2085. PrEP Interest and Preferences Among US Black and Hispanic Men – A National Survey

Background

Use of daily oral HIV pre-exposure prophylaxis (DO PrEP) has increased steadily in the past several years, but patterns of racial disparities have emerged in PrEP uptake. Although Black and Hispanic people are disproportionately affected by HIV in the US, they constitute a minority among those accessing DO PrEP. Newly available prevention options, such as long-acting injectable (LA) PrEP may help close the gap in unmet need for PrEP; however, interest in LA PrEP has not been evaluated specifically among racial/ethnic minority groups. Awareness, willingness, and usage of PrEP as well as HIV prevention preferences were assessed among sexually active adult men in the US.

Methods

Participants were recruited through a geographically targeted social media campaign and completed a self-administered, cross-sectional, online survey on demographics, sexual health and behavior, healthcare access, PrEP awareness and usage, and PrEP intention and preferences. Eligible participants met the following criteria: cisgender men, self-identified Black race and/or Hispanic ethnicity, 18 years or older, reporting unknown or HIV-negative status, currently residing in the US, and reporting anal or vaginal sex in the past six months. Descriptive statistics were calculated using SAS v9.4.

Results

From November to December 2021, 1365 men completed the survey (median age: 29.0 years; Black non-Hispanic: 43.1%, Black Hispanic: 40.3%, White Hispanic: 10.2%, Other Hispanic: 6.4%). A majority had heard of DO PrEP (66.6%) and LA PrEP (47.5%) as a way to prevent HIV; however, a smaller proportion had spoken to a healthcare provider (HCP) about PrEP (42.1%), had ever used PrEP (24.7%), or were currently taking PrEP (16.3%) (Figure 1). A large majority (74.0%) reported interest in using LA PrEP. When asked about their preferred PrEP option, 60.2% chose LA PrEP and 7.4% chose DO PrEP, while 27.5% stated that they preferred neither PrEP option. Figure 1.

795. Awareness and Interest in PrEP Options Among US Cisgender Women – A National Survey

Background

Cisgender women continue to have low pre-exposure prophylaxis (PrEP) uptake in the US, despite making up almost 20% of new HIV infections. The gap between the number of women who would benefit from PrEP and those who use PrEP highlights the unmet need for HIV prevention in women. As new prevention options, such as long-acting (LA) injectable PrEP, become available, it is important to understand PrEP awareness and preferences among women to help meet this need. Awareness, willingness, and usage of PrEP as well as HIV prevention preferences were assessed among sexually active women in the US.

Methods

Cisgender women were recruited through a geolocation targeted social media campaign and completed a self-administered, cross-sectional, online survey on demographics, sexual health and behavior, healthcare access, PrEP awareness and history, and PrEP intention and preferences. Eligible participants were cisgender women, 18 years or older, who reported an unknown or HIV-negative status, currently resided in the US, and reported vaginal or anal sex in the past six months. Descriptive statistics were calculated using SAS v9.4.

Results

From November to December 2021, 961 participants completed the survey (median age: 28.0 years; Black non-Hispanic: 34.7%; Black Hispanic: 19.9%; White non-Hispanic: 21.3%; White Hispanic: 12.0%; Another race: 9.1%). A majority had heard of PrEP (70.6%) and LA PrEP (50.1%) as a way to prevent HIV; however, a smaller proportion had spoken to a healthcare provider (HCP) about PrEP (37.8%), had ever used PrEP (19.7%), or were currently on PrEP (9.3%). While PrEP awareness was high across all racial and ethnic groups, PrEP discussions with an HCP and PrEP usage was lowest among Black, non-Hispanic women (Figure 1). Most participants (78.8%) expressed intent to regularly use any HIV prevention method and 66.0% reported likelihood of using LA PrEP if it were available. Condoms were the most favored prevention option (46.7%) followed by HCP administered LA PrEP (24.3%), vaginal ring (9.0%), self-administered LA PrEP (8.8%), and oral PrEP (6.7%).

Conclusion

Although most women demonstrated high PrEP awareness and interest, many had never discussed PrEP with an HCP. The availability of LA PrEP may be an important opportunity for HCPs to discuss a preferred PrEP option with women.

Disclosures

Tonia Poteat, PhD, MPH, PAC, Merck & Co. Inc: Advisor/Consultant|Viiv Healthcare: Advisor/Consultant Supriya Sarkar, PhD, MPH, ViiV Healthcare: Salary|ViiV Healthcare: Stocks/Bonds Leigh Ragone, MS, GlaxoSmithKline: Stocks/Bonds|ViiV Healthcare: Employment Keith Rawlings, MD, ViiV Healthcare: Employee Alex R. Rinehart, PhD, ViiV Healthcare: Stocks/Bonds Vani Vannappagari, MBBS, MPH, PhD, ViiV Healthcare: I am full time employee of ViiV Healthcare and receive GlaxoSmithKline stock as part of my compensation package|ViiV Healthcare: Stocks/Bonds.

Developing a Conceptual Disease Model of Patient Experiences and Identifying Patient-Reported Clinical Outcome Assessments for Use in Trials of Treatments for Focal Onset Seizures

PURPOSE

To identify concepts important to understanding the experiences of adults with focal onset seizures (FOS) and evaluate clinical outcome assessments (COAs) for measuring these concepts in clinical trials of treatments for FOS.

METHODS

A search of published qualitative research, clinical trials, and approved product labels for FOS treatments was performed to develop a conceptual disease model (CDM) of patients' experience of living with FOS. Concepts of interest (COI) were selected, and a second literature search was conducted to identify COAs measuring these concepts. Ten COAs were selected and reviewed to document their development process, evidence of measurement properties, and methods for interpreting change scores using criteria proposed in regulatory guidelines for patient-reported outcomes to support label claims.

