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UNSTRUCTURED Data integration, the processes by which data is aggregated, interpreted, combined, and made available for use, has been key to the development and growth of many technological solutions. In health care, we are experiencing a revolution in the use of sensors to collect data on patient behaviors and experiences. Yet, the potential of these data to transform health outcomes has been limited to date. Deficits in standards, use of different terminology, different metric systems, data rights, permissioning, privacy, and security have been well documented as challenges to digital innovation. However, the cultural adoption of sensor data integration as a priority for large-scale deployment and impact on patient lives has yet to be examined. In this paper, we take an in-depth look at case studies of sensor data integration into health data platforms for clinical research and patient care to advance key considerations in order to achieve the promise of digital health to improve clinical research and patient care at scale. These considerations are designed to support optimized, holistic (i.e. anchored in value for end consumers and patients) decision making and enable more effective sensor data integration by increasing accessibility, reliability, and trustworthiness to multiple users. We share intermediate insights from our multi-stakeholder project focused on putting forward an early framework and toolkit for sensor data integration and enable more situational awareness, thereby ensuring the future success of healthcare data integration as a whole.

Asthma self-management can improve symptom control, but adherence to established self-management behaviors is often poor. With adult asthma uncontrolled in over 60% of U.S. cases, there is a need for scalable, cost-effective tools to improve asthma outcomes. Here we describe a protocol for the Asthma Digital Study, a 24-month, decentralized, pragmatic, open-label, randomized controlled trial investigating the impact of a digital asthma self-management (DASM) program on asthma outcomes in adults. The program leverages consumer-grade devices with a smartphone app to provide "smart nudges," symptom logging, trigger tracking, and other features. Participants are recruited (target N = 900) from throughout the U.S., and randomized to a DASM or control arm (1:1). Co-primary outcomes at one year are a) asthma-associated costs for acute care and b) change from baseline in Asthma Control Test™ scores. Findings may inform decisions around adoption of digital tools for asthma self-management. Trial registration:clinicaltrials.gov identifier: NCT04609644. Registered: Oct 30, 2020.

Background Some guidelines state that in-person weight management interventions are more efficacious than those delivered digitally. However, digital programs are more scalable and accessible. We hypothesized that one-on-one health coaching via app-based video chat would simulate an in-person experience and help achieve outcomes comparable to those of in-person interventions. Methods A 12-month digital weight management intervention was provided to overweight or obese adults recruited from a large technology company. One-on-one health coaching sessions were offered during a 24-week intensive phase as well as subsequent maintenance phase. Focused on sustainable changes in activity and diet, the intervention incorporates SMART goals, in-app food and activity logs, Fitbit integration, as well as optional sleep and stress modules. Self-Determination Theory and the Transtheoretical Model are incorporated to drive behavior change. Multilevel mixed-effects models were used to analyze weight changes retrospectively. Results Six hundred eighty-three participants reported 29,051 weights. At 12 months, mean percent changes in body weight were -7.2% and -7.6% for overweight and obese groups, respectively. A weight change of -5% is commonly targeted for in-person weight management interventions. Observed weight loss exceeded this target by 2.2% (95% CI, 0.7% to 3.8%; P < .01) for the overweight group and 2.6% (95% CI, 1.4% to 3.9%; P < .01) for the obese group. Conclusions Further research is needed with randomization to in-person or digital interventions. Though limited by an observational, retrospective design, preliminary results suggest that some digital weight management programs with one-on-one coaching may achieve outcomes comparable to those of robust, in-person interventions.

Purpose. This study evaluated the economic impact of an online disease management program within a broader population health management strategy. Design. A retrospective, quasi-experimental, cohort design evaluated program participants and a matched cohort of nonparticipants on 2003–2007 claims data in a mixed model. Sample. The study was conducted through Highmark Inc, Blue Cross Blue Shield, covering 4.8 million members in five regions of Pennsylvania. Overall, 413 online self-management program participants were compared with a matched cohort of 360 nonparticipants. Measures. The costs and claims data were measured per person per calendar year. Total payments were aggregated from inpatient, outpatient, professional services, and pharmacy payments. The costs of the online program were estimated on a per-participant basis. All dollars were adjusted to 2008 values. Intervention. The online intervention, implemented in 2006, was a commercially available, tailored program for chronic condition self management, nested within the Blues on CallSM condition management strategy. Analysis. General linear modeling (with covariate adjustment) was used. Data trends were also explored using second-order polynomial regressions. Results. Health care costs per person per year were $757 less than predicted for participants relative to matched nonparticipants, yielding a return on investment of $9.89 for every dollar spent on the program. Conclusions. This online intervention showed a favorable and cost-effective impact on health care cost.

