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Kling SMR, Kalwani NM, Winget M, Gupta K, Saliba-Gustafsson EA, Baratta J, Garvert DW, Veruttipong D, Brown-Johnson CG, Vilendrer S, Gaspar C, Levin E, Tsai S. An initiative to promote value-based stress test selection in primary care and cardiology clinics: A mixed methods evaluation. J Eval Clin Pract 2024; 30:107-118. [PMID: 37459156 DOI: 10.1111/jep.13896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 03/01/2024]
Abstract
OBJECTIVES Exercise stress echocardiograms (stress echos) are overused, whereas exercise stress electrocardiograms (stress ECGs) can be an appropriate, lower-cost substitute. In this post hoc, mixed methods evaluation, we assessed an initiative promoting value-based, guideline-concordant ordering practices in primary care (PC) and cardiology clinics. METHODS Change in percent of stress ECGs ordered of all exercise stress tests (stress ECGs and echos) was calculated between three periods: baseline (January 2019-February 2020); Period 1 with reduced stress ECG report turnaround time + PC-targeted education (began June 2020); and Period 2 with the addition of electronic health record-based alternative alert (AA) providing point-of-care clinical decision support. The AA was deployed in two of five PC clinics in July 2020, two additional PC clinics in January 2021, and one of four cardiology clinics in February 2021. Nineteen primary care providers (PCPs) and five cardiologists were interviewed in Period 2. RESULTS Clinicians reported reducing ECG report turnaround time was crucial for adoption. PCPs specifically reported that value-based education helped change their practice. In PC, the percent of stress ECGs ordered increased by 38% ± 6% (SE) (p < 0.0001) from baseline to Period 1. Most PCPs identified the AA as the most impactful initiative, yet stress ECG ordering did not change (6% ± 6%; p = 0.34) between Periods 1 and 2. In contrast, cardiologists reportedly relied on their expertise rather than AAs, yet their stress ECGs orders increased from Period 1 to 2 to a larger degree in the cardiology clinic with the AA (12% ± 5%; p = 0.01) than clinics without the AA (6% ± 2%; p = 0.01). The percent of stress ECGs ordered was higher in Period 2 than baseline for both specialties (both p < 0.0001). CONCLUSIONS This initiative influenced ordering behaviour in PC and cardiology clinics. However, clinicians' perceptions of the initiative varied between specialties and did not always align with the observed behaviour change.
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Affiliation(s)
- Samantha M R Kling
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Neil M Kalwani
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Marcy Winget
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Kush Gupta
- Stanford University School of Medicine, Stanford, California, USA
| | - Erika A Saliba-Gustafsson
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Juliana Baratta
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Donn W Garvert
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Darlene Veruttipong
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Cati G Brown-Johnson
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Stacie Vilendrer
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Stanford Health Care, Stanford, California, USA
| | | | - Eleanor Levin
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Stanford Health Care, Stanford, California, USA
| | - Sandra Tsai
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Stanford Health Care, Stanford, California, USA
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2
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Savage JS, Moore AM, Kling SMR, Marini M, Hernandez E, Franceschelli Hosterman J, Hassink S, Paul IM, Bailey-Davis L. Coordination Between Primary Care and Women, Infants, and Children to Prevent Obesity for Infants from Low-Income Families: A Pragmatic Randomized Clinical Trial. Child Obes 2023; 19:515-524. [PMID: 36367983 DOI: 10.1089/chi.2022.0137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Rapid weight gain during infancy is associated with risk for later obesity, yet little research to date has examined the effect of a responsive parenting (RP) intervention with care coordination between pediatric primary care providers and Women, Infants, and Children nutritionists on infant weight. Methods: The Women, Infants, and Children Enhancements to Early Healthy Lifestyles for Baby (WEE Baby) Care study is a pragmatic, randomized clinical trial for mothers and infants (n = 288) designed to examine the effect of a patient-centered RP intervention that used advanced health information technology strategies to coordinate care to reduce rapid infant weight gain compared with standard care. General linear models examined intervention effects on infant conditional weight gain scores, weight-for-age z scores, BMI, and overweight status (BMI-for-age ≥85th percentile) from birth to age 6 months, and mothers' use of food to soothe from age 2 to 6 months. Results: There were no intervention effects on infant conditional weight gain scores or overweight status at 6 months. Infants in the RP intervention had lower mean weight-for-age z scores [M = -0.04, standard error (SE) = 0.04 vs. M = 0.05, SE = 0.04; p = 0.008] and lower mean BMI (M = 16.05, SE = 0.09 vs. M = 16.24, SE = 0.09; p = 0.03) compared with standard care. Mothers' use of emotion-based food to soothe was lower in the RP intervention compared with standard care from age 2 to 6 months [M difference = -0.32, standard deviation (SD) = 0.81 vs. 0.00, SD = 0.90; p = 0.01]. Conclusions: This pragmatic, patient-centered RP intervention did not reduce rapid infant weight gain or overweight but was associated with modestly lower infant BMI and reduced mothers' use of emotion-based food to soothe. Trial Registration: clinicaltrials.gov identifier: NCT03482908.
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Affiliation(s)
- Jennifer S Savage
- Center for Childhood Obesity Research, The Pennsylvania State University, University Park, PA, USA
| | - Amy M Moore
- Center for Childhood Obesity Research, The Pennsylvania State University, University Park, PA, USA
| | - Samantha M R Kling
- Evaluation Sciences Unit, Division of Primary Care Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Michele Marini
- Center for Childhood Obesity Research, The Pennsylvania State University, University Park, PA, USA
| | - Erika Hernandez
- Center for Childhood Obesity Research, The Pennsylvania State University, University Park, PA, USA
| | | | - Sandra Hassink
- Nemours Children's Health (Emeritus), Wilmington, DE, USA
| | - Ian M Paul
- Pediatrics and Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Lisa Bailey-Davis
- Population Health Sciences, Obesity Institute, Geisinger, Danville, PA, USA
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Kling SMR, Lessios AS, Holdsworth LM, Yefimova M, Wu S, Martin M, Sheffrin M, Winget M. Caregiver Experiences Participating in a Home-Based Primary Care Program: A Pragmatic Evaluation Including Qualitative Interviews and Quantitative Surveys. J Appl Gerontol 2023; 42:2066-2077. [PMID: 37269325 DOI: 10.1177/07334648231176380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023] Open
Abstract
The aim of this evaluation was to assess caregiver experience and burden during their first year in a geriatric home-based primary care (HBPC) program with qualitative interviews and surveys. HBPC included in-home visits for homebound, older adult patients. Seventeen caregivers, with varied amount of experience with HBPC, participated in semi-structured interviews. Change in caregiver burden from baseline was captured for 44 caregivers at 3 months post-enrollment, 27 caregivers at 6 months, and 22 caregivers at 12 months. Satisfaction survey was administered at these timepoints, but the last response of 48 caregivers was analyzed. Caregiver interviews revealed three themes: caregiving stressors, reliance on HBPC in relation to other medical care, and healthcare in the home. Surveyed caregivers were highly satisfied, but burden did not change substantially over the 1 year intervention. Caregivers appreciated HBPC reduced patient transportation and provided satisfactory primary care, but additional research is needed to tailor this care to reduce caregiver burden.
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Affiliation(s)
- Samantha M R Kling
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Anna Sophia Lessios
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Laura M Holdsworth
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Maria Yefimova
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Office of Research Patient Care Services, Stanford Healthcare, Stanford, CA, USA
| | - Siqi Wu
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Marina Martin
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Meera Sheffrin
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Marcy Winget
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Brown-Johnson CG, Lessios AS, Thomas S, Kim M, Fukaya E, Wu S, Kling SMR, Brown G, Winget M. A Nurse-Led Care Delivery App and Telehealth System for Patients Requiring Wound Care: Mixed Methods Implementation and Evaluation Study. JMIR Form Res 2023; 7:e43258. [PMID: 37610798 PMCID: PMC10483299 DOI: 10.2196/43258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 05/04/2023] [Accepted: 05/29/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Innovative solutions to nursing care are needed to address nurse, health system, patient, and caregiver concerns related to nursing wellness, work flexibility and control, workforce retention and pipeline, and access to patient care. One innovative approach includes a novel health care delivery model enabling nurse-led, off-hours wound care (PocketRN) to triage emergent concerns and provide additional patient health education via telehealth. OBJECTIVE This pilot study aimed to evaluate the implementation of PocketRN from the perspective of nurses and patients. METHODS Patients and part-time or per-diem, wound care-certified and generalist nurses were recruited through the Stanford Medicine Advanced Wound Care Center in 2021 and 2022. Qualitative data included semistructured interviews with nurses and patients and clinical documentation review. Quantitative data included app use and brief end-of-interaction in-app satisfaction surveys. RESULTS This pilot study suggests that an app-based nursing care delivery model is acceptable, clinically appropriate, and feasible. Low technology literacy had a modest effect on initial patient adoption; this barrier was addressed with built-in outreach and by simplifying the patient experience (eg, via phone instead of video calls). This approach was acceptable for users, despite total patient enrollment and use numbers being lower than anticipated (N=49; 17/49, 35% of patients used the app at least once beyond the orientation call). We interviewed 10 patients: 7 who had used the app were satisfied with it and reported that real-time advice after hours reduced anxiety, and 3 who had not used the app after enrollment reported having other resources for health care advice and noted their perception that this tool was meant for urgent issues, which did not occur for them. Interviewed nurses (n=10) appreciated working from home, and they reported comfort with the scope of practice and added quality of care facilitated by video capabilities; there was interest in additional wound care-specific training for nonspecialized nurses. Nurses were able to provide direct patient care over the web, including the few participating nurses who were unable to perform in-person care (n=2). CONCLUSIONS This evaluation provides insights into the integration of technology into standard health care services, such as in-clinic wound care. Using in-system nurses with access to electronic medical records and specialized knowledge facilitated app integration and continuity of care. This care delivery model satisfied nurse desires for flexible and remote work and reduced patient anxiety, potentially reducing postoperative wound care complications. Feasibility was negatively impacted by patients' technology literacy and few language options; additional patient training, education, and language support are needed to support equitable access. Adoption was impacted by a lack of perceived need for additional care; lower-touch or higher-acuity settings with a longer wait between visits could be a better fit for this type of nurse-led care.