RESULTS

Concepts identified from the published literature (13 articles, 1 conference abstract), 24 clinical trials, and 8 product labels were included in a novel CDM. Impacts on physical, cognitive, and social and emotional function were chosen as COI for evaluating treatment outcomes for FOS; the additional concept of social support and coping strategies was chosen to understand patients' lived experiences. From 51 unique COAs identified, 10 were selected based on their potential coverage of the COI; some symptom severity and health-related quality of life (HRQoL) COAs covered multiple COI. Of these 10, 8 COAs evaluated impacts/limitations on physical function, 8 measured social and emotional impacts, and 5 assessed social support and coping strategies. While most assessments had gaps in evidence validating their measurement properties, 2 COAs measuring symptom severity and 1 COA measuring HRQoL had evidence confirming their potential utility in clinical trials to support label claims.

CONCLUSION

This research provides insights into the experience of patients with FOS and identifies COAs that measure concepts considered to support endpoints in clinical trials for FOS.

Prevention and management of osteoporosis and osteoporotic fractures in persons with a spinal cord injury or disorder: A systematic scoping review

Objectives: The primary objective was to review the literature regarding methodologies to assess fracture risk, to prevent and treat osteoporosis and to manage osteoporotic fractures in SCI/D.Study Design: Scoping review.Settings/Participants: Human adult subjects with a SCI/D.Outcome measures: Strategies to identify persons with SCI/D at risk for osteoporotic fractures, nonpharmacological and pharmacological therapies for osteoporosis and management of appendicular fractures.Results: 226 articles were included in the scoping review. Risk of osteoporotic fractures in SCI is predicted by a combination of DXA-defined low BMD plus clinical and demographic characteristics. Screening for secondary causes of osteoporosis, in particular hyperparathyroidism, hyperthyroidism, vitamin D insufficiency and hypogonadism, should be considered. Current antiresorptive therapies for treatment of osteoporosis have limited efficacy. Use of surgery to treat fractures has increased and outcomes are good and comparable to conservative treatment in most cases. A common adverse event following fracture was delayed healing.Conclusions: Most of the research in this area is limited by small sample sizes, weak study designs, and significant variation in populations studied. Future research needs to address cohort definition and study design issues.

Exploring content and psychometric validity of newly developed assessment tools for itch and skin pain in atopic dermatitis

Background

Atopic dermatitis (AD) is a common skin disorder characterized by chronic inflammation, altered skin barrier function, and inflammatory cell skin infiltration that decreases health-related quality of life (HRQoL). The study objective was to understand the patient perspective of AD burden and determine suitable patient-reported outcome (PRO) measures.

Methods

This mixed methods study involved the collection of qualitative and quantitative information from adults (≥ 18 years old) and adolescents (12 – 17 years old) with clinician-confirmed AD regarding their experiences of AD symptoms and its impact on HRQoL. The first part of the study included three stages: in-person concept elicitation (CE) interviews, a 2-week daily electronic diary (eDiary) study, and in-person cognitive debriefing (CD) interviews. An Itch numeric rating scale (NRS) (v1.0) and a Skin Pain NRS (v1.0) evaluation during CD interviews required participants to think about their ‘worst’ itch and ‘worst’ skin pain in the past 24 h. Other PRO measures allowed for psychometric testing. The second part of the study involved telephone-depth interviews (TDIs) and qualitative feedback from participants who had not participated in the CD interviews. Qualitative data were thematically analyzed. Psychometric evaluation of NRS measures was performed using eDiary data.

Results

In the CE interviews, itch and/or itching and skin pain were the most prevalent symptoms consistently discussed by participants. Both NRS measures demonstrated strong psychometric reliability and were applicable across ages with suitable concurrent validity. During the CD interviews, some participants focused their answers on their ‘average’ itch/itching in the past 24 h, rather than their ‘worst’ itch. Some participants answered the Skin Pain NRS thinking about general pain or other types of pain, rather than skin pain specifically. Consequently, modifications to both measures addressed these issues and re-tested as paper-and-pen versions in subsequent TDIs. Itch NRS (v2.0) modifications helped participants focus on their worst itching. Most participants preferred Skin Pain NRS v2.0b, which included skin pain descriptors.

Conclusions

Itching and skin pain are the most important and relevant AD symptoms. The Itch NRS (v2.0) and Skin Pain NRS (v2.0b) appear to be appropriate endpoints for the assessment of itching and skin pain severity for clinical trials with adults and adolescents with AD.

An Exploratory Pilot Study to Describe Shared Decision-Making for PTSD Treatment Planning: The Provider Perspective

OBJECTIVE

To describe current practices used by Veterans Administration (VA) mental health (MH) providers involved in post-traumatic stress disorder (PTSD) treatment planning to support engagement of veterans with PTSD in shared decision-making (SDM).

METHODS

Semi-structured interviews with MH providers (n = 9) were conducted at 1 large VA, audio-recorded, and transcribed verbatim. Transcripts were analyzed deductively, guided by a published account of the integral SDM components for MH care.

RESULTS

While discussing forming a cohesive team with patients, providers noted the importance of establishing rapport and assessing treatment readiness. Providers' clinical knowledge/expertise, knowledge of the facility's treatment options, knowledge of how to navigate the VA MH care system, and patient factors (goals/preferences, factors influencing treatment engagement) were noted as important to consider when patients and providers exchange information. When negotiating the treatment plan, providers indicated that conversations should include treatment recommendations and concurrent opportunities for personalization. They also emphasized the importance of discussions to finalize a mutually agreeable patient- and provider-informed treatment plan and measure treatment impact.

