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Atrial fibrillation (AF) is the most common significant cardiac rhythm disorder and is a powerful common risk factor for stroke. Randomized trials have demonstrated that anticoagulation can reduce the risk of stroke in patients with AF. Yet, there continues to be widespread underutilization of this therapy. To address this practice gap locally and improve efforts to reduce the risk of stroke for patients with AF in our health system, we have designed a study to implement and evaluate the effectiveness of an Atrial Fibrillation Decision Support Tool (AFDST) embedded within our electronic health record.Our intervention is provider-facing and focused on decision support. The clinical setting is ambulatory patients being seen by primary care physicians. Patients include those with both incident and prevalent AF. This randomized, prospective trial will enroll 800 patients in our University of Cincinnati Health System who are currently receiving less than optimal anticoagulation therapy as determined by the AFDST. Patients will be randomized to one of two arms - 1) usual care, in which the AFDST is available for use; 2) addition of a best practice advisory (BPA) to the AFDST notifying the clinician that their patient stands to gain a significant benefit from a change in their current thromboprophylactic therapy.The primary outcome is effectiveness of the BPA measured by change to "appropriate thromboprophylaxis" based on the AFDST recommendation at 3 months post randomization. Secondary endpoints include Reach and Adoption, from the RE-AIM framework for implementation studies. Sample size is based upon an improvement from inappropriate to appropriate anticoagulation therapy estimated at 4% in the usual care arm and ≥10% in the experimental arm.Our goal is to examine whether addition of a BPA to an AFDST focused on primary care physicians in an ambulatory care setting will improve "appropriate thromboprophylaxis" compared with usual care. Results will be examined at 3 months post randomization and at the end of the study to evaluate durability of changes. We expect to complete patient enrollment by the end of June 2022.Clinicaltrials.gov NCT04099485.

Special Issue Editors' Introduction, Rhetoric of Chronicity

As wearable medical technologies take on an increasingly prominent role in how health care is delivered, pressure to make the development process for such devices shorter increases. This case study will recount one attempt at a do-it-yourself (DIY) development process and collaborative usability testing. I argue that these efforts can complement traditional usability methods used in the development process of a wearable diabetes technology and provide more immediate access to technologies that can meet the diverse needs of end users. The case involves an open source DIY project developed by parents of children with type 1 diabetes in order to remotely monitor the blood sugar levels of their children.

This article offers an empirical study of literature in the rhetoric of health and medicine (RHM) and the medical humanities (MH). Article traces the topics, funding mechanisms, research methods, theoretical frameworks, evidence types, audience, discourse arrangement patterns, and action orientation that constitute the scholarship in the sample to offer a landscape of the current state of RHM and the MH. Findings can be leveraged to assess the potential for alignment between these fields for future research.

Background Appropriate thromboprophylaxis for patients with atrial fibrillation (AF) remains a national challenge. Methods We hypothesized that provision of decision support in the form of an Atrial Fibrillation Decision Support Tool (AFDST) would improve thromboprophylaxis for AF patients. We conducted a cluster randomized trial involving 15 primary care practices and 1,493 adults with nonvalvular AF in an integrated health care system between April 2014 and February 2015. Physicians in the intervention group received patient-level treatment recommendations made by the AFDST. Our primary outcome was the proportion of patients with antithrombotic therapy that was discordant from AFDST recommendation. Results Treatment was discordant in 42% of 801 patients in the intervention group. Physicians reviewed reports for 240 patients. Among these patients, thromboprophylaxis was discordant in 63%, decreasing to 59% 1 year later ( P = .02). In nonstratified analyses, changes in discordant care were not significantly different between the intervention group and control groups. In multivariate regression models, assignment to the intervention group resulted in a nonsignificant trend toward decreased discordance ( P = .29), and being a patient of a resident physician ( P = .02) and a higher HAS-BLED score predicted decreased discordance ( P = .03), whereas female gender ( P = .01) and a higher CHADSVASc score ( P = .10) predicted increased discordance. Conclusions Among patients whose physicians reviewed recommendations of the decision support tool discordant therapy decreased significantly over 1 year. However, in nonstratified analyses, the intervention did not result in significant improvements in discordant antithrombotic therapy.

