Search

BACKGROUND: The Diabetes Prevention Program (DPP) has been translated into digital formats. We report an economic evaluation of a digital DPP implemented in a large, integrated health care system. METHODS: Patients (n = 4148) were invited to participate in digital DPP based on clinical characteristics (HbA1c 5.7%–6.4% and body mass index ≥ 30 kg/m(2)) assessed using electronic medical record data. Using a propensity score we matched (1:1) enrolled and not enrolled patients for a total of 784. We identified high-risk patients (ie, above the 50th percentile of risk; n = 202) by calculating each patient’s 2-year of developing diabetes. We report the cost of the intervention and the costs of medical care over 12- and 24-month follow-up, and the incremental cost-effectiveness ratio as the cost per additional kilogram weight loss at 24 months. RESULTS: At 12 months, enrolled patients had lower total costs ($6,926, 95% CI $5,681–$8,171) than not enrolled patients ($7,538, 95% CI $6,293–$8,783). This pattern attenuated slightly at 24 months (enrolled = $16,255, 95% CI $14,097–$18,412; not enrolled = $16,688, 95% CI $14,531–$18,846). We found an incremental cost-effectiveness ratio of $81.92 per additional kilogram weight loss. For high-risk patients, the digital DPP group had, on average, lower costs and greater weight loss. We found a 55% chance of the digital DPP program being cost-effective at a willingness-to-pay of $150 per additional kilogram of weight loss; at the same willingness-to-pay, there is a 60% chance in the high-risk subgroup. Limitations include the nonrandomized design and potential volunteer bias. CONCLUSION: Digital DPP had a favorable cost-effectiveness profile compared to other lifestyle interventions.

Background Dental caries affects billions worldwide and in the U.S. is among the most prevalent noncommunicable diseases in both children and adults. Early in the caries process, it can be arrested by dental sealants, which are non-invasive and thus tooth sparing, however, few dentists have adopted this approach. Deliberative engagement processes enable participants to engage with diverse perspectives on a policy issue and develop and share with policy makers informed opinions about the policy issue. We examined the effects of a deliberative engagement process on the ability of oral health providers to endorse implementation interventions and to apply dental sealants. Methods Using a stepped wedge design, 16 dental clinics were cluster randomized, and 680 providers and staff were exposed to a deliberative engagement process that included an introductory session, workbook, facilitated small group deliberative forum, and post-forum survey. Forum participants were assigned to forums to ensure diverse role representation. Mechanisms of action examined included sharing voice and diversity of opinion. Three months after each clinic’s forum, the clinic manager was interviewed about implementation interventions deployed. There were 98 clinic-months in the non-intervention period and 101 clinic-months in the intervention period. Results Compared with providers and staff in small clinics, providers and staff in medium and large clinics more strongly agreed that their clinic should adopt two of the three proposed implementation interventions targeting the first barrier and one of the two proposed implementation interventions targeting the second barrier. Compared with the non-intervention period, in the intervention period providers did not place more sealants on occlusal non-cavitated carious lesions. Survey respondents reported sharing both promotive and prohibitive voice. From the beginning to the end of the forums, most forum participants did not change their opinions about the possible implementation interventions. At the end of the forums, there was no significant within-group variability in implementation interventions endorsed. Conclusions Deliberative engagement intervention may help clinic leadership identify implementation interventions when there is a challenging problem, a network of semi-autonomous clinics, and autonomous providers within those clinics. It remains to be determined whether there is a range of perspectives within clinics. Trial Registration: This project is registered at ClinicalTrials.gov with ID NCT04682730. The trial was first registered on 12/18/2020. https://clinicaltrials.gov/ct2/show/NCT04682730

Involving dental offices in routine vaccinations could have a positive impact on public health. In this study, we assessed dental providers' attitudes and perceptions regarding implementing vaccination in dental settings.We performed semi-structured interviews with 31 dental providers (25 dentists and 6 dental hygienists) enrolled in the Western region of the National Dental Practice-Based Research Network as of June 28, 2021. Interviews were recorded and transcribed. We analyzed transcripts using deductive and inductive coding approaches.We identified three main themes that captured the perceptions of dental practitioners regarding the feasibility of implementing vaccine administration in a dental setting: (1) dental practitioners perceive contributing to the public health mission of disease prevention as having high value, (2) dental practitioners face considerable complexity when deciding whether to implement vaccine administration, and (3) dental practitioners do not understand current laws and associated reimbursement models related to vaccine administration.To make vaccination commonplace in dental practices, legal changes to allow dental practitioners to administer vaccines should be followed by concrete guidance and relevant trainings to help interested dental practitioners successfully implement vaccination programs in their clinical settings.