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Affiliation(s)
- Cati G Brown-Johnson
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Anna Sophia Lessios
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | | | | | - Eri Fukaya
- Division of Vascular Surgery, Vascular Medicine Section, Stanford University School of Medicine, Stanford, CA, United States
| | - Siqi Wu
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Samantha M R Kling
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Gretchen Brown
- Office of the Chief Nursing Informatics Officer, Nursing Innovation & Informatics, Stanford Medicine, Stanford, CA, United States
| | - Marcy Winget
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
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5
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Kling SMR, Aleshin MA, Saliba-Gustafsson EA, Garvert DW, Brown-Johnson CG, Amano A, Kwong BY, Calugar A, Shaw JG, Ko JM, Winget M. Evolution of a Project to Improve Inpatient-to-Outpatient Dermatology Care Transitions: Mixed Methods Evaluation. JMIR Dermatol 2023; 6:e43389. [PMID: 37632927 PMCID: PMC10335331 DOI: 10.2196/43389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 03/17/2023] [Accepted: 04/04/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND In-hospital dermatological care has shifted from dedicated dermatology wards to consultation services, and some consulted patients may require postdischarge follow-up in outpatient dermatology. Safe and timely care transitions from inpatient-to-outpatient specialty care are critical for patient health, but communication around these transitions can be disjointed, and workflows can be complex. OBJECTIVE In this 3-phase quality improvement effort, we developed and evaluated an intervention that leveraged an electronic health record (EHR) feature, known as SmartPhrase, to enable a new workflow to improve transitions from inpatient care to outpatient dermatology. METHODS Phase 1 (February-March 2021) included interviews with patients and process mapping with key stakeholders to identify gaps and inform an intervention: a SmartPhrase table and associated workflow to promote collection of patient information needed for scheduling follow-up and closed-loop communication between dermatology and scheduling teams. In phase 2 (April-May 2021), semistructured interviews-with dermatologists (n=5), dermatology residents (n=5), and schedulers (n=6)-identified pain points and refinements. In phase 3, the intervention was evaluated by triangulating data from these interviews with measured changes in scheduling efficiency, visit completion, and messaging volume preimplementation (January-February 2021) and postimplementation (April-May 2021). RESULTS Preintervention pain points included unclear workflow for care transitions, limited patient input in follow-up planning, multiple messaging channels (eg, EHR based, email, and phone messages), and time-inefficient patient tracking. The intervention addressed most pain points; interviewees reported the intervention was easy to adopt and improved scheduling efficiency, workload, and patient involvement. More visits were completed within the desired timeframe of 14 days after discharge during the postimplementation period (21/47, 45%) than the preimplementation period (28/41, 68%; P=.03). The messaging workload also decreased from 88 scheduling-related messages sent for 25 patients before implementation to 30 messages for 8 patients after implementation. CONCLUSIONS Inpatient-to-outpatient specialty care transitions are complex and involve multiple stakeholders, thus requiring multifaceted solutions. With deliberate evaluation, broad stakeholder input, and iteration, we designed and implemented a successful solution using a standard EHR feature, SmartPhrase, integrated into a standardized workflow to improve the timeliness of posthospital specialty care and reduce workload.
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Affiliation(s)
- Samantha M R Kling
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Maria A Aleshin
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA, United States
| | - Erika A Saliba-Gustafsson
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Donn W Garvert
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Cati G Brown-Johnson
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Alexis Amano
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Bernice Y Kwong
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA, United States
| | - Ana Calugar
- Ambulatory Quality Department, Stanford Health Care, Stanford, CA, United States
| | - Jonathan G Shaw
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Justin M Ko
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA, United States
| | - Marcy Winget
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
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Kling SMR, Garvert DW, Lessios AS, Yefimova M, Martin M, Sheffrin M, Winget M. Home-Based Primary Care for Older Adults: Matched Case-Control Evaluation of Program’s Impact on Healthcare Utilization. Home Health Care Management & Practice 2023. [DOI: 10.1177/10848223231151975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Home-based Primary Care (HBPC) is an alternative model for homebound older adults. Healthcare utilization in HBPC was evaluated with a matched case-control design. Medical providers and social workers provided in-home visits. Enrolled patients were matched to controls on age, prior hospitalizations, and frailty risk. Difference-in-differences in utilization of primary care, specialty, and hospital services between 1-year pre- and 1-year post-enrollment were evaluated with hierarchical linear models. Analyses included 117 HBPC cases and 328 controls. HBPC cases had a significant increase in primary care visits compared to controls (7.8 ± 0.6; p < .0001) but significantly decreased utilization of in-clinic primary care visits (−3.2 ± 0.6; p < .0001). In-clinic specialty visits and hospital services did not differ between cases and controls (all p’s ≥ .75). Homebound patients accessed high-touch primary and social care, which is typically unachievable in clinic settings; however, additional work is needed to optimize services and target in-home care to impact healthcare utilization.
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Affiliation(s)
| | | | | | - Maria Yefimova
- Stanford University School of Medicine, Stanford, CA, USA
- Stanford Health Care, Stanford, CA, USA
| | - Marina Martin
- Stanford University School of Medicine, Stanford, CA, USA
| | - Meera Sheffrin
- Stanford University School of Medicine, Stanford, CA, USA
| | - Marcy Winget
- Stanford University School of Medicine, Stanford, CA, USA
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Juarez-Reyes M, Purington N, Kling SMR. Mindfulness-Based Group Medical Visits in Primary Care for Stress and Anxiety: An Observational Study. J Integr Complement Med 2022; 28:721-728. [PMID: 35671517 DOI: 10.1089/jicm.2021.0329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Background: The prevalence of anxiety disorders in primary care is 20%, with 41% of these patients reporting no current treatment. Patients with anxiety are also more likely to have comorbidities with other medical and/or psychiatric conditions, increasing medical costs. Integrating mindfulness-based interventions (MBIs) into a group medical visit (GMV) format has been successfully used to manage pain, but limited literature is available on the effectiveness of these visit formats for patients with stress and anxiety. Methods: Ninety-two adult patients with self-reported stress and/or anxiety were recruited from three university outpatient primary care clinics between 2016 and 2019. Participants attended at least 4 of 6 weekly GMVs focused on MBIs. Change in heart rate, blood pressure, Generalized Anxiety Disorder-7 (GAD-7) score, and 9 item Patient Health Questionnaire (PHQ-9) score from the first to last visit were evaluated using mixed effect linear regression models. Results: Both GAD-7 (estimated change: -5.1; 95% confidence interval [CI]: -6.4 to -3.7) and PHQ-9 (estimated change: -3.3; 95% CI: -4.3 to -2.2) scores significantly decreased from the first to last visit. These reductions were independent of age, sex, and number of visits attended. No significant changes in heart rate or blood pressure were found. Conclusions: Significant reductions in anxiety and depression in primary care patients were observed after a 6-week standardized mindfulness based GMV. Intergroup variability was not significant indicating that the intervention is reproducible over time and across providers. Future randomized controlled trials with appropriate controls will better evaluate which components of the intervention account for findings.
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Affiliation(s)
- Maria Juarez-Reyes
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Portola Valley, CA, USA
| | - Natasha Purington
- Department of Medicine, Qualitative Sciences Unit, School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Samantha M R Kling
- Department of Medicine, Evaluation Sciences Unit, Division of Primary Care and Population Health, Stanford University, Palo Alto, CA, USA
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Vilendrer S, Lough ME, Garvert DW, Lambert MH, Lu JH, Patel B, Shah NH, Williams MY, Kling SMR. Nursing Workflow Change in a COVID-19 Inpatient Unit Following the Deployment of Inpatient Telehealth: Observational Study Using a Real-Time Locating System. J Med Internet Res 2022; 24:e36882. [PMID: 35635840 PMCID: PMC9208574 DOI: 10.2196/36882] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/13/2022] [Accepted: 05/11/2022] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic prompted widespread implementation of telehealth, including in the inpatient setting, with the goals to reduce potential pathogen exposure events and personal protective equipment (PPE) utilization. Nursing workflow adaptations in these novel environments are of particular interest given the association between nursing time at the bedside and patient safety. Understanding the frequency and duration of nurse-patient encounters following the introduction of a novel telehealth platform in the context of COVID-19 may therefore provide insight into downstream impacts on patient safety, pathogen exposure, and PPE utilization. OBJECTIVE The aim of this study was to evaluate changes in nursing workflow relative to prepandemic levels using a real-time locating system (RTLS) following the deployment of inpatient telehealth on a COVID-19 unit. METHODS In March 2020, telehealth was installed in patient rooms in a COVID-19 unit and on movable carts in 3 comparison units. The existing RTLS captured nurse movement during 1 pre- and 5 postpandemic stages (January-December 2020). Change in direct nurse-patient encounters, time spent in patient rooms per encounter, and total time spent with patients per shift relative to baseline were calculated. Generalized linear models assessed difference-in-differences in outcomes between COVID-19 and comparison units. Telehealth adoption was captured and reported at the unit level. RESULTS Change in frequency of encounters and time spent per encounter from baseline differed between the COVID-19 and comparison units at all stages of the pandemic (all P<.001). Frequency of encounters decreased (difference-in-differences range -6.6 to -14.1 encounters) and duration of encounters increased (difference-in-differences range 1.8 to 6.2 minutes) from baseline to a greater extent in the COVID-19 units relative to the comparison units. At most stages of the pandemic, the change in total time nurses spent in patient rooms per patient per shift from baseline did not differ between the COVID-19 and comparison units (all P>.17). The primary COVID-19 unit quickly adopted telehealth technology during the observation period, initiating 15,088 encounters that averaged 6.6 minutes (SD 13.6) each. CONCLUSIONS RTLS movement data suggest that total nursing time at the bedside remained unchanged following the deployment of inpatient telehealth in a COVID-19 unit. Compared to other units with shared mobile telehealth units, the frequency of nurse-patient in-person encounters decreased and the duration lengthened on a COVID-19 unit with in-room telehealth availability, indicating "batched" redistribution of work to maintain total time at bedside relative to prepandemic periods. The simultaneous adoption of telehealth suggests that virtual care was a complement to, rather than a replacement for, in-person care. However, study limitations preclude our ability to draw a causal link between nursing workflow change and telehealth adoption. Thus, further evaluation is needed to determine potential downstream implications on disease transmission, PPE utilization, and patient safety.