OBJECTIVES. Although research with bereaved families has shown that they appreciate contact with clinicians after the child's death, this realm of clinical practice remains empirically uncharted. The objective of this study was to describe pediatric critical care practitioners' attitudes and self-reported practices regarding contacting families after a patient's death. METHODS. A total of 376 board-certified members of the American Academy of Pediatrics Section of Critical Care received e-mail invitations to complete a Web-based questionnaire; 204 members responded (effective response rate: 54.3%). RESULTS. Most (95%) participants reported 0 to 1 patient deaths per week. A total of 79% of the respondents reported contacting families at least sometimes, 71.9% had attended funerals, and only 2.5% thought that it was inappropriate for clinicians to attend funerals. A total of 75.9% agreed that follow-up contact helps the family, whereas 47.3% agreed that follow-up contact helps the physicians. The most common methods of follow-up contact included the passive measures of providing contact information; active methods such as meeting with the family, calling them by telephone, or writing a letter or note were used less often. In multivariable analysis, respondents were more likely to report contact with a family after the death of a child when they affirmed the belief that such contact was useful to the family or to the physician or when they were female physicians. Regarding reported funeral attendance after the death of a patient, multivariable analysis revealed similar patterns of association but to an attenuated and nonstatistically significant degree. CONCLUSIONS. A high proportion of pediatric critical care physicians have contacted bereaved families and attended funerals after the death of a child patient. These practices were consistently associated with the belief that such follow-up contact helps the family or the practitioner.

Effective treatments can be rendered useless by poor patient recall of treatment instructions. Studies suggest that patients forget a great deal of important information and that recall can be increased through recall-promoting behaviors (RPBs) like repetition or summarization.To assess how frequently RPBs are used in primary care, and to reveal how they might be applied more effectively.Recordings of 49 unannounced standardized patient (SP) visits were obtained using hidden audiorecorders. All SPs presented with typical gastroesophageal reflux disease symptoms. Transcripts were coded for treatment recommendations and RPBs.Forty-nine primary care physicians.Of 1,140 RPBs, 53.7% were repetitions, 28.2% were communication of the rationale for a treatment, 11.7% were categorizations of treatments (i.e., stating that a treatment could be placed into a treatment category, such as medication-related or lifestyle-related categories), and 3.8% were emphasis of a recommendation's importance. Physicians varied substantially in their use of most RPBs, although no physicians summarized or asked patients to restate recommendations. The number of RPBs was positively correlated with visit length.Primary care physicians apply most RPBs inconsistently, do not utilize several RPBs that are particularly helpful, and may use RPBs inefficiently. Simple principles guiding RPB use may help physicians apply these communication tools more effectively.

Recent literature has described how the capacity for concurrent self-assessment-ongoing moment-to-moment self-monitoring-is an important component of the professional competence of physicians. Self-monitoring refers to the ability to notice our own actions, curiosity to examine the effects of those actions, and willingness to use those observations to improve behavior and thinking in the future. Self-monitoring allows for the early recognition of cognitive biases, technical errors, and emotional reactions and may facilitate self-correction and development of therapeutic relationships. Cognitive neuroscience has begun to explore the brain functions associated with self-monitoring, and the structural and functional changes that occur during mental training to improve attentiveness, curiosity, and presence. This training involves cultivating habits of mind such as experiencing information as novel, thinking of "facts" as conditional, seeing situations from multiple perspectives, suspending categorization and judgment, and engaging in self-questioning. The resulting awareness is referred to as mindfulness and the associated moment-to-moment self-monitoring as mindful practice-in contrast to being on "automatic pilot" or "mindless" in one's behavior. This article is a preliminary exploration into the intersection of educational assessment, cognitive neuroscience, and mindful practice, with the hope of promoting ways of improving clinicians' capacity to self-monitor during clinical practice, and, by extension, improve the quality of care that they deliver.