INTRODUCTION: Implementation of a Diabetes Prevention Program (DPP) in both in-person and digital health-care settings has been increasing. The purpose of this article is to describe the protocol of a mixed-methods, natural experiment study designed to evaluate the implementation of DPP in a large, integrated health system. METHODS: Kaiser Permanente Northwest patients who were 19 to 75 years with prediabetes (hemoglobin A1c or glycated hemoglobin, 5.7–6.4) and obesity (body mass index ≥ 30 kg/m(2)) were invited, via the Kaiser Permanente Northwest patient portal, to participate in the digital (n = 4124) and in-person (n = 2669) DPP during 2016 through 2018. Primary (weight) and secondary (hemoglobin A1c or glycated hemoglobin level) outcome data will be obtained from electronic health records. A cost-effectiveness analysis as well as qualitative interviews with patients (enrolled and not enrolled in the DPP) and stakeholders will be conducted to examine further implementation, acceptability, and sustainability. CONCLUSION: The mixed-methods, natural experiment design we will use to evaluate Kaiser Permanente Northwest’s implementation of the digital and in-person DPP builds on existing evidence related to the effectiveness of these two DPP delivery modes and will contribute new knowledge related to best practices for implementing and sustaining the DPP within large health systems over the long term.

Given the effectiveness of both in-person and digital diabetes prevention programs (DPPs), participants have an opportunity to select a delivery mode based on their needs and preferences. The objective of this study was to understand and compare participants' experiences with digital and in-person DPPs to identify factors that affected how useful participants perceived these two program delivery modes.Semi-structured interviews with participants who were enrolled in DPPs as either a digital (Findings from the interviews indicated that creating accountability for weight loss was crucial for all program participants. In the digital program, weight and food tracking played a central role in creating accountability, while in the in-person program, group interactions fostered accountability. The digital program was perceived to encourage self-monitoring, oftentimes resulting in participants' reflection on their habits. The in-person program provided a platform for group support and mutual encouragement.Participants perceived both programs as similarly useful. Yet program characteristics such as the ability to engage with other participants in-person or to seamlessly track weight on a daily basis appealed to different participants. It may be beneficial to align participants' preferences with programs' characteristics and strengths.

Objectives: This study evaluated how often patients who reported social risk factors requested assistance with these risks in an integrated health system. Methods: We examined how self-reports of risk related to stated desire for help with that risk reported during social risk screenings at Kaiser Permanente Northwest (KPNW). We examined how patient characteristics were associated with desire for help with each social risk domain using logistic regression. Results: Approximately 24% (n = 7,807) of the 32,865 KPNW members aged ≥ 18 years who were screened between June 1, 2017, and December 31, 2019, reported at least 1 social risk. More than half of patients who reported a risk were risk/help concordant (i.e., they also wanted help with that risk). The highest concordance (81.7%) was observed among patients reporting medical financial hardship. Several demographic, health, and other factors were associated with concordance across domains. Conclusions: Patients do not request assistance for all reported social needs. Our findings could help shape future work examining patients9 reasons for not accepting assistance and developing interventions to help patients with high social risk more effectively.