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Affiliation(s)
- Stacie Vilendrer
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Mary E Lough
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States.,Office of Research Patient Care Services, Stanford Health Care, Palo Alto, CA, United States
| | - Donn W Garvert
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Monique H Lambert
- Office of Research Patient Care Services, Stanford Health Care, Palo Alto, CA, United States
| | - Jonathan Hsijing Lu
- Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Birju Patel
- Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Nigam H Shah
- Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Michelle Y Williams
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States.,Office of Research Patient Care Services, Stanford Health Care, Palo Alto, CA, United States
| | - Samantha M R Kling
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
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9
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Kling SMR, Saliba-Gustafsson EA, Winget M, Aleshin MA, Garvert DW, Amano A, Brown-Johnson CG, Kwong BY, Calugar A, El-Banna G, Shaw JG, Asch SM, Ko JM. Teledermatology to Facilitate Patient Care Transitions from Inpatient to Outpatient Dermatology: a Mixed Methods Evaluation (Preprint). J Med Internet Res 2022; 24:e38792. [PMID: 35921146 PMCID: PMC9386584 DOI: 10.2196/38792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/14/2022] [Accepted: 06/21/2022] [Indexed: 01/26/2023] Open
Abstract
Background Both clinicians and patients have increasingly turned to telemedicine to improve care access, even in physical examination–dependent specialties such as dermatology. However, little is known about whether teledermatology supports effective and timely transitions from inpatient to outpatient care, which is a common care coordination gap. Objective Using mixed methods, this study sought to retrospectively evaluate how teledermatology affected clinic capacity, scheduling efficiency, and timeliness of follow-up care for patients transitioning from inpatient to outpatient dermatology care. Methods Patient-level encounter scheduling data were used to compare the number and proportion of patients who were scheduled and received in-clinic or video dermatology follow-ups within 14 and 90 days after discharge across 3 phases: June to September 2019 (before teledermatology), June to September 2020 (early teledermatology), and February to May 2021 (sustained teledermatology). The time from discharge to scheduling and completion of patient follow-up visits for each care modality was also compared. Dermatology clinicians and schedulers were also interviewed between April and May 2021 to assess their perceptions of teledermatology for postdischarge patients. Results More patients completed follow-up within 90 days after discharge during early (n=101) and sustained (n=100) teledermatology use than at baseline (n=74). Thus, the clinic’s capacity to provide follow-up to patients transitioning from inpatient increased from baseline by 36% in the early (101 from 74) and sustained (100 from 74) teledermatology periods. During early teledermatology use, 61.4% (62/101) of the follow-ups were conducted via video. This decreased significantly to 47% (47/100) in the following year, when COVID-19–related restrictions started to lift (P=.04), indicating more targeted but still substantial use. The proportion of patients who were followed up within the recommended 14 days after discharge did not differ significantly between video and in-clinic visits during the early (33/62, 53% vs 15/39, 38%; P=.15) or sustained (26/53, 60% vs 28/47, 49%; P=.29) teledermatology periods. Interviewees agreed that teledermatology would continue to be offered. Most considered postdischarge follow-up patients to be ideal candidates for teledermatology as they had undergone a recent in-person assessment and might have difficulty attending in-clinic visits because of competing health priorities. Some reported patients needing technological support. Ultimately, most agreed that the choice of follow-up care modality should be the patient’s own. Conclusions Teledermatology could be an important tool for maintaining accessible, flexible, and convenient care for recently discharged patients needing follow-up care. Teledermatology increased clinic capacity, even during the pandemic, although the timeliness of care transitions did not improve. Ultimately, the care modality should be determined through communication with patients to incorporate their and their caregivers’ preferences.
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Affiliation(s)
- Samantha M R Kling
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Erika A Saliba-Gustafsson
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Marcy Winget
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Maria A Aleshin
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA, United States
| | - Donn W Garvert
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Alexis Amano
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Cati G Brown-Johnson
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Bernice Y Kwong
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA, United States
| | - Ana Calugar
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA, United States
| | - Ghida El-Banna
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA, United States
| | - Jonathan G Shaw
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Steven M Asch
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
- Center for Innovation to Implementation (Ci2i), Veterans Affairs Palo Alto Heath Care System, Menlo Park, CA, United States
| | - Justin M Ko
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA, United States
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10
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Reigh NA, Rolls BJ, Francis LA, Buss KA, Hayes JE, Hetherington MM, Moding KJ, Kling SMR, Keller KL. Examining the Role of Food Form on Children's Self-Regulation of Energy Intake. Front Nutr 2022; 9:791718. [PMID: 35223945 PMCID: PMC8865049 DOI: 10.3389/fnut.2022.791718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 01/17/2022] [Indexed: 11/15/2022] Open
Abstract
Increasing childhood obesity rates in both the United States and worldwide demonstrate a need for better prevention and intervention strategies. However, little is understood about what factors influence children's ability to sense and respond to hunger and fullness cues, a critical component of self-regulation of energy intake and maintenance of a healthy body weight. Research in adults suggests that food form may influence self-regulation of energy intake. More specifically, beverages are not as satiating as solid foods when matched for factors such as energy content, energy density, and volume and therefore elicit poorer energy intake self-regulation. However, much less is known about the impact of food form on children's ability to regulate their energy intake. This report describes a study that will examine the relationship between biological, cognitive, and psychological factors and children's appetite self-regulation (ASR). In this registered report, we will examine the influence of food form on children's short-term energy compensation, a proxy indicator of energy intake self-regulation. The study will employ a within-subjects, crossover design in which children (n = 78) ages 4.5-6 years will attend five laboratory visits, each ~1 week apart. During each visit, children will be presented with one of five possible preload conditions: apple slices, apple sauce, apple juice, apple juice sweetened with non-nutritive sweetener (NNS), or no preload. The order of preload conditions will be pseudorandomized and counterbalanced across participants. Following consumption of the preload (or no preload), children will consume a standardized ad libitum test meal of common foods for this age group. We hypothesize that children will demonstrate poorer short-term energy compensation (greater meal intake) in response to the liquid and semi-solid preloads compared to the solid preload. Understanding how energy in various forms affects children's ability to self-regulate intake has implications for dietary recommendations and will help identify those who are most at-risk for poor intake regulation and the development of obesity.
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Affiliation(s)
- Nicole A. Reigh
- The Metabolic Kitchen and Children's Eating Behavior Laboratory, Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA, United States
| | - Barbara J. Rolls
- The Laboratory for the Study of Human Ingestive Behavior, Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA, United States
| | - Lori A. Francis
- Center for Family Research in Diverse Contexts, Department of Biobehavioral Health, The Pennsylvania State University, University Park, PA, United States
| | - Kristin A. Buss
- The Emotion Development Laboratory, Departments of Psychology and Human Development and Family Studies, The Pennsylvania State University, University Park, PA, United States
| | - John E. Hayes
- Department of Food Science, Sensory Evaluation Center, The Pennsylvania State University, University Park, PA, United States
| | - Marion M. Hetherington
- Human Appetite Research Unit, School of Psychology, Woodhouse, The University of Leeds, Leeds, United Kingdom
| | - Kameron J. Moding
- Child Temperament and Health Laboratory, Department of Human Development and Family Studies, Purdue University, West Lafayette, IN, United States
| | - Samantha M. R. Kling
- Evaluation Sciences Unit, Division of Primary Care Population Health, Department of Medicine, School of Medicine, Stanford University, Stanford, CA, United States
| | - Kathleen L. Keller
- The Metabolic Kitchen and Children's Eating Behavior Laboratory, Departments of Nutritional Sciences and Food Science, The Pennsylvania State University, University Park, PA, United States
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11
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Kling SMR, Falco-Walter JJ, Saliba-Gustafsson EA, Garvert DW, Brown-Johnson CG, Miller-Kuhlmann R, Shaw JG, Asch SM, Yang L, Gold CA, Winget M. Patient and Clinician Perspectives of New and Return Ambulatory Teleneurology Visits. Neurol Clin Pract 2021; 11:472-483. [PMID: 34992955 PMCID: PMC8723969 DOI: 10.1212/cpj.0000000000001065] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 02/10/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVES To evaluate the adoption and perceived utility of video visits for new and return patient encounters in ambulatory neurology subspecialties. METHODS Video visits were launched in an academic, multi-subspecialty, ambulatory neurology clinic in March 2020. Adoption of video visits for new and return patient visits was assessed using clinician-level scheduling data from March 22 to May 16, 2020. Perceived utility of video visits was explored via a clinician survey and semistructured interviews with clinicians and patients/caregivers. Findings were compared across 5 subspecialties and 2 visit types (new vs return). RESULTS Video visits were adopted rapidly; all clinicians (n = 65) integrated video visits into their workflow within the first 6 weeks, and 92% of visits were conducted via video, although this varied by subspecialty. Utility of video visits was higher for return than new patient visits, as indicated by surveyed (n = 48) and interviewed clinicians (n = 30), aligning with adoption patterns. Compared with in-person visits, clinicians believed that it was easier to achieve a similar physical examination, patient-clinician rapport, and perceived quality of care over video for return rather than new patient visits. Of the 25 patients/caregivers interviewed, most were satisfied with the care provided via video, regardless of visit type, with the main limitation being the physical examination. DISCUSSION Teleneurology was robustly adopted for both new and return ambulatory neurology patients during the COVID-19 pandemic. Return patient visits were preferred over new patient visits, but both were feasible. These results provide a foundation for developing targeted guidelines for sustaining teleneurology in ambulatory care.