CONCLUSION

These results offer a preliminary understanding of VA MH providers' facilitation of SDM for PTSD care. Findings may provide insights for MH providers who wish to engage patients with PTSD in SDM.

Evaluating broad-scale system change using the Consolidated Framework for Implementation Research: challenges and strategies to overcome them

OBJECTIVE

The objective of this paper is to demonstrate the utility of the CFIR framework for evaluating broad-scale change by discussing the challenges to be addressed when planning the assessment of broad-scale change and the solutions developed by the evaluation team to address those challenges. The evaluation of implementation of Patient-centered Care and Cultural Transformation (PCC&CT) within the Department of Veterans Affairs (VA) will be used as a demonstrative example. Patient-Centered Care (PCC) is personalized health care that considers a patient's circumstances and goals. The Department of Veterans Affairs (VA) is working towards implementing PCC throughout its healthcare system, comprised of multiple interventions with a singular long-term goal of cultural transformation, however little is known about the factors influencing its implementation. This paper discusses the issues that arose using CFIR to qualitatively assess the factors influencing implementation of cultural transformation.

RESULTS

Application of CFIR to this broad-scale evaluation revealed three strategies recommended for use in evaluating implementation of broad-scale change: (1) the need for adapted definitions for CFIR constructs (especially due to new application to broad-scale change), (2) the use of a mixed deductive-inductive approach with thematic coding to capture emergent themes not encompassed by CFIR, and (3) its use for expedited analysis and synthesis for rapid delivery of findings to operational partners. This paper is among the first to describe use of CFIR to guide the evaluation of a broad-scale transformation, as opposed to discrete interventions. The processes and strategies described in this paper provide a detailed example and structured approach that can be utilized and expanded upon by others evaluating implementation of broad-scale evaluations. Although CFIR was the framework selected for this evaluation, the strategies described in this paper including: use of adapted definitions, use of mixed deductive-inductive approach, and the approach for expedited analysis and synthesis can be transferred and tested with other frameworks.

Potential of personal health record portals in the care of individuals with spinal cord injuries and disorders: Provider perspectives

CONTEXT/OBJECTIVE

Although personal health record (PHR) portals are designed for patients, healthcare providers are a key influence in how patients use their features and realize benefits from them. A few studies have examined provider attitudes toward PHR portals, but none have focused on those who care for individuals with spinal cord injuries and disorders (SCI/D). We characterize SCI/D provider perspectives of PHR portals, including perceived advantages and disadvantages of PHR portal use in SCI/D care.

DESIGN

Cross-sectional; semi-structured interviews.

SETTING

Spinal Cord Injury (SCI) Centers in the Veterans Health Administration.

PARTICIPANTS

Twenty-six SCI/D healthcare providers.

INTERVENTIONS

None.

OUTCOME MEASURES

Perceived advantages and disadvantages of PHR portals.

RESULTS

The complex situations of individuals with SCI/D shaped provider perspectives of PHR portals and their potential role in practice. Perceived advantages of PHR portal use in SCI/D care included the ability to coordinate information and care, monitor and respond to outpatient requests, support patient self-management activities, and provide reliable health information to patients. Perceived disadvantages of PHR portal use in SCI/D care included concerns about the quality of patient-generated health data, other potential liabilities for providers and workload burden, and the ability of individuals with SCI/D to understand clinical information accessed through a portal.

CONCLUSION

Our study highlights advantages and disadvantages that should be considered when promoting engagement of SCI/D healthcare providers in use of PHR portals, and portal features that may have the most utility in SCI/D care.

How can healthcare organizations implement patient-centered care? Examining a large-scale cultural transformation

BACKGROUND

Healthcare organizations increasingly are focused on providing care which is patient-centered rather than disease-focused. Yet little is known about how best to transform the culture of care in these organizations. We sought to understand key organizational factors for implementing patient-centered care cultural transformation through an examination of efforts in the US Department of Veterans Affairs.

METHODS

We conducted multi-day site visits at four US Department of Veterans Affairs medical centers designated as leaders in providing patient-centered care. We conducted qualitative semi-structured interviews with 108 employees (22 senior leaders, 42 middle managers, 37 front-line providers and 7 staff). Transcripts of audio recordings were analyzed using a priori codes based on the Consolidated Framework for Implementation Research. We used constant comparison analysis to synthesize codes into meaningful domains.

RESULTS

Sites described actions taken to foster patient-centered care in seven domains: 1) leadership; 2) patient and family engagement; 3) staff engagement; 4) focus on innovations; 5) alignment of staff roles and priorities; 6) organizational structures and processes; 7) environment of care. Within each domain, we identified multi-faceted strategies for implementing change. These included efforts by all levels of organizational leaders who modeled patient-centered care in their interactions and fostered willingness to try novel approaches to care amongst staff. Alignment and integration of patient centered care within the organization, particularly surrounding roles, priorities and bureaucratic rules, remained major challenges.

CONCLUSIONS

Transforming healthcare systems to focus on patient-centered care and better serve the "whole" patient is a complex endeavor. Efforts to transform healthcare culture require robust, multi-pronged efforts at all levels of the organization; leadership is only the beginning. Challenges remain for incorporating patient-centered approaches in the context of competing priorities and regulations. Through actions within each of the domains, organizations may begin to truly transform to patient-driven care.