Background Developing effective implementation strategies requires adequate tracking and reporting on their application. Guidelines exist for defining and reporting on implementation strategy characteristics, but not for describing how strategies are adapted and modified in practice. We built on existing implementation science methods to provide novel methods for tracking strategy modifications. Methods These methods were developed within a stepped-wedge trial of an implementation strategy package designed to help community clinics adopt social determinants of health-related activities: in brief, an ‘Implementation Support Team’ supports clinics through a multi-step process. These methods involve five components: 1) describe planned strategy; 2) track its use; 3) monitor barriers; 4) describe modifications; and 5) identify / describe new strategies. We used the Expert Recommendations for Implementing Change taxonomy to categorize strategies, Proctor et al.’s reporting framework to describe them, the Consolidated Framework for Implementation Research to code barriers / contextual factors necessitating modifications, and elements of the Framework for Reporting Adaptations and Modifications-Enhanced to describe strategy modifications. Results We present three examples of the use of these methods: 1) modifications made to a facilitation-focused strategy (clinics reported that certain meetings were too frequent, so their frequency was reduced in subsequent wedges); 2) a clinic-level strategy addition which involved connecting one study clinic seeking help with community health worker-related workflows to another that already had such a workflow in place; 3) a study-level strategy addition which involved providing assistance in overcoming previously encountered (rather than de novo) challenges. Conclusions These methods for tracking modifications made to implementation strategies build on existing methods, frameworks, and guidelines; however, as none of these were a perfect fit, we made additions to several frameworks as indicated, and used certain frameworks’ components selectively. While these methods are time-intensive, and more work is needed to streamline them, they are among the first such methods presented to implementation science. As such, they may be used in research on assessing effective strategy modifications and for replication and scale-up of effective strategies. We present these methods to guide others seeking to document implementation strategies and modifications to their studies. Trial registration clinicaltrials.gov ID: NCT03607617 (first posted 31/07/2018).

Successfully incorporating social determinants of health (SDH) screening into clinic workflows can help care teams provide targeted care, appropriate referrals, and other interventions to address patients' social risk factors. However, integrating SDH screening into clinical routines is known to be challenging. To achieve widespread adoption of SDH screening, we need to better understand the factors that can facilitate or hinder implementation of effective, sustainable SDH processes. The authors interviewed 43 health care staff and professionals at 8 safety net community health center (CHC) organizations in 5 states across the United States; these CHCs had adopted electronic health record (EHR)-based SDH screening without any external implementation support. Interviewees included staff in administrative, quality improvement, informatics, front desk, and clinical roles (providers, nurses, behavioral health staff), and community health workers. Interviews focused on how each organization integrated EHR-based SDH screening into clinic workflows, and factors that affected adoption of this practice change. Factors that facilitated effective integration of EHR-based SDH screening were: (1) external incentives and motivators that prompted introduction of this screening (eg, grant requirements, encouragement from professional associations); (2) presence of an SDH screening advocate; and (3) maintaining flexibility with regard to workflow approaches to optimally align them with clinic needs, interests, and resources. Results suggest that it is possible to purposefully create an environment conducive to successfully implementing EHR-based SDH screening. Approaching the task of implementing SDH screening into clinic workflows as understanding the interplay of context-dependent factors, rather than following a step-by-step process, may be critical to success in primary care settings.

Objectives: In this study, we conducted telephone interviews with patients in community clinics who had abnormal fecal immunochemical test (FIT) results to identify follow-up colonoscopy challenges. The FIT is an effective colorectal cancer screening method, but its value is contingent on follow-up diagnostic colonoscopy. Methods: We explored barriers at 3 timepoints: (1) abnormal FIT-result communication, (2) scheduling/completion of colonoscopy, and (3) receipt of results. We sought to understand variation in experience by both Spanish and English language patients. Results: We interviewed 32 patients (16 English; 16 Spanish), 66% of whom were women. There were 13 early completers (≤ 2 months after FIT result), 14 later completers (> 2 months after FIT result), and 5 non-completers of the colonoscopy. The greatest challenge was fear of the procedure, expressed more often by Spanish language (SL) participants and later completers. SL participants also cited cost and lack of clear communication about the need for a colonoscopy. English language (EL) participants experienced lack of reliable transportation. Conclusions: Barriers to timely colonoscopy completion following an abnormal FIT can occur at different transitions in care and vary by patient characteristics. Our findings may inform the design of programs to improve colonoscopy completion in safety net clinics.

This study aimed to evaluate the laboratory-related outcomes of participants who were offered genomic testing based on cancer family history risk assessment tools.Patients from clinics that serve populations with access barriers, who are screened at risk for a hereditary cancer syndrome based on adapted family history collection tools (the Breast Cancer Genetics Referral Screening Tool and PREMMOf all the participants, 87% successfully returned a saliva kit. Overall, 5% had a pathogenic/likely pathogenic cancer risk variant and 1% had a secondary finding. Almost all (14/15, 93%) participants completed recommended consultations with nongenetics providers after an average of 17 months. The recommended actions (eg, breast magnetic resonance imaging) were completed by 17 of 25 participants. Participant personal history of cancer and PREMMThis accessible model of hereditary cancer risk assessment and genetic testing yielded results that were often acted upon by patients and physicians.

