Patient and Provider Perceptions About Communication After Bariatric Surgery: A Qualitative Analysis

INTRODUCTION

Communication between patients and providers can strongly influence patient behavior after surgery. The objective of this study was to assess patient and provider perceptions of how communication affected weight-related behaviors after bariatric surgery.

MATERIALS AND METHODS

Semistructured interviews with bariatric surgery patients and providers were conducted from April-November 2020. Patients who had Medicaid within 3 y of surgery were defined as socioeconomically disadvantaged. Interview guides were derived from Andersen's Behavioral Model of Health Services and Torain's Framework for Surgical Disparities. Participants described postoperative experiences regarding diet, physical activity, and follow-up care. A codebook was developed deductively based on the two theories. Directed content analysis identified themes pertaining to patient-provider communication.

RESULTS

Forty-five participants were interviewed, including 24 patients (83% female; 79% White), six primary care providers, four health psychologists, five registered dietitians, and six bariatric surgeons. Four themes regarding communication emerged: (1) Patients experiencing weight regain did not want to follow-up with providers to discuss their weight; (2) Patients from socioeconomically disadvantaged backgrounds had less trust and required more rapport-building from providers to enhance trust; (3) Patients felt that providers did not get to know them personally, which was perceived as a lack of personalized communication; and (4) Providers often changed their language to be simpler, so patients could understand them.

CONCLUSIONS

Patient-provider communication after bariatric surgery is essential, but perceptions about the elements of communication differ between patients and providers. Reassuring patients who have attained less weight loss than expected and establishing trust with socioeconomically vulnerable patients could strengthen care after bariatric surgery.

Applying the Hornik & Woolf Approach to Identify Messaging Themes and Improve COVID-19 Vaccine Confidence Among Federally Qualified Health Centers' Workforce in Wisconsin

The Federally Qualified Health Centers (FQHCs) in Wisconsin serve the most under-resourced communities in the state and are trusted sources in local communities. Although healthcare workers can be leveraged to champion COVID-19 vaccines, existing vaccine hesitancy among the FQHC workforce itself calls for research to identify promising messaging themes that can boost their vaccine confidence. In spring 2021, through a partnership with the Wisconsin Primary Health Association, we took a community-engaged approach to develop and field a survey including 46 beliefs (Ms = 1.36-4.25, SDs = 0.81-1.46, all on 5-point Likert scales) among employees of 10 out of the 17 FQHCs in Wisconsin. In total, 347 clinical team members and 349 non-clinical staff members (a) indicated their levels of (dis)agreement with all 46 belief items and (b) reported vaccine acceptance (dichotomized, acceptance = 77.6%) as well as recommendation intentions (dichotomized, yes = 73.9%). We carried out the Hornik & Woolf analyses in a multilevel logistic regression framework with bootstrapping to rank order all beliefs, segmented by subgroup and behavioral outcome. Our results suggest that communication-based interventions should promote beliefs such as those related to perceived safety and efficacy, rather than normative pressure from peers, while aiming to reduce doubts about information withholding and manipulation, the safety of the mRNA technology, the approval process, and "unnatural" ingredients in the vaccines. Subgroup-specific belief rankings are also provided. This study demonstrates the usefulness of incorporating the H&W approach into community-engaged research with local healthcare systems to improve health messaging for vaccine promotion.

Impact of COVID-19 on the Postoperative Bariatric Surgery Patient Experience

OBJECTIVE

To characterize patient and provider perceptions of the impact of coronavirus disease 2019 (COVID-19) on weight loss following bariatric surgery.

BACKGROUND

COVID-19 has disrupted routines and healthcare throughout the United States, but its impact on bariatric surgery patients' postoperative experience is unknown.

METHODS

Semistructured interviews with bariatric surgery patients, primary care providers, and health psychologists were conducted from April to November 2020. As part of a secondary analysis, patients and providers described how the COVID-19 pandemic affected the postoperative experience within 3 domains: dietary habits, physical activity, and follow-up care. Interview guides were created from 2 conceptual models: Torain's Surgical Disparities Model and Andersen's Behavioral Model of Health Services Use. Study team members derived codes, which were grouped into themes using conventional content analysis.

