The Trajectories of Online Mental Health Information Seeking: Modeling Search Behavior Before and After Completion of Self-report Screens

There is an appreciable mental health treatment gap in the United States. Efforts to bridge this gap and improve resource accessibility have led to the provision of online, clinically-validated tools for mental health self-assessment. In theory, these screens serve as an invaluable component of information-seeking, representing the preparative and action-oriented stages of this process while altering or reinforcing the search content and language of individuals as they engage with information online. Accordingly, this work investigated the association of screen completion with mental health-related search behaviors. Three-year internet search histories from N=7,572 Microsoft Bing users were paired with their respective depression, anxiety, bipolar disorder, or psychosis online screen completion and sociodemographic data available through Mental Health America. Data was transformed into network representations to model queries as discrete steps with probabilities and times-to-transition from one search type to another. Search data subsequent to screen completion was also modeled using Markov chains to simulate likelihood trajectories of different search types through time. Differences in querying dynamics relative to screen completion were observed, with searches involving treatment, diagnosis, suicidal ideation, and suicidal intent commonly emerging as the highest probability behavioral information seeking endpoints. Moreover, results pointed to the association of low risk states of psychopathology with transitions to extreme clinical outcomes (i.e., active suicidal intent). Future research is required to draw definitive conclusions regarding causal relationships between screens and search behavior.

Communicating visit information to family caregivers: How does method matter? A national survey

OBJECTIVES

The clinic visit is a critical point of contact for family caregivers. However, only 37% of family caregivers are able to accompany patients to visits. When they cannot attend, caregivers receive visit information to assist with their caregiving. However, little is known about how method of receiving information from clinic visits is associated with important caregiver outcomes. This study sought to determine whether mode of receiving clinic visit information (speaking with the patient, attending the visit, or using an after-visit summary [AVS]) was associated with changes in caregiver burden, caregiver preparedness, and the positive aspects of caregiving.

METHODS

Cross-sectional web-based survey of a national sample of adult family caregivers. Multiple linear regression models determined associations between communication modes and caregivers' burden, preparedness, and positive aspects of caregiving, adjusting for sociodemographic covariates.

RESULTS

Respondents (N = 340) were mostly male (58%), White (59%), ranged from 18 to 85 years old, and supported patients with conditions including diabetes, dementia, and cancer. Speaking with patients was associated with increases in positive aspects of caregiving (95% CI = 2.01, 5.42) and an AVS was associated with increases in positive aspects of caregiving (95% CI = 0.4, 3.56) and preparedness for caregiving (95% CI = 0.61, 3.15). Using any method of receiving information from visits was associated with the greatest increase in preparedness, compared to not receiving visit information. We did not observe an association between method of communication and caregiver burden.

SIGNIFICANCE OF RESULTS

Method of communicating visit information is associated with improvements in caregiver preparedness and the positive aspects of caregiving, though caregiver burden may be unaffected by information exchange. Given the limitations of current communication methods, future work should explore directionality of the associations we found and identify visit communication strategies with caregivers that optimize caregiver and patient outcomes.

Family Caregiver Comfort with Telehealth Technologies: Differences by Race and Ethnicity in a Cross-Sectional Survey

Background: Telehealth has seen widespread use since the onset of the COVID-19 pandemic, and 82% patients required assistance in accessing their telehealth appointments. This assistance commonly comes from a family caregiver who may or may not be comfortable using the technologies associated with telehealth. The objective of our study was to analyze a demographically representative survey of U.S. family caregivers to understand the level of comfort using telehealth technologies among family caregivers. Methods: A secondary analysis of survey data collected during the COVID-19 pandemic in 2020. Level of caregiver comfort using computers, smartphones, and tablets was determined through three Likert-style questions. Proportional odds logistic regression was used to understand the associations between demographic variables and level of caregiver comfort using each technology, when adjusting for covariates. Results: A total of 340 caregivers were included in the analysis. Compared with non-Hispanic white caregivers, Asian caregivers had higher odds (odds ratio [OR] 3.14; 95% confidence interval [CI] 1.36, 8.02; p = 0.01) of expressing comfort using computers; black caregivers (OR 0.46; 95% CI 0.21, 0.98; p = 0.04) and Hispanic caregivers (OR 0.36; 95% CI 0.17, 0.79; p = 0.01) expressed lower odds of comfort using smartphones; and Asian caregivers had higher odds (OR 4.64; 95% CI 2.05, 11.69; p = 0.001) of expressing comfort using tablets. Conclusion and Implications: There are identified disparities in the level of technological comfort using computers, smartphones, and tablets by different racial and ethnic groups. Health systems should consider early stakeholder involvement in the design of telehealth technologies, culturally responsive training materials on telehealth technology use to reduce disparities in comfort using telehealth technologies.

Evaluating Physician Emotion Regulation in Serious Illness Conversations Using Multimodal Assessment

CONTEXT

Emotion regulation by the physician can influence the effectiveness of serious illness conversations. The feasibility of multimodal assessment of emotion regulation during these conversations is unknown.

OBJECTIVES

To develop and assess an experimental framework for evaluating physician emotion regulation during serious illness conversations.

METHODS

We developed and then assessed a multimodal assessment framework for physician emotion regulation using a cross-sectional, pilot study on physicians trained in the Serious Illness Conversation Guide (SICG) in a simulated, telehealth encounter. Development of the assessment framework included a literature review and subject matter expert consultations. Our predefined feasibility endpoints included: an enrollment rate of ≥60% of approached physicians, >90% completion rate of survey items, and <20% missing data from wearable heart rate sensors. To describe physician emotion regulation, we performed a thematic analysis of the conversation, its documentation, and physician interviews.

RESULTS

Out of 12 physicians approached, 11 (92%) SICG-trained physicians enrolled in the study: five medical oncology and six palliative care physicians. All 11 completed the survey (100% completion rate). Two sensors (chest band, wrist sensor) had <20% missing data during study tasks. The forearm sensor had >20% missing data. The thematic analysis found that physicians': 1) overarching goal was to move beyond prognosis to reasonable hope; 2) tactically focused on establishing a trusting, supportive relationship; and 3) possessed incomplete awareness of their emotion regulation strategies.

CONCLUSION

Our novel, multimodal assessment of physician emotion regulation was feasible in a simulated SICG encounter. Physicians exhibited an incomplete understanding of their emotion regulation strategies.

Digitally filling the access gap in mental health care: An investigation of the association between rurality and online engagement with validated self-report screens across the United States

Mental health disorders are highly prevalent, yet few persons receive access to treatment; this is compounded in rural areas where mental health services are limited. The proliferation of online mental health screening tools are considered a key strategy to increase identification, diagnosis, and treatment of mental illness. However, research on real-world effectiveness, especially in hard to reach rural communities, is limited. Accordingly, the current work seeks to test the hypothesis that online screening use is greater in rural communities with limited mental health resources. The study utilized a national, online, population-based cohort consisting of Microsoft Bing search engine users across 18 months in the United States (representing approximately one-third of all internet searches), in conjunction with user-matched data of completed online mental health screens for anxiety, bipolar, depression, and psychosis (N = 4354) through Mental Health America, a leading non-profit mental health organization in the United States. Rank regression modeling was leveraged to characterize U.S. county-level screen completion rates as a function of rurality, health-care availability, and sociodemographic variables. County-level rurality and mental health care availability alone explained 42% of the variance in MHA screen completion rate (R2 = 0.42, p < 5.0 × 10-6). The results suggested that online screening was more prominent in underserved rural communities, therefore presenting as important tools with which to bridge mental health-care gaps in rural, resource-deficient areas.

Evaluating clinician emotion regulation during a serious illness conversation in oncology using multimodal assessment: A pilot study

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Background: Clinician emotion regulation (ER), self and the patient’s, likely moderates successful prognostic discussions with patients, yet challenges around its evaluation limit its investigation. We performed a pilot study to develop and assess an experimental framework that uses multimodal assessment (self-report, observer, and biometric data) to measure clinician ER during a simulated, serious illness conversation (SIC). Methods: We developed our experimental framework in four steps: 1) drafted a patient case and assessment framework; 2) refined the data collection strategy using a multidisciplinary research team; 3) trained our actor; and 4) iteratively piloted the case to optimize data collection. For the assessment, we conducted a cross-sectional, case series pilot study with physicians trained in SIC to assess its feasibility and acceptability, defined a priori as an enrollment rate >60% of approached clinicians, > 90% completion rate of survey items, < 20% missing data from wearable heart rate variability (HRV) sensors. To characterize clinician ER strategies, we analyzed the visit dialogue, physician interviews performed while watching the visit back, and physician SIC documentation generated post visit. We used a hybrid approach of inductive and deductive coding and theme development based on preexisting ER theory. Results: The development phase yielded two major modifications: 1) abandoned use of AppleWatch since it did not provide continuous HRV measurement; and 2) used telehealth with video given context of COVID-19 pandemic. We approached 12 physicians and 11 enrolled, of which 5 were female and 10 white, 5 were medical oncologists, and 6 specialty palliative care physicians. All participants completed all study survey items. The results of our three HRV sensors were as follows: Empatica E4 and Polar H10 met our pre-specified HRV collection in all 11 resting tasks and SIC encounters, and the Scoche R24 the benchmark in 7/11 resting tasks and 4/11 of simulated encounters. Preliminary qualitative analysis suggests investigators can characterize clinician use of intrapersonal and interpersonal ER strategies. Conclusions: The use of multimodal assessment of clinician ER in a simulated, telehealth SIC visit was acceptable and feasible.