INTRODUCTION: In April 2018, the Centers for Medicare & Medicaid Services (CMS) began reimbursing both clinical and community settings for providing the Center for Disease Control (CDC)-recognized Diabetes Prevention Program (DPP) to eligible Medicare beneficiaries. To better understand the process of offering the program for Medicare beneficiaries, we interviewed relevant stakeholders in a large, integrated healthcare delivery system. METHODS: Semi-structured interviews with 12 delivery system stakeholders. Data were analyzed following a thematic analysis approach. RESULTS: Stakeholders described systemic challenges to the implementation of Medicare DPP (MDPP), including inadequate reimbursement for the healthcare system, low awareness among patients and providers of MDPP, and challenges with utilizing third-party vendors to connect patients to CDC-recognized MDPPs. CONCLUSIONS: Although the reimbursement of DPP for Medicare beneficiaries was a landmark decision, the current structure and requirements make it difficult for health systems and community-based providers to implement and promote this benefit. This study highlights the challenges even integrated health systems are facing to implement MDPP as well as potential strategies to overcome these barriers and expand the reach of the program. Medicare should seek ways to increase the financial incentives and decrease the barriers associated with implementing MDPP.

Healthier lifestyles in early pregnancy are associated with lower rates of pregnancy complications, childhood adiposity, and maternal and child cardiovascular risks. However, it is not known whether lifestyle coaching initiated prior to pregnancy can affect behavior and attitudes during pregnancy.Three hundred and twenty six women planning pregnancy within 2 years with BMI ≥27 kg/mOne hundred and sixty eight participants experienced pregnancy during the study (intervention: 91; usual care: 77). From randomization to mid-pregnancy, participants who received the intervention had larger increases in fruit intake than usual care participants (+0.67 vs. +0.06 cups;A coaching-based intervention beginning in pre-pregnancy successfully helped women attain healthier diet and exercise habits in mid-pregnancy.Registered with ClinicalTrials.gov, NCT02346162, first registered on January 26, 2015, before date of initial participant enrollment (May 2015), https://clinicaltrials.gov/ct2/show/NCT02346162.

Individuals having genomic sequencing can choose to be notified about pathogenic variants in genes unrelated to the testing indication. A decision aid can facilitate weighing one's values before making a choice about these additional results.We conducted a randomized trial (N = 231) comparing informed values-choice congruence among adults at risk for a hereditary cancer syndrome who viewed either the Optional Results Choice Aid (ORCA) or web-based additional findings information alone. ORCA is values-focused with a low-literacy design.Individuals in both arms had informed values-choice congruence (75% and 73% in the decision aid and web-based groups, respectively; odds ratio [OR] = 1.10, 95% CI = 0.58-2.08). Most participants had adequate knowledge (79% and 76% in the decision aid and web-based groups, respectively; OR = 1.20, 95% CI = 0.61-2.34), with no significant difference between groups. Most had information-seeking values (97% and 98% in the decision aid and web-based groups, respectively; OR = 0.59, 95% CI = 0.10-3.61) and chose to receive additional findings.The ORCA decision aid did not significantly improve informed values-choice congruence over web-based information in this cohort of adults deciding about genomic results. Both web-based approaches may be effective for adults to decide about receiving medically actionable additional results.