RESULTS

Thirty-four participants were interviewed: 24 patients (12 Roux-en-Y gastric bypass and 12 sleeve gastrectomy), 6 primary care providers, and 4 health psychologists. Patients were predominately female (83%) and White (79%). Providers were predominately female (90%) and White (100%). COVID-19 affected the postoperative bariatric surgery patient experience via 3 mechanisms: (1) it disrupted dietary and physical activity routines due to facility closures and fear of COVID-19 exposure; (2) it required patients to transition their follow-up care to telemedicine delivery; and (3) it increased stress due to financial and psychosocial challenges.

CONCLUSIONS

COVID-19 has exacerbated patient vulnerability. The pandemic is not over, thus bariatric surgery patients need ongoing support to access mental health professionals, develop new physical activity routines, and counteract increased food insecurity.

Socioeconomic disparities and bariatric surgery outcomes: A qualitative analysis

BACKGROUND

Disparities in socioeconomic status (SES) have been associated with less weight loss after bariatric surgery. The objective of this study was to identify socioeconomic barriers to weight loss after bariatric surgery.

METHODS

We performed semi-structured interviews with bariatric surgery patients and providers from April-November 2020. Participants were asked to describe their post-operative experiences regarding dietary habits, physical activity, and follow-up care. Interview data were coded using Directed Content Analysis based on domains in Andersen's Behavioral Model of Health Services Use and Torain's Surgical Disparities Model.

RESULTS

24 patients (median of 4.1 years post-operatively; mean age 50.6 ± 10.7 years; 12 bypass and 12 sleeve; 83% female) and 21 providers (6 bariatric surgeons, 5 registered dietitians, 4 health psychologists, and 6 primary care providers) were interviewed. Barriers to weight loss included: 1) challenging employment situations; 2) limited income; 3) unreliable transportation; 4) unsafe/inconvenient neighborhoods; and 5) limited health literacy.

CONCLUSIONS

Interventions targeting socioeconomic barriers to weight loss are needed to support patients, particularly those who are socioeconomically disadvantaged.

The All of Us Research Program: Data quality, utility, and diversity

The All of Us Research Program seeks to engage at least one million diverse participants to advance precision medicine and improve human health. We describe here the cloud-based Researcher Workbench that uses a data passport model to democratize access to analytical tools and participant information including survey, physical measurement, and electronic health record (EHR) data. We also present validation study findings for several common complex diseases to demonstrate use of this novel platform in 315,000 participants, 78% of whom are from groups historically underrepresented in biomedical research, including 49% self-reporting non-White races. Replication findings include medication usage pattern differences by race in depression and type 2 diabetes, validation of known cancer associations with smoking, and calculation of cardiovascular risk scores by reported race effects. The cloud-based Researcher Workbench represents an important advance in enabling secure access for a broad range of researchers to this large resource and analytical tools.

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The All of Us Research Program has released data for over 315,000 participants

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Demonstration projects support the utility and validity of the All of Us dataset

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The cloud-based Researcher Workbench provides secure, low-cost compute power

The engagement of participants in the research process and broad availability of data to diverse researchers are essential elements in building precision medicine equitably available for all. The NIH has established the ambitious All of Us Research Program to build one of the most diverse health databases in history with tools to support research to improve human health. Here, we present the initial launch of the Researcher Workbench with data types including surveys, physical measurements, and electronic health record data with validation studies to support researcher use of this novel platform. Broad access for researchers to data like these is a critical step in returning value to participants seeking to support the advancement of precision medicine and improved health for all.

Identifying Substantial Racial and Ethnic Disparities in Health Outcomes and Care in Wisconsin Using Electronic Health Record Data

BACKGROUND

Our goal was to identify racial and ethnic disparities in health outcome and care measures in Wisconsin.

METHODS

We used electronic health record data from 25 health systems submitting to the Wisconsin Collaborative for Healthcare Quality to identify disparities in measures, including vaccinations, screenings, risk factors for chronic disease, and chronic disease management.

