mixed-effects statistical modeling was used to investigate the effects of age, sex, clinical full-time equivalent status, and EHR work during scheduled clinic hours on the use of EHRs outside scheduled clinic hours.

Results

Primary care pediatricians (n=56) in this study generated 1,523,872 access log data points (across 1069 physician workdays) and spent an average of 4.4 (SD 2.0) hours and 0.8 (SD 0.8) hours per physician per workday engaged in EHRs during and outside scheduled clinic hours, respectively. Approximately three-quarters of the time working in EHR during or outside scheduled clinic hours was spent reviewing data and reports. Mixed-effects regression revealed no associations of age, sex, or clinical full-time equivalent status with EHR use during or outside scheduled clinic hours.

Conclusions

For every hour primary care pediatricians spent engaged with the EHR during scheduled clinic hours, they spent approximately 10 minutes interacting with the EHR outside scheduled clinic hours. Most of their time (during and outside scheduled clinic hours) was spent reviewing data, records, and other information in EHR.

Improving Training Motivation and Transfer in Hospitals: Extension of a Conceptual Model

Health-care professionals undergo numerous training programs each year in order to fulfill licensure requirements and organizational obligations. However, evidence suggests that a substantial amount of what is taught during training is never learned or transferred back to routine work. A major contributor to this issue is low training motivation. Prior conceptual models on training transfer in the organizational sciences literature consider this deficit, yet do not account for the unique conditions of the hospital setting. This chapter seeks to close this gap by adapting conceptual models of training transfer to this setting that are grounded in organizational science. Based on theory and supplemented by semistructured key informant interviews (i.e., organizational leaders and program directors), we introduce an applied model of training motivation to facilitate training transfer in the hospital setting. In this model, training needs analysis is positioned as a key antecedent to ensure support for training, relevant content, and perceived utility of training. We posit that these factors, along with training design and logistics, enhance training motivation in hospital environments. Further, we suggest that training motivation subsequently impacts learning and transfer, with elements of the work environment also serving as moderators of the learning-transfer relationship. Factors such as external support for training content (e.g., from accrediting bodies) and allocation of time for training are emphasized as facilitators. The proposed model suggests there are factors unique to the hospital work setting that impact training motivation and transfer that should be considered when developing and implementing training initiatives in this setting.

Examining Patients' Capacity to Use Patient Portals: Insights for Telehealth

BACKGROUND

The increase in telehealth in response to the coronavirus disease 2019 pandemic highlights the need to understand patients' capacity to utilize this care modality. Patient portals are a tool whose use requires similar resources and skills as those required for telehealth. Patients' capacity to use patient portals may therefore provide insight regarding patients' readiness and capacity to use telehealth.

OBJECTIVE

The aim of this study was to examine factors related to patients' capacity to use a patient portal and test the impact of these factors on patients' portal use.

RESEARCH DESIGN AND SUBJECTS

Using data from a large-scale pragmatic randomized controlled trial of patient portal use, 1081 hospitalized patients responded to survey items that were then mapped onto the 4 dimensions of the Engagement Capacity Framework: self-efficacy, resources, willingness, and capabilities.

MEASURES

The outcome variable was frequency of outpatient portal use. We evaluated associations between Engagement Capacity Framework dimensions and patient portal use, using regression analyses.

RESULTS

Patients with fewer resources, fewer capabilities, lower willingness, and lower overall capacity to use patient portals used the portal less; in contrast, those with lower perceived self-efficacy used the portal more.

CONCLUSIONS

Our findings highlight differences in patients' capacity to use patient portals, which provide an initial understanding of factors that may influence the use of telehealth and offer important guidance in efforts to support patients' telehealth use. Offering patients training tailored to the use of telehealth tools may be particularly beneficial.

Patient Portals: Useful for Whom and for What? A Cross-Sectional Analysis of National Survey Data

BACKGROUND

Patients who use patient portals may be more engaged and empowered in their care; however, differences in who accesses patient portals remain. The characteristics of who uses patient portals more frequently and who perceives them as useful may also differ, as well as which functions people use.

OBJECTIVE

We assessed the characteristics of patient portal users to examine who uses them more frequently and who perceives them as useful. In addition, we wanted to see if those who use them more frequently or perceive them to be more useful use different functions or more functions of patient portals.

METHODS

Pooled cross-sectional data from 2017 to 2018 Health Information National Trends Survey (HINTS) were used. Ordinal regression models were developed to assess frequency of use and perceived usefulness by demographics, and multivariable logistic regression models were used to examine the association between the use of 10 patient portal functions and frequency of use and perceived usefulness of patient portals.