BACKGROUND: Chronic pain is a prevalent health concern in the United States (US) and a frequent reason for patients to seek primary care. The challenges associated with developing effective pain management strategies can be perceived as a burden on the patient-provider relationship. OBJECTIVE: This study explored the relationship between patients’ overall satisfaction with their primary care providers (PCPs) and their satisfaction with their chronic pain treatment, as well as the provider behaviors that contributed to chronic pain patients’ satisfaction with their PCPs. DESIGN: Concurrent nested mixed-methods design PARTICIPANTS: 97 patients with chronic pain who were assigned to the usual care arm of the Pain Program for Active Coping and Training (PPACT) study. APPROACH: We analyzed phone interview and survey data (n = 97). Interviews assessed provider behaviors that led to patient satisfaction. Interview transcripts were analyzed based on a content analysis approach. Survey responses assessed patient satisfaction with primary care and pain services. We calculated a Pearson’s correlation coefficient using five response categories. KEY RESULTS: Interviews revealed that high satisfaction with primary care was driven by five concrete PCP behaviors: (1) listening, (2) maintaining communication with patients, (3) acting as an access point to comprehensive pain care, (4) providing an honest assessment of the possibilities of pain care, and (5) taking time during consultations with patients. In surveys, participants reported higher satisfaction with their primary care services than with the pain services they received; these variables were only moderately correlated (r = 0.586). CONCLUSIONS: Results suggest that patients with chronic pain can view the relationship with their PCPs as positive, even in the face of low satisfaction with their pain treatment. The expectations that these patients held of PCPs could be met regardless of providers’ ability to successfully relieve chronic pain. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05339-2) contains supplementary material, which is available to authorized users.

The invisibility of migrants has been widely analysed in relation to states’ policies and practices. I argue in this article that emphasising the role of states and institutions in marginalising vulnerable populations by rendering them invisible throws a shadow over the multifaceted ways in which migrants interpret and relate to invisibility. Among Myanmar migrants in Thailand, as we shall see here, the notion that invisibility provides a protective shield to migrant bodies is in fact widespread. While invisibility is at times perceived as a threat to the future of these people, conceiving of invisibility solely as a tool of domination precludes us from fully understanding the complexity of Myanmar migrants’ experiences in Thailand and, more specifically, the many forms of empowerment that shape these experiences. Privileging the discourses and practices of Myanmar migrants in Thailand about their sartorial choices reveals that migrants appreciate invisibility for its capacity to create control over their own bodies. Further, it reveals the complexities of negotiating and expressing diasporic sartorial conventions.

Introduction In this study we assessed the feasibility of recruiting colorectal cancer survivors and their employers to participate in research on returning to work after a cancer diagnosis. Methods Semistructured qualitative interviews were conducted with 6 survivors and 4 employers to collect feedback on 2 recruitment approaches: 1) an employee/cancer survivor-focused approach whereby researchers obtained employer contact information directly from survivors and 2) an employer-focused approach whereby researchers interviewed employers to identify pathways to recruiting survivor-supervisor dyads. Recordings of all interviews were transcribed and analyzed. Results Of the 6 survivor participants, 3 (50%) consented to follow up with their supervisors. One of the 3 supervisors responded but declined participation in the study. The 4 participating employers included 2 compensation/benefits managers and 2 human resources managers. Employers identified specific avenues for potential recruitment of survivor-supervisor dyads, including first obtaining organizational support for participating in this type of research. Discussion While challenges and opportunities exist with both the employee- and the employer-focused recruitment approaches, our findings suggest that an employer-focused approach, whereby researchers obtain organizational support for the research first, may be more promising for recruiting survivor-supervisor dyads to studies on cancer and employment. Results from this study underscore the importance of gaining support from all stakeholders-from administrators to employees who are cancer survivors. Conclusion Our study informs recruitment strategies that bring together cancer survivors and employers to improve our understanding of the barriers and facilitators of returning to work after cancer, in effort to develop interventions that mitigate employment challenges for cancer survivors.

Dental service providers have limited capacity to identify strategies to implement evidence-based practices (EBPs). We developed a rigorous yet parsimonious scoping review approach to identify, select, and rate implementation strategies based on an oral health system context. From 153 strategies identified, we selected the top 11 strategies, which had a moderate level of support of evidence and where managers were the main actors. The main actions were to educate, remind, structure, and influence. Targets included dentists, dental hygienists, and assistants and managers from a large prepaid dental care delivery system. This approach responds to calls for rapid and innovative methods to implement EBPs in oral health.

