Publications by authors named "Kathleen M Mazor"

173 Publications

Advancing Clinical Trials in Nursing Homes: A Proposed Roadmap to Success.

J Am Med Dir Assoc 2021 Dec 22. Epub 2021 Dec 22.

UNC Chapel Hill, Chapel Hill, NC, USA.

An effective clinical research effort in nursing homes to address prevention and treatment of COVID-19 faced overwhelming challenges. Under the Health Care Systems Research Network-Older Americans Independence Centers AGING Initiative, a multidisciplinary Stakeholder Advisory Panel was convened to develop recommendations to improve the capability of the clinical research enterprise in US nursing homes. The Panel considered the nursing home as a setting for clinical trials, reviewed the current state of clinical trials in nursing homes, and ultimately developed recommendations for the establishment of a nursing home clinical trials research network that would be centrally supported and administered. This report summarizes the Panel's recommendations, which were developed in alignment with the following core principles: build on available research infrastructure where appropriate; leverage existing productive partnerships of researchers with groups of nursing homes and nursing home corporations; encompass both efficacy and effectiveness clinical trials; be responsive to a broad range of stakeholders including nursing home residents and their care partners; be relevant to an expansive range of clinical and health care delivery research questions; be able to pivot as necessary to changing research priorities and circumstances; create a pathway for industry-sponsored research as appropriate; invest in strategies to increase diversity in study populations and the research workforce; and foster the development of the next generation of nursing home researchers.
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http://dx.doi.org/10.1016/j.jamda.2021.11.034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8692165PMC
December 2021

Facility Characteristics Associated With Intensity of Care of Nursing Homes and Hospital Referral Regions.

J Am Med Dir Assoc 2021 Nov 23. Epub 2021 Nov 23.

Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA; Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

Objectives: Intensity of care, such as hospital transfers and tube feeding of residents with advanced dementia varies by nursing home (NH) within and across regions. Little work has been done to understand how these 2 levels of influence relate. This study's objectives are to identify facility factors associated with NHs providing high-intensity care to residents with advanced dementia and determine whether these factors differ within and across hospital referral regions (HRRs).

Design: Cross-sectional analysis.

Setting And Participants: 1449 NHs.

Methods: Nationwide 2016-2017 Minimum Data Set was used to categorize NHs and HRRs into 4 levels of care intensity based on rates of hospital transfers and tube feeding among residents with advanced dementia: low-intensity NH in a low-intensity HRR, high-intensity NH in a low-intensity HRR, low-intensity NH in a high-intensity HRR, and a high-intensity NH in a high-intensity HRR.

Results: In high-intensity HRRs, high-vs low-intensity NHs were more likely to be urban, lack a dementia unit, have a nurse practitioner or physician (NP or PA) on staff, and have a higher proportion of residents who were male, aged <65 years, Black, had pressure ulcers, and shorter hospice stays. In low-intensity HRRs, higher proportion of Black residents was the only characteristic associated with being a high-intensity NH.

Conclusions And Implications: These findings suggest that within high-intensity HRRs, there are potentially modifiable factors that could be targeted to reduce burdensome care in advanced dementia, including having a dementia unit, palliative care training for NPs and PAs, and increased use of hospice care.
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http://dx.doi.org/10.1016/j.jamda.2021.10.015DOI Listing
November 2021

Preferences for COVID-19 vaccination information and location: Associations with vaccine hesitancy, race and ethnicity.

Vaccine 2021 10 25;39(45):6591-6594. Epub 2021 Sep 25.

Department of Medicine, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA 01655, United States; Meyers Health Care Institute, A Joint Endeavor of the UMass Chan Medical School, Reliant Medical Group, and Fallon Health, 385 Grove Street, Worcester, MA 01605, United States.

This study examined the association between preferences for being informed about the COVID-19 vaccine and where to receive it with vaccination intent and race/ethnicity. We conducted an online survey, oversampling Black and Latino panel members. The 1668 participants were 53.2% female, 34.8% White, 33.3% Black, and 31.8% Latino. Participants who were vaccine hesitant (answered "not sure" or "no" to vaccination intent) were more likely to prefer a conversation with their doctor compared to those who answered "yes" (25.0% and 23.4% vs 7.8%, P < .001, respectively). Among participants who responded "not sure", 61.8% prefer to be vaccinated at a doctor's office, compared with 35.2% of those who responded "yes" (P < .001). Preferred location differed by race/ethnicity (P < .001) with 67.6% of Black "not sure" participants preferring a doctor's office compared to 60.2% of Latino and 54.9% of White "not sure" participants. These findings underscore the need to integrate healthcare providers into COVID-19 vaccination programs.
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http://dx.doi.org/10.1016/j.vaccine.2021.09.058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8463309PMC
October 2021

Association between Initiation of Pulmonary Rehabilitation and Rehospitalizations in Patients Hospitalized with Chronic Obstructive Pulmonary Disease.

Am J Respir Crit Care Med 2021 11;204(9):1015-1023

Institute for Healthcare Delivery and Population Science.

Although clinical trials have found that pulmonary rehabilitation (PR) can reduce the risk of readmissions after hospitalization for a chronic obstructive pulmonary disease (COPD) exacerbation, less is known about PR's impact in routine clinical practice. To evaluate the association between initiation of PR within 90 days of discharge and rehospitalization(s). We analyzed a retrospective cohort of Medicare beneficiaries (66 years of age or older) hospitalized for COPD in 2014 who survived at least 30 days after discharge. We used propensity score matching and estimated the risk of recurrent all-cause rehospitalizations at 1 year using a multistate model to account for the competing risk of death. Of 197,376 total patients hospitalized in 4,446 hospitals, 2,721 patients (1.5%) initiated PR within 90 days of discharge. Overall, 1,534 (56.4%) patients who initiated PR and 125,720 (64.6%) who did not were rehospitalized one or more times within 1 year of discharge. In the propensity-score-matched analysis, PR initiation was associated with a lower risk of readmission in the year after PR initiation (hazard ratio, 0.83; 95% confidence interval, 0.77-0.90). The mean cumulative number of rehospitalizations at 1 year was 0.95 for those who initiated PR within 90 days and 1.15 for those who did not ( < 0.001). After hospitalization for COPD, Medicare beneficiaries who initiated PR within 90 days of discharge experienced fewer rehospitalizations over 1 year. These results support findings from randomized controlled clinical trials and highlight the need to identify effective strategies to increase PR participation.
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http://dx.doi.org/10.1164/rccm.202012-4389OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8663014PMC
November 2021

Can sharing clinic notes improve communication and promote self-management? A qualitative study of patients with COPD.

Patient Educ Couns 2021 Jun 8. Epub 2021 Jun 8.

Department of Medicine, University of Massachusetts Medical School, Worcester, USA; Meyers Primary Care Institute, A Joint Endeavor of the University of Massachusetts Medical School, Reliant Medical Group and Fallon Health, Worcester, USA. Electronic address:

Objective: To understand the impact of sharing clinic notes on communication and self-management among patients with COPD and to develop recommendations for writing patient-centered notes.

Methods: Thirty patients with COPD participated in 'think-aloud' interviews in which they reviewed their COPD-specific clinic note. Interviews were coded using conventional content analysis, organized by the six-function communication framework.