The ways in which patients' requests for antidepressants affect physicians' prescribing behavior are poorly understood.To describe physicians' affective and cognitive responses to standardized patients' (SPs) requests for antidepressants, as well as the attitudinal and contextual factors influencing prescribing behavior.Focus group interviews and brief demographic questionnaires.Twenty-two primary care physicians in 6 focus groups; all had participated in a prior RCT of the influence of patients' requests on physicians' prescribing.Iterative review of interview transcripts, involving qualitative coding and thematic analysis.Physicians participating in the focus groups were frequently unaware of and denied the degree to which their thinking was biased by patient requests, but were able to recognize such biases after facilitated reflection. Common affective responses included annoyance and empathy. Common cognitive reactions resulted in further diagnostic inquiry or in acquiescing to the patient's demands to save time or build the patient-clinician relationship. Patients' requests for medication prompted the participants to err on the side of overtreating versus careful review of clinical indications. Lack of time and participants' attitudes--toward the role of the patient and the pharmaceutical ads--also influenced their responses, prompting them to interpret patient requests as diagnostic clues or opportunities for efficiency.This study provides a taxonomy of affective and cognitive responses to patients' requests for medications and the underlying attitudes and contextual factors influencing them. Improved capacity for moment-to-moment self-awareness during clinical reasoning processes may increase the appropriateness of prescribing.

Objective:To determine if self-selection is an effective way to match positive interventions to individuals.Design:Each time a participant in the choice group selected one of four positive interventions, a depression-matched yoked control participant was assigned the same intervention.Method:Positive interventions and surveys were administered online. Happiness and depression were assessed at baseline, one week, and two weeks.Results:If participants could identify the positive intervention that was most suitable for them, then interventions should have been more effective for the choice group than for the yoked control group. This was not observed. Both groups experienced significantly increased happiness and decreased depression, but the magnitudes of these changes did not significantly differ between groups.Conclusions:These data suggest that self-selection may not be a good way to identify well-suited positive interventions, and that other selection approaches should be investigated.

Background The compression of morbidity model posits a breakpoint in the adult lifespan that separates an initial period of relative health from a subsequent period of ever increasing morbidity. Researchers often assume that such a breakpoint exists; however, this assumption is hitherto untested. Purpose To test the assumption that a breakpoint exists—which we term a morbidity tipping point—separating a period of relative health from a subsequent deterioration in health status. An analogous tipping point for healthcare costs was also investigated. Methods Four years of adults’ (N = 55,550) morbidity and costs data were retrospectively analyzed. Data were collected in Pittsburgh, PA between 2006 and 2009; analyses were performed in Rochester, NY and Ann Arbor, MI in 2012 and 2013. Cohort-sequential and hockey stick regression models were used to characterize long-term trajectories and tipping points, respectively, for both morbidity and costs. Results Morbidity increased exponentially with age (P

When asked to randomly select answer choices on easy multiple choice questions, people select more correct answers than expected by chance. Sparrow and Wegner showed that this tendency was eliminated if participants answered questions correctly before answering randomly. They argued that answering a question correctly unprimes the tendency to choose the correct answer, thereby reducing the correct response rate close to the chance level of.5. An alternative explanation, consistent with these results, is that answering questions correctly provides a baseline, which allows participants to strategize, i.e., to match and mismatch equal numbers of their purportedly random responses to the baseline response. Three studies showed that the presence of a baseline, even when unpriming is not feasible, led to lower correct response rates than those obtained in a condition in which no baseline was available. Furthermore, the presence of a baseline led to more nonrandom sequences of correct and incorrect responses. One specific sequence-alternating correct and incorrect answers-mediated the relation between the presence of a baseline and lower correct response rate. These findings suggest that strategizing, not unpriming, accounts for Sparrow and Wegner's results.

Although most healthcare professionals take pride in their ability to assess and respond to a clinical situation objectively and fairly, more than three decades of research regarding decision makin...

A meta-analysis of 63 studies showed a significant negative association between intelligence and religiosity. The association was stronger for college students and the general population than for participants younger than college age; it was also stronger for religious beliefs than religious behavior. For college students and the general population, means of weighted and unweighted correlations between intelligence and the strength of religious beliefs ranged from −.20 to −.25 (mean r = −.24). Three possible interpretations were discussed. First, intelligent people are less likely to conform and, thus, are more likely to resist religious dogma. Second, intelligent people tend to adopt an analytic (as opposed to intuitive) thinking style, which has been shown to undermine religious beliefs. Third, several functions of religiosity, including compensatory control, self-regulation, self-enhancement, and secure attachment, are also conferred by intelligence. Intelligent people may therefore have less need for religious beliefs and practices.