RESULTS

The odds of using patient portals more frequently were higher among those with Bachelor's degrees, incomes between $35,000 and $75,000, and those with two or more chronic conditions. Respondents with three or more chronic conditions had higher odds of rating patient portals as useful. Those who used their patient portal 10 or more times in the past year had higher odds of using all functions except for viewing test results compared with those who used their patient portal one to two times per year. Those who rated patient portals as "very useful" had higher odds of using seven of the functions compared with those who rated them "not very"/"not at all useful."

CONCLUSION

It is important to continue to assess usefulness, frequency of use, and overall patient portal function use to identify opportunities to increase patient engagement with patient portals.

Management practices for leaders to promote infection prevention: Lessons from a qualitative study

BACKGROUND

Prevention of healthcare-associated infections (HAIs) is critical to reduce preventable deaths and healthcare costs. Variable success with HAI prevention efforts has suggested that management practices are critical to support clinical infection prevention practices. This study examined hospital leaders' management practices around the prevention of catheter-associated urinary tract infections (CAUTIs) and central line-associated bloodstream infections (CLABSIs) to identify actions that leaders can take to promote HAI prevention efforts.

METHODS

We conducted interviews with 420 key informants, including managers and frontline staff, in 18 hospitals across the United States. Interviewees were asked about management practices supporting HAI prevention. We analyzed interview transcripts using rigorous qualitative methods to understand how management practices were operationalized in infection prevention efforts.

RESULTS

Across hospitals and interviewees, three management practices were characterized as important facilitators of HAI prevention: (1) engagement of executive leadership; (2) information sharing; and (3) manager coaching. We found that visible executive leadership, efficient communication, and frequent opportunities to provide and promote learning from feedback were perceived to promote and sustain HAI prevention efforts.

CONCLUSIONS

Our findings provide insight into management practices for leaders that support successful HAI prevention. In practice, these tactics may need to be adjusted to accommodate the current restrictions caused by the COVID-19 pandemic, in order to maintain HAI prevention efforts as a priority.

Identifying Opportunities to Strengthen the Public Health Informatics Infrastructure: Exploring Hospitals' Challenges with Data Exchange

Policy Points Even though most hospitals have the technological ability to exchange data with public health agencies, the majority continue to experience challenges. Most challenges are attributable to the general resources of public health agencies, although workforce limitations, technology issues such as a lack of data standards, and policy uncertainty around reporting requirements also remain prominent issues. Ongoing funding to support the adoption of technology and strengthen the development of the health informatics workforce, combined with revising the promotion of the interoperability scoring approach, will likely help improve the exchange of electronic data between hospitals and public health agencies.

CONTEXT

The novel coronavirus 2019 (COVID-19) pandemic has highlighted significant barriers in the exchange of essential information between hospitals and local public health agencies. Thus it remains important to clarify the specific issues that hospitals may face in reporting to public health agencies to inform focused approaches to improve the information exchange for the current pandemic as well as ongoing public health activities and population health management.

METHODS

This study uses cross-sectional data of acute-care, nonfederal hospitals from the 2017 American Hospital Association Annual Survey and Information Technology supplement. Guided by the technology-organization-environment framework, we coded the responses to a question regarding the challenges that hospitals face in submitting data to public health agencies by using content analysis according to the type of challenge (i.e., technology, organization, or environment), responsible entity (i.e., hospital, public health agency, vendor, multiple), and the specific issue described. We used multivariable logistic and multinomial regression to identify characteristics of hospitals associated with experiencing the types of challenges.

FINDINGS

Our findings show that of the 2,794 hospitals in our analysis, 1,696 (61%) reported experiencing at least one challenge in reporting health data to a public health agency. Organizational issues were the most frequently reported type of challenge, noted by 1,455 hospitals. The most common specific issue, reported by 1,117 hospitals, was the general resources of public health agencies. An advanced EHR system and participation in a health information exchange both decreased the likelihood of not reporting experiencing a challenge and increased the likelihood of reporting an organizational challenge.

CONCLUSIONS

Our findings inform policy recommendations such as improving data standards, increasing funding for public health agencies to improve their technological capabilities, offering workforce training programs, and increasing clarity of policy specifications and reporting. These approaches can improve the exchange of information between hospitals and public health agencies.