Results: Participants were predominantly White (93.3%), with a mean age of 65.5 years. More than half had a high school degree or less, half reported difficulty understanding spoken information, and nearly half sometimes need help reading medical materials. Patients indicated notes provided an opportunity to learn details of their condition and facilitated information sharing - strengthening information exchange. Reading notes enabled self-management through motivation, prompting information seeking, and reminding them of action steps. Patients reacted positively to statements suggesting the provider listened to them, saw them as a person, and was attentive to details, which fostered the relationship. Most patients reacted negatively to medical terminology, incorrect information, and wording that was perceived as disparaging.

Conclusions: Sharing clinic notes with patients can promote information exchange, enable self-management, and strengthen the patient-provider relationship.

Practice Implications: Incorporating patients' recommendations for writing notes could strengthen the benefits of sharing notes.
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http://dx.doi.org/10.1016/j.pec.2021.06.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8651798PMC
June 2021

Prognostic Uncertainty in Critically Ill Patients with Traumatic Brain Injury: A Multicenter Qualitative Study.

Neurocrit Care 2021 10 2;35(2):311-321. Epub 2021 Jun 2.

Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA.

Background: Prognostic uncertainty is frequently cited as a barrier to communication between physicians and patients and is particularly burdensome for surrogate decision-makers, who must make choices on behalf of their incapacitated family members. The Conceptual Taxonomy of Uncertainty is one model through which physician and surrogate communication can be analyzed to identify strategies for reducing uncertainty in surrogate decision-making. Our objective was to examine themes of uncertainty in physician communication of prognosis and surrogate goals-of-care decision-making for critically ill patients with traumatic brain injury (TBI).

Methods: We performed a secondary analysis of a previous qualitative study that involved semistructured interviews of 16 surrogates of critically ill patients with TBI from two level 1 trauma centers and 20 TBI expert physicians from seven trauma centers. Open-ended questions about prognostic uncertainty were asked. We identified major themes with an inductive approach. The Conceptual Taxonomy of Uncertainty was applied to further characterize these themes as data-centered, system-centered, and patient-centered issues of uncertainty.

Results: Nearly all surrogates (15 of 16) and physicians (19 of 20) recognized the emotional burden of uncertainty in the decision-making process for surrogates. More than three quarters of surrogates (13 of 16) described instances in which a lack of information regarding their loved one's disease or prognosis created uncertainty in their decision-making process, identifying both positive and negative instances of prognostic communication by physicians. We found that physicians used one of three strategies to communicate prognostic uncertainty to surrogates: leaving no room for uncertainty, honesty about uncertainty, and range of possibilities. These strategies did not meet the communication preferences of the majority of surrogates, with more than a third of decision-makers (6 of 15) being frustrated by too much ambiguity about prognosis as well as the failure to acknowledge the existence of uncertainty.

Conclusions: We found that physician communication strategies rarely addressed surrogate needs regarding uncertainty adequately, suggesting an urgent need for future research into improved communication of prognostic uncertainty.
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http://dx.doi.org/10.1007/s12028-021-01230-3DOI Listing
October 2021

Evaluating the Effectiveness of NoteAid in a Community Hospital Setting: Randomized Trial of Electronic Health Record Note Comprehension Interventions With Patients.

J Med Internet Res 2021 05 13;23(5):e26354. Epub 2021 May 13.

Department of Computer Science, University of Massachusetts Lowell, Lowell, MA, United States.

Background: Interventions to define medical jargon have been shown to improve electronic health record (EHR) note comprehension among crowdsourced participants on Amazon Mechanical Turk (AMT). However, AMT participants may not be representative of the general population or patients who are most at-risk for low health literacy.

Objective: In this work, we assessed the efficacy of an intervention (NoteAid) for EHR note comprehension among participants in a community hospital setting.

Methods: Participants were recruited from Lowell General Hospital (LGH), a community hospital in Massachusetts, to take the ComprehENotes test, a web-based test of EHR note comprehension. Participants were randomly assigned to control (n=85) or intervention (n=89) groups to take the test without or with NoteAid, respectively. For comparison, we used a sample of 200 participants recruited from AMT to take the ComprehENotes test (100 in the control group and 100 in the intervention group).

Results: A total of 174 participants were recruited from LGH, and 200 participants were recruited from AMT. Participants in both intervention groups (community hospital and AMT) scored significantly higher than participants in the control groups (P<.001). The average score for the community hospital participants was significantly lower than the average score for the AMT participants (P<.001), consistent with the lower education levels in the community hospital sample. Education level had a significant effect on scores for the community hospital participants (P<.001).

Conclusions: Use of NoteAid was associated with significantly improved EHR note comprehension in both community hospital and AMT samples. Our results demonstrate the generalizability of ComprehENotes as a test of EHR note comprehension and the effectiveness of NoteAid for improving EHR note comprehension.
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http://dx.doi.org/10.2196/26354DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8160802PMC
May 2021

ADVANCE: Methodology of a qualitative study.

J Am Geriatr Soc 2021 08 10;69(8):2132-2142. Epub 2021 May 10.

Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.

Background/objectives: Quantitative studies have documented persistent regional, facility, and racial differences in the intensity of care provided to nursing home (NH) residents with advanced dementia including, greater intensity in the Southeastern United States, among black residents, and wide variation among NHs in the same hospital referral region (HRR). The reasons for these differences are poorly understood, and the appropriate way to study them is poorly described.

Design: Assessment of Disparities and Variation for Alzheimer's disease Nursing home Care at End of life (ADVANCE) is a large qualitative study to elucidate factors related to NH organizational culture and proxy perspectives contributing to differences in the intensity of advanced dementia care. Using nationwide 2016-2017 Minimum DataSet information, four HRRs were identified in which the relative intensity of advanced dementia care was high (N = 2 HRRs) and low (N = 2 HRRs) based on hospital transfer and tube-feeding rates among residents with this condition. Within those HRRs, we identified facilities providing high (N = 2 NHs) and low (N = 2 NHs) intensity care relative to all NHs in that HRR (N = 16 total facilities; 4 facilities/HRR).

Results/conclusions: To date, the research team conducted 275 h of observation in 13 NHs and interviewed 158 NH providers from varied disciplines to assess physical environment, care processes, decision-making processes, and values. We interviewed 44 proxies (black, N = 19; white, N = 25) about their perceptions of advance care planning, decision-making, values, communication, support, trust, literacy, beliefs about death, and spirituality. This report describes ADVANCE study design and the facilitators and challenges of its implementation, providing a template for the successful application of large qualitative studies focused on quality care in NHs.
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http://dx.doi.org/10.1111/jgs.17217DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8373706PMC
August 2021

Adapting a Traumatic Brain Injury Goals-of-Care Decision Aid for Critically Ill Patients to Intracerebral Hemorrhage and Hemispheric Acute Ischemic Stroke.

Crit Care Explor 2021 Mar 9;3(3):e0357. Epub 2021 Mar 9.

Department of Neurology, University of Massachusetts Medical School, Worcester, MA.

Objectives: Families in the neurologic ICU urgently request goals-of-care decision support and shared decision-making tools. We recently developed a goals-of-care decision aid for surrogates of critically ill traumatic brain injury patients using a systematic development process adherent to the International Patient Decision Aid Standards. To widen its applicability, we adapted this decision aid to critically ill patients with intracerebral hemorrhage and large hemispheric acute ischemic stroke.

Design: Prospective observational study.

Setting: Two academic neurologic ICUs.

Subjects: Twenty family members of patients in the neurologic ICU were recruited from July 2018 to October 2018.

Interventions: None.