To assess changes in employee productivity impairment observed after the implementation of several Web-based health promotion programs.Health risk assessments and self-report measures of productivity impairment were administered on-line to more than 43,000 participants of Web-based health promotion programs.Reductions in productivity impairment were observed after 1 month of program utilization. Productivity impairment at 90- and 180-day follow-ups also decreased relative to baseline. Improvements in employee health were associated with reductions in employee productivity impairment.The use of Web-based health promotion programs was associated with reductions in productivity impairment and improvements in employee health. After the implementation of Web-based health promotion programs, reductions in productivity impairment may be observed before reductions in direct health care costs.

OBJECTIVES To evaluate components of the family-physician relationship that affect the likelihood of self-reported physician follow-up with bereaved families. DESIGN Randomized, split-sample, national survey. SUBJECTS Two hundred four pediatric critical care attending physicians in the United States (54% response rate). MEASUREMENTS AND MAIN RESULTS Subjects were randomly assigned to respond to differing versions of three clinical vignettes varying in each instance in: 1) the patient's length of stay in the intensive care unit; 2) the depiction of the degree of trust of the family toward medical staff; or 3) the depiction of the family's emotional reactions. Subjects then reported their likelihood of following-up with the family after the patient's death. Physicians were more likely to report they would contact families depicted as having a trusting relationship with staff (p = .01). Variations in depicted length of patient stay (p = .5) and in the nature of the family's emotional reaction (p = .9) were not associated with self-reported likelihood of follow-up (p = .5). The only difference observed regarding the method of contacting families after a death was that participants were more likely to say they would attend the funeral of the patient with a trustful family (p < .01). CONCLUSIONS Pediatric critical care attending physicians were more likely to report following-up with a bereaved family and attend a funeral in a vignette portraying a trustful relationship between the family and staff.

Objective To test the hypothesis that hopeful patterns of thoughts and emotions of parents of pediatric patients receiving palliative care consultative services are related to subsequent decisions, specifically regarding limit of intervention (LOI) orders. Design Prospective cohort study. Setting Children's hospital and surrounding region. Participants Thirty-three pediatric patients receiving palliative care consultative services who did not have LOI orders at time of cohort entry and their 43 parental adults. Main Exposures Parental levels at time of cohort entry of hopeful patterns of thinking and emotions, in conjunction with perceptions about patients' health trajectories. Main Outcome Measure Enactment of an LOI order after entry into the cohort. Results During the 6 months of observation, 14 patients (42.4%) had an LOI order enacted. In adjusted analyses, higher levels of parental hopeful patterns of thinking were significantly associated with increased odds of enactment of an LOI order (adjusted odds ratio [AOR], 2.73; 95% confidence interval [CI], 1.04-7.22). Increased odds of LOI enactment were associated to nonsignificant degrees with lower levels of parental positive affect (AOR, 0.44; 95% CI, 0.17-1.12), higher levels of parental negative affect (AOR, 2.02; 95% CI, 0.98-4.16), and parental perceptions of worsening health over time (AOR, 1.72; 95% CI, 0.73-4.07). Conclusion For pediatric patients receiving palliative care consultative services, higher levels of parents' hopeful patterns of thinking are associated with subsequent enactment of LOI orders, suggesting that emotional and cognitive processes have a combined effect on medical decision making.

Research of positive psychology interventions (PPIs) has expanded dramatically in recent years, and many novel PPIs may be useful in couples therapy. The present work identifies, summarizes, and suggests adaptations of PPIs that may improve couples therapy outcomes. Each intervention is presented as part of a larger organizational framework that may help couples therapists determine how and when each intervention can be effectively applied. Finally, a case illustration demonstrates how these methods can complement traditional therapeutic approaches.