RESULTS

American Indian/Alaska Native and Black populations experienced substantial disparities across multiple measures. Asian/Pacific Islander, Hispanic/Latino, and White populations experienced substantial disparities for 2 measures each.

DISCUSSION

Reducing health disparities is a statewide imperative. Root causes of health disparities, such as systemic racism and socioeconomic factors, should be addressed for groups experiencing multiple disparities, with focused efforts on selected measures when indicated.

Attitudes toward advance care planning among persons with dementia and their caregivers

OBJECTIVES

To examine factors that influence decision-making, preferences, and plans related to advance care planning (ACP) and end-of-life care among persons with dementia and their caregivers, and examine how these may differ by race.

DESIGN

Cross-sectional survey.

SETTING

13 geographically dispersed Alzheimer's Disease Centers across the United States.

PARTICIPANTS

431 racially diverse caregivers of persons with dementia.

MEASUREMENTS

Survey on "Care Planning for Individuals with Dementia."

RESULTS

The respondents were knowledgeable about dementia and hospice care, indicated the person with dementia would want comfort care at the end stage of illness, and reported high levels of both legal ACP (e.g., living will; 87%) and informal ACP discussions (79%) for the person with dementia. However, notable racial differences were present. Relative to white persons with dementia, African American persons with dementia were reported to have a lower preference for comfort care (81% vs. 58%) and lower rates of completion of legal ACP (89% vs. 73%). Racial differences in ACP and care preferences were also reflected in geographic differences. Additionally, African American study partners had a lower level of knowledge about dementia and reported a greater influence of religious/spiritual beliefs on the desired types of medical treatments. Notably, all respondents indicated that more information about the stages of dementia and end-of-life health care options would be helpful.

CONCLUSIONS

Educational programs may be useful in reducing racial differences in attitudes towards ACP. These programs could focus on the clinical course of dementia and issues related to end-of-life care, including the importance of ACP.

Brain–Computer Interface With Functional Electrical Stimulation Training for Upper-Extremity Rehabilitation Performance Outcomes

Date Presented 3/31/2017

A study was conducted to evaluate the efficacy of a 6-wk brain–computer interface with functional electrical stimulation (BCI–FES) therapy in improving upper-extremity (UE) motor function in adults poststroke. Data suggest BCI–FES therapy is promising for UE rehabilitation poststroke.

Primary Author and Speaker: Samantha Evander Elmore

Additional Authors and Speakers: Laura Kiekhoefer, Jessica Abrams, Rebecca Vermilyea

Contributing Authors: Dorothy Farrar-Edwards, Muhammad Al-Heizan, Brittany Young, Alexander Remsik

Barriers and Strategies for Recruitment of Racial and Ethnic Minorities: Perspectives from Neurological Clinical Research Coordinators

INTRODUCTION

Randomized controlled trials (RCTs) are the gold standard within evidence-based research. Low participant accrual rates, especially of underrepresented groups (e.g., racial-ethnic minorities), may jeopardize clinical studies' viability and strength of findings. Research has begun to unweave clinical trial mechanics, including the roles of clinical research coordinators, to improve trial participation rates.

METHODS

Two semi-structured focus groups were conducted with a purposive sample of 29 clinical research coordinators (CRCs) at consecutive international stroke conferences in 2013 and 2014 to gain in-depth understanding of coordinator-level barriers to racial-ethnic minority recruitment and retention into neurological trials. Coded transcripts were used to create themes to define concepts, identify associations, summarize findings, and posit explanations.

RESULTS

Barriers related to translation, literacy, family composition, and severity of medical diagnosis were identified. Potential strategies included a focus on developing personal relationships with patients, community and patient education, centralized clinical trial administrative systems, and competency focused training and education for CRCs.

CONCLUSION

Patient level barriers to clinical trial recruitment are well documented. Less is known about barriers facing CRCs. Further identification of how and when barriers manifest and the effectiveness of strategies to improve CRCs recruitment efforts is warranted.