Measurements And Main Results: We reviewed the existing critically ill traumatic brain injury patients decision aid for content and changed: 1) the essential background information, 2) disease-specific terminology to "hemorrhagic stroke" and "ischemic stroke", and 3) disease-specific prognosis tailored to individual patients. We conducted acceptability and usability testing using validated scales. All three decision aids contain information from validated, disease-specific outcome prediction models, as recommended by international decision aid standards, including careful emphasis on their uncertainty. We replaced the individualizable icon arrays graphically depicting probabilities of a traumatic brain injury patient's prognosis with icon arrays visualizing intracerebral hemorrhage and hemispheric acute ischemic stroke prognostic probabilities using high-quality disease-specific data. We selected the Intracerebral Hemorrhage Score with validated 12-month outcomes, and for hemispheric acute ischemic stroke, the 12-month outcomes from landmark hemicraniectomy trials. Twenty family members participated in acceptability and usability testing ( = 11 for the intracerebral hemorrhage decision aid; = 9 for the acute ischemic stroke decision aid). Median usage time was 22 minutes (interquartile range, 16-26 min). Usability was excellent (median System Usability Scale = 84/100 [interquartile range, 61-93; with > 68 indicating good usability]); 89% of participants graded the decision aid content as good or excellent, and greater than or equal to 90% rated it favorably for information amount, balance, and comprehensibility.

Conclusions: We successfully adapted goals-of-care decision aids for use in surrogates of critically ill patients with intracerebral hemorrhage and hemispheric acute ischemic stroke and found excellent usability and acceptability. A feasibility trial using these decision aids is currently ongoing to further validate their acceptability and test their feasibility for use in busy neurologic ICUs.
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http://dx.doi.org/10.1097/CCE.0000000000000357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7994105PMC
March 2021

Using crowdsourced analog patients to provide feedback on physician communication skills.

Patient Educ Couns 2021 09 1;104(9):2297-2303. Epub 2021 Mar 1.

Department of Medicine, University of Washington, United States.

Objective: Effective physician-patient communication is important, but physicians who are seeking to improve have few opportunities for practice or receive actionable feedback. The Video-based Communication Assessment (VCA) provides both. Using the VCA, physicians respond to communication dilemmas depicted in brief video vignettes; crowdsourced analog patients rate responses and offer comments. We characterized analog patients' comments and generated actionable recommendations for improving communication.

Methods: Physicians and residents completed the VCA; analog patients rated responses and answered:"What would you want the provider to say in this situation?" We used qualitative analysis to identify themes.

Results: Forty-three participants completed the VCA; 556 analog patients provided 1035 comments. We identified overarching themes (e.g., caring, empathy, respect) and generated actionable recommendations, incorporating analog patient quotes.

Conclusion: While analog patients' comments could be provided directly to users, conducting a thematic analysis and developing recommendations for physician-patient communication reduced the burden on users, and allowed for focused feedback. Research is needed into physicians' reactions to the recommendations and the impact on communication.

Practice Implications: Physicians seeking to improve communication skills may benefit from practice and feedback. The VCA was designed to provide both, incorporating the patient voice on how best to communicate in clinical situations.
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http://dx.doi.org/10.1016/j.pec.2021.02.047DOI Listing
September 2021

Identifying prescribing cascades in Alzheimer's disease and related dementias: The calcium channel blocker-diuretic prescribing cascade.

Pharmacoepidemiol Drug Saf 2021 08 23;30(8):1066-1073. Epub 2021 Mar 23.

Department of Family Medicine and Community Health, University of Massachusetts Medical School & Meyers Primary Care Institute, Worcester, Massachusetts, USA.

Purpose: Prescribing cascades occur when a physician prescribes a new drug to address the side-effect of another drug. Persons with Alzheimer's disease and related dementias (ADRD) are at increased risk for prescribing cascades. Our objective was to develop an approach to estimating the proportion of calcium channel blocker-diuretic (CCB-diuretic) prescribing cascades among persons with ADRD in two U.S. health plans.

Methods: We identified patients aged ≥50 on January 1, 2017, dispensed a drug to treat ADRD in the 365-days prior to/on cohort entry date. Patients had medical/pharmacy coverage for 1 year before and through cohort entry. We excluded individuals with an institutional stay encounter in the 45 days prior to cohort entry and censored patients based on: disenrollment from coverage, death, or end of data. We identified incident and prevalent CCB use in the 183-days following cohort entry, and identified subsequent incident diuretic use among incident and prevalent CCB-users within 365-days from cohort entry.

Results: There were 121 538 eligible patients. Approximately 62% were female, with a mean age of 79.5 (SD ±8.6). Overall 2.1% of the cohort experienced a prevalent CCB-diuretic prescribing cascade with 1586 incident diuretic-users among 36 462 prevalent CCB-users (4.3%, 95% CI 4.1-4.6%]); and there were161 incident diuretic-users among 3304 incident CCB-users (4.9%, 95% CI 4.2-5.7%) (incident CCB-diuretic cascade).

Conclusions: We describe an approach to identify prescribing cascades in persons with ADRD, which can be used to assess the proportion of prescribing cascades in large cohorts. We determined the proportion of CCB-diuretic prescribing cascades was low.
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http://dx.doi.org/10.1002/pds.5230DOI Listing
August 2021

Effect of a Multifaceted Clinical Pharmacist Intervention on Medication Safety After Hospitalization in Persons Prescribed High-risk Medications: A Randomized Clinical Trial.

JAMA Intern Med 2021 05;181(5):610-618

Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester.

Importance: The National Action Plan for Adverse Drug Event (ADE) Prevention identified 3 high-priority, high-risk drug classes as targets for reducing the risk of drug-related injuries: anticoagulants, diabetes agents, and opioids.

Objective: To determine whether a multifaceted clinical pharmacist intervention improves medication safety for patients who are discharged from the hospital and prescribed medications within 1 or more of these high-risk drug classes.

Design, Setting, And Participants: This randomized clinical trial was conducted at a large multidisciplinary group practice in Massachusetts and included patients 50 years or older who were discharged from the hospital and prescribed at least 1 high-risk medication. Participants were enrolled into the trial from June 2016 through September 2018.

Interventions: The pharmacist-directed intervention included an in-home assessment by a clinical pharmacist, evidence-based educational resources, communication with the primary care team, and telephone follow-up. Participants in the control group were provided educational materials via mail.

Main Outcomes And Measures: The study assessed 2 outcomes over a 45-day posthospital discharge period: (1) adverse drug-related incidents and (2) a subset defined as clinically important medication errors, which included preventable or ameliorable ADEs and potential ADEs (ie, medication-related errors that may not yet have caused injury to a patient, but have the potential to cause future harm if not addressed). Clinically important medication errors were the primary study outcome.

Results: There were 361 participants (mean [SD] age, 68.7 [9.3] years; 177 women [49.0%]; 319 White [88.4%] and 8 Black individuals [2.2%]). Of these, 180 (49.9%) were randomly assigned to the intervention group and 181 (50.1%) to the control group. Among all participants, 100 (27.7%) experienced 1 or more adverse drug-related incidents, and 65 (18%) experienced 1 or more clinically important medication errors. There were 81 adverse drug-related incidents identified in the intervention group and 72 in the control group. There were 44 clinically important medication errors in the intervention group and 45 in the control group. The intervention did not significantly alter the per-patient rate of adverse drug-related incidents (unadjusted incidence rate ratio, 1.13; 95% CI, 0.83-1.56) or clinically important medication errors (unadjusted incidence rate ratio, 0.99; 95% CI, 0.65-1.49).