Odds of Meeting Cancer Prevention Behavior Recommendations by Health Information Seeking Behavior: a Cross-Sectional HINTS Analysis

People who seek health information frequently may be more likely to meet health behavior goals; however, people use many different information sources. The purpose of this paper is to assess how different sources of health information influence likelihood of meeting cancer prevention behavior guidelines. Logistic regression of cross-sectional data from 6 years of the Health Information National Trends Survey (HINTS) was conducted. Independent variables included first source of health information, gender, age, race, education level, income, cancer history, general health, and data year; dependent variables were fruit and vegetable intake, exercise, smoking, mammography, Pap test, and colon cancer screening. Those who seek health information from doctors, the internet, or publications had higher odds of meeting more cancer prevention guidelines than those who do not seek health information. Those who used healthcare providers as an initial information source had higher odds of meeting diet, cervical, and colon cancer screening recommendations, while using the internet as an initial source of health information was associated with higher odds of meeting diet, smoking, and colon cancer screening recommendations. No health information source was associated with meeting either exercise or mammography recommendations. People should be encouraged to seek health information to help them meet their behavior goals, especially from sources that are more likely to be accurate and encourage cancer prevention behavior. Future research is needed to understand the accuracy of health information and what kinds of health information have positive influences on cancer prevention behavior.

The Health Information technology special issue: innovation and emerging opportunities in time of crisis

A letter from the guest editor highlights the contributions of health information technology in improving health care delivery patient-centeredness through innovation in data analytics, connecting providers, and implementation of telehealth.

Rewarding and recognizing frontline staff for success in infection prevention

Management practices help support efforts to prevent healthcare-associated infections (HAIs). Providing rewards and recognition to frontline staff is one management practice found to be in use by hospitals that are higher-performers in HAI prevention. Using data from interviews with hospital managers and frontline staff at 18 US hospitals, our study identifies how managers can use reward and recognition programs as motivational tools to sustain frontline HAI prevention efforts.

The HEALing (Helping to End Addiction Long-term SM) Communities Study: Protocol for a cluster randomized trial at the community level to reduce opioid overdose deaths through implementation of an integrated set of evidence-based practices

BACKGROUND

Opioid overdose deaths remain high in the U.S. Despite having effective interventions to prevent overdose deaths, there are numerous barriers that impede their adoption. The primary aim of the HEALing Communities Study (HCS) is to determine the impact of an intervention consisting of community-engaged, data-driven selection, and implementation of an integrated set of evidence-based practices (EBPs) on reducing opioid overdose deaths.

METHODS

The HCS is a four year multi-site, parallel-group, cluster randomized wait-list controlled trial. Communities (n = 67) in Kentucky, Massachusetts, New York and Ohio are randomized to active intervention (Wave 1), which starts the intervention in Year 1 or the wait-list control (Wave 2), which starts the intervention in Year 3. The HCS will test a conceptually driven framework to assist communities in selecting and adopting EBPs with three components: 1) a community engagement strategy with local coalitions to guide and implement the intervention; 2) a compendium of EBPs coupled with technical assistance; and 3) a series of communication campaigns to increase awareness and demand for EBPs and reduce stigma. An implementation science framework guides the intervention and allows for examination of the multilevel contexts that promote or impede adoption and expansion of EBPs. The primary outcome, number of opioid overdose deaths, will be compared between Wave 1 and Wave 2 communities during Year 2 of the intervention for Wave 1. Numerous secondary outcomes will be examined.

DISCUSSION

The HCS is the largest community-based implementation study in the field of addiction with an ambitious goal of significantly reducing fatal opioid overdoses.

Model and approach for assessing implementation context and fidelity in the HEALing Communities Study

BACKGROUND

In response to the U.S. opioid epidemic, the HEALing (Helping to End Addiction Long-term^SM) Communities Study (HCS) is a multisite, wait-listed, community-level cluster-randomized trial that aims to test the novel Communities That HEAL (CTH) intervention, in 67 communities. CTH will expand an integrated set of evidence-based practices (EBPs) across health care, behavioral health, justice, and other community-based settings to reduce opioid overdose deaths. We present the rationale for and adaptation of the RE-AIM/PRISM framework and methodological approach used to capture the CTH implementation context and to evaluate implementation fidelity.