Prevalence of Opioid Misuse Risk in Patients With Cancer

BACKGROUND

Opioid misuse risk may be similar in individuals with chronic cancer and noncancer pain. However, risk screening is not uniformly used for patients with cancer, so its prevalence is unknown.

OBJECTIVES

The primary aim of this study was to estimate the level of risk for opioid misuse among patients with cancer. Secondary aims were to compare opioid misuse risk across cancer types and specialties and to explore psychosocial factors that may contribute to opioid misuse risk.

METHODS

Clinicians were trained to administer the Opioid Risk Tool during ambulatory visits. Data were retrieved from electronic health records and analyzed using descriptive statistics.

FINDINGS

Five percent of patients seen in the cancer center during the data collection period were screened for opioid misuse risk. Of the 226 patients screened, 163 were at low risk, 34 were at moderate risk, and 29 were at high risk for future opioid misuse. The most frequent cancer diagnoses for patients at moderate or high risk were lung (n = 15), breast (n = 16), gastrointestinal (n = 10), and genitourinary (n = 8). Of the 63 patients at moderate or high risk, 50 had a family history of substance misuse, 45 had a personal history of substance misuse, and 29 had a history of psychological disease.

Perceptions of the impact of COVID-19 on healthcare communication in a nationally representative cross-sectional survey of family caregivers

OBJECTIVE

To understand the perceptions of the impact of the COVID-19 pandemic on healthcare communication with family caregivers.

DESIGN

Nationally representative survey.

SETTING

USA (national).

PARTICIPANTS

340 family caregivers, demographically representative of the US population by race/ethnicity.

PRIMARY OUTCOME MEASURES

Communication outcomes (feeling involved by the provider, feeling involved by the care recipient, feeling more encouraged to be involved in care, feeling contributory to discussions, feeling questions are being answered), behavioural/wellness outcomes (feeling anxious, feeling isolated, feeling it is easier to attend the clinic visit), and desire to continue using telemedicine.

RESULTS

Having less than a college degree was associated with decreased odds of feeling involved by the provider (OR 0.46; 95% CI 0.26 to 0.83; p=0.01), feeling involved by the care recipient (OR 0.44; 95% CI 0.24 to 0.79; p=0.01), feeling more encouraged to be involved in care (OR 0.49; 95% CI 0.27 to 0.86; p=0.01), feeling like they contribute to discussions (OR 0.45; 95% CI 0.25 to 0.82; p=0.01) and feeling like their questions are being answered (OR 0.33; 95% CI 0.18 to 0.60; p<0.001).

CONCLUSION

In our sample, the shift to telemedicine during COVID-19 was well received but caregivers of low educational attainment reported poorer health communication, and a greater proportion of black/African American and Hispanic caregivers reported a desire to return to in-person visits. There is an opportunity to improve health systems and increase equity as telemedicine becomes more widespread.

Impact of online mental health screening tools on help-seeking, care receipt, and suicidal ideation and suicidal intent: Evidence from internet search behavior in a large U.S. cohort

INTRODUCTION

Most people with psychiatric illnesses do not receive treatment for almost a decade after disorder onset. Online mental health screens reflect one mechanism designed to shorten this lag in help-seeking, yet there has been limited research on the effectiveness of screening tools in naturalistic settings.

MATERIAL AND METHODS

We examined a cohort of persons directed to a mental health screening tool via the Bing search engine (n = 126,060). We evaluated the impact of tool content on later searches for mental health self-references, self-diagnosis, care seeking, psychoactive medications, suicidal ideation, and suicidal intent. Website characteristics were evaluated by pairs of independent raters to ascertain screen type and content. These included the presence/absence of a suggestive diagnosis, a message on interpretability, as well as referrals to digital treatments, in-person treatments, and crisis services.

RESULTS

Using machine learning models, the results suggested that screen content predicted later searches with mental health self-references (AUC = 0·73), mental health self-diagnosis (AUC = 0·69), mental health care seeking (AUC = 0·61), psychoactive medications (AUC = 0·55), suicidal ideation (AUC = 0·58), and suicidal intent (AUC = 0·60). Cox-proportional hazards models suggested individuals utilizing tools with in-person care referral were significantly more likely to subsequently search for methods to actively end their life (HR = 1·727, p = 0·007).

DISCUSSION

Online screens may influence help-seeking behavior, suicidal ideation, and suicidal intent. Websites with referrals to in-person treatments could put persons at greater risk of active suicidal intent. Further evaluation using large-scale randomized controlled trials is needed.

An Audio Personal Health Library of Clinic Visit Recordings for Patients and Their Caregivers (HealthPAL): User-Centered Design Approach

Background

Providing digital recordings of clinic visits to patients has emerged as a strategy to promote patient and family engagement in care. With advances in natural language processing, an opportunity exists to maximize the value of visit recordings for patients by automatically tagging key visit information (eg, medications, tests, and imaging) and linkages to trustworthy web-based resources curated in an audio-based personal health library.

Objective

This study aims to report on the user-centered development of HealthPAL, an audio personal health library.

Methods

Our user-centered design and usability evaluation approach incorporated iterative rounds of video-recorded sessions from 2016 to 2019. We recruited participants from a range of community settings to represent older patient and caregiver perspectives. In the first round, we used paper prototypes and focused on feature envisionment. We moved to low-fidelity and high-fidelity versions of the HealthPAL in later rounds, which focused on functionality and use; all sessions included a debriefing interview. Participants listened to a deidentified, standardized primary care visit recording before completing a series of tasks (eg, finding where a medication was discussed in the recording). In the final round, we recorded the patients’ primary care clinic visits for use in the session. Findings from each round informed the agile software development process. Task completion and critical incidents were recorded in each round, and the System Usability Scale was completed by participants using the digital prototype in later rounds.

Results

We completed 5 rounds of usability sessions with 40 participants, of whom 25 (63%) were women with a median age of 68 years (range 23-89). Feedback from sessions resulted in color-coding and highlighting of information tags, a more prominent play button, clearer structure to move between one’s own recordings and others’ recordings, the ability to filter recording content by the topic discussed and descriptions, 10-second forward and rewind controls, and a help link and search bar. Perceived usability increased over the rounds, with a median System Usability Scale of 78.2 (range 20-100) in the final round. Participants were overwhelmingly positive about the concept of accessing a curated audio recording of a clinic visit. Some participants reported concerns about privacy and the computer-based skills necessary to access recordings.

Conclusions

To our knowledge, HealthPAL is the first patient-centered app designed to allow patients and their caregivers to access easy-to-navigate recordings of clinic visits, with key concepts tagged and hyperlinks to further information provided. The HealthPAL user interface has been rigorously co-designed with older adult patients and their caregivers and is now ready for further field testing. The successful development and use of HealthPAL may help improve the ability of patients to manage their own care, especially older adult patients who have to navigate complex treatment plans.

Natural language processing for automated annotation of medication mentions in primary care visit conversations

OBJECTIVES

The objective of this study is to build and evaluate a natural language processing approach to identify medication mentions in primary care visit conversations between patients and physicians.

MATERIALS AND METHODS

Eight clinicians contributed to a data set of 85 clinic visit transcripts, and 10 transcripts were randomly selected from this data set as a development set. Our approach utilizes Apache cTAKES and Unified Medical Language System controlled vocabulary to generate a list of medication candidates in the transcribed text and then performs multiple customized filters to exclude common false positives from this list while including some additional common mentions of the supplements and immunizations.

RESULTS

Sixty-five transcripts with 1121 medication mentions were randomly selected as an evaluation set. Our proposed method achieved an F-score of 85.0% for identifying the medication mentions in the test set, significantly outperforming existing medication information extraction systems for medical records with F-scores ranging from 42.9% to 68.9% on the same test set.

