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Objective: To examine the perspectives of caregivers that are not part of the antibiotic stewardship program (ASP) leadership team (eg, physicians, nurses, and clinical pharmacists), but who interact with ASPs in their role as frontline healthcare workers. Design: Qualitative semistructured interviews. Setting: The study was conducted in 2 large national healthcare systems including 7 hospitals in the Veterans’ Health Administration and 4 hospitals in Intermountain Healthcare. Participants: We interviewed 157 participants. The current analysis includes 123 nonsteward clinicians: 47 physicians, 26 pharmacists, 29 nurses, and 21 hospital leaders. Methods: Interviewers utilized a semistructured interview guide based on the Consolidated Framework for Implementation Research (CFIR), which was tailored to the participant’s role in the hospital as it related to ASPs. Qualitative analysis was conducted using a codebook based on the CFIR. Results: We identified 4 primary perspectives regarding ASPs. (1) Non-ASP pharmacists considered antibiotic stewardship activities to be a high priority despite the added burden to work duties: (2) Nurses acknowledged limited understanding of ASP activities or involvement with these programs; (3) Physicians criticized ASPs for their restrictions on clinical autonomy and questioned the ability of antibiotic stewards to make recommendations without the full clinical picture; And (4) hospital leaders expressed support for ASPs and recognized the unique challenges faced by non-ASP clinical staff. Conclusion: Further understanding these differing perspectives of ASP implementation will inform possible ways to improve ASP implementation across clinical roles.

We explored experiences and perceptions surrounding the Self-Stewardship Time-Out Program (SSTOP) intervention across implementation sites to improve antimicrobial use. Semistructured qualitative interviews were conducted with Antibiotic Stewardship physicians and pharmacists, from which 5 key themes emerged. SSTOP may serve to achieve sustainable promotion of antibiotic use improvements.

The Veterans Health Administration (VHA) has long recognized the need for age-friendly care. VHA leadership anticipated the impact of aging World War II veterans on VA healthcare systems and in 1975 developed Geriatric Research, Education, and Clinical Centers (GRECCs) to meet this need. GRECCs catalyzed a series of innovations in geriatric models of care that span the continuum of care, most of which endure. These innovative care models also contributed to the evidence base supporting the present-day Age-Friendly Health Systems movement, with which VHA is inherently aligned. As both a provider of and payor for care, VHA is strongly incentivized to promote coordination across the continuum of care, with resultant cost savings. VHA is also a major contributor to developing the workforce that is essential for the provision of age-friendly care. As VHA continues to develop and refine innovative geriatric models of care, policymakers and non-VHA health care systems should look to VHA programs as exemplars for the development and implementation of age-friendly care.

Information transfers in long-term care (LTC) settings between and among providers, staff, residents, and family caregivers are often fragmented. In order to identify training needs to improve communication, a survey instrument was developed and refined to assess the self-efficacy of LTC staff in communicating with staff, providers, residents, and caregivers. This 11-item survey instrument, based on a literature review, covered four key concepts (mutual respect, recognizing and responding to sensory deficits, limited health literacy, and changes in condition) relevant to communicating health information in LTC settings. Ten content experts evaluated each survey item using a 4-point scale. The content validity of the survey was established by using the content validity index to assess results at the item and scale levels. All items scored 0.90 or greater and were retained. Future work should entail broad-scale validation and testing of this survey across the United States. By assessing the self-efficacy of LTC staff in communicating with the interprofessional team, leadership teams can design personalized interprofessional continuing education activities aimed at improving communication skills. [ J Contin Educ Nurs . 2022;53(3):123–130.]

Objective:As part of a project to implement antimicrobial dashboards at select facilities, we assessed physician attitudes and knowledge regarding antibiotic prescribing.Design:An online survey explored attitudes toward antimicrobial use and assessed respondents’ management of four clinical scenarios: cellulitis, community-acquired pneumonia, non–catheter-associated asymptomatic bacteriuria, and catheter-associated asymptomatic bacteriuria.Setting:This study was conducted across 16 Veterans’ Affairs (VA) medical centers in 2017.Participants:Physicians working in inpatient settings specializing in infectious diseases (ID), hospital medicine, and non-ID/hospitalist internal medicine.Methods:Scenario responses were scored by assigning +1 for answers most consistent with guidelines, 0 for less guideline-concordant but acceptable answers and −1 for guideline-discordant answers. Scores were normalized to 100% guideline concordant to 100% guideline discordant across all questions within a scenario, and mean scores were calculated across respondents by specialty. Differences in mean score per scenario were tested using analysis of variance (ANOVA).Results:Overall, 139 physicians completed the survey (19 ID physicians, 62 hospitalists, and 58 other internists). Attitudes were similar across the 3 groups. We detected a significant difference in cellulitis scenario scores (concordance: ID physicians, 76%; hospitalists, 58%; other internists, 52%; P = .0087). Scores were numerically but not significantly different across groups for community-acquired pneumonia (concordance: ID physicians, 75%; hospitalists, 60%; other internists, 56%; P = .0914), for non–catheter-associated asymptomatic bacteriuria (concordance: ID physicians, 65%; hospitalists, 55%; other internists, 40%; P = .322), and for catheter-associated asymptomatic bacteriuria (concordance: ID physicians, 27% concordant; hospitalists, 8% discordant; other internists 13% discordant; P = .12).Conclusions:Significant differences in performance regarding management of cellulitis and low overall performance regarding asymptomatic bacteriuria point to these conditions as being potentially high-yield targets for stewardship interventions.