Experience and Utility of Using the Participatory Research Method, Photovoice, in Individuals With Spinal Cord Injury

Background: There is a need to engage persons with spinal cord injuries/disorders (SCI/D) in research methodologies beyond traditional approaches. This provides an opportunity for individuals to convey their perspectives in a variety of ways. Photovoice empowers people to share their perspectives through photographs and narrative; this is well-suited for individuals who are less comfortable speaking up when other methods are used, such as focus groups. Objective: To examine photovoice methodology in US Veterans with SCI/D to describe their experiences with and the utility of photovoice. We also provide a sample of content (qualitative data) to illustrate how individuals with SCI/D conceptualized function and factors important to them. Methods: Photovoice, a qualitative participatory research method, was used to collect photographs from Veterans with SCI/D, which was followed by personal narratives describing the meaning of their photos. Results: Participants (N = 9) were 64 years old, on average, and 75% had paraplegia. Participants discussed the challenges with taking photographs, but they enjoyed participating, appreciated inclusion, and hoped the information they provided would help others with disabilities. Conclusion: These findings suggest that despite challenges and ethical barriers, individuals with SCI/D are interested in, highly capable of, and should be given the opportunity to be included in studies like this that empower participants to share their views using novel ways of expression. These findings demonstrate the desirability, feasibility, and utility of using photovoice in individuals with SCI/D. This method may be used to understand factors impacting health and well-being and can be made available to individuals with SCI/D to minimize inequalities in research opportunities.

Patient-centred care is a way of doing things: How healthcare employees conceptualize patient-centred care

Background

Patient‐centred care is now ubiquitous in health services research, and healthcare systems are moving ahead with patient‐centred care implementation. Yet, little is known about how healthcare employees, charged with implementing patient‐centred care, conceptualize what they are implementing.

Objective

To examine how hospital employees conceptualize patient‐centred care.

Research Design

We conducted qualitative interviews about patient‐centred care during site four visits, from January to April 2013.

Subjects

We interviewed 107 employees, including leadership, middle managers, front line providers and staff at four US Veteran Health Administration (VHA) medical centres leading VHA's patient‐centred care transformation.

Measures

Data were analysed using grounded thematic analysis. Findings were then mapped to established patient‐centred care constructs identified in the literature: taking a biopsychosocial perspective; viewing the patient‐as‐person; sharing power and responsibility; establishing a therapeutic alliance; and viewing the doctor‐as‐person.

Results

We identified three distinct conceptualizations: (i) those that were well aligned with established patient‐centred care constructs surrounding the clinical encounter; (ii) others that extended conceptualizations of patient‐centred care into the organizational culture, encompassing the entire patient‐experience; and (iii) still others that were poorly aligned with patient‐centred care constructs, reflecting more traditional patient care practices.

Conclusions

Patient‐centred care ideals have permeated into healthcare systems. Additionally, patient‐centred care has been expanded to encompass a cultural shift in care delivery, beginning with patients' experiences entering a facility. However, some healthcare employees, namely leadership, see patient‐centred care so broadly, it encompasses on‐going hospital initiatives, while others consider patient‐centred care as inherent to specific positions. These latter conceptualizations risk undermining patient‐centred care implementation by limiting transformational initiatives to specific providers or simply repackaging existing programmes.

Use of the PARIHS Framework for Retrospective and Prospective Implementation Evaluations

BACKGROUND

The Promoting Action on Research Implementation in Health Services (PARIHS) framework has been used by implementation researchers to assess factors impacting implementation and to use that information to identify optimal interventions and implementation strategies. In this paper, two studies are presented demonstrating the utility of PARIHS as a tool for retrospective and prospective evaluation of implementation in the health care setting.

STUDY DESIGN

Descriptive case study.

METHODS

A qualitative consensus process was used to evaluate provider perceptions of PARIHS constructs of evidence, context, and facilitation and their subelements which were scored on a continuum of low to high.

RESULTS

The first example demonstrates retrospective use of PARIHS which provided insight into the factors contributing to variations in implementation across sites in an ongoing program. Evidence was strong (high), whereas context noted some challenges in culture and measurement (mixed), and the presence of dedicated program facilitators was positive but dual roles limited their ability to fully support implementation (mixed). The second example demonstrates prospective use of PARIHS for evaluation which gathered information about intervention sites for the purposes of selecting implementation strategies responsive to site needs. Evidence supporting the intervention was limited (low), context noted that limited awareness of the intervention was a challenge (low), and that a strong internal facilitator supported implementation (high).

LINKING EVIDENCE TO ACTION

The descriptive case study presented here underscores the value of a theory-guided approach to implementation and highlights that PARIHS can help implementers understand factors impacting implementation, identify areas for future intervention, and inform selection of strategies to support or enhance implementation efforts.

Patient prioritization of comorbid chronic conditions in the Veteran population: Implications for patient-centered care

Objective:

Patients with comorbid chronic conditions may prioritize some conditions over others; however, our understanding of factors influencing those prioritizations is limited. In this study, we sought to identify and elaborate a range of factors that influence how and why patients with comorbid chronic conditions prioritize their conditions.

Methods:

We conducted semi-structured, one-on-one interviews with 33 patients with comorbidities recruited from a single Veterans Health Administration Medical Center.

Findings:

The diverse factors influencing condition prioritization reflected three overarching themes: (1) the perceived role of a condition in the body, (2) self-management tasks, and (3) pain. In addition to these themes, participants described the rankings that they believed their healthcare providers would assign to their conditions as an influencing factor, although few reported having shared their priorities or explicitly talking with providers about the importance of their conditions.

Conclusion:

Studies that advance understanding of how and why patients prioritize their various conditions are essential to providing care that is patient-centered, reflecting what matters most to the individual while improving their health. This analysis informs guideline development efforts for the care of patients with comorbid chronic conditions as well as the creation of tools to promote patient–provider communication regarding the importance placed on different conditions.