Objective Little is known though about the experiences that pregnant and postpartum women have in integrated care programs for substance use disorder and the mechanisms that may contribute to the treatment success. Methods We conducted 16 semi-structured interviews with women and staff who participated in an integrated care initiative for pregnant and postpartum women with SUD focusing on participants' experiences with the support group. The data was analyzed following a thematic analysis approach. Results Three themes emerged that captured the benefits women felt they received from the peer support group: 1) sustained engagement in, and accountability for, participation in SUD treatment, 2) well-coordinated access to medical and social support resources, and 3) establishing community around motherhood to learn selfacceptance and experience validation. Conclusions This study demonstrates the important role a peer support group within an integrated treatment program can play in supporting mothers in their recovery.

Objective To describe the development of a web-based, patient-facing decision aid to support patients and research participants to make an informed, values-based decision about whether to receive additional results from genomic sequencing. Methods We developed the decision aid following the multi-step process described in the International Patient Decision Aids Standards. This utilized literature review, focus groups, and alpha testing with research participants undergoing clinical genomic sequencing. Results The decision aid, the Optional Results Choice Aid (ORCA), includes a seven-question “values clarification exercise,” illustrative patient quotes, and summative guidance for the user. The decision aid was found to be highly readable, acceptable and relevant in alpha testing. Conclusion We developed a decision aid to support informed, values-based decision making for patients and research participants considering whether to receive additional results from genomic sequencing. ORCA is being implemented in the NHGRI-funded Cancer Health Assessment Reaching Many (CHARM) study, where we are measuring informed values-choice congruence. Practice implications ORCA was designed to support patients and research participants to make an informed, values-based decision about whether to receive additional results from genomic sequencing.

Objective: This evaluation captures the perspectives of multiple stakeholders within a salaried dental care delivery organization (dentists, dental assistants, dental hygienists, and dental management) on the implementation of a pit-and-fissure sealant guideline in the Kaiser Permanente Dental Program. Also assessed is the role of formal processes and structures in providing a framework for guideline implementation. Methods: We collected qualitative data through field observations, stakeholder interviews (n = 6), and focus groups (30 participants in 5 focus groups). Field observation notes captured summaries of conversations and other activities. Interviews and focus groups were recorded and transcribed. We analyzed transcripts and field notes using a template analysis with NVivo 12 software to identify themes related to the existing implementation process of clinical guidelines and stakeholder perspectives on the strengths and weaknesses of this process. Results: Stakeholders perceived 2 main barriers for achieving implementation of the pit-and-fissure sealant guideline: 1) shortcomings in the implementation infrastructure resulting in lack of clarity about the roles and responsibilities in the guideline implementation process and lack of effective mechanisms to disseminate guideline content and 2) resource constraints, such as limited human, space, and material resources. Perceived opportunities for the dissemination and implementation of guidelines included recognition of the importance of guidelines in dental practice and well-functioning workflows within dental specialties. Conclusion: Our research points to the importance of developing and maintaining an infrastructure to ensure standardized, predictable mechanisms for implementation of guidelines and thereby promoting practice change. While addressing resource constraints may not be possible in all circumstances, an important step for improving guideline implementation—wherever feasible—would be the development of a robust implementation infrastructure that captures and delineates roles and responsibilities of different clinical actors in the guideline implementation process. Knowledge Transfer Statement: The results of this study can be used by health care leadership and administrators to understand possible reasons for a lack of guideline implementation and provide suggestions for establishing sustainable infrastructure to promote the adoption of clinical guidelines in salaried dental clinics.

The national verification process that has provided formalized guidelines to regulate the migration of Myanmar workers to Thailand permanently places migrants in a zone of temporary legality. This zone is a bureaucratic space in which legality surfaces as a flexible concept serving the interests of the Thai and Myanmar states while placing an economic burden on migrants. Legality also emerges as a commodity that does not relate to migrants' compliance with the law, but rather to their ability to mobilize resources. Brokers not only guide migrants in navigating the transnational bureaucracies, but also mediate the emotional ties between migrants and those bureaucracies. The emotional undercurrents of the process ultimately serve as a reminder that any bureaucratic space is inherently affective.