DISCUSSION

Our medication information extraction approach for primary care visit conversations showed promising results, extracting about 27% more medication mentions from our evaluation set while eliminating many false positives in comparison to existing baseline systems. We made our approach publicly available on the web as an open-source software.

CONCLUSION

Integration of our annotation system with clinical recording applications has the potential to improve patients' understanding and recall of key information from their clinic visits, and, in turn, to positively impact health outcomes.

Supporting communication of visit information to informal caregivers: A systematic review

Importance

When caregivers cannot attend the clinic visit for the person they provide care for, patients are the predominant source of clinic visit information; however, poor patient recall inhibits the quality of information shared, resulting in poor caregiver preparedness and contributing to caregiver morbidity. Technological solutions exist to sharing clinic visit information, but their effectiveness is unclear.

Objectives

To assess if and how technology is being used to connect informal caregivers to patient clinic visit information when they cannot otherwise attend, and its impact on caregiver and patient outcomes.

Evidence review

MEDLINE, Cochrane, Scopus, and CINAHL were searched through 5/3/2020 with no language restrictions or limits. ClinicalTrials.gov and other reference lists were included in the search. Randomized controlled trials (RCTs) and nonrandomized trials that involved using a technological medium e.g., video or the electronic health record, to communicate visit information to a non-attending caregiver were included. Data were collected and screened using a standardized data collection form. Cochrane’s Risk of Bias 2.0 and the Newcastle-Ottawa Scale were used for RCTs and nonrandomized trials, respectively. All data were abstracted by two independent reviewers, with disagreements resolved by a third reviewer.

Findings

Of 2115 studies identified in the search, four met criteria for inclusion. Two studies were randomized controlled trials and two were nonrandomized trials. All four studies found positive effects of their intervention on caregiver outcomes of interest, and three out of four studies found statistically significant improvements in key outcomes for caregivers receiving visit information. Improved outcomes included caregiver happiness, caregiver activation, caregiver preparedness, and caregiver confidence in managing patient health.

Conclusions and relevance

Our review suggests that using technology to give a caregiver access to clinical visit information could be beneficial to various caregiver outcomes. There is an urgent need to address the lack of research in this area.

Precision Assessment of COVID-19 Phenotypes Using Large-Scale Clinic Visit Audio Recordings: Harnessing the Power of Patient Voice

COVID-19 cases are exponentially increasing worldwide; however, its clinical phenotype remains unclear. Natural language processing (NLP) and machine learning approaches may yield key methods to rapidly identify individuals at a high risk of COVID-19 and to understand key symptoms upon clinical manifestation and presentation. Data on such symptoms may not be accurately synthesized into patient records owing to the pressing need to treat patients in overburdened health care settings. In this scenario, clinicians may focus on documenting widely reported symptoms that indicate a confirmed diagnosis of COVID-19, albeit at the expense of infrequently reported symptoms. While NLP solutions can play a key role in generating clinical phenotypes of COVID-19, they are limited by the resulting limitations in data from electronic health records (EHRs). A comprehensive record of clinic visits is required—audio recordings may be the answer. A recording of clinic visits represents a more comprehensive record of patient-reported symptoms. If done at scale, a combination of data from the EHR and recordings of clinic visits can be used to power NLP and machine learning models, thus rapidly generating a clinical phenotype of COVID-19. We propose the generation of a pipeline extending from audio or video recordings of clinic visits to establish a model that factors in clinical symptoms and predict COVID-19 incidence. With vast amounts of available data, we believe that a prediction model can be rapidly developed to promote the accurate screening of individuals at a high risk of COVID-19 and to identify patient characteristics that predict a greater risk of a more severe infection. If clinical encounters are recorded and our NLP model is adequately refined, benchtop virologic findings would be better informed. While clinic visit recordings are not the panacea for this pandemic, they are a low-cost option with many potential benefits, which have recently begun to be explored.

Does the use of patient decision aids lead to cost savings? a systematic review

OBJECTIVES

To update a previous systematic review to determine if patient decision aid (PDA) interventions generate savings in healthcare settings, and if so, from which perspective (ie, patient, organisation providing care, society).

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, CINAHL, PsycINFO, Web of Science, Cochrane Library, Embase, Campbell Collaboration Library, EconLit, Business Source Complete, Centre for Reviews and Dissemination: NHS Economic Evaluations Database (NHS EED), Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA) from 15 March 2013 to 25 January 2019. The references of studies that met the eligibility criteria and any publications related to conference abstracts or registered clinical trials were reviewed to increase the sensitivity of the search.

ELIGIBILITY CRITERIA

Full and partial economic evaluations with an experimental, quasi-experimental or randomised controlled design were included. The intervention had to satisfy the pre-determined minimum conditions necessary to be defined as a PDA, and (for full evaluations) provide details on the comparator used.

DATA EXTRACTION AND SYNTHESIS

All study outcomes and economic data were extracted. The reporting and quality of the economic analyses were independently assessed by two health economists.

RESULTS

Of 5066 studies, 22 studies were included, including the 8 studies from the previous review. Twelve studies reported cost-savings (range=US$10 to US$81 156; US dollars in 2020), primarily from the organisational or health system perspective, and 10 studies did not. However, due to the quality of the economic analyses, and the related issues with the interpretative validity of results it would be inappropriate to say that PDAs will generate savings, from any perspective.

CONCLUSIONS

It is unclear whether PDAs will generate savings. Greater consensus on what constitutes a PDA and the need to compare them against usual care over a sufficient time horizon to allow valid assessment of costs and outcomes is required.

PROSPERO REGISTRATION NUMBER

CRD42019118457.

Flattening the Mental Health Curve: COVID-19 Stay-at-Home Orders Are Associated With Alterations in Mental Health Search Behavior in the United States

BACKGROUND

The coronavirus disease (COVID-19) has led to dramatic changes worldwide in people's everyday lives. To combat the pandemic, many governments have implemented social distancing, quarantine, and stay-at-home orders. There is limited research on the impact of such extreme measures on mental health.

OBJECTIVE

The goal of this study was to examine whether stay-at-home orders produced differential changes in mental health symptoms using internet search queries on a national scale.

METHODS

In the United States, individual states vary in their adoption of measures to reduce the spread of COVID-19; as of March 23, 2020, 11 of the 50 states had issued stay-at-home orders. The staggered rollout of stay-at-home measures across the United States allows us to investigate whether these measures impact mental health by exploring variations in mental health search queries across the states. This paper examines the changes in mental health search queries on Google between March 16-23, 2020, across each state and Washington, DC. Specifically, this paper examines differential changes in mental health searches based on patterns of search activity following issuance of stay-at-home orders in these states compared to all other states. The participants were all the people who searched mental health terms in Google between March 16-23. Between March 16-23, 11 states underwent stay-at-home orders to prevent the transmission of COVID-19. Outcomes included search terms measuring anxiety, depression, obsessive-compulsive, negative thoughts, irritability, fatigue, anhedonia, concentration, insomnia, and suicidal ideation.

RESULTS

Analyzing over 10 million search queries using generalized additive mixed models, the results suggested that the implementation of stay-at-home orders are associated with a significant flattening of the curve for searches for suicidal ideation, anxiety, negative thoughts, and sleep disturbances, with the most prominent flattening associated with suicidal ideation and anxiety.

CONCLUSIONS

These results suggest that, despite decreased social contact, mental health search queries increased rapidly prior to the issuance of stay-at-home orders, and these changes dissipated following the announcement and enactment of these orders. Although more research is needed to examine sustained effects, these results suggest mental health symptoms were associated with an immediate leveling off following the issuance of stay-at-home orders.

No date for the PROM: the association between patient-reported health events and clinical coding in primary care

OBJECTIVE

It is unclear whether data from patient-reported outcome measures (PROMs) are captured and used by clinicians despite policy initiatives. We examined the extent to which fall risk and urinary incontinence (UI) reported on PROMS and provided to clinicians prior to a patient visit are subsequently captured in the electronic medical record (EMR). Additionally, we aimed to determine whether the use of PROMs and EMR documentation is higher for visits where PROM data was provided to clinicians.

DESIGN

We conducted a cross-sectional patient-reported risk assessment survey and semi-structured interviews with clinicians to identify themes related to the use of PROMs.

SETTING

Fourteen primary care clinics in the US (eight intervention and six control clinics), between October 2013 and May 2015.

PARTICIPANTS

Primary care clinicians and older adult (≥66 years) patients completing a 46-item health risk assessment, including PROMs for fall risk and UI.