Conclusions And Relevance: In this randomized clinical trial, there was not an observed lower rate of adverse drug-related incidents or clinically important medication errors during the posthospitalization period that was associated with a clinical pharmacist intervention. However, there were study recruitment challenges and lower than expected numbers of events among the study population.

Trial Registration: ClinicalTrials.gov Identifier: NCT02781662.
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http://dx.doi.org/10.1001/jamainternmed.2020.9285DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7922235PMC
May 2021

How Communication "Failed" or "Saved the Day": Counterfactual Accounts of Medical Errors.

J Patient Exp 2020 Dec 26;7(6):1247-1254. Epub 2020 May 26.

Meyers Primary Care Institute, a Joint Endeavor of the University of Massachusetts Medical School, Reliant Medical Group and Fallon Health, Worcester, MA, USA.

Communication breakdowns among clinicians, patients, and family members can lead to medical errors, yet effective communication may prevent such mistakes. This investigation examined patients' and family members' experiences where they believed communication failures contributed to medical errors or where effective communication prevented a medical error ("close calls"). The study conducted a thematic analysis of open-ended responses to an online survey of patients' and family members' past experiences with medical errors or close calls. Of the 93 respondents, 56 (60%) provided stories of medical errors, and the remaining described close calls. Two predominant themes emerged in medical error stories that were attributed to health care providers-information inadequacy (eg, delayed, inaccurate) and not listening to or being dismissive of a patient's or family member's concerns. In stories of close calls, a patient's or family member's proactive communication (eg, being assertive, persistent) most often "saved the day." The findings highlight the importance of encouraging active patient/family involvement in a patient's medical care to prevent errors and of improving systems to provide meaningful information in a timely manner.
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http://dx.doi.org/10.1177/2374373520925270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786716PMC
December 2020

Antidopaminergic-Antiparkinsonian Medication Prescribing Cascade in Persons with Alzheimer's Disease.

J Am Geriatr Soc 2021 05 11;69(5):1328-1333. Epub 2021 Jan 11.

University of Massachusetts Medical School & Meyers Primary Care Institute, Worcester, Massachusetts, USA.

Objectives: Persons living with Alzheimer's disease (AD) may be at increased risk for prescribing cascades due to greater multimorbidity, polypharmacy, and the need for more complex care. Our objective was to assess the proportion of the antidopaminergic-antiparkinsonian medication prescribing cascades among persons living with Alzheimer's disease.

Setting: Two large administrative claims databases in the United States.

Participants: We identified patients aged ≥50 on January 1, 2017, who were dispensed a drug used to treat Alzheimer's disease for at least 1 day in the 365 days prior to or on cohort entry date and who had medical and pharmacy coverage in the 365 days prior to the cohort entry date. We excluded individuals with a recent institutional stay. We identified incident antidopaminergic (antipsychotic/metoclopramide) use in the 183 days following cohort entry and identified subsequent incident antiparkinsonian drug use within 8 to 365 days.

Results: There were 121,538 patients with Alzheimer's disease eligible for inclusion. Approximately 62% were women with a mean age of 79.5 (SD ± 8.6). The mean number of drugs dispensed was 9.2 (SD ± 4.9). There were 36 incident antiparkinsonian users among 4,534 incident antipsychotic/metoclopramide users (0.8%).

Conclusion: We determined that the proportion of antidopaminergic-antiparkinsonian medication prescribing cascades, widely considered as high-priority, was low. Our approach can be used to assess the proportion of prescribing cascades in populations considered to be at high risk and to prioritize system-level interventional efforts to improve medication safety in these patients.
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http://dx.doi.org/10.1111/jgs.17013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8284916PMC
May 2021

Prescribing cascades in persons with Alzheimer's disease: engaging patients, caregivers, and providers in a qualitative evaluation of print educational materials.

Ther Adv Drug Saf 2020 30;11:2042098620968310. Epub 2020 Oct 30.

University of Massachusetts Medical School, Worcester, MA, USA and Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA.

Introduction: Prescribing cascades occur when the side effect of a drug is misinterpreted as a new medical condition, and a second drug is prescribed to address the side effect. Persons with Alzheimer's disease (AD) are at increased risk of prescribing cascades due to greater multimorbidity, polypharmacy, and complexity of care. The objective of this study was to evaluate educational materials about prescribing cascades in persons with AD, and elicit input on their use in a future trial.

Methods: We interviewed community-dwelling adults with either an AD diagnosis or a prescription drug used to treat AD ( = 12), caregivers of patients meeting the same criteria ( = 14), and providers ( = 15). We coded interview transcripts and organized themes according to the communication-human information processing model. We revised the materials based on the interviews, and surveyed participating caregivers and providers for their reactions to the revised materials.

Results: Analysis of patients', caregivers', and providers' comments suggest: (a) Providers had conflicting views about the messaging of materials; (b) Caregivers were likely to read letters addressed to patients; (c) Providers were likely to ignore letters, but were receptive to patient/caregiver-initiated conversations; (d) Patients and caregivers had difficulty understanding prescribing cascades; (e) Providers worried that mailed materials would undermine trust; (f) Participants had mixed views on how materials might affect the clinical encounter; (g) Participants felt that materials would improve patient/caregiver engagement. When surveyed, most providers found the revised materials informative and actionable, and most caregivers found them understandable and useful.

Conclusions: This evaluation of educational materials about prescribing cascades in patients with AD provides strong support for engaging caregivers to communicate with providers about prescribing cascades. By giving patients and caregivers a basic description of the prescribing cascade concept, our educational materials may help them prepare for a conversation with the provider, who can then tailor the discussion of the possible cascade to the specific needs of the individual patient and caregiver. However, evidence on whether materials can stimulate such conversations awaits testing in a future trial.

Lay Summary: Prescribing cascades occur when the side effect of a medication is misinterpreted as a new medical condition, and a second medication is prescribed to treat the side effect. Persons with Alzheimer's disease (AD) are at increased risk of prescribing cascades because they often have more medical conditions, more medications, and more complex care. The goal of this study was to evaluate mailed educational materials about prescribing cascades in persons with AD, and get input on their use in a future study. We interviewed 12 adults with AD, or prescribed a medication to treat AD, 14 caregivers of persons with AD, and 15 providers. We reviewed the interview transcripts to identify important findings about our educational materials. We edited the materials based on the interviews, and sent participating caregivers and providers a questionnaire to get their reactions to the new materials. Important findings from the interviews suggest: (a) Providers had conflicting views about the recommendations given; (b) Caregivers were likely to read letters addressed to patients; (c) Providers were likely to ignore letters, but were receptive to patients/caregivers introducing the topic; (d) Patients and caregivers had difficulty understanding prescribing cascades; (e) Providers worried mailed materials would undermine trust; (f) Participants had mixed views on how materials might affect a doctor's appointment; (g) Participants felt strongly that materials would improve patient/caregiver engagement. When surveyed, almost all providers found the revised materials informative and actionable; and most caregivers found them understandable and useful. These findings provide strong support for engaging caregivers to communicate with providers about prescribing cascades. The educational materials may help patients and caregivers prepare for a conversation with the provider, who can then tailor the discussion of the possible cascade to the specific needs of the individual patient and caregiver. However, evidence on whether materials can stimulate such conversations awaits testing in a future study.
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http://dx.doi.org/10.1177/2042098620968310DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675869PMC
October 2020

Enhancing Success of Medicare's Shared Decision Making Mandates Using Implementation Science: Examples Applying the Pragmatic Robust Implementation and Sustainability Model (PRISM).