Background The value of physician self-disclosure (MD-SD) in creating successful patient-physician partnerships has not been demonstrated. Methods To describe antecedents, delivery, and effects of MD-SD in primary care visits, we conducted a descriptive study using sequence analysis of transcripts of 113 unannounced, undetected, standardized patient visits to primary care physicians. Our main outcome measures were the number of MD-SDs per visit; number of visits with MD-SDs; word count; antecedents, timing, and effect of MD-SD on subsequent physician and patient communication; content and focus of MD-SD. Results The MD-SDs included discussion of personal emotions and experiences, families and/or relationships, professional descriptions, and personal experiences with the patient’s diagnosis. Seventy-three MD-SDs were identified in 38 (34%) of 113 visits. Ten MD-SDs (14%) were a response to a patient question. Forty-four (60%) followed patient symptoms, family, or feelings; 29 (40%) were unrelated. Only 29 encounters (21%) returned to the patient topic preceding the disclosure. Most MD-SDs (n = 62; 85%) were not considered useful to the patient by the research team. Eight MD-SDs (11%) were coded as disruptive. Conclusions Practicing primary care physicians disclosed information about themselves or their families in 34% of new visits with unannounced, undetected, standardized patients. There was no evidence of positive effect of MD-SDs; some appeared disruptive. Primary care physicians should consider when self-disclosing whether other behaviors such as empathy might accomplish their goals more effectively.

A label-free semiquantitative peptide feature profiling method was developed in response to challenges associated with analysis of two-dimensional liquid chromatography-tandem mass spectrometry data. One hundred twenty human sera (49 from invasive breast carcinoma patients, 26 from non-invasive breast carcinoma patients, 35 from benign breast disease patients, and 10 from normal controls) were repeatedly analyzed using a standardized two-dimensional liquid chromatography-mass spectrometry method. Data were extracted using the novel semiquantitative peptide feature profiling method, which is based on comparisons of normalized relative ion intensities. Hierarchical cluster analyses and principle component analyses were used to evaluate the predicative capability of the extracted data, and results were promising. Extracted data were also randomly assigned to either a training group (65%) or to a test group (35%) for artificial neural network modeling. Models best identified invasive breast carcinomas (212 predictions, 94% accurate) and benign non-neoplastic breast disease (96 predictions, 81.3% accurate). These results suggest that, after further development, the novel method may be useful for large scale clinical proteomic profiling.

To examine how primary care physicians respond to ambiguous patient symptom presentations.Observational study, using thematic analysis within a larger cross-sectional study employing standardized patients (SPs), to describe physician responses to ambiguous patient symptoms and patterns of physician-patient interaction.Community-based primary care offices within a metropolitan area.Twenty-three primary care physicians (internists and family physicians).Participating physicians had 2 unannounced SP visits randomly inserted into their daily practice schedules and the visits were audiotaped and transcribed. A coding system focusing on physician responses to concerned patients presenting with ambiguous symptoms was developed through an inductive process. Thematic analyses were then applied to coded data.Physicians' responses to ambiguous symptoms were categorized into 2 primary patterns: high partnering (HP) and usual care (UC). HP was characterized by greater responsiveness to patients' expression of concern, positivity, sensitivity to patients' clues about life circumstances, greater acknowledgment of symptom ambiguity, and solicitation of patients' perspectives on their problems. UC was characterized by denial of ambiguity and less inclusion of patients' perspectives on their symptoms. Neither HP physicians nor UC physicians actively included patients in treatment planning.Primary care physicians respond to ambiguity by either ignoring the ambiguity and becoming more directive (UC) or, less often, by acknowledging the ambiguity and attempting to explore symptoms and patient concerns in more detail (HP). Future areas of study could address whether physicians can learn HP behaviors and whether HP behaviors positively affect health outcomes.

Multi-dimensional protein identification technology (MudPIT) is becoming a prevalent proteomic approach due to its high-throughput separations and accurate mass detection. Prior to MudPIT analysis, complicated samples required in-solution digestion. Unlike in-gel digestion, in which enzymes work on just a few proteins, in-solution digestion involves simultaneous digestion of hundreds or thousands of proteins. In-solution digestion protocols must therefore be very efficient. Few investigations have evaluated the efficiency of in-solution digestion protocols. The present research compared three such protocols. Results suggest that a protocol utilizing trifluoroethanol (TFE) as denaturant is most efficient.

Human urine samples are ideal for proteomic profiling and have tremendous potential as sources of biomarkers. Multi-dimensional protein identification technology (MudPIT) is an effective approach to analyzing human urine or other fluids dominated by diverse metabolites. MudPIT analysis was used to identify 87 proteins in just 15 ml of human urine. A high throughput, reproducible, and sensitive technology, MudPIT may soon be used for more proteomic analyses of metabolites.