Starting a new conversation: Engaging Veterans with spinal cord injury in discussions of what function means to them, the barriers/facilitators they encounter, and the adaptations they use to optimize function

BACKGROUND

Assessments of function in persons with spinal cord injury (SCI) often utilize pre-defined constructs and measures without consideration of patient context, including how patients define function and what matters to them.

OBJECTIVES/HYPOTHESIS

We utilized photovoice to understand how individuals define function, facilitators and barriers to function, and adaptations to support functioning.

METHODS

Veterans with SCI were provided with cameras and guidelines to take photographs of things that: (1) help with functioning, (2) are barriers to function, and (3) represent adaptations used to support functioning. Interviews to discuss photographs followed and were audio-recorded, transcribed, and analyzed using grounded-thematic coding. Nvivo 8 was used to store and organize data.

RESULTS

Participants (n = 9) were male (89%), Caucasian (67%), had paraplegia (75%), averaged 64 years of age, and were injured, on average, for 22 years. Function was described in several ways: the concept of 'normalcy,' aspects of daily living, and ability to be independent. Facilitators included: helpful tools, physical therapy/therapists, transportation, and caregivers. Barriers included: wheelchair-related issues and interior/exterior barriers both in the community and in the hospital. Examples of adaptations included: traditional examples like ramps, and also creative examples like the use of rubber bands on a can to help with grip.

CONCLUSION(S)

Patient-perspectives elicited in-depth information that expanded the common definition of function by highlighting the concept of "normality," facilitators and barriers to function, and adaptations to optimize function. These insights emphasize function within a patient-context, emphasizing a holistic definition of function that can be used to develop personalized, patient-driven care plans.

Do perceptions of family-centered care differ in older and younger family/caregivers of U.S. veterans?

INTRODUCTION

Family-centered care (FCC) involves partnering with patients and family/caregivers ("caregivers"), engaging them in decisions, and providing support. FCC may be measured across 3 dimensions: respect, collaboration, and support and needs likely vary by caregiver age. The objective was to examine and compare caregiver perceptions of FCC by age.

METHOD

We mailed surveys to family/caregivers of Veterans. We collected demographics and measured respect, collaboration, and support using the Family-Centered Care Survey (FCCS). We calculated mean values and conducted bivariate comparisons, dichotomized by caregiver age (≥60 vs. <60), of demographics and FCC constructs. We completed thematic analysis on open-ended text.

RESULTS

Caregivers (n = 2,111) aged ≥60 versus <60 were more likely to be spouses (81% vs. 62%, p < .0001) and White (74% vs. 50%, p < .0001). Overall FCC subscales values were high: respect (3.30), collaboration (3.07), and support (2.99). Older caregivers reported higher respect (3.36 vs. 3.22, p < .001), collaboration (3.12 vs. 2.98, p < .0001), and support (3.06 vs. 2.88, p < .0001). Qualitative analysis revealed collaboration, communication, hospital climate, and physical environment as important to FCC and supplemented quantitative findings on age. Examples highlighted both positive perceptions of FCC and areas of concern, such as feeling "unheard" and "like I am bothering providers," and needing "more comfortable seating" and "better parking."

DISCUSSION

Caregivers perceived high FCC levels at VA facilities, reporting highest on respect and lowest on support. Older caregivers perceived better FCC compared with younger caregivers. Several concerns identified can be used to target improvements to FCC including: improved support, collaboration between patient/family/provider, and climate/environmental enhancements. (PsycINFO Database Record

Patient Perceptions of the Environment of Care in Which Their Healthcare is Delivered

Objective:

To measure patients’ perceptions of the environment of care (EOC), with a focus on the physical environment, in which healthcare is delivered.

Background:

The EOC may impact patient experiences, care perceptions, and health outcomes. EOC may be improved through redesign of existing physical structures or spaces or by adding nurturing amenities.

Methods:

Demographics, health status, hospital use, and data on the environment (physical, comfort, orientation, and privacy) were collected via a mailed cross-sectional survey sent to patients seen at four hospital Centers of Innovation (COIs; that implemented many modifications to the healthcare environment to address physical, comfort, orientation, and privacy factors) and four matched controls, supplemented with checklist and VA administrative data. A modified Perceived Hospital Environment Quality Indicators instrument was used to measure patients’ EOC perceptions.

Results:

Respondents (3,321/5,117; 65% response) rated, [mean ( SD)], exterior space highest, 3.09 (0.73), followed by interior space, 2.96 (0.74), and privacy, 2.44 (1.01). COIs had significantly higher ratings than controls on interior space (2.99 vs. 2.96, p = .02) and privacy (2.48 vs. 2.38, p = .005) but no differences for exterior space. Subscales with significantly higher ratings in COIs (vs. controls) in interior space were “spatial–physical comfort” and “orientation,” for example, clean, good signage, spacious rooms, and for privacy included “not too crowded” and “able to talk without being overheard.” Checklist findings confirmed the presence of EOC innovations rated highly by patients.

Conclusions:

Patients identified cleanliness, good signs/information points, adequate seating, nonovercrowding, and privacy for conversations as important. Hospital design modifications, with particular attention to the physical environment, can improve patient EOC perceptions.

Development of a unit-specific antibiogram and planning for implementation: Preimplementation findings

This practice forum reports experiences with the development of a unit-specific antibiogram and planning for its implementation. Involvement of internal and external facilitators was a key strategy for addressing issues, including data limitations, coordination, and planning. These activities were incorporated and reported as part of the facility's broader antimicrobial stewardship program, and represent the first step in a set of planned projects to evaluate the impact of antibiograms on provider behavior and patient outcomes.