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Affiliation(s)
- Samantha M R Kling
- Evaluation Sciences Unit (SMRK, EAS-G, DWG, CGB-J, JGS, SMA, MW), Division of Primary Care Population Health, Department of Medicine, and Department of Neurology & Neurological Sciences (JJF-W, RM-K, LY, CAG), Stanford University School of Medicine, CA
| | - Jessica J Falco-Walter
- Evaluation Sciences Unit (SMRK, EAS-G, DWG, CGB-J, JGS, SMA, MW), Division of Primary Care Population Health, Department of Medicine, and Department of Neurology & Neurological Sciences (JJF-W, RM-K, LY, CAG), Stanford University School of Medicine, CA
| | - Erika A Saliba-Gustafsson
- Evaluation Sciences Unit (SMRK, EAS-G, DWG, CGB-J, JGS, SMA, MW), Division of Primary Care Population Health, Department of Medicine, and Department of Neurology & Neurological Sciences (JJF-W, RM-K, LY, CAG), Stanford University School of Medicine, CA
| | - Donn W Garvert
- Evaluation Sciences Unit (SMRK, EAS-G, DWG, CGB-J, JGS, SMA, MW), Division of Primary Care Population Health, Department of Medicine, and Department of Neurology & Neurological Sciences (JJF-W, RM-K, LY, CAG), Stanford University School of Medicine, CA
| | - Cati G Brown-Johnson
- Evaluation Sciences Unit (SMRK, EAS-G, DWG, CGB-J, JGS, SMA, MW), Division of Primary Care Population Health, Department of Medicine, and Department of Neurology & Neurological Sciences (JJF-W, RM-K, LY, CAG), Stanford University School of Medicine, CA
| | - Rebecca Miller-Kuhlmann
- Evaluation Sciences Unit (SMRK, EAS-G, DWG, CGB-J, JGS, SMA, MW), Division of Primary Care Population Health, Department of Medicine, and Department of Neurology & Neurological Sciences (JJF-W, RM-K, LY, CAG), Stanford University School of Medicine, CA
| | - Jonathan G Shaw
- Evaluation Sciences Unit (SMRK, EAS-G, DWG, CGB-J, JGS, SMA, MW), Division of Primary Care Population Health, Department of Medicine, and Department of Neurology & Neurological Sciences (JJF-W, RM-K, LY, CAG), Stanford University School of Medicine, CA
| | - Steven M Asch
- Evaluation Sciences Unit (SMRK, EAS-G, DWG, CGB-J, JGS, SMA, MW), Division of Primary Care Population Health, Department of Medicine, and Department of Neurology & Neurological Sciences (JJF-W, RM-K, LY, CAG), Stanford University School of Medicine, CA
| | - Laurice Yang
- Evaluation Sciences Unit (SMRK, EAS-G, DWG, CGB-J, JGS, SMA, MW), Division of Primary Care Population Health, Department of Medicine, and Department of Neurology & Neurological Sciences (JJF-W, RM-K, LY, CAG), Stanford University School of Medicine, CA
| | - Carl A Gold
- Evaluation Sciences Unit (SMRK, EAS-G, DWG, CGB-J, JGS, SMA, MW), Division of Primary Care Population Health, Department of Medicine, and Department of Neurology & Neurological Sciences (JJF-W, RM-K, LY, CAG), Stanford University School of Medicine, CA
| | - Marcy Winget
- Evaluation Sciences Unit (SMRK, EAS-G, DWG, CGB-J, JGS, SMA, MW), Division of Primary Care Population Health, Department of Medicine, and Department of Neurology & Neurological Sciences (JJF-W, RM-K, LY, CAG), Stanford University School of Medicine, CA
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12
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Vilendrer SM, Kling SMR, Wang H, Brown-Johnson C, Jayaraman T, Trockel M, Asch SM, Shanafelt TD. How Feedback Is Given Matters: A Cross-Sectional Survey of Patient Satisfaction Feedback Delivery and Physician Well-being. Mayo Clin Proc 2021; 96:2615-2627. [PMID: 34479736 DOI: 10.1016/j.mayocp.2021.03.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 01/28/2021] [Accepted: 03/15/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate how variation in the way patient satisfaction feedback is delivered relates to physician well-being and perceptions of its impact on patient care, job satisfaction, and clinical decision making. PARTICIPANTS AND METHODS A cross-sectional electronic survey was sent to faculty physicians from a large academic medical center in March 29, 2019. Physicians reported their exposure to feedback (timing, performance relative to peers, or channel) and related perceptions. The Professional Fulfillment Index captured burnout and professional fulfillment. Associations between feedback characteristics and well-being or perceived impact were tested using analysis of variance or logistic regression adjusted for covariates. RESULTS Of 1016 survey respondents, 569 (56.0%) reported receiving patient satisfaction feedback. Among those receiving feedback, 303 (53.2%) did not believe that this feedback improved patient care. Compared with physicians who never received feedback, those who received any type of feedback had higher professional fulfillment scores (mean, 6.6±2.1 vs 6.3±2.0; P=.03) but also reported an unfavorable impact on clinical decision making (odds ratio [OR], 2.9; 95% CI, 1.8 to 4.7; P<.001). Physicians who received feedback that included one-on-one discussions (as opposed to feedback without this channel) held more positive perceptions of the feedback's impact on patient care (OR, 2.0; 95% CI, 1.3 to 3.0; P=.003), whereas perceptions were less positive in physicians whose feedback included comparisons to named colleagues (OR, 0.5; 95% CI, 0.3 to 0.8; P=.003). CONCLUSION Providing patient satisfaction feedback to physicians was associated with mixed results, and physician perceptions of the impact of feedback depended on the characteristics of feedback delivery. Our findings suggest that feedback is viewed most constructively by physicians when delivered through one-on-one discussions and without comparison to peers.
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Affiliation(s)
- Stacie M Vilendrer
- Division of Primary Care and Population Health, Stanford School of Medicine, Stanford, CA.
| | - Samantha M R Kling
- Division of Primary Care and Population Health, Stanford School of Medicine, Stanford, CA
| | - Hanhan Wang
- Stanford Medicine WellMD Center, Stanford School of Medicine, Stanford, CA
| | - Cati Brown-Johnson
- Division of Primary Care and Population Health, Stanford School of Medicine, Stanford, CA
| | | | - Mickey Trockel
- Stanford Medicine WellMD Center, Stanford School of Medicine, Stanford, CA; Department of Psychiatry and Behavioral Sciences, Stanford School of Medicine, Stanford, CA
| | - Steven M Asch
- Division of Primary Care and Population Health, Stanford School of Medicine, Stanford, CA; VA Center for Innovation to Implementation, Menlo Park, CA
| | - Tait D Shanafelt
- Stanford Medicine WellMD Center, Stanford School of Medicine, Stanford, CA
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13
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Vilendrer S, Brown-Johnson C, Kling SMR, Veruttipong D, Amano A, Bohman B, Daines WP, Overton D, Srivastava R, Asch SM. Financial Incentives for Medical Assistants: A Mixed-Methods Exploration of Bonus Structures, Motivation, and Population Health Quality Measures. Ann Fam Med 2021; 19:427-436. [PMID: 34546949 PMCID: PMC8437570 DOI: 10.1370/afm.2719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 01/29/2021] [Accepted: 03/17/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Medical assistants (MAs) have seen their roles expand as a result of team-based primary care models. Unlike their physician counterparts, MAs rarely receive financial incentives as a part of their compensation. This exploratory study aims to understand MA acceptability of financial incentives and perceived MA control over common population health measures. METHODS We conducted semistructured focus groups between August and December of 2019 across 10 clinics affiliated with 3 institutions in California and Utah. MAs' perceptions of experienced and hypothetical financial incentives, their potential influence on workflow processes, and perceived levels of control over population health measures were discussed, recorded, and qualitatively analyzed for emerging themes. Perceived levels of control were further quantified using a Likert survey; measures were grouped into factors representing vaccinations, and workflow completed in the same day or multiple days (multiday). Mean scores for each factor were compared using repeated 1-way ANOVA with Tukey-Kramer adjustment. RESULTS MAs reported little direct experience with financial incentives. They indicated that a hypothetical bonus representing 2% to 3% of their average annual base pay would be acceptable and influential in improving consistent performance during patient rooming workflow. MAs reported having greater perceived control over vaccinations (P <.001) and same-day measures (P <.001) as compared with multiday measures. CONCLUSIONS MAs perceived that relatively small financial incentives would increase their motivation and quality of care. Our findings suggests target measures should focus on MA work processes that are completed in the same day as the patient encounter, particularly vaccinations. Future investigation is needed to understand the effectiveness of MA financial incentives in practice.
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Affiliation(s)
- Stacie Vilendrer
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Cati Brown-Johnson
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Samantha M R Kling
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Darlene Veruttipong
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Alexis Amano
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Bryan Bohman
- Department of Anesthesiology Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - William P Daines
- Internal Medicine Clinical Program, Intermountain Healthcare, Murray, Utah
| | | | - Raj Srivastava
- Intermountain Healthcare Delivery Institute, Intermountain Healthcare, Salt Lake City, Utah
| | - Steven M Asch
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California.,Center for Innovation to Implementation, Veterans Affairs, Menlo Park, California
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14
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Patel B, Vilendrer S, Kling SMR, Brown I, Ribeira R, Eisenberg M, Sharp C. Using a Real-Time Locating System to Evaluate the Impact of Telemedicine in an Emergency Department During COVID-19: Observational Study. J Med Internet Res 2021; 23:e29240. [PMID: 34236993 PMCID: PMC8315159 DOI: 10.2196/29240] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/27/2021] [Accepted: 06/13/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Telemedicine has been deployed by health care systems in response to the COVID-19 pandemic to enable health care workers to provide remote care for both outpatients and inpatients. Although it is reasonable to suspect telemedicine visits limit unnecessary personal contact and thus decrease the risk of infection transmission, the impact of the use of such technology on clinician workflows in the emergency department is unknown. OBJECTIVE This study aimed to use a real-time locating system (RTLS) to evaluate the impact of a new telemedicine platform, which permitted clinicians located outside patient rooms to interact with patients who were under isolation precautions in the emergency department, on in-person interaction between health care workers and patients. METHODS A pre-post analysis was conducted using a badge-based RTLS platform to collect movement data including entrances and duration of stay within patient rooms of the emergency department for nursing and physician staff. Movement data was captured between March 2, 2020, the date of the first patient screened for COVID-19 in the emergency department, and April 20, 2020. A new telemedicine platform was deployed on March 29, 2020. The number of entrances and duration of in-person interactions per patient encounter, adjusted for patient length of stay, were obtained for pre- and postimplementation phases and compared with t tests to determine statistical significance. RESULTS There were 15,741 RTLS events linked to 2662 encounters for patients screened for COVID-19. There was no significant change in the number of in-person interactions between the pre- and postimplementation phases for both nurses (5.7 vs 7.0 entrances per patient, P=.07) and physicians (1.3 vs 1.5 entrances per patient, P=.12). Total duration of in-person interactions did not change (56.4 vs 55.2 minutes per patient, P=.74) despite significant increases in telemedicine videoconference frequency (0.6 vs 1.3 videoconferences per patient, P<.001 for change in daily average) and duration (4.3 vs 12.3 minutes per patient, P<.001 for change in daily average). CONCLUSIONS Telemedicine was rapidly adopted with the intent of minimizing pathogen exposure to health care workers during the COVID-19 pandemic, yet RTLS movement data did not reveal significant changes for in-person interactions between staff and patients under investigation for COVID-19 infection. Additional research is needed to better understand how telemedicine technology may be better incorporated into emergency departments to improve workflows for frontline health care clinicians.