Age-Related Changes in BOLD Activation Pattern in Phonemic Fluency Paradigm: An Investigation of Activation, Functional Connectivity and Psychophysiological Interactions

Healthy aging is associated with decline of cognitive functions. However, even before those declines become noticeable, the neural architecture underlying those mechanisms has undergone considerable restructuring and reorganization. During performance of a cognitive task, not only have the task-relevant networks demonstrated reorganization with aging, which occurs primarily by recruitment of additional areas to preserve performance, but the task-irrelevant network of the “default-mode” network (DMN), which is normally deactivated during task performance, has also consistently shown reduction of this deactivation with aging. Here, we revisited those age-related changes in task-relevant (i.e., language system) and task-irrelevant (i.e., DMN) systems with a language production paradigm in terms of task-induced activation/deactivation, functional connectivity, and context-dependent correlations between the two systems. Our task fMRI data demonstrated a late increase in cortical recruitment in terms of extent of activation, only observable in our older healthy adult group, when compared to the younger healthy adult group, with recruitment of the contralateral hemisphere, but also other regions from the network previously underutilized. Our middle-aged individuals, when compared to the younger healthy adult group, presented lower levels of activation intensity and connectivity strength, with no recruitment of additional regions, possibly reflecting an initial, uncompensated, network decline. In contrast, the DMN presented a gradual decrease in deactivation intensity and deactivation extent (i.e., low in the middle-aged, and lower in the old) and similar gradual reduction of functional connectivity within the network, with no compensation. The patterns of age-related changes in the task-relevant system and DMN are incongruent with the previously suggested notion of anti-correlation of the two systems. The context-dependent correlation by psycho-physiological interaction (PPI) analysis demonstrated an independence of these two systems, with the onset of task not influencing the correlation between the two systems. Our results suggest that the language network and the DMN may be non-dependent systems, potentially correlated through the re-allocation of cortical resources, and that aging may affect those two systems differently.

DTI measures track and predict motor function outcomes in stroke rehabilitation utilizing BCI technology

Tracking and predicting motor outcomes is important in determining effective stroke rehabilitation strategies. Diffusion tensor imaging (DTI) allows for evaluation of the underlying structural integrity of brain white matter tracts and may serve as a potential biomarker for tracking and predicting motor recovery. In this study, we examined the longitudinal relationship between DTI measures of the posterior limb of the internal capsule (PLIC) and upper-limb motor outcomes in 13 stroke patients (median 20-month post-stroke) who completed up to 15 sessions of intervention using brain-computer interface (BCI) technology. Patients' upper-limb motor outcomes and PLIC DTI measures including fractional anisotropy (FA), axial diffusivity (AD), radial diffusivity (RD), and mean diffusivity (MD) were assessed longitudinally at four time points: pre-, mid-, immediately post- and 1-month-post intervention. DTI measures and ratios of each DTI measure comparing the ipsilesional and contralesional PLIC were correlated with patients' motor outcomes to examine the relationship between structural integrity of the PLIC and patients' motor recovery. We found that lower diffusivity and higher FA values of the ipsilesional PLIC were significantly correlated with better upper-limb motor function. Baseline DTI ratios were significantly correlated with motor outcomes measured immediately post and 1-month-post BCI interventions. A few patients achieved improvements in motor recovery meeting the minimum clinically important difference (MCID). These findings suggest that upper-limb motor recovery in stroke patients receiving BCI interventions relates to the microstructural status of the PLIC. Lower diffusivity and higher FA measures of the ipsilesional PLIC contribute toward better motor recovery in the stroke-affected upper-limb. DTI-derived measures may be a clinically useful biomarker in tracking and predicting motor recovery in stroke patients receiving BCI interventions.