Background Opioid treatment for chronic pain has garnered heightened public attention and political pressure to control a devastating public health crisis in the United States (U.S.). Resulting policy changes, together with ongoing public and political attention, have pushed health care systems and providers to lower doses or deprescribe and taper patients off opioids. However, little attention has been paid to the impact of such practice changes on patients who had relied on opioid treatment to manage their chronic pain. The aim of this article is to explore experiences with opioid-related care under aggressive tapering efforts and concomitant heightened monitoring and institutional oversight among patients with chronic pain in an integrated delivery system through in-depth interviews. Methods We interviewed 97 patients with chronic pain who were assigned to the usual care arm of the Pain Program for Active Coping and Training (PPACT) study. These patients had been prescribed opioids as part of their treatment regimens and taken opioids closely monitored by their health care providers. We followed the framework method for coding and analysing transcripts using NVivo 12. Results The experiences of these patients during this period of change can be understood through three interconnected themes: (1) many patients taking opioids experience debilitating physical side effects; (2) navigating opioid treatment contributes to significant emotional distress among many patients with chronic pain and; (3) the quality of patients’ relationship with their primary care provider can be negatively affected by negotiations regarding long-term opioid treatment for chronic pain. Conclusion We highlight the importance of utilizing communication approaches that are patient-centered and include shared decision making during the tapering and/or deprescribing processes of opioids and ensuring alternative pain treatments are available to patients with chronic pain.

Objective To assess the challenges and needs of colorectal cancer (CRC) survivors in maintaining employment and returning to work (RTW) from the perspectives of both CRC survivors and employers in the United States. Methods Semi-structured interviews with CRC survivors (n = 10) and employers (n = 4) were transcribed, coded and thematically analysed using NVivo 12 software. Results Workplace challenges for survivors included the following: inadequate availability of paid and unpaid leave, limited availability of workplace accommodations, and employers' lack of knowledge about CRC and the recovery process. Survivors were concerned about the lack of adequate financial resources to take unpaid leave and the need to relearn control of bodily functions. Workplace challenges for employers of cancer survivors included the following: limited institutional flexibility to provide individualised accommodations, communication with frontline managers about leave availability for employees and communication with employees about legal protections and limitations. Employers perceived that employees were unwilling to take leave. Conclusion Colorectal cancer survivors in the US face difficult, sometimes insurmountable, challenges when trying to balance their physical and financial needs within the constraints of employment. Employers recognise challenges associated with this concern. Multi-level interventions-ranging from flexible work schedules to training for frontline managers-might facilitate the RTW process.

Objective Previous research has demonstrated the importance of eliciting patients' goals and values during shared decision-making (SDM), but this does not occur in most SDM conversations. Understanding challenges to eliciting patients' goals and values is crucial. This study assessed how clinicians balanced sharing medical information and considering patients' goals and values during breast cancer surgery consultation in an integrated health care system. Methods We conducted interviews with clinicians (n = 6) and patients (n = 11) and conducted naturalistic, ethnographic observations of eight surgical consultations in a multidisciplinary breast cancer clinic. We analyzed the data following the template method using the qualitative software NVivo 10. Results Clinicians prioritized sharing medical information. We identified four patient factors necessary to integrate patients' values and goals into the conversation in addition to sharing medical information: ability to process large quantities of information quickly, willingness to embrace swift decision-making, ability to quickly formulate one's values, and prioritization of surgical choice as the goal of the conversation. Conclusions We found that SDM implementation results in practices that emphasize information and choice, with less focus on patient goals and values. More research is needed to explore factors that may encourage the elicitation of patients' goals and values.

Background National leaders recommend documenting social determinants of health and actions taken to address social determinants of health in electronic health records, and a growing body of evidence suggests the health benefits of doing so. However, little evidence exists to guide implementation of social determinants of health documentation/action. Methods This paper describes a 5-year, mixed-methods, stepped-wedge trial with realist evaluation, designed to test the impact of providing 30 community health centers with step-by-step guidance on implementing electronic health record-based social determinants of health documentation. This guidance will entail 6 months of tailored support from an interdisciplinary team, including training and technical assistance. We will report on tailored support provided at each of five implementation steps; impact of tailored implementation support; a method for tracking such tailoring; and context-specific pathways through which these tailored strategies effect change. We will track the competencies and resources needed to support the study clinics’ implementation efforts. Discussion Results will inform how to tailor implementation strategies to meet local needs in real-world practice settings. Secondary analyses will assess impacts of social determinants of health documentation and referral-making on diabetes outcomes. By learning whether and how scalable, tailored implementation strategies help community health centers adopt social determinants of health documentation and action, this study will yield timely guidance to primary care providers. We are not aware of previous studies exploring implementation strategies that support adoption of social determinants of action using electronic health and interventions, despite the pressing need for such guidance. Trial registration clinicaltrials.gov, NCT03607617, registration date: 7/31/2018—retrospectively registered Electronic supplementary material The online version of this article (10.1186/s13012-019-0855-9) contains supplementary material, which is available to authorized users.