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Affiliation(s)
- Birju Patel
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Stacie Vilendrer
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Samantha M R Kling
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Ian Brown
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Ryan Ribeira
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Matthew Eisenberg
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Christopher Sharp
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
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15
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Holdsworth LM, Kling SMR, Smith M, Safaeinili N, Shieh L, Vilendrer S, Garvert DW, Winget M, Asch SM, Li RC. Predicting and Responding to Clinical Deterioration in Hospitalized Patients by Using Artificial Intelligence: Protocol for a Mixed Methods, Stepped Wedge Study. JMIR Res Protoc 2021; 10:e27532. [PMID: 34255728 PMCID: PMC8295833 DOI: 10.2196/27532] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/14/2021] [Accepted: 06/03/2021] [Indexed: 12/12/2022] Open
Abstract
Background The early identification of clinical deterioration in patients in hospital units can decrease mortality rates and improve other patient outcomes; yet, this remains a challenge in busy hospital settings. Artificial intelligence (AI), in the form of predictive models, is increasingly being explored for its potential to assist clinicians in predicting clinical deterioration. Objective Using the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model, this study aims to assess whether an AI-enabled work system improves clinical outcomes, describe how the clinical deterioration index (CDI) predictive model and associated work processes are implemented, and define the emergent properties of the AI-enabled work system that mediate the observed clinical outcomes. Methods This study will use a mixed methods approach that is informed by the SEIPS 2.0 model to assess both processes and outcomes and focus on how physician-nurse clinical teams are affected by the presence of AI. The intervention will be implemented in hospital medicine units based on a modified stepped wedge design featuring three stages over 11 months—stage 0 represents a baseline period 10 months before the implementation of the intervention; stage 1 introduces the CDI predictions to physicians only and triggers a physician-driven workflow; and stage 2 introduces the CDI predictions to the multidisciplinary team, which includes physicians and nurses, and triggers a nurse-driven workflow. Quantitative data will be collected from the electronic health record for the clinical processes and outcomes. Interviews will be conducted with members of the multidisciplinary team to understand how the intervention changes the existing work system and processes. The SEIPS 2.0 model will provide an analytic framework for a mixed methods analysis. Results A pilot period for the study began in December 2020, and the results are expected in mid-2022. Conclusions This protocol paper proposes an approach to evaluation that recognizes the importance of assessing both processes and outcomes to understand how a multifaceted AI-enabled intervention affects the complex team-based work of identifying and managing clinical deterioration. International Registered Report Identifier (IRRID) PRR1-10.2196/27532
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Affiliation(s)
- Laura M Holdsworth
- Department of Medicine, School of Medicine, Stanford University, Stanford, CA, United States
| | - Samantha M R Kling
- Department of Medicine, School of Medicine, Stanford University, Stanford, CA, United States
| | - Margaret Smith
- Department of Medicine, School of Medicine, Stanford University, Stanford, CA, United States
| | - Nadia Safaeinili
- Department of Medicine, School of Medicine, Stanford University, Stanford, CA, United States
| | - Lisa Shieh
- Department of Medicine, School of Medicine, Stanford University, Stanford, CA, United States
| | - Stacie Vilendrer
- Department of Medicine, School of Medicine, Stanford University, Stanford, CA, United States
| | - Donn W Garvert
- Department of Medicine, School of Medicine, Stanford University, Stanford, CA, United States
| | - Marcy Winget
- Department of Medicine, School of Medicine, Stanford University, Stanford, CA, United States
| | - Steven M Asch
- Department of Medicine, School of Medicine, Stanford University, Stanford, CA, United States.,Center for Innovation to Implementation, VA, Palo Alto, CA, United States
| | - Ron C Li
- Department of Medicine, School of Medicine, Stanford University, Stanford, CA, United States
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16
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Shepard J, Kling SMR, Lee G, Wong F, Frederick J, Skhiri M, Holubar M, Shaw JG, Stafford D, Schilling L, Kim J, Ick Chang S, Frush K, Hadhazy E. The prevalence of COVID-19 in healthcare personnel in an adult and pediatric academic medical center. Am J Infect Control 2021; 49:542-546. [PMID: 33896582 PMCID: PMC8062156 DOI: 10.1016/j.ajic.2021.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND It is vital to know which healthcare personnel (HCP) have a higher chance of testing positive for severe acute respiratory syndrome coronavirus 2 (COVID-19). METHODS A retrospective analysis was conducted at Stanford Children's Health (SCH) and Stanford Health Care (SHC) in Stanford, California. Analysis included all HCP, employed by SCH or SHC, who had a COVID-19 reverse transcriptase polymerase chain reaction (RT-PCR) test resulted by the SHC Laboratory, between March 1, 2020 and June 15, 2020. The primary outcome was the RT-PCR percent positivity and prevalence of COVID-19 for HCP and these were compared across roles. RESULTS SCH and SHC had 24,081 active employees, of which 142 had at least 1 positive COVID-19 test. The overall HCP prevalence of COVID-19 was 0.59% and percent positivity was 1.84%. Patient facing HCPs had a significantly higher prevalence (0.66% vs 0.43%; P = .0331) and percent positivity (1.95% vs 1.43%; P = .0396) than nonpatient facing employees, respectively. Percent positivity was higher in food service workers (9.15%), and environmental services (5.96%) compared to clinicians (1.93%; P < .0001) and nurses (1.46%; P < .0001), respectively. DISCUSSION AND CONCLUSION HCP in patient-facing roles and in support roles had a greater chance of being positive of COVID-19.
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Affiliation(s)
- John Shepard
- Department of Quality, Patient Safety and Clinical Effectiveness, Stanford Health Care, Stanford, CA.
| | - Samantha M R Kling
- Stanford University, School of Medicine, Department of Medicine, Primary Care and Population Health, Occupational Health Respiratory Evaluation Center, Stanford, CA
| | - Grace Lee
- Stanford Children's Health & Stanford University School of Medicine, Department of Pediatrics, Palo Alto, CA
| | - Frances Wong
- Kaiser Permanente Fontana Medical Center, Department of Inpatient Pharmacy, Fontana, CA
| | - John Frederick
- Western Michigan University, Homer Stryker M.D. School of Medicine, Kalamazoo, MI
| | - Mehdi Skhiri
- Stanford University, School of Medicine, Department of Medicine, Primary Care and Population Health, Occupational Health Respiratory Evaluation Center, Stanford, CA
| | - Marisa Holubar
- Stanford University, School of Medicine, Department of Medicine, Division of Infectious Diseases, Stanford, CA
| | - Jonathan G Shaw
- Stanford University, School of Medicine, Department of Medicine, Primary Care and Population Health, Occupational Health Respiratory Evaluation Center, Stanford, CA
| | - Diane Stafford
- Stanford Children's Health & Stanford University School of Medicine, Department of Pediatrics, Palo Alto, CA
| | - Lisa Schilling
- Department of Quality, Patient Safety and Clinical Effectiveness, Stanford Health Care, Stanford, CA
| | - Joseph Kim
- Stanford Children's Health & Stanford University School of Medicine, Department of Pediatrics, Palo Alto, CA
| | - Sang Ick Chang
- Stanford University, School of Medicine, Department of Medicine, Primary Care and Population Health, Occupational Health Respiratory Evaluation Center, Stanford, CA
| | - Karen Frush
- Department of Quality, Patient Safety and Clinical Effectiveness, Stanford Health Care, Stanford, CA; Stanford University, School of Medicine, Department of Emergency Medicine, Stanford, CA
| | - Eric Hadhazy
- Department of Quality, Patient Safety and Clinical Effectiveness, Stanford Health Care, Stanford, CA
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17
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Brown-Johnson CG, Spargo T, Kling SMR, Saliba-Gustafsson EA, Lestoquoy AS, Garvert DW, Vilendrer S, Winget M, Asch SM, Maggio P, Nazerali RS. Patient and surgeon experiences with video visits in plastic surgery-toward a data-informed scheduling triage tool. Surgery 2021; 170:587-595. [PMID: 33941389 DOI: 10.1016/j.surg.2021.03.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 03/01/2021] [Accepted: 03/21/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Coronavirus disease 2019 provided the impetus for unprecedented adoption of telemedicine. This study aimed to understand video visit adoption by plastic surgery providers; and patient and surgeon perceptions about its efficacy, value, accessibility, and long-term viability. A secondary aim was to develop the proposed 'Triage Tool for Video Visits in Plastic Surgery' to help determine visit video eligibility. METHODS This mixed-methods evaluation assessed provider-level scheduling data from the Division of Plastic and Reconstructive Surgery at Stanford Health Care to quantify telemedicine adoption and semi-structured phone interviews with patients (n = 20) and surgeons (n = 10) to explore stakeholder perspectives on video visits. RESULTS During the 13-week period after the local stay-at-home orders due to coronavirus disease 2019, 21.4% of preoperative visits and 45.5% of postoperative visits were performed via video. Video visits were considered acceptable by patients and surgeons in plastic surgery in terms of quality of care but were limited by the inability to perform a physical examination. Interviewed clinicians reported that long-term viability needs to be centered around technology (eg, connection, video quality, etc) and physical examinations. Our findings informed a proposed triage tool to determine the appropriateness of video visits for individual patients that incorporates visit type, anesthesia, case, surgeon's role, and patient characteristics. CONCLUSION Video technology has the potential to facilitate and improve preoperative and postoperative patient care in plastic surgery but the following components are needed: patient education on taking high-quality photos; standardized clinical guidelines for conducting video visits; and an algorithm-assisted triage tool to support scheduling.