ImportanceThe effectiveness of public health measures implemented to mitigate the spread and impact of SARS-CoV-2 relies heavily on honesty and adherence from the general public.ObjectiveTo examine the frequency of, reasons for, and factors associated with misrepresentation and nonadherence regarding COVID-19 public health measures.Design, Setting, and ParticipantsThis survey study recruited a national, nonprobability sample of US adults to participate in an online survey using Qualtrics online panels (participation rate, 1811 of 2260 [80.1%]) from December 8 to 23, 2021. The survey contained screening questions to allow for a targeted sample of one-third who had had COVID-19, one-third who had not had COVID-19 and were vaccinated, and one-third who had not had COVID-19 and were unvaccinated.Main Outcomes and MeasuresThe survey assessed 9 different types of misrepresentation and nonadherence related to COVID-19 public health measures and the reasons underlying such behaviors. Additional questions measured COVID-19–related beliefs and behaviors and demographic characteristics.ResultsThe final sample included 1733 participants. The mean (SD) participant age was 41 (15) years and the sample predominantly identified as female (1143 of 1732 [66.0%]) and non-Hispanic White (1151 of 1733 [66.4%]). Seven hundred twenty-one participants (41.6%) reported misrepresentation and/or nonadherence in at least 1 of the 9 items; telling someone they were with or about to be with in person that they were taking more COVID-19 preventive measures than they actually were (420 of 1726 [24.3%]) and breaking quarantine rules (190 of 845 [22.5%]) were the most common manifestations. The most commonly endorsed reasons included wanting life to feel normal and wanting to exercise personal freedom. All age groups younger than 60 years (eg, odds ratio for those aged 18-29 years, 4.87 [95% CI, 3.27-7.34]) and those who had greater distrust in science (odds ratio, 1.14 [95% CI, 1.05-1.23]) had significantly higher odds of misrepresentation and/or nonadherence for at least 1 of the 9 items.Conclusions and RelevanceIn this survey study of US adults, nearly half of participants reported misrepresentation and/or nonadherence regarding public health measures against COVID-19. Future work is needed to examine strategies for communicating the consequences of misrepresentation and nonadherence and to address contributing factors.

Background Warnings about drug-drug interactions (DDIs) between warfarin and nonsteroidal anti-inflammatory drugs (NSAIDs) within electronic health records indicate potential harm but fail to account for contextual factors and preferences. We developed a tool called DDInteract to enhance and support shared decision-making (SDM) between patients and physicians when both warfarin and NSAIDs are used concurrently. DDInteract was designed to be integrated into electronic health records using interoperability standards. Objective The purpose of this study was to conduct a formative evaluation of a DDInteract that incorporates patient and product contextual factors to estimate the risk of bleeding. Methods A randomized formative evaluation was conducted to compare DDInteract to usual care (UC) using physician-patient dyads. Using case vignettes, physicians and patients on warfarin participated in simulated virtual clinical encounters where they discussed the use of taking ibuprofen and warfarin concurrently and determined an appropriate therapeutic plan based on the patient’s individualized risk. Dyads were randomized to either DDInteract or UC. Participants completed a postsession interview and survey of the SDM process. This included the 9-item Shared Decision-Making Questionnaire (SDM-Q-9), tool usability and workload National Aeronautics and Space Administration (NASA) Task Load Index, Unified Theory of Acceptance and Use of Technology (UTAUT), Perceived Behavioral Control (PBC) scale, System Usability Scale (SUS), and Decision Conflict Scale (DCS). They also were interviewed after the session to obtain perceptions on DDInteract and UC resources for DDIs. Results Twelve dyad encounters were performed using virtual software. Most (n=11, 91.7%) patients were over 50 years of age, and 9 (75%) had been taking warfarin for more than 2 years (75%). Regarding scores on the SDM-Q-9, participants rated DDInteract higher than UC for questions pertaining to helping patients clarify the decision (P=.03), involving patients in the decision (P=.01), displaying treatment options (P Conclusions Overall, DDInteract may improve encounters where there is a risk of bleeding due to a potential drug-drug interaction involving anticoagulants. Participants rated DDInteract as logical and useful for enhancing SDM. They reported that they would be willing to use the tool for an interaction involving warfarin and NSAIDs.