INTERVENTION

Risk assessment results provided to the clinician or nurse practitioners prior to the clinic visit in intervention clinics; data was not provided in control clinics.

MAIN OUTCOME

1) Agreement between ICD-9 codes of fall risk or UI in the EMR and patient-reports, and 2) clinician experience of PROMs use and impact on coding.

RESULTS

A total of 505 older adult patients were included in the study, 176 at control clinics and 329 at intervention clinics. While patient reports of fall risk and UI were readily captured by PROMs, this information was only coded in the EMR between 3% - 14% of the time (poor Kappa agreement). Intervention clinics performed slightly better than control clinics. Clinician interviews (n = 16) revealed low use of PROMs data with multiple barriers cited including poor access to data, high quantity of data, interruption to workflow, and a lack of training on PROMs.

CONCLUSIONS

Current strategies of providing PROMs data prior to clinic visits may not be an effective way of communicating important health information to busy clinicians; ultimately resulting in underuse. Better systems of presenting PROMs data, and clinician training on the importance of PROMs and their use, is needed.

Medical Students' Knowledge and Attitudes Toward Shared Decision Making: Results From a Multinational, Cross-Sectional Survey

Introduction. We aimed to conduct a multinational cross-sectional online survey of medical students' attitudes toward, knowledge of, and experience with shared decision making (SDM). Methods. We conducted the survey from September 2016 until May 2017 using the following: 1) a convenience sample of students from four medical schools each in Canada, the United States, and the Netherlands (n = 12), and 2) all medical schools in the United Kingdom through the British Medical School Council (n = 32). We also distributed the survey through social media. Results. A total of 765 students read the information sheet and 619 completed the survey. Average age was 24, 69% were female. Mean SDM knowledge score was 83.6% (range = 18.8% to 100%; 95% confidence interval [CI] = 82.8% to 84.5%). US students had the highest knowledge scores (86.2%, 95% CI = 84.8% to 87.6%). The mean risk communication score was 57.4% (range = 0% to 100%; 95% CI = 57.4% to 60.1%). Knowledge did not vary with age, race, gender, school, or school year. Attitudes were positive, except 46% believed SDM could only be done with higher educated patients, and 80.9% disagreed that physician payment should be linked to SDM performance (increased with years in training, P < 0.05). Attitudes did not vary due to any tested variable. Students indicated they were more likely than experienced clinicians to practice SDM (72.1% v. 48.8%). A total of 74.7% reported prior SDM training and 82.8% were interested in learning more about SDM. Discussion. SDM knowledge is high among medical students in all four countries. Risk communication is less well understood. Attitudes indicate that further research is needed to understand how medical schools deliver and integrate SDM training into existing curricula.

A retrospective study on the acceptability, feasibility, and effectiveness of LoveYourBrain Yoga for people with traumatic brain injury and caregivers

PURPOSE

To conduct a mixed methods, pre-post, retrospective study on the feasibility, acceptability, and effectiveness of the LoveYourBrain Yoga program.

MATERIALS AND METHODS

People were eligible if they were a traumatic brain injury survivor or caregiver, age 15-70, ambulatory, and capable of gentle exercise and group discussion. We analyzed attendance, satisfaction, and mean differences in scores on Quality of Life After Brain Injury Overall scale (QOLIBRI-OS) and four TBI-QOL/Neuro-QOL scales. Content analysis explored perceptions of benefits and areas of improvement.

RESULTS

1563 people (82.0%) participated ≥1 class in 156 programs across 18 states and 3 Canadian provinces. Mean satisfaction was 9.3 out of 10 (SD 1.0). Mixed effects linear regression found significant improvements in QOLIBRI-OS (B 9.70, 95% CI: 8.51, 10.90), Resilience (B 1.30, 95% CI: 0.60, 2.06), Positive Affect and Well-being (B 1.49, 95% CI: 1.14, 1.84), and Cognition (B 1.48, 95% CI: 0.78, 2.18) among traumatic brain injury survivors (n = 705). No improvement was found in Emotional and Behavioral Dysregulation, however, content analysis revealed better ability to regulate anxiety, anger, stress, and impulsivity. Caregivers perceived improvements in physical and psychological health.

CONCLUSIONS

LoveYourBrain Yoga is feasible and acceptable and may be an effective mode of community-based rehabilitation.IMPLICATIONS FOR REHABILITATIONPeople with traumatic brain injury and their caregivers often experience poor quality of life and difficulty accessing community-based rehabilitation services.Yoga is a holistic, mind-body therapy with many benefits to quality of life, yet is largely inaccessible to people affected by traumatic brain injury in community settings.Participants in LoveYourBrain Yoga, a six-session, community-based yoga with psychoeducation program in 18 states and 3 Canadian provinces, experienced significant improvements in quality of life, resilience, cognition, and positive affect.LoveYourBrain Yoga is feasible and acceptable when implemented on a large scale and may be an effective mode of, or adjunct to, community-based rehabilitation.

Implementation of the uterine fibroids Option Grid patient decision aids across five organizational settings: a randomized stepped-wedge study protocol

BACKGROUND

Uterine fibroids are non-cancerous overgrowths of the smooth muscle in the uterus. As they grow, some cause problems such as heavy menstrual bleeding, pelvic pain, discomfort during sexual intercourse, and rarely pregnancy complications or difficulty becoming pregnant. Multiple treatment options are available. The lack of comparative evidence demonstrating superiority of any one treatment means that choosing the best option is sensitive to individual preferences. Women with fibroids wish to consider treatment trade-offs. Tools known as patient decision aids (PDAs) are effective in increasing patient engagement in the decision-making process. However, the implementation of PDAs in routine care remains challenging. Our aim is to use a multi-component implementation strategy to implement the uterine fibroids Option Grid™ PDAs at five organizational settings in the USA.

METHODS

We will conduct a randomized stepped-wedge implementation study where five sites will be randomized to implement the uterine fibroid Option Grid PDA in practice at different time points. Implementation will be guided by the Consolidated Framework for Implementation Research (CFIR) and Normalization Process Theory (NPT). There will be a 6-month pre-implementation phase, a 2-month initiation phase where participating clinicians will receive training and be introduced to the Option Grid PDAs (available in text, picture, or online formats), and a 6-month active implementation phase where clinicians will be expected to use the PDAs with patients who are assigned female sex at birth, are at least 18 years of age, speak fluent English or Spanish, and have new or recurrent symptoms of uterine fibroids. We will exclude postmenopausal patients. Our primary outcome measure is the number of eligible patients who receive the Option Grid PDAs. We will use logistic and linear regression analyses to compare binary and continuous quantitative outcome measures (including survey scores and Option Grid use) between the pre- and active implementation phases while adjusting for patient and clinician characteristics.

DISCUSSION

This study may help identify the factors that impact the implementation and sustained use of a PDA in clinic workflow from various stakeholder perspectives while helping patients with uterine fibroids make treatment decisions that align with their preferences.

TRIAL REGISTRATION

Clinicaltrials.gov , NCT03985449. Registered 13 July 2019, https://clinicaltrials.gov/ct2/show/NCT03985449.

Heart sounds: a pilot randomised trial to determine the feasibility and acceptability of audio recordings to improve discharge communication for cardiology inpatients protocol

Introduction

Ineffective hospital discharge communication can significantly impact patient understanding, safety and treatment adherence. This may be especially true for cardiology inpatients who leave the hospital with complex discharge plans delivered in a time-pressured discharge discussion. The goal of this pilot trial was to determine if providing supplemental audio-recorded discharge instructions is feasible and to explore its impact on cardiology patients' ability to understand and self-manage their care .

Methods and analysis

We will conduct a parallel-group, randomised controlled trial in adult cardiology inpatients with balanced blocking by a physician. Patients (n=50) will be randomised to usual care (verbal discussion and written summary) or intervention (usual care, plus audio-recorded discharge discussion provided to patients on a portable electronic recording device). Enrolled patients will complete study assessments immediately prior to the discharge discussion, immediately postdischarge discussion and 1 week after hospital discharge by telephone. Primary outcomes include the proportion of eligible providers and inpatients who agree to take part in the trial, the proportion of inpatients who receive the audio recording in accordance with a fidelity checklist, and the proportion who use the audio recording. We will analyse preliminary data about the impact of audio recording on patient activation, health confidence, provider communication ability, adherence and 30-day readmissions.

Ethics and dissemination

This trial was approved by The Committee for the Protection of Human Subjects (CPHS) at Dartmouth College (CPHS# 00031211). Findings will be disseminated in scientific journals and at meetings.