METHODS

HCS measures key domains of the internal and external CTH implementation context with repeated annual surveys and qualitative interviews with community coalition members and key stakeholders. Core constructs of fidelity include dosage, adherence, quality, and program differentiation-the adaptation of the CTH intervention to fit each community's needs. Fidelity measures include a monthly CTH checklist, collation of artifacts produced during CTH activities, coalition and workgroup attendance, and coalition meeting minutes. Training and technical assistance delivered by the research sites to the communities are tracked monthly.

DISCUSSION

To help attenuate the nation's opioid epidemic, the adoption of EBPs must be increased in communities. The HCS represents one of the largest and most complex implementation research experiments yet conducted. Our systematic examination of implementation context and fidelity will significantly advance understanding of how to best evaluate community-level implementation of EBPs and assess relations among implementation context, fidelity, and intervention impact.

Development and validation of an organizational readiness to change instrument focused on cultural competency

OBJECTIVE

To validate a brief survey developed to be used in hospitals nationwide to assess organizational readiness to change to increase cultural competency.

DATA SOURCES/STUDY SETTING

Analysis of primary data collected as part of a 125-item Organizational Assessment Survey conducted in the ten US hospitals participating in the Robert Wood Johnson Foundation Expecting Success program in 2005-2006.

STUDY DESIGN

The study utilized a cross-sectional survey.

DATA COLLECTION

Surveys were distributed to participants in the ten hospitals based on job title and role within the organization (including clinicians, clinical administrators, other clinical professionals, and those in relevant nonclinical roles; respondents = 513; response rate = 31%). Missing data were deleted listwise. We computed internal consistency reliability via Cronbach's alpha and interrater agreement using the r_wg(j) index, and conducted exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) to examine validity of the survey. We subsequently conducted ANOVAs to examine whether the instrument adequately distinguished between hospitals.

PRINCIPAL FINDINGS

Across 408 complete responses, a scree plot generated by the EFA and a follow-up CFA indicated a 2-factor solution (RMSEA = 0.06; CFI = 0.96; GFI = 0.96; RMSR = 0.08). We identified these primary factors as two scales, a 12-item Readiness to Address Quality scale (α = 0.85; r_wg(j)  = 0.93) and an 11-item Readiness to Address Disparities scale (α = 0.65; r_wg(j)  = 0.89). ANOVAs suggested that these scales distinguished between hospitals (RTAQ: F[9, 428] = 3.70, P < .001; RTAD: F[9, 435] = 3.02, P = .002).

CONCLUSIONS

This survey can help identify an organization's readiness to change to increase cultural competency.

Hospital- and System-Wide Interventions for Health Care-Associated Infections: A Systematic Review

Hospitals face increasing pressure to reduce health care-associated infections (HAI) due to their costs and evidence of preventability. However, there is limited synthesis of evidence regarding interventions that can be successfully implemented hospital- or system-wide. Using Donabedian's structure-process-outcome model, we conducted a systematic literature review from 2008 to early 2019, identifying 96 studies with 214 outcomes examining the relationship between hospital- or system-wide interventions and HAIs. This literature's methodologic and reporting quality was generally poor. The most common HAIs studied were methicillin-resistant Staphylococcus aureus (22%) and Clostridium difficile (21%). 97 outcomes showed a desirable change, 72 showed no significant effect, 17 showed conflicting effects, and 3 found undesirable effects; 25 outcomes were from studies without a statistical analysis. Our findings highlight structural and process approaches meriting additional research and policy exploration, and identify recommendations for future investigation and reporting of hospital and system-wide HAI interventions to address gaps in existing literature.

Differences Between Races in Health Information Seeking and Trust Over Time: Evidence From a Cross-Sectional, Pooled Analyses of HINTS Data

PURPOSE

Assessed racial disparities in health information-seeking behavior and trust of information sources from 2007 to 2017.

DESIGN

Pooled cross-sectional survey data.

SETTING

Health Information National Trends Survey (HINTS).

PARTICIPATION

Data included 6 iterations of HINTS (pooled: N = 19 496; 2007: n = 3593; 2011: n = 3959; 2013: n = 3185; Food and Drug Administration [FDA] 2015: n = 3738; 2017: n = 3285; and FDA 2017: n = 1736).

MEASURES

Outcome variables were health information seeking, high confidence, and high trust of health information from several sources. Independent variable was race group, controlling for other sociodemographic and socioeconomic variables.

ANALYSIS

Weighted descriptive and multivariate logistic regression for the pooled sample assessed associations by race. Fully interacted models with race-survey year interactions compared differences in outcomes between years.