Evaluating implementation of methicillin-resistant Staphylococcus aureus (MRSA) prevention guidelines in spinal cord injury centers using the PARIHS framework: a mixed methods study

BACKGROUND

To prevent methicillin-resistant Staphylococcus aureus (MRSA) in Spinal Cord Injury and Disorder (SCI/D) Centers, the "Guidelines for Implementation of MRSA Prevention Initiative in the Spinal Cord Injury Centers" were released in July 2008 in the Veterans Affairs (VA) Health Care System. The purpose of this study was to use the Promoting Action on Research Implementation in Health Systems (PARiHS) framework to evaluate the experiences of implementation of SCI/D MRSA prevention guidelines in VA SCI/D Centers approximately 2-3 years after the guidelines were released.

METHODS

Mixed methods were used across two phases in this study. The first phase included an anonymous, web-based cross-sectional survey administered to providers at all 24 VA SCI/D Centers. The second phase included semi-structured telephone interviews with providers at 9 SCI/D Centers. The PARiHS framework was used as the foundation of both the survey questions and semi-structured interview guide.

RESULTS

The survey was completed by 295 SCI/D providers (43.8 % response rate) from 22 of the 24 SCI/D Centers (91.7 % participation rate). Respondents included nurses (57.3 %), therapists (24.4 %), physicians (11.1 %), physician assistants (3.4 %), and other health care professionals (3.8 %). Approximately 36 % of the SCI/D providers surveyed had not seen, did not remember seeing, or had never heard of the MRSA SCI/D guidelines, whereas 42.3 % of providers reported that the MRSA SCI/D guidelines were fully implemented in their SCI/D Center. Data revealed numerous barriers and facilitators to guideline implementation. Facilitators included enhanced leadership support and provider education, focused guideline dissemination to reach SCI/D providers, and strong perceived evidence supporting the guidelines. Barriers included lack of awareness of the guidelines among physical therapists and physician assistants and challenges in cohorting/isolating MRSA-positive patients and following contact precautions.

CONCLUSIONS

Successful implementation of MRSA infection prevention guidelines in SCI/D settings requires (1) guideline dissemination that reaches the full range of SCI/D providers working in inpatient, outpatient, and other care settings, (2) provider education that is frequent and systematic, (3) strong leadership support, and (4) that barriers unique to the recommendations are addressed. These findings may be used to inform selection of implementation strategies and optimize infection prevention beyond MRSA as well as in other specialty care populations.

What is the extent and quality of documentation and reporting of fidelity to implementation strategies: a scoping review

BACKGROUND

Implementation fidelity is critical to the internal and external validity of implementation research. Much of what is written about implementation fidelity addresses fidelity of evidence-informed interventions rather than fidelity of implementation strategies. The documentation and reporting of fidelity to implementation strategies requires attention. Therefore, in this scoping review, we identify the extent and quality of documentation and reporting of fidelity of implementation strategies that were used to implement evidence-informed interventions.

METHODS

A six-stage methodological framework for scoping studies guided our work. Studies were identified from the outputs of the Effective Practice and Organization of Care (EPOC) review group within the Cochrane Database of Systematic Reviews. EPOC's primary focus, implementation strategies influencing provider behavior change, optimized our ability to identify articles for inclusion. We organized the retrieved articles from the systematic reviews by journal and selected the three journals with the largest number of retrieved articles. Using a data extraction tool, we organized retrieved article data from these three journals. In addition, we summarized implementation strategies using the EPOC categories. Data extraction pertaining to the quality of reporting the fidelity of implementation strategies was facilitated with an "Implementation Strategy Fidelity Checklist" based on definitions adapted from Dusenbury et al. We conducted inter-rater reliability checks for all of the independently scored articles. Using linear regression, we assessed the fidelity scores in relation to the publication year.

RESULTS

Seventy-two implementation articles were included in the final analysis. Researchers reported neither fidelity definitions nor conceptual frameworks for fidelity in any articles. The most frequently employed implementation strategies included distribution of education materials (n = 35), audit and feedback (n = 32), and educational meetings (n = 25). Fidelity of implementation strategies was documented in 51 (71 %) articles. Inter-rater reliability coefficients of the independent reviews for each component of fidelity were as follows: adherence = 0.85, dose = 0.89, and participant responsiveness = 0.96. The mean fidelity score was 2.6 (SD = 2.25). We noted a statistically significant decline in fidelity scores over time.

CONCLUSIONS

In addition to identifying the under-reporting of fidelity of implementation strategies in the health literature, we developed and tested a simple checklist to assess the reporting of fidelity of implementation strategies. More research is indicated to assess the definitions and scoring schema of this checklist. Careful reporting of details about fidelity of implementation strategies will make an important contribution to implementation science.

Noise Levels in Patient Rooms and at Nursing Stations at Three VA Medical Centers

Objectives:

To conduct an assessment of sound, dB(A) levels, in two areas of the hospital: patient rooms and nurse stations using sound meters (SMs).

Background:

The World Health Organization (WHO) recommends sound levels of 35 dB(A) during the day and 30 dB(A) during the night; however, many hospitals exceed these recommended levels. Assessing post-occupancy sound levels enables hospital administrators and healthcare workers to identify whether interventions to improve sound levels are needed.

Methods:

Sound assessments were conducted at three healthcare facilities in both patient rooms and nursing stations, and we include information on facility characteristics. An Amprobe SM-20A Sound Level Meter was placed for a 24-hr period and recorded decibel levels every 8 min. These sound levels were averaged for each hour for reporting purposes. Averages as well as highest and lowest readings are reported for both daytime (8 a.m.–10 p.m.) and nighttime (10 p.m.–8 a.m.) for each facility.