Trial registration number

NCT03735342

Protocol version

1.0

Healthcare Options for People Experiencing Depression (HOPE*D): the development and pilot testing of an encounter-based decision aid for use in primary care

OBJECTIVE

To develop and pilot an encounter-based decision aid (eDA) for people with depression for use in primary care.

DESIGN

We developed an eDA for depression through cognitive interviews and pilot tested it using a one-group pretest, post-test design in primary care. Feasibility, fidelity of eDA use and acceptability were assessed using recruitment rates and semistructured interviews with patients, medical assistants and clinicians. Treatment choice and shared decision-making (SDM) were also assessed.

SETTING

Interviews with adult patients and the public were conducted in a mall and library in Grafton County, New Hampshire, while clinician interviews took place by phone or at the clinician's office. Pilot testing occurred in a New Hampshire primary care practice.

PARTICIPANTS

Cognitive interviews were conducted with adults, ≥18 years, who could read English from the following stakeholder groups: history of depression, the public and clinicians. Patients with a Patient Health Questionnaire-9 score of ≥5 were recruited for piloting.

RESULTS

Three stages of cognitive interviews were conducted (n=28). Changes to eDA included moving the combination therapy information and access to treatment information, adding colour, modifying pictograms and editing the talk-therapy description. Clinician concerns about patient health literacy were not reflected in patient interviews. Of 59 patients who reviewed study information, 56 were eligible and agreed to participate in pilot testing; however, only 29 could be reached for follow-up. The eDA was widely accepted, though clinicians did not always use it as intended. We found no impact of eDA use on SDM, though patients chose a wider range of treatment options.

CONCLUSIONS

We demonstrated the feasibility of the use of an eDA for depression in primary care that was widely accepted. Further research is needed to improve the fidelity with which the eDA is used and to assess its impact on SDM and related health outcomes.

End-user views of an electronic encounter decision aid linked to routine depression screening

OBJECTIVE

Our aim was to gather community stakeholder input to inform the development of a digital system linking depression screening to decision support.

METHODS

Views and feature requirements were identified through (1) focus groups with patients and consumers with depression, and interviews with primary care clinicians and (2) usability sessions where patients and consumers used the current version of encounter decision aid (eDA) in a primary care waiting room. Qualitative data were analyzed using the framework method.

RESULTS

We conducted six focus groups with 15 participants, seven clinician interviews and 10 usability sessions. Patients were comfortable completing the Patient Health Questionnaire (PHQ-9) and receiving the electronic eDA in clinic. They felt this would allow patients to prepare for their visit and instill a sense of agency. Participants were comfortable receiving the PHQ-9 results and a subsequent eDA on a tablet in the waiting room.

CONCLUSION

Patients with and without depression, as well as clinicians, viewed linking the PHQ-9, results, and eDA positively. Patients were comfortable doing this in the clinic waiting room.

PRACTICE IMPLICATIONS

Linking depression decision support to screening was viewed positively by patients and clinicians, and could help overcome barriers to shared decision-making implementation in this population.

Shared decision making embedded in the undergraduate medical curriculum: A scoping review

OBJECTIVE

Shared decision making (SDM) training is shown to be effective and is increasingly embedded in continuing medical education. There is little evidence, however, about undergraduate medical education for SDM. The aim of this scoping review was to identify existing SDM training embedded in the undergraduate medical curriculum and analyze their impact.

METHODS

The authors systematically searched the extant literature for peer reviewed articles, hand searched key journals and reference lists of key articles, and contacted relevant stakeholders as part of a key informant analysis.

RESULTS

Included in the qualitative synthesis were 12 studies evaluating 11 SDM courses in medical education across six countries. Most courses integrated SDM training in clinical clerkship and varied in length from one to seven hours. The majority of studies assessed course impact on students' skills in SDM. Most studies suggested that students' skills and confidence in SDM significantly increased post-training, but three studies reported no significant improvement in SDM. Ten courses continue to be taught routinely.

CONCLUSION

Overall, studies suggested a positive impact on medical students' skills, confidence, and attitudes regarding SDM. Embedding SDM training in undergraduate medical education may be a practical and effective solution for current barriers to the widespread adoption of SDM.

US-based cross-sectional survey of clinicians' knowledge and attitudes about shared decision-making across healthcare professions and specialties

OBJECTIVE

In this study, we aim to compare shared decision-making (SDM) knowledge and attitudes between US-based physician assistants (PAs), nurse practitioners (NPs) and physicians across surgical and family medicine specialties.

SETTING

We administered a cross-sectional, web-based survey between 20 September 2017 and 1 November 2017.

PARTICIPANTS

272 US-based NPs, PA and physicians completed the survey. 250 physicians were sent a generic email invitation to participate, of whom 100 completed the survey. 3300 NPs and PAs were invited, among whom 172 completed the survey. Individuals who met the following exclusion criteria were excluded from participation: (1) lack of English proficiency; (2) area of practice other than family medicine or surgery; (3) licensure other than physician, PA or NP; (4) practicing in a country other than the US.

RESULTS

We found few substantial differences in SDM knowledge and attitudes across clinician types, revealing positive attitudes across the sample paired with low to moderate knowledge. Family medicine professionals (PAs) were most knowledgeable on several items. Very few respondents (3%; 95% CI 1.5% to 6.2%) favoured a paternalistic approach to decision-making.

CONCLUSIONS

Recent policy-level promotion of SDM may have influenced positive clinician attitudes towards SDM. Positive attitudes despite limited knowledge warrant SDM training across occupations and specialties, while encouraging all clinicians to promote SDM. Given positive attitudes and similar knowledge across clinician types, we recommend that SDM is not confined to the patient-physician dyad but instead advocated among other health professionals.

Audio-/Videorecording Clinic Visits for Patient's Personal Use in the United States: Cross-Sectional Survey

Background

Few clinics in the United States routinely offer patients audio or video recordings of their clinic visits. While interest in this practice has increased, to date, there are no data on the prevalence of recording clinic visits in the United States.

Objective

Our objectives were to (1) determine the prevalence of audiorecording clinic visits for patients’ personal use in the United States, (2) assess the attitudes of clinicians and public toward recording, and (3) identify whether policies exist to guide recording practices in 49 of the largest health systems in the United States.

Methods

We administered 2 parallel cross-sectional surveys in July 2017 to the internet panels of US-based clinicians (SERMO Panel) and the US public (Qualtrics Panel). To ensure a diverse range of perspectives, we set quotas to capture clinicians from 8 specialties. Quotas were also applied to the public survey based on US census data (gender, race, ethnicity, and language other than English spoken at home) to approximate the US adult population. We contacted 49 of the largest health systems (by clinician number) in the United States by email and telephone to determine the existence, or absence, of policies to guide audiorecordings of clinic visits for patients’ personal use. Multiple logistic regression models were used to determine factors associated with recording.

Results

In total, 456 clinicians and 524 public respondents completed the surveys. More than one-quarter of clinicians (129/456, 28.3%) reported that they had recorded a clinic visit for patients’ personal use, while 18.7% (98/524) of the public reported doing so, including 2.7% (14/524) who recorded visits without the clinician’s permission. Amongst clinicians who had not recorded a clinic visit, 49.5% (162/327) would be willing to do so in the future, while 66.0% (346/524) of the public would be willing to record in the future. Clinician specialty was associated with prior recording: specifically oncology (odds ratio [OR] 5.1, 95% CI 1.9-14.9; P=.002) and physical rehabilitation (OR 3.9, 95% CI 1.4-11.6; P=.01). Public respondents who were male (OR 2.11, 95% CI 1.26-3.61; P=.005), younger (OR 0.73 for a 10-year increase in age, 95% CI 0.60-0.89; P=.002), or spoke a language other than English at home (OR 1.99; 95% CI 1.09-3.59; P=.02) were more likely to have recorded a clinic visit. None of the large health systems we contacted reported a dedicated policy; however, 2 of the 49 health systems did report an existing policy that would cover the recording of clinic visits for patient use. The perceived benefits of recording included improved patient understanding and recall. Privacy and medicolegal concerns were raised.

Conclusions

Policy guidance from health systems and further examination of the impact of recordings—positive or negative—on care delivery, clinician-related outcomes, and patients’ behavioral and health-related outcomes is urgently required.

Estimation of an inter-rater intra-class correlation coefficient that overcomes common assumption violations in the assessment of health measurement scales

Background

Intraclass correlation coefficients (ICC) are recommended for the assessment of the reliability of measurement scales. However, the ICC is subject to a variety of statistical assumptions such as normality and stable variance, which are rarely considered in health applications.