Characterizing relationships of DTI, fMRI, and motor recovery in stroke rehabilitation utilizing brain-computer interface technology

The relationship of the structural integrity of white matter tracts and cortical activity to motor functional outcomes in stroke patients is of particular interest in understanding mechanisms of brain structural and functional changes while recovering from stroke. This study aims to probe these underlying mechanisms using diffusion tensor imaging (DTI) and fMRI measures. We examined the structural integrity of the posterior limb of the internal capsule (PLIC) using DTI and corticomotor activity using motor-task fMRI in stroke patients who completed up to 15 sessions of rehabilitation therapy using Brain-Computer Interface (BCI) technology. We hypothesized that (1) the structural integrity of PLIC and corticomotor activity are affected by stroke; (2) changes in structural integrity and corticomotor activity following BCI intervention are related to motor recovery; (3) there is a potential relationship between structural integrity and corticomotor activity. We found that (1) the ipsilesional PLIC showed significantly decreased fractional anisotropy (FA) values when compared to the contralesional PLIC; (2) lower ipsilesional PLIC-FA values were significantly associated with worse motor outcomes (i.e., ipsilesional PLIC-FA and motor outcomes were positively correlated.); (3) lower ipsilesional PLIC-FA values were significantly associated with greater ipsilesional corticomotor activity during impaired-finger-tapping-task fMRI (i.e., ipsilesional PLIC-FA and ipsilesional corticomotor activity were negatively correlated), with an overall bilateral pattern of corticomotor activity observed; and (4) baseline FA values predicted motor recovery assessed after BCI intervention. These findings suggest that (1) greater vs. lesser microstructural integrity of the ipsilesional PLIC may contribute toward better vs. poor motor recovery respectively in the stroke-affected limb and demand lesser vs. greater cortical activity respectively from the ipsilesional motor cortex; and that (2) PLIC-FA is a promising biomarker in tracking and predicting motor functional recovery in stroke patients receiving BCI intervention.

Abstract W P306: Identifying Stroke Researcher Challenges to Minority Inclusion in Clinical Research

Background: Race-ethnic disparities exist in stroke incidence, recurrence and mortality. Minority participation in stroke clinical trials is staggeringly low. A significant literature describes patient-reported barriers to recruitment, but researcher barriers are not well documented.

Aim: To assess stroke researcher best practices and challenges to minority inclusion in stroke trials.

Methods: The National Initiative for Minority Involvement in Neurological Clinical Trials (NIMICT) uses a mixed methods approach including surveys, focus groups and key informant interviews to expand on understanding of minority recruitment and retention in stroke clinical trials. We designed and tested a 40-item survey based on literature review and used the results to inform semi-structured focus groups and key informant interviews among stroke clinical trial investigators (N=110).

Results: Key stroke investigators, identified through the Princeton Conference, were invited via email to participate in the survey. Over 70% (n=93) responded: 68% White. Less than half (N=43) reported actively setting recruitment goals for minority inclusion. Only 37% (N=29) required cultural sensitivity training for recruitment staff. Over 80% reported treating adults unable to consent and were concerned about acute stroke time constraints negatively impacting patient/family participation decisions. Key themes from focus groups (N=17) included: 1) Role of government in defining valid minority sub analyses and enforcing existing inclusion guidelines; 2) Challenges unique to acute setting including consent in conditions of prognostic uncertainty; 3) Lack of scientific/research literacy in the lay population; 4) Lack of community engagement including Primary Care Physicians; 5) Lack of cost data to adequately budget for inclusion efforts. Best practices included health literate consent forms, cultural competency, and motivational interview training for coordinators.

Conclusion: NIMICT’s mixed methods approach contributes new perspectives on unique challenges in stroke clinical research. These findings will inform strategies to improve minority recruitment and retention among neurological clinical trials.

Abstract 154: Changes in Task fMRI After Stroke Rehabilitation Using Closed-Loop Neurofeedback

Introduction: Brain-computer interface (BCI) is an emerging technology for stroke rehabilitation, but little is known about brain changes associated with its use. We examine changes in laterality index (LI) and functional connectivity (FC) during hand movements associated with BCI interventional therapy.

Methods: We collected anatomical and functional MRI of 8 stroke patients with upper extremity motor impairment before, during, and after up to 6 weeks of therapy using a BCI system with tongue and functional electrical stimulations. We acquired functional images during imagined (MI) and executed (ME) tapping and squeezing of each hand; not all subjects performed all tasks. Two subjects’ scans were flipped so that as a group the lesion was left (L) and the impaired limb right (R). We computed LI using 3 mask sets: whole brain, motor network, and motor cortex. Group-level analyses examined FC changes to motor network seeds using AFNI and Matlab NBS toolbox.