RESULTS

Black respondents, relative to white, had greater odds of having high confidence in their ability to attain health information, trust of health information from newspapers and magazines, radio, internet, television, government, charitable organizations, and religious organizations. Hispanic respondents, relative to white, had lower odds of seeking health information and trusting health information from doctors. They had higher odds of trusting health information from the radio, the internet, television, charitable organizations, and religious organizations.

CONCLUSION

Disparities between races in trust of information sources remained across time. Understanding optimal information media, their reach, and credibility among racial groups could enable more targeted approaches to developing interventions. Our analytical approach minimized limitations present in the HINTS.

Care Team Perspectives About an Inpatient Portal: Benefits and Challenges of Patients' Portal Use During Hospitalization

While current research about inpatient portals has focused largely on the patient perspective, it is also critical to consider the care team point of view, as support from these individuals is essential to successful portal implementation and use. We held brief in-person interviews with 433 care team members across a six-hospital health system to explore opinions about patients' use of an inpatient portal as perceived by care team members. Using the Inpatient Portal Evaluation Framework, we characterized benefits and challenges of portal use that care team members reported affected patients, themselves, and the collaborative work of these care teams with their patients. Interviewees noted inpatient portals can improve patient care and experience and also indicated room for improvement in portal use for hospitalized patients. Further understanding of the care team perspective is critical to inform approaches to inpatient portal implementation that best benefit both patients and providers.

Likelihood of Smoking Among Cancer Survivors: An Updated Health Information National Trends Survey Analysis

INTRODUCTION

Cancer survivors are at high risk for cancer reoccurrence, highlighting the importance of managing behavioral risk factors for cancer. Despite this risk, many cancer survivors continue to smoke cigarettes. This article describes the relationship between smoking behavior and demographic and clinical factors in cancer survivors.

METHODS

Multinomial logistic regression of cross-sectional data from the Health Information National Trends Survey was conducted using combined data from years 2003, 2005, 2007, 2011, 2012, 2013, and 2014. Independent variables included age, cancer history, race, education level, marital status, insurance status, and data year; the dependent variable was smoking status (current vs. former or never).

RESULTS

Cancer survivors were less likely to be current smokers but more likely to be former smokers than those with no history of cancer. Cancer survivors that currently smoked were more likely to have lower education levels, be divorced, separated, or single, or not have health insurance. Older cancer survivors, Hispanic, and non-Hispanic black survivors were less likely to smoke. Among cancer subgroups, prostate cancer survivors had the lowest rate (8.8%) of current smoking from 2011 to 2014, and cervical cancer survivors had the highest rate (31.1%).

CONCLUSIONS

Although those with no history of cancer had higher rates of current smoking, many subgroups of cancer survivors continued to smoke at higher rates than average cancer survivors. Cancer survivors that were younger, had lower education levels, were any marital status other than married or widowed, were uninsured, or survived cervical cancer were more likely to be smokers than other survivors.

IMPLICATIONS

It is important to understand which types of cancer survivors are at high risk of continued smoking to better inform tobacco dependence treatment interventions among those at high risk of cancer reoccurrence. Our findings suggest targeted tobacco dependence treatment efforts among cancer survivors should focus on survivors of cervical cancer and survivors that are young, unmarried, uninsured, or have lower education levels.

The effect of cancer treatment summaries on patient-centered communication and quality of care for cancer survivors: A pooled cross-sectional HINTS analysis

OBJECTIVE

Provision of cancer treatment summaries to patients is recommended to improve patient-centered communication (PCC). The objective of this study is to assess relationships between cancer treatment summary receipt, PCC, and quality of care (QOC).

METHODS

Linear and logistic regression of cross-sectional data from the Health Information National Trends Survey (HINTS) was conducted using data from years 2012, 2014, and 2017. The independent variable was receipt of treatment summary; the dependent variables were overall PCC score, six domains of PCC, and QOC.

RESULTS

In the pooled sample, 36.9% of patients with cancer treatment history reported receiving a treatment summary. There was a significant positive association between overall PCC score and treatment summary receipt, and higher odds of high scores for the PCC domains "responding to emotions" and "managing uncertainty." We did not observe significant associations between treatment summary receipt and other PCC domains or QOC.

CONCLUSION

Providing patients cancer treatment summaries may improve PCC, but fewer than half of patients reported receiving one of these summaries.

PRACTICE IMPLICATIONS

Providing cancer treatment summaries is important, however, providing them without engaging in additional communication may be insufficient to improve all patient-centered care domains or quality of care.