MDM Policy Pract 2020 Jul-Dec;5(2):2381468320963070. Epub 2020 Oct 15.

VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, Colorado.

The Centers for Medicare and Medicaid Services (CMS) has mandated shared decision making (SDM) using patient decision aids for three conditions (lung cancer screening, atrial fibrillation, and implantable defibrillators). These forward-thinking approaches are in response to a wealth of efficacy data demonstrating that decision aids can improve patient decision making. However, there has been little focus on how to implement these approaches in real-world practice. This article demonstrates how using an implementation science framework may help programs understand multilevel challenges and opportunities to improve adherence to the CMS mandates. Using the PRISM (Pragmatic Robust Implementation and Sustainability Model) framework, we discuss general challenges to implementation of SDM, issues specific to each mandate, and how to plan for, enhance, and assess SDM implementation outcomes. Notably, a theme of this discussion is that successful implementation is context-specific and to truly have successful and sustainable changes in practice, context variability, and adaptation to context must be considered and addressed.
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http://dx.doi.org/10.1177/2381468320963070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7570787PMC
October 2020

Improving stamina and mobility with preop walking in surgical patients with frailty traits -OASIS IV: randomized clinical trial study protocol.

BMC Geriatr 2020 10 7;20(1):394. Epub 2020 Oct 7.

University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA.

Background: Frail older surgical patients face more than a two-fold increase in postoperative complications, including myocardial infarction, deep vein thrombosis, pulmonary embolism, pneumonia, ileus, and others. Many of these complications occur because of postoperative loss of stamina and poor mobility. Preoperative exercise may better prepare these vulnerable patients for surgery. We present the protocol for our ongoing randomized trial to assess the impact of a preoperative walking intervention with remote coaching and pedometer on outcomes of stamina (six-minute walk distance- 6MWD) and mobility (postoperative steps) in older adults with frailty traits.

Methods: We will be conducting a randomized clinical trial with a total of 120 patients permitting up to a 33% rate of attrition, to reach a final sample size of 80 (with 40 patients for each study arm). We will include patients who are age 60 or higher, score 4 or greater on the Edmonton Frailty Scale assessment, and will be undergoing a surgical operation that requires a 2 or more night hospital stay to be eligible for our trial. Using block randomization stratified on baseline 6MWD, we will assign patients to wear a pedometer. At the end of three baseline days, an athletic trainer (AT) will provide a daily step count goal reflecting a 10-20% increase from baseline. Subsequently, the AT will call weekly to further titrate the goal or calls more frequently if the patient is not meeting the prescribed goal. Controls will receive general walking advice. Our main outcome is change in 6MWD on postoperative day (POD) 2/3 vs. baseline. We will also collect 6MWD approximately 4 weeks after surgery and daily in-hospital steps.

Conclusion: If changes in a 6MWD and step counts are significantly higher for the intervention group, we believe this will confirm our hypothesis that the intervention leads to decreased loss of stamina and mobility. Once confirmed, we anticipate expanding to multiple centers to assess the interventional impact on clinical endpoints.

Trial Registration: The randomized clinical trial was registered on clinicaltrials.gov under the identifier NCT03892187 on March 27, 2019.
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http://dx.doi.org/10.1186/s12877-020-01799-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7542706PMC
October 2020

Electronic Health Record Portal Messages and Interactive Voice Response Calls to Improve Rates of Early Season Influenza Vaccination: Randomized Controlled Trial.

J Med Internet Res 2020 09 25;22(9):e16373. Epub 2020 Sep 25.

Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.

Background: Patient reminders for influenza vaccination, delivered via an electronic health record patient portal and interactive voice response calls, offer an innovative approach to engaging patients and improving patient care.

Objective: The goal of this study was to test the effectiveness of portal and interactive voice response outreach in improving rates of influenza vaccination by targeting patients in early September, shortly after vaccinations became available.

Methods: Using electronic health record portal messages and interactive voice response calls promoting influenza vaccination, outreach was conducted in September 2015. Participants included adult patients within a large multispecialty group practice in central Massachusetts. Our main outcome was electronic health record-documented early influenza vaccination during the 2015-2016 influenza season, measured in November 2015. We randomly assigned all active portal users to 1 of 2 groups: (1) receiving a portal message promoting influenza vaccinations, listing upcoming clinics, and offering online scheduling of vaccination appointments (n=19,506) or (2) receiving usual care (n=19,505). We randomly assigned all portal nonusers to 1 of 2 groups: (1) receiving interactive voice response call (n=15,000) or (2) receiving usual care (n=43,596). The intervention also solicited patient self-reports on influenza vaccinations completed outside the clinic. Self-reported influenza vaccination data were uploaded into the electronic health records to increase the accuracy of existing provider-directed electronic health record clinical decision support (vaccination alerts) but were excluded from main analyses.

Results: Among portal users, 28.4% (5549/19,506) of those randomized to receive messages and 27.1% (5294/19,505) of the usual care group had influenza vaccinations documented by November 2015 (P=.004). In multivariate analysis of portal users, message recipients were slightly more likely to have documented vaccinations when compared to the usual care group (OR 1.07, 95% CI 1.02-1.12). Among portal nonusers, 8.4% (1262/15,000) of those randomized to receive calls and 8.2% (3586/43,596) of usual care had documented vaccinations (P=.47), and multivariate analysis showed nonsignificant differences. Over half of portal messages sent were opened (10,112/19,479; 51.9%), and over half of interactive voice response calls placed (7599/14,984; 50.7%) reached their intended target, thus we attained similar levels of exposure to the messaging for both interventions. Among portal message recipients, 25.4% of message openers (2570/10,112) responded to a subsequent question on receipt of influenza vaccination; among interactive voice response recipients, 72.5% of those reached (5513/7599) responded to a similar question.

Conclusions: Portal message outreach to a general primary care population achieved a small but statistically significant improvement in rates of influenza vaccination (OR 1.07, 95% CI 1.02-1.12). Interactive voice response calls did not significantly improve vaccination rates among portal nonusers (OR 1.03, 95% CI 0.96-1.10). Rates of patient engagement with both modalities were favorable.

Trial Registration: ClinicalTrials.gov NCT02266277; https://clinicaltrials.gov/ct2/show/NCT02266277.
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http://dx.doi.org/10.2196/16373DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7547389PMC
September 2020

Attitudes Toward a Potential SARS-CoV-2 Vaccine : A Survey of U.S. Adults.

Ann Intern Med 2020 12 4;173(12):964-973. Epub 2020 Sep 4.

Meyers Primary Care Institute and University of Massachusetts Medical School, Worcester, Massachusetts (K.A.F., S.C., K.M.M.).

Background: Coronavirus disease 2019 (COVID-19) has rapidly instigated a global pandemic. Vaccine development is proceeding at an unprecedented pace. Once available, it will be important to maximize vaccine uptake and coverage.

Objective: To assess intent to be vaccinated against COVID-19 among a representative sample of adults in the United States and identify predictors of and reasons for vaccine hesitancy.

Design: Cross-sectional survey, fielded from 16 through 20 April 2020.

Setting: Representative sample of adults residing in the United States.

Participants: Approximately 1000 adults drawn from the AmeriSpeak probability-based research panel, covering approximately 97% of the U.S. household population.