Methods

A Bayesian approach using hierarchical regression and variance-function modeling is proposed to estimate the ICC with emphasis on accounting for heterogeneous variances across a measurement scale. As an application, we review the implementation of using an ICC to evaluate the reliability of Observer OPTION⁵, an instrument which used trained raters to evaluate the level of Shared Decision Making between clinicians and patients. The study used two raters to evaluate recordings of 311 clinical encounters across three studies to evaluate the impact of using a Personal Decision Aid over usual care. We particularly focus on deriving an estimate for the ICC when multiple studies are being considered as part of the data.

Results

The results demonstrate that ICC varies substantially across studies and patient-physician encounters within studies. Using the new framework we developed, the study-specific ICCs were estimated to be 0.821, 0.295, and 0.644. If the within- and between-encounter variances were assumed to be the same across studies, the estimated within-study ICC was 0.609. If heteroscedasticity is not properly adjusted for, the within-study ICC estimate was inflated to be as high as 0.640. Finally, if the data were pooled across studies without accounting for the variability between studies then ICC estimates were further inflated by approximately 0.02 while formerly allowing for between study variation in the ICC inflated its estimated value by approximately 0.066 to 0.072 depending on the model.

Conclusion

We demonstrated that misuse of the ICC statistics under common assumption violations leads to misleading and likely inflated estimates of interrater reliability. A statistical analysis that overcomes these violations by expanding the standard statistical model to account for them leads to estimates that are a better reflection of a measurement scale’s reliability while maintaining ease of interpretation. Bayesian methods are particularly well suited to estimating the expanded statistical model.

A three-talk model for shared decision making: multistage consultation process

Objectives To revise an existing three-talk model for learning how to achieve shared decision making, and to consult with relevant stakeholders to update and obtain wider engagement.Design Multistage consultation process.Setting Key informant group, communities of interest, and survey of clinical specialties.Participants 19 key informants, 153 member responses from multiple communities of interest, and 316 responses to an online survey from medically qualified clinicians from six specialties.Results After extended consultation over three iterations, we revised the three-talk model by making changes to one talk category, adding the need to elicit patient goals, providing a clear set of tasks for each talk category, and adding suggested scripts to illustrate each step. A new three-talk model of shared decision making is proposed, based on "team talk," "option talk," and "decision talk," to depict a process of collaboration and deliberation. Team talk places emphasis on the need to provide support to patients when they are made aware of choices, and to elicit their goals as a means of guiding decision making processes. Option talk refers to the task of comparing alternatives, using risk communication principles. Decision talk refers to the task of arriving at decisions that reflect the informed preferences of patients, guided by the experience and expertise of health professionals.Conclusions The revised three-talk model of shared decision making depicts conversational steps, initiated by providing support when introducing options, followed by strategies to compare and discuss trade-offs, before deliberation based on informed preferences.

Sharing Annotated Audio Recordings of Clinic Visits With Patients-Development of the Open Recording Automated Logging System (ORALS): Study Protocol

Background

Providing patients with recordings of their clinic visits enhances patient and family engagement, yet few organizations routinely offer recordings. Challenges exist for organizations and patients, including data safety and navigating lengthy recordings. A secure system that allows patients to easily navigate recordings may be a solution.

Objective

The aim of this project is to develop and test an interoperable system to facilitate routine recording, the Open Recording Automated Logging System (ORALS), with the aim of increasing patient and family engagement. ORALS will consist of (1) technically proficient software using automated machine learning technology to enable accurate and automatic tagging of in-clinic audio recordings (tagging involves identifying elements of the clinic visit most important to patients [eg, treatment plan] on the recording) and (2) a secure, easy-to-use Web interface enabling the upload and accurate linkage of recordings to patients, which can be accessed at home.

Methods

We will use a mixed methods approach to develop and formatively test ORALS in 4 iterative stages: case study of pioneer clinics where recordings are currently offered to patients, ORALS design and user experience testing, ORALS software and user interface development, and rapid cycle testing of ORALS in a primary care clinic, assessing impact on patient and family engagement. Dartmouth’s Informatics Collaboratory for Design, Development and Dissemination team, patients, patient partners, caregivers, and clinicians will assist in developing ORALS.

Results

We will implement a publication plan that includes a final project report and articles for peer-reviewed journals. In addition to this work, we will regularly report on our progress using popular relevant Tweet chats and online using our website, www.openrecordings.org. We will disseminate our work at relevant conferences (eg, Academy Health, Health Datapalooza, and the Institute for Healthcare Improvement Quality Forums). Finally, Iora Health, a US-wide network of primary care practices (www.iorahealth.com), has indicated a willingness to implement ORALS on a larger scale upon completion of this development project.

Conclusions

Upon the completion of this project we will have developed a novel recording system that will be ready for large-scale testing. Our long-term goal is for ORALS to seamlessly fit into a clinic’s and patient’s daily routine, increasing levels of patient engagement and transparency of care.

Using CollaboRATE, a brief patient-reported measure of shared decision making: Results from three clinical settings in the United States

Introduction

CollaboRATE is a brief patient survey focused on shared decision making. This paper aims to (i) provide insight on facilitators and challenges to implementing a real‐time patient survey and (ii) evaluate CollaboRATE scores and response rates across multiple clinical settings with varied patient populations.

Method

All adult patients at three United States primary care practices were eligible to complete CollaboRATE post‐visit. To inform key learnings, we aggregated all mentions of unanticipated decisions, problems and administration errors from field notes and email communications. Mixed‐effects logistic regression evaluated the impact of site, clinician, patient age and patient gender on the CollaboRATE score.

Results

While CollaboRATE score increased only slightly with increasing patient age (OR 1.018, 95% CI 1.014‐1.021), female patient gender was associated with significantly higher CollaboRATE scores (OR 1.224, 95% CI 1.073‐1.397). Clinician also predicts CollaboRATE score (random effect variance 0.146). Site‐specific factors such as clinical workflow and checkout procedures play a key role in successful in‐clinic implementation and are significantly related to CollaboRATE scores, with Site 3 scoring significantly higher than Site 1 (OR 1.759, 95% CI 1.216 to 2.545) or Site 2 (z=−2.71, 95% CI −1.114 to −0.178).

Discussion

This study demonstrates that CollaboRATE can be used in diverse primary care settings. A clinic's workflow plays a crucial role in implementation. Patient experience measurement risks becoming a burden to both patients and administrators. Episodic use of short measurement tools could reduce this burden.

Assessing medical student knowledge and attitudes about shared decision making across the curriculum: protocol for an international online survey and stakeholder analysis

INTRODUCTION

Shared decision making (SDM) is a goal of modern medicine; however, it is not currently embedded in routine care. Barriers include clinicians’ attitudes, lack of knowledge and training and time constraints. Our goal is to support the development and delivery of a robust SDM curriculum in medical education. Our objective is to assess undergraduate medical students’ knowledge of and attitudes towards SDM in four countries.

METHODS AND ANALYSIS

The first phase of the study involves a web-based cross-sectional survey of undergraduate medical students from all years in selected schools across the United States (US), Canada and undergraduate and graduate students in the Netherlands. In the United Kingdom (UK), the survey will be circulated to all medical schools through the UK Medical School Council. We will sample students equally in all years of training and assess attitudes towards SDM, knowledge of SDM and participation in related training. Medical students of ages 18 years and older in the four countries will be eligible. The second phase of the study will involve semistructured interviews with a subset of students from phase 1 and a convenience sample of medical school curriculum experts or stakeholders. Data will be analysed using multivariable analysis in phase 1 and thematic content analysis in phase 2. Method, data source and investigator triangulation will be performed. Online survey data will be reported according to the Checklist for Reporting the Results of Internet E-Surveys. We will use the COnsolidated criteria for REporting Qualitative research for all qualitative data.

ETHICS AND DISSEMINATION

The study has been approved for dissemination in the US, the Netherlands, Canada and the UK. The study is voluntary with an informed consent process. The results will be published in a peer-reviewed journal and will help inform the inclusion of SDM-specific curriculum in medical education worldwide.

Evaluating CollaboRATE in a clinical setting: analysis of mode effects on scores, response rates and costs of data collection

BACKGROUND

Shared decision-making (SDM) has become a policy priority, yet its implementation is not routinely assessed. To address this gap we tested the delivery of CollaboRATE, a 3-item patient reported experience measure of SDM, via multiple survey modes.

OBJECTIVE

To assess CollaboRATE response rates and respondent characteristics across different modes of administration, impact of mode and patient characteristics on SDM performance and cost of administration per response in a real-world primary care practice.