Results:

All three sites are considered urban and are classified with the highest complexity level (1a). Average daytime measurements for patient rooms and their corresponding nurses stations were as follows: Site A—63 dB(A)/56 dB(A), Site B—52 dB(A)/55 dB(A), and Site C—42 dB(A)/59 dB(A). Average nighttime measurements for patient rooms and nurses stations were Site A—62 dB(A)/55 dB(A), Site B—48 dB(A)/55 dB(A), and Site C—42 dB(A)/60 dB(A).

Conclusion:

Our findings, considered independently and collectively, showed that facilities in this study exceeded the WHO-recommended sound levels for patient rooms of 35 dB(A) during daytime and 30 dB(A) during nighttime. Research has reported negative patient outcomes, for example, decreased satisfaction, sleep disturbance, and higher incidence of rehospitalization in patients staying in areas with higher noise levels.

Implementing a declination form programme to improve influenza vaccine uptake by staff in Department of Veterans Affairs spinal cord injury centres: a pilot study

BACKGROUND

Individuals with spinal cord injuries and disorders are at high risk for respiratory and influenza-related complications after developing influenza. These individuals often have frequent contact with the healthcare system. Vaccination rates in healthcare workers at Department of Veterans Affairs (VA) spinal cord injury (SCI) centres have been approximately 50% for several years. Efforts are needed to increase vaccination uptake among SCI HCWs. Declination form programmes (DFPs) in combination with other strategies have resulted in significant increases in influenza vaccination uptake in HCWs.

AIM

Use of external and internal facilitation including local teams and consensus processes to pilot a DFP in two VA SCI centres and evaluate factors influencing implementation.

METHODS

Implementation meetings and a consensus-building process with leadership and implementation team members were conducted, along with semi-structured post-implementation interviews with members of each implementation team (N = 7).

FINDINGS

The DFP was well accepted and easy to use. Leadership was a key facilitator for DFP implementation. Barriers included difficulty communicating with HCWs working during early/late shifts. Participation was 100% at Site 1 and 48% at Site 2.

CONCLUSION

Use of local teams and consensus to identify strategies to implement a DFP is feasible and effective for achieving moderate-to-high levels of participation in the programme.

Healthcare worker influenza declination form program

BACKGROUND

Health care worker (HCW) vaccination rates have been low for many years (approximately 50%). Our goal was to implement an influenza declination form program (DFP) to assess feasibility, participation, HCW vaccination, and costs.

METHODS

This was a prospective interventional pilot study using mixed methods to evaluate the DFP implementation processes and outcomes. We conducted a formative evaluation and interviews; data were transcribed and coded into themes. Secondary outcomes included self-reported HCW influenza vaccine uptake (pre-/postsurvey) and program costs; data were evaluated using descriptive and bivariate analyses.

RESULTS

The DFP was compatible with ongoing strategies and unit culture. Barriers included multiple hospital shifts and competing demands. Facilitators included complementary ongoing strategies and leadership engagement. HCW vaccination rates were higher post- versus preimplementation (77.4% vs 53.5%, P =.01). To implement the DFP at site 1, using a mobile flu cart, 100% of declination forms were completed in 42.5 staff hours over <2 months. At site 2, using a vaccination table on all staff meeting days, 49% of forms were completed in 26.5 staff hours over 4.5 months. Average cost of staff time was $2,093 per site.

CONCLUSION

DFP implementation required limited resources and resulted in increased HCW influenza vaccine rates; this may have positive clinical implications for influenza infection control/prevention.

Relationship between knowledge and attitudes of methicillin-resistant Staphylococcus aureus and hand hygiene behavior in Veterans with spinal cord injury and disorder

The objective of this analysis was to understand the relationship between knowledge and attitudes regarding methicillin-resistant Staphylococcus aureus and hand hygiene behavior based on a baseline survey administered to Veterans with spinal cord injuries and disorders. Higher knowledge was associated with higher attitude scores (r = 0.35, P = .003), but knowledge and attitudes were not associated with behavior. Also, those with quadriplegia had higher knowledge scores (P = .03). Knowledge and attitudes, although related, do not appear to fully explain patients' hand hygiene behavior.

Perceptions of methicillin-resistant Staphylococcus aureus and hand hygiene provider training and patient education: results of a mixed method study of health care providers in Department of Veterans Affairs spinal cord injury and disorder units

BACKGROUND

The goal of this study was to assess current practices for training of spinal cord injury and disorder (SCI/D) health care workers and education of veterans with SCI/D in Department of Veterans Affairs (VA) spinal cord injury (SCI) centers on methicillin-resistant Staphylococcus aureus (MRSA) prevention.

METHODS

Mixed methods. A Web-based survey was distributed to 673 VA SCI/D providers across 24 SCI centers; 21 acute care and 1 long-term care facility participated. There were 295 that responded, 228 had complete data and were included in this analysis. Semistructured interviews were conducted with 30 SCI/D providers across 9 SCI centers.

RESULTS

Nurses, physicians, and therapists represent most respondents (92.1%, n = 210); over half (56.6%, n = 129) were nurses. Of providers, 75.9% (n = 173) reported receiving excellent or good training on how to educate patients about MRSA. However, nurses were more likely to report having excellent or good training for how to educate patients about MRSA (P = .005). Despite this, only 63.6% (n = 82) of nurses perceived the education they provide patients on how MRSA is transmitted as excellent or good.

CONCLUSION

Despite health care workers reporting receiving excellent or good training on MRSA-related topics, this did not translate to excellent or good education for patients, suggesting that health care workers need additional training for educating patients. Population-specific MRSA prevention educational materials may also assist providers in educating patients about MRSA prevention for individuals with SCI/D.