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Affiliation(s)
- Cati G Brown-Johnson
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA.
| | - Tavish Spargo
- Division of Plastic and Reconstructive Surgery, Stanford Health Care, Stanford, CA
| | - Samantha M R Kling
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Erika A Saliba-Gustafsson
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Anna Sophia Lestoquoy
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Donn W Garvert
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Stacie Vilendrer
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Marcy Winget
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Steven M Asch
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Paul Maggio
- Department of Surgery, Stanford Health Care, Stanford, CA
| | - Rahim S Nazerali
- Division of Plastic and Reconstructive Surgery, Stanford Health Care, Stanford, CA
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18
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Juarez-Reyes M, Mui HZ, Kling SMR, Brown-Johnson C. Accessing behavioral health care during COVID: rapid transition from in-person to teleconferencing medical group visits. Ther Adv Chronic Dis 2021; 12:2040622321990269. [PMID: 33633823 PMCID: PMC7887692 DOI: 10.1177/2040622321990269] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 01/06/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND AIM Effective and safe behavioral health interventions in primary care are critical during pandemic and other disaster situations. California shelter-in-place orders necessitated rapid transition of an effective mindfulness-based medical group visit (MGV) program from in-person to videoconferenced sessions (VCSs). Aim: to Describe procedures, acceptability, and feasibility of converting from in-person to VCS. PATIENTS AND METHODS Methods: qualitative. Dataset: primary care. Intervention: a six-session 2-h MGV program with educational and mindfulness components was converted. Four in-person sessions and two VCSs were held. General Anxiety Disorder and Patient Health Questionnaire-9 were administered at first and last sessions. A semi-structured focus group was conducted after session six. Population studied: six primary care patients (42 ± 11 years) with stress, anxiety, or depression participated. RESULTS Procedural changes included remote material distribution, scheduling, hosting, and facilitation functions using the Zoom platform. The focus group revealed that patients preferred in-person sessions during initial visits, but appreciated transitioning to VCS, which provided continued support during a challenging time. Instruction on technical (e.g. logging on) and social (e.g. signaling next speaker) aspects of VCS was suggested. Building relationships through conversations was an important part before and after in-person sessions missing from VCS. Patients suggested combining in-person and VCS to allow relationship building while also improving access. CONCLUSION While many procedural changes were needed to facilitate conversion to VCS, primary care patients seeking stress, anxiety, and depression interventions found VCS acceptable during COVID-19. Future iterations of this program are proposed which incorporate procedural changes and facilitate relationship building between patients in VCS.
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Affiliation(s)
- Maria Juarez-Reyes
- School of Medicine, Stanford University, 3250 Alpine Rd, Portola Valley, CA 94028, USA
| | - Heather Z Mui
- Evaluation Sciences Unit, Stanford University School of Medicine, Stanford, CA, USA
| | - Samantha M R Kling
- Evaluation Sciences Unit, Stanford University School of Medicine, Stanford, CA, USA
| | - Cati Brown-Johnson
- Evaluation Sciences Unit, Stanford University School of Medicine, Stanford, CA, USA
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19
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Saliba-Gustafsson EA, Miller-Kuhlmann R, Kling SMR, Garvert DW, Brown-Johnson CG, Lestoquoy AS, Verano MR, Yang L, Falco-Walter J, Shaw JG, Asch SM, Gold CA, Winget M. Rapid Implementation of Video Visits in Neurology During COVID-19: Mixed Methods Evaluation. J Med Internet Res 2020; 22:e24328. [PMID: 33245699 PMCID: PMC7732357 DOI: 10.2196/24328] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/22/2020] [Accepted: 11/23/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Telemedicine has been used for decades. Despite its many advantages, its uptake and rigorous evaluation of feasibility across neurology's ambulatory subspecialties has been sparse. However, the COVID-19 pandemic prompted health care systems worldwide to reconsider traditional health care delivery. To safeguard health care workers and patients, many health care systems quickly transitioned to telemedicine, including across neurology subspecialties, providing a new opportunity to evaluate this modality of care. OBJECTIVE To evaluate the accelerated implementation of video visits in ambulatory neurology during the COVID-19 pandemic, we used mixed methods to assess adoption, acceptability, appropriateness, and perceptions of potential sustainability. METHODS Video visits were launched rapidly in ambulatory neurology clinics of a large academic medical center. To assess adoption, we analyzed clinician-level scheduling data collected between March 22 and May 16, 2020. We assessed acceptability, appropriateness, and sustainability via a clinician survey (n=48) and semistructured interviews with providers (n=30) completed between March and May 2020. RESULTS Video visits were adopted rapidly; overall, 65 (98%) clinicians integrated video visits into their workflow within the first 6 implementation weeks and 92% of all visits were conducted via video. Video visits were largely considered acceptable by clinicians, although various technological issues impacted their satisfaction. Video visits were reported to be more convenient for patients, families, and caregivers than in-person visits; however, access to technology, the patient's technological capacity, and language difficulties were considered barriers. Many clinicians expressed optimism about future utilization of video visits in neurology. They believed that video visits promote continuity of care and can be incorporated into their practice long-term, although several insisted that they can never replace the in-person examination. CONCLUSIONS Video visits are an important addition to clinical care in ambulatory neurology and are anticipated to remain a permanent supplement to in-person visits, promoting patient care continuity, and flexibility for patients and clinicians alike.
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Affiliation(s)
- Erika A Saliba-Gustafsson
- Primary Care and Population Health, Stanford University School of Medicine, Stanford University, Palo Alto, CA, United States
| | - Rebecca Miller-Kuhlmann
- Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford University, Palo Alto, CA, United States
| | - Samantha M R Kling
- Primary Care and Population Health, Stanford University School of Medicine, Stanford University, Palo Alto, CA, United States
| | - Donn W Garvert
- Primary Care and Population Health, Stanford University School of Medicine, Stanford University, Palo Alto, CA, United States
| | - Cati G Brown-Johnson
- Primary Care and Population Health, Stanford University School of Medicine, Stanford University, Palo Alto, CA, United States
| | - Anna Sophia Lestoquoy
- Primary Care and Population Health, Stanford University School of Medicine, Stanford University, Palo Alto, CA, United States
| | - Mae-Richelle Verano
- Primary Care and Population Health, Stanford University School of Medicine, Stanford University, Palo Alto, CA, United States
| | - Laurice Yang
- Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford University, Palo Alto, CA, United States
| | - Jessica Falco-Walter
- Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford University, Palo Alto, CA, United States
| | - Jonathan G Shaw
- Primary Care and Population Health, Stanford University School of Medicine, Stanford University, Palo Alto, CA, United States
| | - Steven M Asch
- Primary Care and Population Health, Stanford University School of Medicine, Stanford University, Palo Alto, CA, United States
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, United States
| | - Carl A Gold
- Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford University, Palo Alto, CA, United States
| | - Marcy Winget
- Primary Care and Population Health, Stanford University School of Medicine, Stanford University, Palo Alto, CA, United States
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20
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Kling SMR, Pearce AL, Reynolds ML, Garavan H, Geier CF, Rolls BJ, Rose EJ, Wilson SJ, Keller KL. Development and Pilot Testing of Standardized Food Images for Studying Eating Behaviors in Children. Front Psychol 2020; 11:1729. [PMID: 32793062 PMCID: PMC7385190 DOI: 10.3389/fpsyg.2020.01729] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/23/2020] [Indexed: 11/13/2022] Open
Abstract
Food images are routinely used to investigate the cognitive and neurobiological mechanisms of eating behaviors, but there is a lack of standardized image sets for use in children, which limits cross-study comparisons. To address this gap, we developed a set of age-appropriate images that included 30 high-energy-dense (ED) foods (>2.00 kcal/g), 30 low-ED foods (<1.75 kcal/g), and 30 office supplies photographed in two amounts (i.e., "larger" and "smaller"). Preliminary testing was conducted with children (6-10 years) to assess recognition, emotional valence (1 = very sad, 5 = very happy), and excitability (1 = very bored, 5 = very excited). After the initial testing, 10 images with low recognition were replaced; thus, differences between Image Set 1 and Image Set 2 were analyzed. Thirty (n = 30, mean age 8.3 ± 1.2 years) children rated Set 1, and a different cohort of 29 children (mean age 8.1 ± 1.1 years) rated Set 2. Changes made between image sets improved recognition of low-ED foods (Set 1 = 88.3 ± 10.5% vs. Set 2 = 95.6 ± 10.6%; p < 0.0001) and office supplies (83.7 ± 10.5 vs. 93.0 ± 10.6%; p < 0.0001). For the revised image set, children recognized more high-ED foods (98.4 ± 10.6%) than low-ED foods (95.6 ± 10.6%; p < 0.05) and office supplies (93.0 ± 10.6%; p < 0.0001). Recognition also improved with age (p < 0.001). Excitability and emotional valence scores were greater for high-ED foods compared with both low-ED foods and office supplies (p < 0.0001 for both). However, child fullness ratings influenced the relationship between excitability/emotional valence and category of item (p < 0.002). At the lowest fullness level, high-ED foods were rated the highest in both excitability and emotional valence, followed by low-ED foods and then office supplies. At the highest fullness level, high-ED foods remained the highest in excitability and emotional valence, but ratings for low-ED foods and office supplies were not different. This suggests that low-ED foods were more exciting and emotionally salient (relative to office supplies) when children were hungry. Ratings of recognition, excitability, and emotional valence did not differ by image amount. This new, freely available, image set showed high recognition and expected differences between image category for emotional valence and excitability. When investigating children's responsiveness to food cues, specifically energy density, it is essential for investigators to account for potential influences of child age and satiety level.