Objectives To assess the appropriateness of oral anticoagulant therapy (OAT) in women and elderly adults, looking for patterns of undertreatment or unnecessary treatment. Design Retrospective cohort study. Setting Primary care practices of an academic healthcare system. Participants Adults (aged 28–93) with nonvalvular atrial fibrillation (AF) seen between March 2013 and February 2014 (N = 1,585). Measurements Treatment recommendations were made using an AF decision support tool (AFDST) based on projections of quality-adjusted life expectancy calculated using a decision analytical model that integrates individual-specific risk factors for stroke and hemorrhage. Results Treatment was discordant from AFDST-recommended treatment in 45% (326/725) of women and 39% (338/860) of men (P = .02). Although current treatment was discordant from recommended in 35% (89/258) of participants aged 85 and older and in 43% (575/1,328) of those younger than 85 (P = .01), many undertreated elderly adults were receiving aspirin as the sole antithrombotic agent. Conclusion Physicians should understand that female sex is a significant risk factor for AF-related stroke and incorporate this into decision-making about thromboprophylaxis. Treating older adults with aspirin instead of OAT exposes them to significant risk of bleeding with little to no reduction in AF-related stroke risk.

Business communication evolves and adapts to suit the times, and today’s workplace documents are increasingly multimodal. Therefore, business and professional communication specialists need to adapt to a new media workplace ecology—one that requires proficiencies with technologies such as video production, digital animation, and sound. Business and professional writing teachers, in turn, need to adopt teaching methods that include working with evolving technologies and be willing to teach multimodal skills to students. In this article I offer a case study of a flipped learning pedagogy to teach multimodal skills in the professional writing classroom.

Purpose The purpose of this study was to describe type 2 diabetes (T2DM) communication and risk reduction recommendations from the perspective of family members at risk for T2DM based on family history. Methods Semistructured qualitative interviews were conducted with 33 individuals with a first-degree relative with T2DM. Participants were recruited from the community and a previous pharmacogenetics study. Deductive and inductive codes were applied to the transcripts. Results Conversations with family members with and without T2DM focused on symptoms and disease management of the family member with T2DM. With at-risk relatives, conversations also focused on prevention. Lack of perceived relevance to family members without T2DM was a barrier to communication. Recommendations to facilitate communication included education of an at-risk family member to increase awareness of risk, followed by sharing of learned information with others. Conclusion Efforts are needed to increase awareness and improve communication about T2DM risk factors, familial risk, and risk reduction behaviors within families with a family history of T2DM. Family members with and without T2DM should be encouraged to communicate with their relatives about T2DM and the risk to family members. Identification of family members who can facilitate communication, education, and modeling of healthy behaviors may increase awareness and motivate at-risk individuals to engage in risk-reducing behaviors.

In this essay, I argue that structural approaches to narrative articulate identity and agency as internal constructs. As such, these analyses neglect the roles of institutional and social factors. A pluralistic analysis of these illness narratives, such as the one offered in this essay, can help narrative scholars better understand how these forces interact with the individual experiences of people living with illness in supporting and constraining agency.

Background— Guidelines for anticoagulant therapy in patients with atrial fibrillation are based on stroke risk as calculated by either the CHADS 2 or the CHA 2 DS 2 VASc scores and do not integrate bleeding risk in an explicit, quantitative manner. Our objective was to quantify the net clinical benefit resulting from improved decision making about antithrombotic therapy. Methods and Results— This study is a retrospective cohort study of 1876 adults with nonvalvular atrial fibrillation or flutter seen in primary care settings of an integrated healthcare delivery system between December 2012 and January 2014. Projections for quality-adjusted life expectancy reported as quality-adjusted life-years were calculated by a decision analytic model that integrates patient-specific risk factors for stroke and hemorrhage and examines strategies of no antithrombotic therapy, aspirin, or oral anticoagulation with warfarin. Net clinical benefit was defined by the gain or loss in quality-adjusted life expectancy between current treatment and treatment recommended by an Atrial Fibrillation Decision Support Tool. Current treatment was discordant from treatment recommended by the Atrial Fibrillation Decision Support Tool in 931 patients. A clinically significant gain in quality-adjusted life expectancy (defined as ≥0.1 quality-adjusted life-years) was projected in 832 patients. Subgroups were examined. For example, oral anticoagulant therapy was recommended for 188 who currently were receiving no antithrombotic therapy. For the entire cohort, a total of 736 quality-adjusted life-years could be gained were treatment changed to that recommended by the Atrial Fibrillation Decision Support Tool. Conclusions— Use of a decision support tool that integrates patient-specific stroke and bleeding risk could result in significant gains in quality-adjusted life expectancy for a primary care population of patients with atrial fibrillation.

This article examines the 2012 Republican presidential campaign, exposing the articulation of two incongruous discourses: arguments for increasingly strict regulations on women's reproductive rights and antiregulatory attacks on Obamacare. Drawing on articulation theory and on a Foucauldian understanding of biocitizenship, we argue that women's reproductive and sexual capacities were discursively disarticulated or split from their status as free citizens and rhetorically affiliated with Obamacare as both entities came to be seen as potentially dangerous.