DESIGN

Observational study design, with repeated assessment of SDM performance using CollaboRATE in a primary care clinic over 15 months of data collection. Different modes of administration were introduced sequentially including paper, patient portal, interactive voice response (IVR) call, text message and tablet computer.

PARTICIPANTS

Consecutive patients ≥18 years, or parents/guardians of patients <18 years, visiting participating primary care clinicians.

MAIN MEASURES

CollaboRATE assesses three core SDM tasks: (1) explanation about health issues, (2) elicitation of patient preferences and (3) integration of patient preferences into decisions. Responses to each item range from 0 (no effort was made) to 9 (every effort was made). CollaboRATE scores are calculated as the proportion of participants who report a score of nine on each of the three CollaboRATE questions.

KEY RESULTS

Scores were sensitive to mode effects: the paper mode had the highest average score (81%) and IVR had the lowest (61%). However, relative clinician performance rankings were stable across the different data collection modes used. Tablet computers administered by research staff had the highest response rate (41%), although this approach was costly. Clinic staff giving paper surveys to patients as they left the clinic had the lowest response rate (12%).

CONCLUSIONS

CollaboRATE can be introduced using multiple modes of survey delivery while producing consistent clinician rankings. This may allow routine assessment and benchmarking of clinician and clinic SDM performance.

Utilization of Mental Health Resources and Complementary and Alternative Therapies for Alopecia Areata: A U.S. Survey

Background

The efficacy of traditional medical treatments for alopecia areata (AA) is limited, leading some to pursue alternative treatments. The utilization and nature of these treatments are unclear.

Objective

To assess the extent to which patients with AA pursue alternative treatments and to characterize these treatments.

Methods

A 13-item electronic survey was E-mailed by the National Alopecia Areata Foundation (NAAF) to their patient database and shared on the NAAF social media to individuals with AA.

Results

Of 1083 respondents, 78.1% of patients were very or somewhat unsatisfied, compared to 7.7% who were very or somewhat satisfied with the current medical treatments for AA. Approximately a third of patients pursued therapy-related mental health services (31.2%) and attended support groups (29.0%). Patients were more likely to pursue a mental health-related therapy if they had long-standing alopecia, or if they were young, female, or white.

Limitations

This was a convenience sample of patients recruited online and via the NAAF AA registry.

Conclusion

Many patients with AA are dissatisfied with current treatments and are seeking mental health treatment for AA. While the efficacy of alternative therapies is unknown, further research is needed to determine their role in the treatment of AA.

Developing and Pilot Testing a Spanish Translation of CollaboRATE for Use in the United States

BACKGROUND/AIM

Given the need for access to patient-facing materials in multiple languages, this study aimed to develop and pilot test an accurate and understandable translation of CollaboRATE, a three-item patient-reported measure of shared decision-making, for Spanish-speaking patients in the United States (US).

METHOD

We followed the Translate, Review, Adjudicate, Pre-test, Document (TRAPD) survey translation protocol. Cognitive interviews were conducted with Spanish-speaking adults within an urban Massachusetts internal medicine clinic. For the pilot test, all patients with weekday appointments between May 1 and May 29, 2015 were invited to complete CollaboRATE in either English or Spanish upon exit. We calculated the proportion of respondents giving the best score possible on CollaboRATE and compared scores across key patient subgroups.

RESULTS

Four rounds of cognitive interviews with 26 people were completed between January and April 2015. Extensive, iterative refinements to survey items between interview rounds led to final items that were generally understood by participants with diverse educational backgrounds. Pilot data collection achieved an overall response rate of 73 percent, with 606 (49%) patients completing Spanish CollaboRATE questionnaires and 624 (51%) patients completing English CollaboRATE questionnaires. The proportion of respondents giving the best score possible on CollaboRATE was the same (86%) for both the English and Spanish versions of the instrument.

DISCUSSION

Our translation method, guided by emerging best practices in survey and health measurement translation, encompassed multiple levels of review. By conducting four rounds of cognitive interviews with iterative item refinement between each round, we arrived at a Spanish language version of CollaboRATE that was understandable to a majority of cognitive interview participants and was completed by more than 600 pilot questionnaire respondents.

Competing priorities in treatment decision-making: a US national survey of individuals with depression and clinicians who treat depression

OBJECTIVE

To identify information priorities for consumers and clinicians making depression treatment decisions and assess shared decision-making (SDM) in routine depression care.

DESIGN

20 questions related to common features of depression treatments were provided. Participants were initially asked to select which features were important, and in a second stage they were asked to rank their top 5 'important features' in order of importance. Clinicians were asked to provide rankings according to both consumer and clinician perspectives. Consumers completed CollaboRATE, a measure of SDM. Multiple logistic regression analysis identified consumer characteristics associated with CollaboRATE scores.

SETTING

Online cross-sectional surveys fielded in September to December 2014.

PARTICIPANTS

We administered surveys to convenience samples of US adults with depression and clinicians who treat depression. Consumer sampling was targeted to reflect age, gender and educational attainment of adults with depression in the USA.

PRIMARY OUTCOME MEASURES

Information priority rankings; CollaboRATE, a 3-item consumer-reported measure of SDM.

RESULTS

972 consumers and 244 clinicians completed the surveys. The highest ranked question for both consumers and clinicians was 'Will the treatment work?' Clinicians were aware of consumers' priorities, yet did not always prioritise that information themselves, particularly insurance coverage and cost of treatment. Only 18% of consumers reported high levels of SDM. Working with a psychiatrist (OR 1.87; 95% CI 1.07 to 3.26) and female gender (OR 2.04; 95% CI 1.25 to 3.34) were associated with top CollaboRATE scores.

CONCLUSIONS

While clinicians know what information is important to consumers making depression treatment decisions, they do not always address these concerns. This mismatch, coupled with low SDM, adversely affects the quality of depression care. Development of a decision support intervention based on our findings can improve levels of SDM and provide clinicians and consumers with a tool to address the existing misalignment in information priorities.

The psychometric properties of Observer OPTION(5), an observer measure of shared decision making

OBJECTIVES

Observer OPTION(5) was designed as a more efficient version of OPTION(12), the most commonly used measure of shared decision making (SDM). The current paper assesses the psychometric properties of OPTION(5).

METHODS

Two raters used OPTION(5) to rate recordings of clinical encounters from two previous patient decision aid (PDA) trials (n=201; n=110). A subsample was re-rated two weeks later. We assessed discriminative validity, inter-rater reliability, intra-rater reliability, and concurrent validity.

RESULTS

OPTION(5) demonstrated discriminative validity, with increases in SDM between usual care and PDA arms. OPTION(5) also demonstrated concurrent validity with OPTION(12), r=0.61 (95%CI 0.54, 0.68) and intra-rater reliability, r=0.93 (0.83, 0.97). The mean difference in rater score was 8.89 (95% Credibility Interval, 7.5, 10.3), with intraclass correlation (ICC) of 0.67 (95% Credibility Interval, 0.51, 0.91) for the accuracy of rater scores and 0.70 (95% Credibility Interval, 0.56, 0.94) for the consistency of rater scores across encounters, indicating good inter-rater reliability. Raters reported lower cognitive burden when using OPTION(5) compared to OPTION(12).

CONCLUSIONS

OPTION(5) is a brief, theoretically grounded observer measure of SDM with promising psychometric properties in this sample and low burden on raters.

PRACTICE IMPLICATIONS

OPTION(5) has potential to provide reliable, valid assessment of SDM in clinical encounters.

Measurement challenges in shared decision making: putting the 'patient' in patient-reported measures

Measuring clinicians' shared decision‐making (SDM) performance is a key requirement given the intensity of policy interest in many developed countries – yet it remains one of the most difficult methodological challenges, which is a concern for many stakeholders. In this Viewpoint Article, we investigate the development of existing patient‐reported measures (PRMs) of SDM identified in a recent review. We find that patients were involved in the development of only four of the 13 measures. This lack of patient involvement in PRM development is associated with two major threats to content validity, common to all 13 PRMs of SDM: (i) an assumption of patient awareness of ‘decision points’ and (ii) an assumption that there is only one decision point in each healthcare consultation. We provide detailed examples of these threats and their impact on accurate assessment of SDM processes and outcomes, which may hamper efforts to introduce incentives for SDM implementation. We propose cognitive interviewing as a recommended method of involving patients in the design of PRMs in the field of SDM and provide a practical example of this approach.