Implementing a patient education intervention about Methicillin-resistant Staphylococcus aureus prevention and effect on knowledge and behavior in veterans with spinal cord injuries and disorders: a pilot randomized controlled trial

OBJECTIVES

To assess the feasibility and effect of a nurse-administered patient educational intervention about Methicillin-resistant Staphylococcus aureus (MRSA) prevention on knowledge and behavior of Veterans with spinal cord injuries and disorders (SCI/D).

DESIGN

Blinded, block-randomized controlled pilot trial.

SETTING

Two Department of Veterans Affairs (VA) SCI Centers.

PARTICIPANTS

Veterans were recruited March-September 2010 through referral by a healthcare provider from inpatient, outpatient, and residential care settings.

INTERVENTION

Thirty participants were randomized to the nurse-administered intervention and 31 to the usual care group. The intervention included a brochure and tools to assist nurses in conducting the education.

OUTCOME MEASURES

Pre- and post-intervention measurement of knowledge and behaviors related to MRSA and prevention strategies and feasibility measures related to implementation.

RESULTS

Participants were primarily male (95.1%), white (63.9%), with tetraplegia (63.9%) and mean age and duration of injury of 64.3 and 20.5 years, respectively. The intervention groups mean knowledge score significantly increased between pre- and post-test (mean change score = 1.70, 95% confidence interval, CI 0.25-3.15) while the usual care groups score did not significantly change (mean change score = 1.45, 95% CI -0.08-2.98). However, the mean knowledge change between intervention and usual care groups was not significantly different (P = 0.81). Overall behavior scores did not significantly differ between treatment groups; however, the intervention group was more likely to report intentions to clean hands (90.0% vs. 64.5%, P = 0.03) and asking providers about MRSA status (46.7% vs. 16.1%, P = 0.01). Nurse educators reported that the quality of the intervention was high and could be implemented in clinical care.

CONCLUSIONS

A targeted educational strategy is feasible to implement in SCI/D clinical practices and may improve some participants' knowledge about MRSA and increase intentions to improve hand hygiene and engagement with providers about their MRSA status.

Patient and provider perspectives on methicillin-resistant Staphylococcus aureus: a qualitative assessment of knowledge, beliefs, and behavior

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause of healthcare-associated infection. Individuals with spinal cord injuries and disorders (SCI/D) are at high risk of MRSA colonization and infection. The Department of Veterans Affairs (VA) released guidelines to prevent the spread of MRSA in Veterans with SCI/D; however, available patient educational materials did not address the unique issues for this population.

OBJECTIVE

To assess perceptions of SCI/D providers and Veterans with SCI/D regarding MRSA and their educational needs about MRSA prevention, with an ultimate goal of developing patient educational materials that address the issues unique to SCI/D.

METHODS

Purposive samples of SCI/D providers (six groups) and Veterans with SCI/D (one group) at two VA facilities participated in 60-90-minute focus group sessions. Qualitative data were analyzed using latent content and constant comparative techniques to identify focal themes.

PARTICIPANTS

Thirty-three providers (physicians and nurses working in inpatient, outpatient, and homecare settings) and eight Veterans participated.

RESULTS

Three overarching themes emerged from the analysis: knowledge about MRSA, hand hygiene, and barriers to educating Veterans with SCI/D.

CONCLUSIONS

SCI/D providers and Veterans with SCI/D identified gaps in general MRSA knowledge, gaps in knowledge of good hand hygiene practices and of required frequency of hand hygiene, and barriers to educating Veterans with SCI/D during inpatient stays. Future educational materials and strategies should address these gaps.

Recurrence of symptomatic ventricular arrhythmias in patients with implantable cardioverter defibrillator after the first device therapy: implications for antiarrhythmic therapy and driving restrictions. CARE Group

OBJECTIVES

The purpose of this study was to investigate whether clinical or electrophysiologic characteristics could predict initial and subsequent implantable cardioverter defibrillator (ICD) therapy.

BACKGROUND

Identification of markers to predict subsequent ICD therapy and symptoms after the first event could affect patient management.

METHODS

We analyzed baseline and follow-up data on 125 ICD patients followed for 408+/-321 days. Medications and ICD programming were not changed after first ICD therapy.

RESULTS

Implantable cardioverter defibrillator therapy occurred in 58 patients (46%). Clinical features were as follows: mean left ventricular ejection fraction (LVEF) 29%+/-15%; coronary artery disease 84%; presenting arrhythmia with sustained monomorphic ventricular tachycardia (SMVT) in 68%. In a multivariate analysis the relative risk for ICD therapy in patients presenting with SMVT versus cardiac arrest (CA) was 2.57 (range, 1.32 to 5.01), and for patients with LVEF < or =25%, 1.95 (1.11 to 3.45), respectively (p < 0.05). Implantable cardioverter defibrillator therapy was not predicted by any other variable. Forty-six patients had second ICD therapy. Mean time to second ICD therapy was only 66+/-93 days compared with 138+/-168 days for first ICD therapy (p < 0.05). No predictor for second ICD therapy was found. Regarding symptoms, impaired consciousness during initial ICD therapy was predicted only by SMVT cycle length <250 ms at electrophysiologic testing. In contrast, symptoms were similar between first and second ICD therapy (p = 0.0001). Of note, ventricular tachycardia cycle length preceding first and second ICD therapy was similar (r = 0.76, p = 0.001).

CONCLUSIONS

First ICD therapy tends to occur in patients presenting with SMVT and LVEF < or =25%. Subsequent therapy occurs sooner and is unpredictable, suggesting that antiarrhythmic drug therapy should be considered after the first symptomatic ICD therapy. Symptoms during first ICD therapy predict subsequent symptoms, and patients presenting with SMVT and asymptomatic first ICD therapy are at very low risk for future syncopal ICD therapy.