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Affiliation(s)
- Samantha M R Kling
- Metabolic Kitchen and Children's Eating Behavior Laboratory, Department of Nutritional Sciences, The Pennsylvania State University, State College, PA, United States.,Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, School of Medicine, Stanford University, Stanford, CA, United States
| | - Alaina L Pearce
- Metabolic Kitchen and Children's Eating Behavior Laboratory, Department of Nutritional Sciences, The Pennsylvania State University, State College, PA, United States
| | - Marissa L Reynolds
- Metabolic Kitchen and Children's Eating Behavior Laboratory, Department of Nutritional Sciences, The Pennsylvania State University, State College, PA, United States
| | - Hugh Garavan
- Department of Psychiatry, University of Vermont Medical School, Burlington, VT, United States.,Department of Psychological Sciences, University of Vermont Medical School, Burlington, VT, United States
| | - Charles F Geier
- Laboratory, Department of Human Development and Family Studies, The Pennsylvania State University, State College, PA, United States
| | - Barbara J Rolls
- Laboratory for the Study of Human Ingestive Behavior, Department of Nutritional Sciences, The Pennsylvania State University, State College, PA, United States
| | - Emma J Rose
- Laboratory, Prevention Research Center, The Pennsylvania State University, State College, PA, United States
| | - Stephen J Wilson
- Addiction Smoking and Health Laboratory, Department of Psychology, The Pennsylvania State University, State College, PA, United States
| | - Kathleen L Keller
- Metabolic Kitchen and Children's Eating Behavior Laboratory, Department of Nutritional Sciences, The Pennsylvania State University, State College, PA, United States.,Metabolic Kitchen and Children's Eating Behavior Laboratory, Department of Food Sciences, The Pennsylvania State University, State College, PA, United States
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21
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Yang L, Brown-Johnson CG, Miller-Kuhlmann R, Kling SMR, Saliba-Gustafsson EA, Shaw JG, Gold CA, Winget M. Accelerated launch of video visits in ambulatory neurology during COVID-19: Key lessons from the Stanford experience. Neurology 2020; 95:305-311. [PMID: 32611634 DOI: 10.1212/wnl.0000000000010015] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022] Open
Abstract
The SARS-CoV-2 (COVID-19) pandemic has rapidly moved telemedicine from discretionary to necessary. Here, we describe how the Stanford Neurology Department (1) rapidly adapted to the COVID-19 pandemic, resulting in over 1,000 video visits within 4 weeks, and (2) accelerated an existing quality improvement plan of a tiered roll out of video visits for ambulatory neurology to a full-scale roll out. Key issues we encountered and addressed were related to equipment/software, provider engagement, workflow/triage, and training. On reflection, the key drivers of our success were provider engagement and dedicated support from a physician champion, who plays a critical role understanding stakeholder needs. Before COVID-19, physician interest in telemedicine was mixed. However, in response to county and state stay-at-home orders related to COVID-19, physician engagement changed completely; all providers wanted to convert a majority of visits to video visits as quickly as possible. Rapid deployment of neurology video visits across all its subspecialties is feasible. Our experience and lessons learned can facilitate broader utilization, acceptance, and normalization of video visits for neurology patients in the present as well as the much anticipated postpandemic era.
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Affiliation(s)
- Laurice Yang
- From the Department of Neurology & Neurological Sciences (L.Y., R.M.-K., C.A.G.), Stanford University School of Medicine; and Evaluation Sciences Unit (C.G.B.-J., S.M.R.K., E.A.S.-G., J.G.S., M.W.), Stanford University School of MedicineCA.
| | - Cati G Brown-Johnson
- From the Department of Neurology & Neurological Sciences (L.Y., R.M.-K., C.A.G.), Stanford University School of Medicine; and Evaluation Sciences Unit (C.G.B.-J., S.M.R.K., E.A.S.-G., J.G.S., M.W.), Stanford University School of MedicineCA
| | - Rebecca Miller-Kuhlmann
- From the Department of Neurology & Neurological Sciences (L.Y., R.M.-K., C.A.G.), Stanford University School of Medicine; and Evaluation Sciences Unit (C.G.B.-J., S.M.R.K., E.A.S.-G., J.G.S., M.W.), Stanford University School of MedicineCA
| | - Samantha M R Kling
- From the Department of Neurology & Neurological Sciences (L.Y., R.M.-K., C.A.G.), Stanford University School of Medicine; and Evaluation Sciences Unit (C.G.B.-J., S.M.R.K., E.A.S.-G., J.G.S., M.W.), Stanford University School of MedicineCA
| | - Erika A Saliba-Gustafsson
- From the Department of Neurology & Neurological Sciences (L.Y., R.M.-K., C.A.G.), Stanford University School of Medicine; and Evaluation Sciences Unit (C.G.B.-J., S.M.R.K., E.A.S.-G., J.G.S., M.W.), Stanford University School of MedicineCA
| | - Jonathan G Shaw
- From the Department of Neurology & Neurological Sciences (L.Y., R.M.-K., C.A.G.), Stanford University School of Medicine; and Evaluation Sciences Unit (C.G.B.-J., S.M.R.K., E.A.S.-G., J.G.S., M.W.), Stanford University School of MedicineCA
| | - Carl A Gold
- From the Department of Neurology & Neurological Sciences (L.Y., R.M.-K., C.A.G.), Stanford University School of Medicine; and Evaluation Sciences Unit (C.G.B.-J., S.M.R.K., E.A.S.-G., J.G.S., M.W.), Stanford University School of MedicineCA
| | - Marcy Winget
- From the Department of Neurology & Neurological Sciences (L.Y., R.M.-K., C.A.G.), Stanford University School of Medicine; and Evaluation Sciences Unit (C.G.B.-J., S.M.R.K., E.A.S.-G., J.G.S., M.W.), Stanford University School of MedicineCA
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22
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Smethers AD, Roe LS, Sanchez CE, Zuraikat FM, Keller KL, Kling SMR, Rolls BJ. Portion size has sustained effects over 5 days in preschool children: a randomized trial. Am J Clin Nutr 2019; 109:1361-1372. [PMID: 30976782 PMCID: PMC6499504 DOI: 10.1093/ajcn/nqy383] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 12/14/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Although short-term studies have found that serving larger portions of food increases intake in preschool children, it is unknown whether this portion size effect persists over a longer period or whether energy intake is moderated through self-regulation. OBJECTIVES We tested whether the portion size effect is sustained in preschool children across 5 consecutive days, a period thought to be sufficient for regulatory systems to respond to the overconsumption of energy. METHODS With the use of a crossover design, over 2 periods we served the same 5 daily menus to 46 children aged 3-5 y in their childcare centers. In 1 period, all foods and milk were served in baseline portions, and in the other period, all portions were increased by 50%. The served items were weighed to determine intake. RESULTS Increasing the portion size of all foods and milk by 50% increased daily consumption: weighed intake increased by a mean ± SEM of 143 ± 21 g/d (16%) and energy intake increased by 167 ± 22 kcal/d (18%; both P < 0.0001). The trajectories of intake by weight and energy across the 5-day period were linear and the slopes did not differ between portion conditions (both P > 0.13), indicating that there were sustained increases in intake from larger portions without compensatory changes over time. Children differed in their response to increased portions: those with higher weight status, lower ratings for satiety responsiveness, or higher ratings for food responsiveness had greater increases in intake from larger portions (all P < 0.03). CONCLUSIONS This demonstration that preschool children failed to adjust their intake during prolonged exposure to larger portions challenges the suggestion that their self-regulatory behavior is sufficient to counter perturbations in energy intake. Furthermore, overconsumption from large portions may play a role in the development of overweight and obesity, as the magnitude of the effect was greater in children of higher weight status. This trial was registered at www.clinicaltrials.gov as NCT02963987.
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Affiliation(s)
- Alissa D Smethers
- Departments of Nutritional Sciences, The Pennsylvania State University, University Park, PA
| | - Liane S Roe
- Departments of Nutritional Sciences, The Pennsylvania State University, University Park, PA
| | - Christine E Sanchez
- Departments of Nutritional Sciences, The Pennsylvania State University, University Park, PA
| | - Faris M Zuraikat
- Departments of Nutritional Sciences, The Pennsylvania State University, University Park, PA
| | - Kathleen L Keller
- Departments of Nutritional Sciences, The Pennsylvania State University, University Park, PA,Departments of Food Science, The Pennsylvania State University, University Park, PA
| | - Samantha M R Kling
- Departments of Nutritional Sciences, The Pennsylvania State University, University Park, PA
| | - Barbara J Rolls
- Departments of Nutritional Sciences, The Pennsylvania State University, University Park, PA,Address correspondence to BJR (e-mail: )
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23
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Keller KL, Kling SMR, Fuchs B, Pearce AL, Reigh NA, Masterson T, Hickok K. A Biopsychosocial Model of Sex Differences in Children's Eating Behaviors. Nutrients 2019; 11:nu11030682. [PMID: 30909426 PMCID: PMC6470823 DOI: 10.3390/nu11030682] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/15/2019] [Accepted: 03/19/2019] [Indexed: 12/11/2022] Open
Abstract
The prevalence of obesity and eating disorders varies by sex, but the extent to which sex influences eating behaviors, especially in childhood, has received less attention. The purpose of this paper is to critically discuss the literature on sex differences in eating behavior in children and present new findings supporting the role of sex in child appetitive traits and neural responses to food cues. In children, the literature shows sex differences in food acceptance, food intake, appetitive traits, eating-related compensation, and eating speed. New analyses demonstrate that sex interacts with child weight status to differentially influence appetitive traits. Further, results from neuroimaging suggest that obesity in female children is positively related to neural reactivity to higher-energy-dense food cues in regions involved with contextual processing and object recognition, while the opposite was found in males. In addition to differences in how the brain processes information about food, other factors that may contribute to sex differences include parental feeding practices, societal emphasis on dieting, and peer influences. Future studies are needed to confirm these findings, as they may have implications for the development of effective intervention programs to improve dietary behaviors and prevent obesity.
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Affiliation(s)
- Kathleen L Keller
- Department of Nutritional Science, The Pennsylvania State University, University Park, PA 16802, USA.
- Department of Food Science, The Pennsylvania State University, University Park, PA 16803, USA.
| | - Samantha M R Kling
- Department of Nutritional Science, The Pennsylvania State University, University Park, PA 16802, USA.
| | - Bari Fuchs
- Department of Nutritional Science, The Pennsylvania State University, University Park, PA 16802, USA.
| | - Alaina L Pearce
- Department of Nutritional Science, The Pennsylvania State University, University Park, PA 16802, USA.
| | - Nicole A Reigh
- Department of Nutritional Science, The Pennsylvania State University, University Park, PA 16802, USA.
| | - Travis Masterson
- Department of Epidemiology, Geisel School of Medicine at Dartmouth College, Hanover, NH 03756, USA.
| | - Kara Hickok
- Department of Nutritional Science, The Pennsylvania State University, University Park, PA 16802, USA.