Purpose: Individuals diagnosed with colorectal cancer (CRC) may experience significant physical, psychological, and emotional effects that pose challenges to retuning to work (RTW). Given the importance on employment as a source of income and health insurance, interruptions to work may impact both financial and health outcomes. Understanding the multistakeholder perspectives, CRC survivors and their employers, may offer insights into factors and shared concerns associated with RTW following cancer, and lead to interventions that improve employment outcomes among survivors. This study assessed the challenges and needs that CRC survivors experience in maintaining or RTW, from both the survivor and employer perspectives. Methods: CRC survivors (n=10) who were ages 18-70 at diagnosis, English-speaking, believed to be employed at diagnosis, and members of Kaiser Permanente Northwest (KPNW) were recruited from the Patient Outcomes Research to Advance Learning (PORTAL) CRC cohort. Employers (n=4) were recruited from the twenty most common employer organizations of KPNW PORTAL CRC cohort participants. Using qualitative methodology, we conducted 14 semistructured interviews with CRC survivors and employers. Interviews were transcribed and coded, then analyzed based on thematic analysis using NVivo 12 software. Results: CRC survivors reported several challenges to RTW following diagnosis, including: Occupational/institutional—lack of knowledge among employers about CRC and recovery, limited availability of (paid) leave, limited availability of workplace accommodations; and Individual—limited ability to take necessary leave, need to relearn control over bodily functions. Employers perceived challenges, including: Occupational/institutional—limited institutional flexibility to provide individualized accommodations, matching organizational structures and the needs of employees, communication with frontline managers to inform them about leave availability for employees, and communication with employees about legal possibilities and limitations; and Individual—limited willingness of employees to take leave. Conclusions: Our findings highlight both shared concerns and unique challenges that CRC survivors and employers perceive to be important for the RTW process following cancer diagnosis. Multilevel interventions that focus on both survivors and employers have the potential to facilitate the RTW process by addressing factors unique to each stakeholder that foster improved employment outcomes and mitigate the financial and health impact of CRC survivors. Citation Format: Inga Gruß, Ginger C. Hanson, Carmit McMullen, Debra Ritzwoller, Cathy Bradley, Stephanie Hodge, Alexandra Varga, Matthew P. Banegas. A qualitative assessment of challenges to return to work for colorectal cancer survivors: Multistakeholder perspectives [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B009.

Introduction Nonbenzodiazepine sedative-hypnotic medications, or "Z-drugs," are commonly used to treat insomnia among older adults (≥ 65 years), despite a lack of evidence of long-term effectiveness and evidence linking long-term use with poor outcomes. Objective To understand patient and clinician barriers and facilitators to deprescribing, or discontinuation, of Z-drugs. Methods We conducted a qualitative interview study among older adults who received a deprescribing intervention and among their clinicians at Kaiser Permanente Northwest. Semistructured interviews explored perceived barriers and facilitators to successful deprescribing of Z-drugs. Interviews were audiorecorded with participant permission. Content was analyzed using QSR NVivo 10 software. Results From the perspectives of patients, the greatest challenges to deprescribing are factors related to their insomnia, including the need for effective treatment of their insomnia; health care system factors, including a desire for personalized approaches to care; and their own positive personal experiences with sedative medication use. From the clinician perspective, a lack of institutional structures and resources to support deprescribing, the attitudes and practices of previous clinicians, and patient-related factors such as dependence and a lack of alternatives to treat insomnia were the most important barriers to deprescribing. Conclusions Health care systems must provide individualized care that supports patient goals for restful sleep and quality of life while also providing evidence-based care that takes patient safety into account. To accomplish this, systems must support patients and clinicians and provide a multidisciplinary approach that addresses insomnia treatment, provides patient education about sedative medication use, and supports the discontinuation process.

No abstract received.