The opportunities and challenges for shared decision-making in the rural United States

The ethical standard for informed consent is fostered within a shared decision-making (SDM) process. SDM has become a recognized and needed approach in health care decision-making. Based on an ethical foundation, the approach fosters the active engagement of patients, where the clinician presents evidence-based treatment information and options and openly elicits the patient's values and preferences. The SDM process is affected by the context in which the information exchange occurs. Rural settings are one context that impacts the delivery of health care and SDM. Rural health care is significantly influenced by economic, geographical and social characteristics. Several specific distinctive features influence rural health care decision-making-poverty, access to health care, isolation, over-lapping relationships, and a shared culture. The rural context creates challenges as well as fosters opportunities for the application of SDM as a natural dynamic within the rural provider-patient relationship. To fulfill the ethical requirements of informed consent through SDM, it is necessary to understand its inherent challenges and opportunities. Therefore, rural clinicians and ethicists need to be cognizant of the impact of the rural setting on SDM and use the insights as an opportunity to achieve SDM.

Providing recording of clinical consultation to patients - a highly valued but underutilized intervention: a scoping review

OBJECTIVE

The benefits of providing patients with recorded clinical consultations have been mostly investigated in oncology settings, generally demonstrating positive outcomes. There has been limited synthesis of evidence about the practice in wider context. Our aim was to summarize, in a scoping review, the evidence about providing consultation recordings to patients.

METHODS

We searched seven literature databases. Full text articles meeting the inclusion criteria were retrieved and reviewed. Arksey and O'Malley's framework for scoping studies guided the review process and thematic analysis was undertaken to synthesize extracted data.

RESULTS

Of 5492 abstracts, 33 studies met the inclusion criteria. Between 53.6% and 100% (72% weighted average) of patients listened to recorded consultations. In 60% of reviewed studies patients shared the audio-recordings with others. Six themes identified in the study provided evidence for enhanced information recall and understanding by patients, and positive reactions to receiving recorded consultations. There has been limited investigation into the views of providers and organizations. Medico-legal concerns have been reported.

CONCLUSION

Patients place a high value on receiving audio-recordings of clinical consultations and majority benefit from listening to consultation recordings.

PRACTICE IMPLICATIONS

Further investigation of the ethical, practical and medico-legal implications of routinely providing recorded consultations is needed.

Public knowledge and perceptions of connected health

RATIONALE, AIMS AND OBJECTIVES

This study aims to examine the public's knowledge and perceptions of connected health (CH).

METHODS

A structured questionnaire was administered by face-to-face interview to an opportunistic sample of 1003 members of the public in 11 shopping centres across Northern Ireland (NI). Topics included public knowledge of CH, opinions about who should provide CH and views about the use of computers in health care. Multivariable analyses were conducted to assess respondents' willingness to use CH in the future.

RESULTS

Sixty-seven per cent of respondents were female, 31% were less than 30 years old and 22% were over 60 years. Most respondents had never heard of CH (92%). Following a standard definition, the majority felt CH was a good idea (≈90%) and that general practitioners were in the best position to provide CH; however, respondents were equivocal about reductions in health care professionals' workload and had some concerns about the ease of device use. Factors positively influencing willingness to use CH in the future included knowledge of someone who has a chronic disease, residence in NI since birth and less concern about the use of information technology (IT) in health care. Those over 60 years old or who felt threatened by the use of IT to store personal health information were less willing to use CH in the future.

CONCLUSION

Increased public awareness and education about CH is required to alleviate concerns and increase the acceptability of this type of care.

Connected health care: the future of health care and the role of the pharmacist

The population of the world is ageing. As a result, the incidence of chronic disease is projected to increase, there are predicted shortages in health care workforce and budget restraints; implications for future health care provision are serious. The current model of health care is not equipped to deal with these changes. Connected health care, via the use of health informatics, disease management and home telehealth technologies, has been suggested as an approach to ease the projected strain on future health care. Evidence to date suggests a positive impact of the use of connected health care model; however, the majority of studies have overlooked the involvement of the community pharmacist. As the most common point of contact with primary health services for most of the population, the community pharmacist may be well placed to provide connected health care. The research to date is promising with improvements in outcomes for cardiovascular patients noted; however, further work is required to investigate the potential role the community pharmacist can play in the future of connected health care.

The epidemiology of red cell transfusion

BACKGROUND AND OBJECTIVES

Understanding of the clinical usage of red cells is limited despite its importance in transfusion practice improvement and planning for blood supply requirements. Previous studies have described red cell use based upon ICD and hospital discharge codes; however, such approaches are open to misclassification. This study addresses this limitation by undertaking an epidemiological analysis of red cell use using case note review.

MATERIALS AND METHODS

Patient, disease and contextual factors were extracted from the medical records of a randomly selected sample of hospital patients in Northern Ireland who received a red cell transfusion during 2005 (n=1474).

RESULTS

Transfused patients received a total of 3804 units (median of two units per transfusion episode). Most transfusions occurred in a medical setting (71%). Patients undergoing treatment for gastrointestinal conditions were responsible for the majority of the demand (29% of transfusion episodes; 34% of red cell units). The presence of bleeding and abnormal tests of coagulation were associated with receiving larger transfusions (≥ 3 units), while patients undergoing orthopaedic surgery and those with a haemoglobin level over 7 g/dl had the lowest risk of receiving ≥ 3 units in any one transfusion episode.

CONCLUSION

The majority of red cells are now prescribed in a medical setting. With an ageing population and increasing therapeutic interventions, the demand for blood is likely to increase despite efforts to reduce usage by eliminating inappropriate transfusions through education and behaviour change. The post-transfusion target (and therefore the number of units to transfuse) for any given clinical situation as well as guidance on a 'safe' transfusion threshold should be considered in future guidelines.

Genomic structure and domain organisation of the human Bak gene

The Bcl-2 homologue, Bak, is a potent inducer of apoptosis. FISH data presented here located the gene to 6p21.3. Mapping was consistent with its location centromeric of the HSET locus and approximately 400kb from the MHC. The construction of a contig of genomic clones across the locus facilitated the sequencing of a PAC containing the gene. Comparison of the gene structure to functional and physical domains revealed a good agreement between the physical structure and the intron-exon organisation. The position of a single intron was conserved in comparison to other members of the Bcl-2 family, namely Bax, CED-9, Bcl-X and Bcl-2, but all other introns were displaced, consistent with a divergent phylogeny.

Production of a polyketide natural product in nonpolyketide-producing prokaryotic and eukaryotic hosts

The polyketides are a diverse group of natural products with great significance as human and veterinary pharmaceuticals. A significant barrier to the production of novel genetically engineered polyketides has been the lack of available heterologous expression systems for functional polyketide synthases (PKSs). Herein, we report the expression of an intact functional PKS in Escherichia coli and Saccharomyces cerevisiae. The fungal gene encoding 6-methylsalicylic acid synthase from Penicillium patulum was expressed in E. coli and S. cerevisiae and the polyketide 6-methylsalicylic acid (6-MSA) was produced. In both bacterial and yeast hosts, polyketide production required coexpression of 6-methylsalicylic acid synthase and a heterologous phosphopantetheinyl transferase that was required to convert the expressed apo-PKS to its holo form. Production of 6-MSA in E. coli was both temperature- and glycerol-dependent and levels of production were lower than those of P. patulum, the native host. In yeast, however, 6-MSA levels greater than 2-fold higher than the native host were observed. The heterologous expression systems described will facilitate the manipulation of PKS genes and consequent production of novel engineered polyketides and polyketide libraries.

Characterization of a recombinant Onchocerca volvulus antigen (Ov33) produced in yeast

A yeast (Saccharomyces cerevisiae) expression system has been adapted to produce reagent quantities of a major Onchocerca antigen, Ov33. Using a pool of monoclonal antibodies produced against third-stage larvae, a cDNA library constructed from adult O. volvulus worms was screened. Twenty-seven cDNAs were isolated, two of which had sequence homology to Ov33, a putative aspartyl protease inhibitor, which is the immunodominant antigen of O. volvulus. These cDNAs were expressed at high levels intracellularly or through the secretory pathway of S. cerevisiae. Localization studies using antisera produced against purified recombinant protein demonstrated that Ov33 is a very abundant parasite protein present in the hypodermis, muscle, and uterus of female worms, as well as in embryonic microfilariae. The soluble recombinant protein secreted by yeast (C71) demonstrated inhibitory activity against the aspartyl protease pepsin. Antibodies to the recombinant protein-mediated leukocyte adherence to and killing of skin microfilariae. The sensitivity of a diagnostic test using recombinant Ov33 was evaluated using sera from 441 patients. The mean sensitivities for the two recombinant constructs, C27 and C71, were 82.2% and 85.4%, respectively. The combined sensitivity using both recombinant proteins was 94%.