When I bought my first Mac I was frustrated by the lack of instructional documentation in my shiny new box. I found myself regularly going online to look for help in the form of PDFs or videos. A company professionally produced these instructional "texts". Enter the webcam, the iPhone, and a host of websites to upload user-generated content, and we increasingly see end users becoming produsers, individuals whom produce as well as consume information.

Scholars in the humanities, social sciences, and medicine are paying increasing attention to the genre of illness narratives. Little of this scholarship, however, focuses on online settings. To better understand these online stories and their structures, the author undertakes the analysis of a collection of patient diagnosis vlogs to argue that the characteristics of YouTube and the Internet more generally enable fluctuations or oscillations in these illness vlogs. These fluctuations foster genre emergence online and reflect the experiences of people living with these illnesses in a way discursive genres cannot. Paying attention to these fluctuations can add to our knowledge of the role of medium in genre emergence online and give us a potential mechanism to help explain the emergence, proliferation, and variability of online genres.

The Appalachian community in the Lower Price Hill (LPH) neighborhood of Cincinnati, Ohio, used community-based participatory principles and methods to develop, implement, and evaluate an on-going initiative to address the high prevalence of diabetes among its residents. Led by the Urban Appalachian Council in partnership with a number of academic and community organizations, the initiative conducted town-hall meetings of LPH residents to identify diabetes-related areas that needed to be addressed and to select an initial pilot intervention. The result was a Community Health Advocate (CHA) program which trained neighborhood residents to canvass households to conduct diabetes risk assessments and provide education on diabetes prevention, schedule follow-up diabetes screenings at a wellness site established by the community, and conduct follow-up telephone calls to ensure wellness site participation. The extensive case-finding effort by the CHAs led to the identification of a substantial number of previously undiagnosed residents as high risk for diabetes. This effort also resulted in the confirmation of the community’s perceptions of other diabetes-related need areas which are being addressed through subsequent interventions. The success and acceptance of the program demonstrates that an Appalachian community can use existing resources to enhance its own capacity to address its health issues.

This usability study assesses the impact on user experience when audio is added to a text-based MOO classroom in a large distance learning Ph.D. program. We found that the addition of audio to this text-based, synchronous classroom enhanced the user experience, but this enhancement was impacted by the control and structure of information and conversation flow, instructor leadership and modeling, and the need for time and support to learn the technology. It also fostered a greater sense of social connection between instructor and students as well as student to student. We found that limitations with adding audio to this environment included trouble with identifying speakers and users having difficulty managing multiple conversations through multiple channels. Additional benefits identified by participants included quick responses to calls for help or clarification, the comfort level of audio communication in general, and the ability to expound on a particular issue in greater detail.

The Pew Internet & American Life Project reports that 86% of Internet users living with a disability or chronic illness have looked for health information online (Fox, 2007). And while so-called e-patients often start this search for information, many find themselves led to communities that provide this and more, such as Tu Diabetes, an online social network site. This pause in what can seem like an endless search for answers may be one that health professionals can gain insight from. Such extended pauses may give insight into the values of this particular community. This article provides the results and analysis of a study using ethnographic methods and rhetorical analysis to examine the texts posted by members of the social networking site Tu Diabetes in order to discern the values held by this community.

Patient values and preferences are an important component to decision making when tradeoffs exist that impact quality of life, such as tradeoffs between stroke prevention and hemorrhage in patients with atrial fibrillation (AF) contemplating anticoagulant therapy. Our objective is to describe the development of an Atrial Fibrillation Guideline Support Tool (AFGuST) to assist the process of integrating patients' preferences into this decision.CHA2DS2VASc and HAS-BLED were used to calculate risks for stroke and hemorrhage. We developed a Markov decision analytic model as a computational engine to integrate patient-specific risk for stroke and hemorrhage and individual patient values for relevant outcomes in decisions about anticoagulant therapy.Individual patient preferences for health-related outcomes may have greater or lesser impact on the choice of optimal antithrombotic therapy, depending upon the balance of patient-specific risks for ischemic stroke and major bleeding. These factors have been incorporated into patient-tailored booklets which, along with an informational video, were developed through an iterative process with clinicians and patient focus groups.Current risk prediction models for hemorrhage, such as the HAS-BLED, used in the AFGuST, do not incorporate all potentially significant risk factors. Novel oral anticoagulant agents recently approved for use in the United States, Canada, and Europe have not been included in the AFGuST. Rather, warfarin has been used as a conservative proxy for all oral anticoagulant therapy.We present a proof of concept that a patient-tailored decision-support tool could bridge the gap between guidelines and practice by incorporating individual patient's stroke and bleeding risks and their values for major bleeding events and stroke to facilitate a shared decision making process. If effective, the AFGuST could be used as an adjunct to published guidelines to enhance patient-centered conversations about the anticoagulation management.