Helping Patients Be Better Patients: A Qualitative Study of Perceptions About Inpatient Portal Use

Introduction: As more hospitals introduce inpatient portals, it is increasingly important to understand their impact on patient experience and the care process. We conducted this study to learn from patients and care team members about their experience with an inpatient portal. Methods: We interviewed 120 patients and 433 care team members across a seven-hospital academic medical center that offers an inpatient portal to hospitalized patients. Interviewees were asked about their use of the inpatient portal and its impact on patient experience. Recorded interviews were transcribed and rigorously analyzed using both inductive and deductive methods. Results: We found that the inpatient portal was perceived to help patients be "better patients" by improving their ability to be informed about their health and by enabling them to be more involved in the care process. Care team members suggested portal use could be improved by addressing challenges with tablet administration, use of the patient education feature, and the functionality of the scheduling feature. Conclusions: Across interviewees, we found that inpatient portals were perceived to improve the hospital experience and increase empowerment for patients by offering information about care in a manner that allowed patients to join their care teams as active, participating members.

Designing Quality Improvement Collaboratives for Dissemination: Lessons from a Multiple Case Study of the Implementation of Obstetric Emergency Safety Bundles

BACKGROUND

Quality improvement collaboratives (QICs) can help to disseminate evidence-based practices, but there is limited guidance from the perspectives of QIC organizers and participants of best practices to support practice change. To address this gap, this study aimed to identify key structures and processes of QICs that support dissemination and implementation of quality improvement projects.

METHODS

Semistructured one-on-one and group interviews were conducted from December 2017 to May 2018 with project administrators (n = 28) at three QICs that had been funded to develop and disseminate obstetric emergency safety bundles in more than 300 hospitals across five states. For further study, the project leads (n = 25) at six hospitals nominated by each QIC were interviewed. A multiple case study design was used to evaluate the dissemination strategies of each of the three QICs. For the QIC interviews, questions asked about dissemination approach, and for the hospital interviews, questions asked about implementation facilitators and barriers. All interviews were transcribed, coded, and analyzed using both deductive and inductive methods.

RESULTS

A key element supporting the dissemination strategy of each QIC was leveraging existing partnerships and relationships and promoting a shared vision with participating hospitals. A robust data infrastructure to support the project was identified as a critical element to support dissemination, yet was a challenge for the QICs.

CONCLUSION

These findings highlight specific elements of a dissemination approach that QICs can deploy to support their dissemination efforts. In particular, building data infrastructure may be a useful strategy to support ongoing quality improvement projects.

Facilitating Organizational Change to Accommodate an Inpatient Portal

BACKGROUND

Patient portals are becoming more commonly used in the hospital inpatient setting. While the potential benefits of inpatient portals are acknowledged, there is a need for research that examines the challenges of portal implementation and the development of best practice approaches for successful implementation.

OBJECTIVE

We conducted this study to improve our understanding of the impact of the implementation of an inpatient portal on care team members in the context of a large academic medical center. Our study focused on the perspectives of nursing care team members about the inpatient portal.

METHODS

We interviewed care team members (n = 437) in four phases throughout the 2 years following implementation of an inpatient portal to learn about their ongoing perspectives regarding the inpatient portal and its impact on the organization.

RESULTS

The perspectives of care team members demonstrated a change in acceptance of the inpatient portal over time in terms of buy-in, positive workflow changes, and acknowledged benefits of the portal for both care team members and patients. There were also changes over time in perspectives of the care team in regards to (1) challenges with new technology, (2) impact of the portal on workflow, and (3) buy-in. Six strategies were identified as important for implementation success: (1) convene a stakeholder group, (2) offer continual portal training, (3) encourage shared responsibility, (4) identify champions, (5) provide provisioning feedback, and (6) support patient use.

CONCLUSION

Inpatient portals are recognized as an important tool for both patients and care team members, but the implementation of such a technology can create challenges. Given the perspectives care team members had about the impact of the inpatient portal, our findings suggest implementation requires attention to organizational changes that are needed to accommodate the tool and the development of strategies that can address challenges associated with the portal.

Central line infections in United States hospitals: An exploration of variation in central line device days and infection rates across hospitals that serve highly complex patient populations

Our descriptive analyses show a wide distribution in rates of central line device days and central line-associated bloodstream infections for a given standardized infection ratio-the measure linked to federal payment penalties-among 215 US hospitals serving highly complex patient populations. We established that the standardized infection ratio masks hospital-level variation in device use and associated patient safety.