Results: BCI intervention led to decreased average LI during tapping. Overall, R taps shifted L to bilateral; all L taps shifted bilateral to R. Trends were consistent across all masks at thresholds p<.05 & p<.001 and were linearly modeled (r2 0.614 to 0.999). During R-ME, FC increased between each thalamus with L M1 and the cingulum. During L-ME, most FC increases were intrahemispheric (R M1 to R thalamus; within L M1). L-ME FC also decreased between each thalamus and contralateral frontal regions and between the cerebellum and frontal lobes. This pattern of inter- and intrahemispheric FC increases during respective R and L movement was also observed with MI, and many FC findings persisted in a subanalysis excluding flipped scans. A network of 6 seeds and 9 edges within the motor network had increased FC during R-ME. All FC changes p<.05.

Conclusions: BCI interventional therapy of the impaired hand leads to more bilateral brain activity, while more lateralized activation was seen of the unimpaired hand to its corresponding contralateral motor regions. With different patterns of change observed during tasks using the impaired or unimpaired hand, lesioned brain areas may respond differently to BCI than unlesioned counterparts.

Abstract TP321: Testing a Neural Activity Triggered Device for Stroke Rehabilitation

Background: In this ongoing study we are testing a closed-loop neurological feedback device that can facilitate functional recovery in stroke patients with upper extremity motor deficits.

Methods: This device combines Brain Computer Interface (BCI) and functional electrical muscle stimulation (FES), together with tongue stimulation (TS) in order to utilize the subject’s intention-to-move with the stimulated output. FMRI is used to examine the brain plasticity changes secondary to the rehabilitation. Subjects, wearing a 16-channel EEG cap, are first trained to voluntarily modulate beta and mu rhythms as they use motor imagery or execution of left and right hand squeezing task and then trained to use this imagery or execution to control the movement of a cursor, either to the right or the left depending on the presentation of a target rectangle shown on the screen. Once subjects achieve consistent accuracy in doing this task, FES in conjunction with TS is used. The subject is then asked to perform the task with the stimulation of FES and TS linked to their task performance.

Results: Two chronic stroke patients (mean age=57, 1 male, more than 1 year postonset) were able to complete the entire 3-week BCI training course and to perform the tasks at a > 70% success rate. Cortical activation recorded by EEG in response to attempted paretic arm movement became concentrated over the contralateral motor areas. Similar changes were confirmed by fMRI measures (Figure 1). Although neither subject showed any improvement on the Action Research Arm Test (ARAT), subjects self-reported increased strength, less spasticity and a greater range of movement in their paretic arm.

Conclusion: Our preliminary results indicate that training with the device may lead to brain plasticity changes toward normalization of cortical activation patterns and promote behavioral improvements for stroke patients even in their chronic stage.

Patterns of research utilization among Certified Hand Therapists

STUDY DESIGN

Mixed methods, cross-sectional.

INTRODUCTION

Nearly 30% of Certified Hand Therapists rarely or never use research findings when treating carpal tunnel syndrome.

PURPOSE OF THE STUDY

To identify groups of CHTs with common research utilization patterns.

METHODS

National randomized mail survey of 600 CHTs (n = 308, RR = 55%). Latent class and thematic analysis of eight questions assessing research use and beliefs.

RESULTS

Four groups of CHT research users were identified: Analytic (n = 135, 45%); Skeptic (n = 65, 22%); Pragmatic (n = 53, 18%); and Traditional (n = 46, 15%). Highest research use was reported among Analytics and Pragmatics although Skeptics willingly relied on research evidence when it contradicted other sources of knowledge. Age, not experience or population density, was a significant covariate of group membership.

CONCLUSIONS

Empowering CHTs to use research findings by increased understanding of their group membership, and understanding others' groups, may increase progress toward evidence-based practice.