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24
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Savage JS, Kling SMR, Cook A, Hess L, Lutcher S, Marini M, Mowery J, Hayward S, Hassink S, Hosterman JF, Paul IM, Seiler C, Bailey-Davis L. A patient-centered, coordinated care approach delivered by community and pediatric primary care providers to promote responsive parenting: pragmatic randomized clinical trial rationale and protocol. BMC Pediatr 2018; 18:293. [PMID: 30180831 PMCID: PMC6123992 DOI: 10.1186/s12887-018-1263-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 08/22/2018] [Indexed: 02/06/2023] Open
Abstract
Background Economically disadvantaged families receive care in both clinical and community settings, but this care is rarely coordinated and can result in conflicting educational messaging. WEE Baby Care is a pragmatic randomized clinical trial evaluating a patient-centered responsive parenting (RP) intervention that uses health information technology (HIT) strategies to coordinate care between pediatric primary care providers (PCPs) and the Special Supplemental Nutrition Program for Women, Infant and Children (WIC) community nutritionists to prevent rapid weight gain from birth to 6 months. It is hypothesized that data integration and coordination will improve consistency in RP messaging and parent self-efficacy, promoting shared decision making and infant self-regulation, to reduce infant rapid weight gain from birth to 6 months. Methods/design Two hundred and ninety mothers and their full-term newborns will be recruited and randomized to the “RP intervention” or “standard care control” groups. The RP intervention includes: 1) parenting and nutrition education developed using the American Academy of Pediatrics Healthy Active Living for Families curriculum in conjunction with portions of a previously tested RP curriculum delivered by trained pediatric PCPs and WIC nutritionists during regularly scheduled appointments; 2) parent-reported data using the Early Healthy Lifestyles (EHL) risk assessment tool; and 3) data integration into child’s electronic health records with display and documentation features to inform counseling and coordinate care between pediatric PCPs and WIC nutritionists. The primary study outcome is rapid infant weight gain from birth to 6 months derived from sex-specific World Health Organization adjusted weight-for-age z-scores. Additional outcomes include care coordination, messaging consistency, parenting behaviors (e.g., food to soothe), self-efficacy, and infant sleep health. Infant temperament and parent depression will be explored as moderators of RP effects on infant outcomes. Discussion This pragmatic patient-centered RP intervention integrates and coordinates care across clinical and community sectors, potentially offering a fundamental change in the delivery of pediatric care for prevention and health promotion. Findings from this trial can inform large scale dissemination of obesity prevention programs. Trial registration Restrospective Clinical Trial Registration: NCT03482908. Registered March 29, 2018.
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Affiliation(s)
- Jennifer S Savage
- Department of Nutritional Sciences, Center for Childhood Obesity Research, 129 Noll Laboratory, The Pennsylvania State University, University Park, PA, 16802, USA.
| | - Samantha M R Kling
- Department of Nutritional Sciences, Center for Childhood Obesity Research, 129 Noll Laboratory, The Pennsylvania State University, University Park, PA, 16802, USA.,Geisinger Obesity Institute, Epidemiology and Health Services Research Geisinger, 100 N Academy Ave, Danville, PA, USA
| | - Adam Cook
- Geisinger Obesity Institute, Epidemiology and Health Services Research Geisinger, 100 N Academy Ave, Danville, PA, USA
| | - Lindsey Hess
- Department of Nutritional Sciences, Center for Childhood Obesity Research, 129 Noll Laboratory, The Pennsylvania State University, University Park, PA, 16802, USA
| | - Shawnee Lutcher
- Geisinger Obesity Institute, Epidemiology and Health Services Research Geisinger, 100 N Academy Ave, Danville, PA, USA
| | - Michele Marini
- Department of Nutritional Sciences, Center for Childhood Obesity Research, 129 Noll Laboratory, The Pennsylvania State University, University Park, PA, 16802, USA
| | - Jacob Mowery
- Geisinger Obesity Institute, Epidemiology and Health Services Research Geisinger, 100 N Academy Ave, Danville, PA, USA
| | - Shannon Hayward
- Maternal and Family Health Services, 15 Public Square, Suite 600, Wilkes-Barre, PA, 18701, USA
| | - Sandra Hassink
- Institute for Healthy Childhood Weight, American Academy of Pediatrics, 2602, Pennington Dr., Wilmington, DE, 19810, USA
| | | | - Ian M Paul
- Pediatrics, Public Health Services, Penn State College of Medicine, HS83, 500 University Drive, Hershey, PA, 17033, USA
| | - Chris Seiler
- Geisinger Obesity Institute, Epidemiology and Health Services Research Geisinger, 100 N Academy Ave, Danville, PA, USA
| | - Lisa Bailey-Davis
- Department of Nutritional Sciences, Center for Childhood Obesity Research, 129 Noll Laboratory, The Pennsylvania State University, University Park, PA, 16802, USA.,Geisinger Obesity Institute, Epidemiology and Health Services Research Geisinger, 100 N Academy Ave, Danville, PA, USA
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Bailey-Davis L, Kling SMR, Cochran WJ, Hassink S, Hess L, Franceschelli Hosterman J, Lutcher S, Marini M, Mowery J, Paul IM, Savage JS. Integrating and coordinating care between the Women, Infants, and Children Program and pediatricians to improve patient-centered preventive care for healthy growth. Transl Behav Med 2018; 8:944-952. [DOI: 10.1093/tbm/ibx046] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Affiliation(s)
- Lisa Bailey-Davis
- Geisinger Obesity Institute, Geisinger Health System, Danville, PA, USA
- Nutritional Sciences, Center for Childhood Obesity Research, The Pennsylvania State University, University Park, PA, USA
- Epidemiology and Health Services Research, Geisinger Health System, Danville, PA, USA
| | | | - William J Cochran
- Department of Pediatric Gastroenterology, Geisinger Medical Center, Danville, PA, USA
| | - Sandra Hassink
- Institute for Healthy Childhood Weight, American Academy of Pediatrics, Wilmington, DE, USA
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, , Wilmington, DE, USA
| | - Lindsey Hess
- Nutritional Sciences, Center for Childhood Obesity Research, The Pennsylvania State University, University Park, PA, USA
| | - Jennifer Franceschelli Hosterman
- Geisinger Obesity Institute, Geisinger Health System, Danville, PA, USA
- Nutrition and Weight Management, Geisinger Medical Center, Danville, PA, USA
| | - Shawnee Lutcher
- Geisinger Obesity Institute, Geisinger Health System, Danville, PA, USA
| | - Michele Marini
- Nutritional Sciences, Center for Childhood Obesity Research, The Pennsylvania State University, University Park, PA, USA
| | - Jacob Mowery
- Geisinger Obesity Institute, Geisinger Health System, Danville, PA, USA
| | - Ian M Paul
- Pediatrics, Penn State College of Medicine, Hershey, PA, USA
- Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Jennifer S Savage
- Nutritional Sciences, Center for Childhood Obesity Research, The Pennsylvania State University, University Park, PA, USA
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Kling SMR, Roe LS, Keller KL, Rolls BJ. Double trouble: Portion size and energy density combine to increase preschool children's lunch intake. Physiol Behav 2016; 162:18-26. [PMID: 26879105 DOI: 10.1016/j.physbeh.2016.02.019] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 01/28/2016] [Accepted: 02/11/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Both portion size and energy density (ED) have substantial effects on intake; however, their combined effects on preschool children's intake have not been examined when multiple foods are varied at a meal. OBJECTIVE We tested the effects on intake of varying the portion size and ED of lunches served to children in their usual eating environment. DESIGN In a crossover design, lunch was served in 3 childcare centers once a week for 6weeks to 120 children aged 3-5y. Across the 6 meals, all items were served at 3 levels of portion size (100%, 150%, or 200%) and 2 levels of ED (100% or 142%). The lunch menu had either lower-ED or higher-ED versions of chicken, macaroni and cheese, vegetables, applesauce, ketchup, and milk. Children's ratings of the foods indicated that the lower-ED and higher-ED meals were similarly well liked. RESULTS The total weight of food and milk consumed at meals was increased by serving larger portions (P<0.0001) but was unaffected by varying the ED (P=0.22). Meal energy intake, however, was independently affected by portion size and ED (both P<0.0001). Doubling the portions increased energy intake by 24% and increasing meal ED by 42% increased energy intake by 40%. These effects combined to increase intake by 175±12kcal or 79% at the higher-ED meal with the largest portions compared to the lower-ED meal with the smallest portions. The foods contributing the most to this increase were chicken, macaroni and cheese, and applesauce. The effects of meal portion size and ED on intake were not influenced by child age or body size, but were significantly affected by parental ratings of child eating behavior. CONCLUSION Strategically moderating the portion size and ED of foods typically consumed by children could substantially reduce their energy intake without affecting acceptability.
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Affiliation(s)
- Samantha M R Kling
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA, United States
| | - Liane S Roe
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA, United States
| | - Kathleen L Keller
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA, United States; Department of Food Science, The Pennsylvania State University, University Park, PA, United States
| | - Barbara J Rolls
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA, United States.
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Roe LS, Kling SMR, Rolls BJ. What is eaten when all of the foods at a meal are served in large portions? Appetite 2016; 99:1-9. [PMID: 26767612 DOI: 10.1016/j.appet.2016.01.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 11/20/2015] [Accepted: 01/02/2016] [Indexed: 02/08/2023]
Abstract
Portion size affects intake, but when all foods are served in large portions, it is unclear whether every food will be consumed in greater amounts. We varied the portion size (PS) of all foods at a meal to investigate the influence of food energy density (ED) on the PS effect as well as that of palatability and subject characteristics. In a crossover design, 48 women ate lunch in the laboratory on four occasions. The meal had three medium-ED foods (pasta, bread, cake) and three low-ED foods (broccoli, tomatoes, grapes), which were simultaneously varied in PS across meals (100%, 133%, 167%, or 200% of baseline amounts). The results showed that the effect of PS on the weight of food consumed did not differ between medium-ED and low-ED foods (p < 0.0001). Energy intake, however, was substantially affected by food ED across all portions served, with medium-ED foods contributing 86% of energy. Doubling the portions of all foods increased meal energy intake by a mean (±SEM) of 900 ± 117 kJ (215 ± 28 kcal; 34%). As portions were increased, subjects consumed a smaller proportion of the amount served; this response was characterized by a quadratic curve. The strongest predictor of the weight of food consumed was the weight of food served, both for the entire meal (p < 0.0001) and for individual foods (p = 0.014); subject characteristics explained less variability. Intake in response to larger portions was greater for foods that subjects ranked higher in taste (p < 0.0001); rankings were not related to food ED. This study demonstrates the complexity of the PS effect. While the response to PS can vary between individuals, the effect depends primarily on the amounts of foods offered and their palatability compared to other available foods.
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Affiliation(s)
- Liane S Roe
- Laboratory for the Study of Human Ingestive Behavior, The Pennsylvania State University, University Park, PA, USA
| | - Samantha M R Kling
- Laboratory for the Study of Human Ingestive Behavior, The Pennsylvania State University, University Park, PA, USA
| | - Barbara J Rolls
- Laboratory for the Study of Human Ingestive Behavior, The Pennsylvania State University, University Park, PA, USA.
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