Measurements: Intent to be vaccinated against COVID-19 was measured with the question, "When a vaccine for the coronavirus becomes available, will you get vaccinated?" Response options were "yes," "no," and "not sure." Participants who responded "no" or "not sure" were asked to provide a reason.

Results: A total of 991 AmeriSpeak panel members responded. Overall, 57.6% of participants ( = 571) intended to be vaccinated, 31.6% ( = 313) were not sure, and 10.8% ( = 107) did not intend to be vaccinated. Factors independently associated with vaccine hesitancy (a response of "no" or "not sure") included younger age, Black race, lower educational attainment, and not having received the influenza vaccine in the prior year. Reasons for vaccine hesitancy included vaccine-specific concerns, a need for more information, antivaccine attitudes or beliefs, and a lack of trust.

Limitations: Participants' intent to be vaccinated was explored before a vaccine was available and when the pandemic was affecting a narrower swath of the United States. Questions about specific information or factors that might increase vaccination acceptance were not included. The survey response rate was 16.1%.

Conclusion: This national survey, conducted during the coronavirus pandemic, revealed that approximately 3 in 10 adults were not sure they would accept vaccination and 1 in 10 did not intend to be vaccinated against COVID-19. Targeted and multipronged efforts will be needed to increase acceptance of a COVID-19 vaccine when one becomes available.

Primary Funding Source: Agency for Healthcare Research and Quality.
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http://dx.doi.org/10.7326/M20-3569DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7505019PMC
December 2020

Assessing and Supporting Late Career Practitioners: Four Key Questions.

Jt Comm J Qual Patient Saf 2020 10 24;46(10):591-595. Epub 2020 Jul 24.

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http://dx.doi.org/10.1016/j.jcjq.2020.07.001DOI Listing
October 2020

Recruitment Challenges for Low-Risk Health System Intervention Trials in Older Adults: A Case Study.

J Am Geriatr Soc 2020 11 25;68(11):2558-2564. Epub 2020 Jul 25.

Meyers Primary Care Institute, a Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.

Objective: To assess factors associated with trial participation in the context of a low-risk intervention intended to reduce adverse drug events in recently hospitalized older adults.

Design: Mixed methods: analysis of data collected during enrollment efforts and focus groups.

Setting: A large, multispecialty group practice.

Participants: Individuals 50 years and older, recently discharged from the hospital and prescribed at least one high-risk medication, were eligible for the trial. Enrollees, decliners, and their caregivers were eligible to participate in focus groups.

Measurements: Reasons for declining to participate during the initial invitation as well as reasons for not providing consent were recorded. Focus groups were conducted with eligible individuals to explore reasons for enrolling or declining. We conducted multivariable logistic regression to compare characteristics (including sex, age, healthcare proxy, number and type of medications, visiting nurse services, reason for admission, and length of hospital stay) of those who enrolled with those who did not enroll.

Results: Of 3,606 individuals determined eligible, 3,147 (87%) declined, 98 (3%) verbally consented to participate but did not complete written consent, and 361 (10%) provided written consent and were considered enrolled. Individuals 80 year and older (odds ratio (OR) = 0.44; 95% confidence interval (CI) = 0.30-0.65) and those with visiting nurse services (OR = 0.64; 95% CI = 0.48-0.85) were least likely to enroll. Among those who provided a reason for declining (2,473), the most common was the belief they did not need additional medication assistance (18%). Another 332 (11%) declined because they were receiving visiting nurse services.

Conclusion: Recruiting older adults recently discharged from the hospital to participate in trials of low-risk, system-level interventions is challenging and may underenroll the oldest individuals and those potentially at the highest risk for adverse events, limiting generalizability of study findings. Alternative study designs may be more effective than individually randomized trials in assessing low-risk, system-level interventions.
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http://dx.doi.org/10.1111/jgs.16696DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7722200PMC
November 2020

Tools to Promote Shared Decision-Making in Lung Cancer Screening Using Low-Dose CT Scanning: A Systematic Review.

Chest 2020 12 3;158(6):2646-2657. Epub 2020 Jul 3.

Department of Family Medicine and Community Health, Worchester, MA; Meyers Primary Care Institute, Worcester, MA.

Background: Decisions about lung cancer screening are inherently complex and create a need for methods to convey the risks and benefits of screening to patients.

Research Question: What kind of decision aids or tools are available to support shared decision-making for lung cancer screening? What is the current evidence for the effectiveness, acceptability, and feasibility of those tools?

Study Design And Methods: We conducted a systematic review of studies and searched PubMed, MEDLINE, EMBASE, Cochrane Clinical Trials Register, and ClinicalTrials.gov from inception to December 2019 for studies that evaluated the effectiveness and acceptability of tools to promote shared decision-making for patients who are considering lung cancer screening.

Results: After screening 2,427 records, we included one randomized control trial, two observational studies, 11 before/after studies of a decision aid or an educational tool. Fifteen distinct tools in various formats were evaluated in 14 studies. Most studies were of fair quality. Studies reported improvement in patients' knowledge of lung cancer screening (n = 9 studies), but improvements in specific areas of knowledge were inconsistent. Decisional conflict was low or reduced after the administration of the tools (n = 7 studies). The acceptability of tools was rated as "high" by patients (n = 7 studies) and physicians (n = 1 study). Low dose CT scan completion rates varied among studies (n = 6 studies).

Interpretation: Evidence from 14 studies suggests that some elements of existing tools for lung cancer screening may help to prepare patients for decision-making by improving knowledge and reducing decisional conflict. Such tools generally are acceptable to patients and providers. Further studies that use consistent measures and reporting methods and assess relevant decisional and clinical outcomes are needed to determine the comparative effectiveness and feasibility of implementation of these tools.

Clinical Trial Registration: PROSPERO 2018 CRD4201874814.
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http://dx.doi.org/10.1016/j.chest.2020.05.610DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783863PMC
December 2020

Goals-of-care decision aid for critically ill patients with TBI: Development and feasibility testing.

Neurology 2020 07 17;95(2):e179-e193. Epub 2020 Jun 17.

From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA.

Objective: To develop and demonstrate early feasibility of a goals-of-care decision aid for surrogates of patients who are critically ill with traumatic brain injury (ciTBI) that meets accepted international decision aid guidelines.

Methods: We developed the decision aid in 4 stages: (1) qualitative study of goals-of-care communication and decision needs of 36 stakeholders of ciTBI (surrogates and physicians), which informed (2) development of paper-based decision aid with iterative revisions after feedback from 52 stakeholders; (3) acceptability and usability testing in 18 neurologic intensive care unit (neuroICU) family members recruited from 2 neuroICU waiting rooms using validated scales; and (4) open-label, randomized controlled feasibility trial in surrogates of ciTBI. We performed an interim analysis of 16 surrogates of 12 consecutive patients who are ciTBI to confirm early feasibility of the study protocol and report recruitment, participation, and retention rates to date.

Results: The resultant goals-of-care decision aid achieved excellent usability (median System Usability Scale 87.5 [possible range 0-100]) and acceptability (97% graded the tool's content as "good" or "excellent"). Early feasibility of the decision aid and the feasibility trial protocol was demonstrated by high rates of recruitment (73% consented), participation (100%), and retention (100% both after the goals-of-care clinician-family meeting and at 3 months) and complete data for the measurements of all secondary decision-related and behavioral outcomes to date.

Conclusions: Our systematic development process resulted in a novel goals-of-care decision aid for surrogates of patients who are ciTBI with excellent usability, acceptability, and early feasibility in the neuroICU environment, and meets international decision aid standards. This methodology may be a development model for other decision aids in neurology to promote shared decision-making.
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http://dx.doi.org/10.1212/WNL.0000000000009770DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7455326PMC
July 2020

Association Between Initiation of Pulmonary Rehabilitation After Hospitalization for COPD and 1-Year Survival Among Medicare Beneficiaries.

JAMA 2020 05;323(18):1813-1823

Pulmonary and Critical Care Division, Saint Francis Hospital and Medical Center, Hartford, Connecticut.

Importance: Meta-analyses have suggested that initiating pulmonary rehabilitation after an exacerbation of chronic obstructive pulmonary disease (COPD) was associated with improved survival, although the number of patients studied was small and heterogeneity was high. Current guidelines recommend that patients enroll in pulmonary rehabilitation after hospital discharge.

Objective: To determine the association between the initiation of pulmonary rehabilitation within 90 days of hospital discharge and 1-year survival.

Design, Setting, And Patients: This retrospective, inception cohort study used claims data from fee-for-service Medicare beneficiaries hospitalized for COPD in 2014, at 4446 acute care hospitals in the US. The final date of follow-up was December 31, 2015.

Exposures: Initiation of pulmonary rehabilitation within 90 days of hospital discharge.

Main Outcomes And Measures: The primary outcome was all-cause mortality at 1 year. Time from discharge to death was modeled using Cox regression with time-varying exposure to pulmonary rehabilitation, adjusting for mortality and for unbalanced characteristics and propensity to initiate pulmonary rehabilitation. Additional analyses evaluated the association between timing of pulmonary rehabilitation and mortality and between number of sessions completed and mortality.

Results: Of 197 376 patients (mean age, 76.9 years; 115 690 [58.6%] women), 2721 (1.5%) initiated pulmonary rehabilitation within 90 days of discharge. A total of 38 302 (19.4%) died within 1 year of discharge, including 7.3% of patients who initiated pulmonary rehabilitation within 90 days and 19.6% of patients who initiated pulmonary rehabilitation after 90 days or not at all. Initiation within 90 days was significantly associated with lower risk of death over 1 year (absolute risk difference [ARD], -6.7% [95% CI, -7.9% to -5.6%]; hazard ratio [HR], 0.63 [95% CI, 0.57 to 0.69]; P < .001). Initiation of pulmonary rehabilitation was significantly associated with lower mortality across start dates ranging from 30 days or less (ARD, -4.6% [95% CI, -5.9% to -3.2%]; HR, 0.74 [95% CI, 0.67 to 0.82]; P < .001) to 61 to 90 days after discharge (ARD, -11.1% [95% CI, -13.2% to -8.4%]; HR, 0.40 [95% CI, 0.30 to 0.54]; P < .001). Every 3 additional sessions was significantly associated with lower risk of death (HR, 0.91 [95% CI, 0.85 to 0.98]; P = .01).

Conclusions And Relevance: Among fee-for-service Medicare beneficiaries hospitalized for COPD, initiation of pulmonary rehabilitation within 3 months of discharge was significantly associated with lower risk of mortality at 1 year. These findings support current guideline recommendations for pulmonary rehabilitation after hospitalization for COPD, although the potential for residual confounding exists and further research is needed.
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http://dx.doi.org/10.1001/jama.2020.4437DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7218499PMC
May 2020

Comparison of a Collective Intelligence Tailored Messaging System on Smoking Cessation Between African American and White People Who Smoke: Quasi-Experimental Design.

JMIR Mhealth Uhealth 2020 04 27;8(4):e18064. Epub 2020 Apr 27.

Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.

Background: The Patient Experience Recommender System for Persuasive Communication Tailoring (PERSPeCT) is a machine learning recommender system with a database of messages to motivate smoking cessation. PERSPeCT uses the collective intelligence of users (ie, preferences and feedback) and demographic and smoking profiles to select motivating messages. PERSPeCT may be more beneficial for tailoring content to minority groups influenced by complex, personally relevant factors.

Objective: The objective of this study was to describe and evaluate the use of PERSPeCT in African American people who smoke compared with white people who smoke.

Methods: Using a quasi-experimental design, we compared African American people who smoke with a historical cohort of white people who smoke, who both received up to 30 emailed tailored messages over 65 days. People who smoke rated the daily message in terms of perceived influence on quitting smoking for 30 days. Our primary analysis compared daily message ratings between the two groups using a t test. We used a logistic model to compare 30-day cessation between the two groups and adjusted for covariates.

Results: The study included 119 people who smoke (African Americans, 55/119; whites, 64/119). At baseline, African American people who smoke were significantly more likely to report allowing smoking in the home (P=.002); all other characteristics were not significantly different between groups. Daily mean ratings were higher for African American than white people who smoke on 26 of the 30 days (P<.001). Odds of quitting as measured by 30-day cessation were significantly higher for African Americans (odds ratio 2.3, 95% CI 1.04-5.53; P=.03) and did not change after adjusting for allowing smoking at home.

Conclusions: Our study highlighted the potential of using a recommender system to personalize for African American people who smoke.

Trial Registration: ClinicalTrials.gov NCT02200432; https://clinicaltrials.gov/ct2/show/NCT02200432.

International Registered Report Identifier (irrid): RR2-10.2196/jmir.6465.
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http://dx.doi.org/10.2196/18064DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7215495PMC
April 2020

"You Leave There Feeling Part of Something": A Qualitative Study of Hospitalized COPD Patients' Perceptions of Pulmonary Rehabilitation.

Int J Chron Obstruct Pulmon Dis 2020 17;15:575-583. Epub 2020 Mar 17.

Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA, USA.

Rationale: Current guidelines recommend that patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease (COPD) initiate pulmonary rehabilitation (PR) shortly after discharge from the hospital. However, fewer than 2 percent of Medicare beneficiaries do so. Few studies have examined hospitalized patients' perceptions of the barriers and facilitators to enroll in PR. The aim of this study was to develop an understanding of these factors by interviewing patients.

Methods: We conducted semi-structured interviews with patients during a hospitalization for COPD exacerbation in a large teaching hospital. Directed content analysis was used to code and analyze interview transcripts.

Results: Of the 15 patients we interviewed, 9 had participated in PR prior to their hospitalization, 10 were women; 4 were black, and 1 was Hispanic. Facilitators of enrollment included a desire to learn more about the disease, social support, and trust in the health-care provider recommending PR. Barriers to enrollment included lack of awareness, family obligations, lack of motivation, and transportation. For those who had previous experience with PR, but who did not complete the program, another barrier was not feeling well enough. Facilitators to adherence included the educational component of the program; feeling better through exercise; and a social connection with both participants and staff. For some patients. PR contributed to a renewed sense of hope or meaning. Most interviewees expressed interest in a peer coaching program.

Conclusion: Our results highlight the importance of increasing awareness of PR and building trust between the provider and patients to facilitate initial enrollment. Future interventions to improve enrollment and adherence should address the need for education about the benefits of PR and the value of social support.
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http://dx.doi.org/10.2147/COPD.S234833DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7085332PMC
June 2021

Provider Perspectives on the Use of Evidence-based Risk Stratification Tools in the Evaluation of Pulmonary Embolism: A Qualitative Study.

Acad Emerg Med 2020 06 27;27(6):447-456. Epub 2020 Mar 27.

the, Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA.

Objectives: Providers often pursue imaging in patients at low risk of pulmonary embolism (PE), resulting in imaging yields <10% and false-positive imaging rates of 10% to 25%. Attempts to curb overtesting have had only modest success and no interventions have used implementation science frameworks. The objective of this study was to identify barriers and facilitators to the adoption of evidence-based diagnostic testing for PE.

Methods: We conducted semistructured interviews with a purposeful sample of providers. An interview guide was developed using the implementation science frameworks, consolidated framework for implementation research, and theoretical domains framework. Interviews were recorded, transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized.

Results: We interviewed 23 providers from four hospital systems, and participants were diverse with regard to years in practice and practice setting. Barriers were predominately at the provider level and included lack of knowledge of the tools, particularly misunderstanding of the validated scoring systems in Wells, as well as risk avoidance and need for certainty. Barriers to prior implementation strategies included the perception of a clinical decision support (CDS) tool for PE as adding steps with little value; most participants reported that they overrode CDS interventions because they had already made the decision. All providers identified institution-level strategies as facilitators to use, including endorsed guidelines, audit feedback with peer comparison about imaging yield, and peer pressure.

Conclusions: This exploration of the use of risk stratification tools in the evaluation of PE found that barriers to use primarily exist at the provider level, whereas facilitators to the use of these tools are largely perceived at the level of the institution. Future efforts to promote the evidence-based diagnosis of PE should be informed by these determinants.
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http://dx.doi.org/10.1111/acem.13908DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7418048PMC
June 2020

We Want to Know-A Mixed Methods Evaluation of a Comprehensive Program Designed to Detect and Address Patient-Reported Breakdowns in Care.

Jt Comm J Qual Patient Saf 2020 05 26;46(5):261-269. Epub 2020 Feb 26.

Background: Patients have important insights into care experiences, including breakdowns, but are often reluctant to speak up. The We Want to Know (WWTK) program was designed to make it easy for hospitalized patients to speak up about breakdowns in care and receive a response.

Methods: The WWTK program was implemented from June 2014 through May 2017 at a large, community hospital in Baltimore. Core program features include (1) multiple channels for patients to report breakdowns, (2) campaign materials to increase patient awareness of the WWTK program, and (3) a specialist to facilitate resolution of breakdowns. This program was evaluated using mixed methods to assess the frequency and type of reported breakdowns, patient awareness of the program, and stakeholder perspectives.

Results: WWTK specialists interviewed 4,676 patients; 822 (17.6%) reported a breakdown in care. Of these, 313 (38.1%) had not spoken with anyone at the hospital about the breakdown, and 547 (66.5%) described associated harm. There were also 55 patient-initiated reports to WWTK; 41 (74.5%) of these reported a care breakdown. Patients had not spoken with anyone at the hospital in 12 (29.3%) patient-initiated cases; 38 (92.7%) described associated harm. Hospital stakeholders found the level of detail and timeliness of reports to be helpful.

Conclusion: Active outreach to hospitalized patients detects substantially more breakdowns in care than patient-initiated reporting. Both approaches identify breakdowns that are consequential to patients and provide opportunities to respond to individual patients.
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http://dx.doi.org/10.1016/j.jcjq.2020.01.008DOI Listing
May 2020

Shared Decision Making in Patients With Suspected Uncomplicated Ureterolithiasis: A Decision Aid Development Study.

Acad Emerg Med 2020 07 16;27(7):554-565. Epub 2020 Feb 16.

Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL.

Objective: The objective was to develop a decision aid (DA) to facilitate shared decision making (SDM) around whether to obtain computed tomography (CT) imaging in patients presenting to the emergency department (ED) with suspected uncomplicated ureterolithiasis.

Methods: We used evidence-based DA development methods, including qualitative methods and iterative stakeholder engagement, to develop and refine a DA. Guided by the Ottawa Decision Support Framework, International Patient Decision Aid Standards (IPDAS), and a steering committee made up of stakeholders, we conducted interviews and focus groups with a purposive sample of patients, community members, emergency clinicians, and other stakeholders. We used an iterative process to code the transcripts and identify themes. We beta-tested the DA with patient-clinician dyads facing the decision in real time.

Results: From August 2018 to August 2019, we engaged 102 participants in the design and iterative refinement of a DA focused on diagnostic options for patients with suspected ureterolithiasis. Forty-six were ED patients, community members, or patients with ureterolithiasis, and the remaining were emergency clinicians (doctors, residents, advanced practitioners), researchers, urologists, nurses, or other physicians. Patients and clinicians identified several key decisional needs including an understanding of accuracy, uncertainty, radiation exposure/cancer risk, and clear return precautions. Patients and community members identified facilitators to SDM, such as a checklist of signs and symptoms. Many stakeholders, including both patients and ED clinicians, expressed a strong pro-CT bias. A six-page DA was developed, iteratively refined, and beta-tested.

Conclusions: Using stakeholder engagement and qualitative inquiry, we developed an evidence-based DA to facilitate SDM around the question of CT scan utilization in patients with suspected uncomplicated ureterolithiasis. Future research will test the efficacy of the DA in facilitating SDM.
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http://dx.doi.org/10.1111/acem.13917DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7580689PMC
July 2020

SUPPORT-AF II: Supporting Use of Anticoagulants Through Provider Profiling of Oral Anticoagulant Therapy for Atrial Fibrillation: A Cluster-Randomized Study of Electronic Profiling and Messaging Combined With Academic Detailing for Providers Making Decisions About Anticoagulation in Patients With Atrial Fibrillation.

Circ Cardiovasc Qual Outcomes 2020 02 17;13(2):e005871. Epub 2020 Feb 17.

University of Massachusetts Memorial Health Care, Worcester (A.K., A.A, E.A., R.E., D.D.M.).

Background: Previous provider-directed electronic messaging interventions have not by themselves improved anticoagulation use in patients with atrial fibrillation. Direct engagement with providers using academic detailing coupled with electronic messaging may overcome the limitations of the prior interventions.

Methods And Results: We randomized outpatient providers affiliated with our health system in a 2.5:1 ratio to our electronic profiling/messaging combined with academic detailing intervention. In the intervention, we emailed providers monthly reports of their anticoagulation percentage relative to peers for atrial fibrillation patients with elevated stroke risk (CHADS-VASc ≥2). We also sent electronic medical record-based messages shortly before an appointment with an anticoagulation-eligible but untreated atrial fibrillation patient. Providers had the option to send responses with explanations for prescribing decisions. We also offered to meet with intervention providers using an academic detailing approach developed based on knowledge gaps discussed in provider focus groups. To assess feasibility, we tracked provider review of our messages. To assess effectiveness, we measured the change in anticoagulation for patients of intervention providers relative to controls. We identified 85 intervention and 34 control providers taking care of 3591 and 1908 patients, respectively; 33 intervention providers participated in academic detailing. More than 80% of intervention providers read our emails, and 98% of the time a provider reviewed our in-basket messages. Replies to messages identified patient refusal as the most common reason for patients not being on anticoagulation (11.2%). For the group of patients not on anticoagulation at baseline assigned to an intervention versus control provider, the adjusted percent increase in the use of anticoagulation over 6 months was 5.2% versus 7.4%, respectively (=0.21).

Conclusions: Our electronic messaging and academic detailing intervention was feasible but did not increase anticoagulation use. Patient-directed interventions or provider interventions targeting patients declining anticoagulation may be necessary to raise the rate of anticoagulation. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT03583008.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.119.005871DOI Listing
February 2020
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