Optimal care in nursing home (NH) settings requires effective team communication. Certified nursing assistants (CNAs) interact with nursing home residents frequently, but the extent to which CNAs feel their input is valued by other team members is not known. We conducted a cross-sectional study in which we administered a communication survey within 20 Utah nursing home facilities to 650 team members, including 124 nurses and 264 CNAs. Respondents used a 4-point scale to indicate the extent to which their input is valued by other team members when reporting their concerns about nursing home residents. We used a one-way ANOVA with a Bonferroni correction. When compared to nurses, CNAs felt less valued (CNA mean = 2.14, nurse mean = 3.24; p < 0.001) when reporting to physicians, and less valued (CNA mean = 1.66, nurse mean = 2.71; p < 0.001) when reporting to pharmacists. CNAs did not feel less valued than nurses (CNA mean = 3.43, nurse mean = 3.37; p = 0.25) when reporting to other nurses. Our findings demonstrate that CNAs feel their input is not valued outside of nursing, which could impact resident care. Additional research is needed to understand the reasons for this perception and to design educational interventions to improve the culture of communication in nursing home settings.

The purpose of this study was to qualitatively examine safety experiences of hospitalized patients and families.We conducted 5 focus groups at 2 sites with patients and family members of patients who had been hospitalized at least once within the preceding 2 years. Using a semistructured focus group script, participants were asked to describe hospital experiences, including any safety risks or problems, and to discuss trust in the hospital care team or members of the care team. All focus groups were audiorecorded and transcribed, and transcriptions were qualitatively analyzed using thematic analysis by experienced qualitative analysts and experts in patient safety.We collected rich descriptions of safety problems in the hospital. We identified 4 main themes from our focus group data. (1) Experiences with safety problems were not unusual among participants, (2) patients and families develop a structured "care story" about their hospital experiences, (3) there is a spectrum of trust between patients and the hospital care team members that can be diminished or enhanced by experiences, and (4) patients believed having someone who could advocate for them during their hospitalization was important.Our results suggest that acknowledgment of safety problems, clear communication, building trust, and a role for advocacy are impactful pathways health care providers and health care systems can improve patient experiences. Information technology such as patient- and clinician-facing displays can support each of these actions.

Background In this study we sought to explore the possibility of using patient centered care (PCC) documentation as a measure of the delivery of PCC in a health system. Methods We first selected 6 VA medical centers based on their scores for a measure of support for self-management subscale from a national patient satisfaction survey (the Survey for Healthcare Experience-Patients). We accessed clinical notes related to either smoking cessation or weight management consults. We then annotated this dataset of notes for documentation of PCC concepts including: patient goals, provider support for goal progress, social context, shared decision making, mention of caregivers, and use of the patient's voice. We examined the association of documentation of PCC with patients’ perception of support for self-management with regression analyses. Results Two health centers had Conclusion Providers document PCC concepts in their clinical notes. In this pilot study we explored the feasibility of using this data as a means to measure the degree to which care in a health center is patient centered. Practice Implications: clinical EHR notes are a rich source of information about PCC that could potentially be used to assess PCC over time and across systems with scalable technologies such as natural language processing.

BACKGROUND Although secure messaging (SM) between patients and clinical team members is a recommended component of continuous care, uptake by patients remains relatively low. We designed a multicomponent Supported Adoption Program (SAP) to increase SM adoption among patients using the Veterans Health Administration (VHA) for primary care. OBJECTIVE Our goals were to (1) conduct a multisite, randomized, encouragement design trial to test the effectiveness of an SAP designed to increase patient engagement with SM through VHA’s online patient portal (My HealtheVet [MHV]) and (2) evaluate the impact of the SAP and patient-level SM adoption on perceived provider autonomy support and communication. Patient-reported barriers to SM adoption were also assessed. METHODS We randomized 1195 patients at 3 VHA facilities who had MHV portal accounts but had never used SM. Half were randomized to receive the SAP, and half served as controls receiving usual care. The SAP consisted of encouragement to adopt SM via mailed educational materials, proactive SM sent to patients, and telephone-based motivational interviews. We examined differences in SM adoption rates between SAP recipients and controls at 9 months and 21 months. Follow-up telephone surveys were conducted to assess perceived provider autonomy support and self-report of telephone communication with clinical teams. RESULTS Patients randomized to the SAP had significantly higher rates of SM adoption than the control group (101/595, 17.0% vs 40/600, 6.7%; PPP=.007) and less telephone use to communicate with their provider (68.8% vs 76.0%, P=.05), compared to patients in the control group. Patient-reported barriers to SM adoption included self-efficacy (eg, not comfortable using a computer, 24%), no perceived need for SM (22%), and difficulties with portal password or login (17%). CONCLUSIONS The multicomponent SAP was successful in increasing use of SM 10 percentage points above standard care; new SM adopters reported improved perceptions of provider autonomy support and less use of the telephone to communicate with their providers. Still, despite the encouragement and technical assistance provided through the SAP, adoption rates were lower than anticipated, reaching only 24% at 21 months (10% above controls). Common barriers to adoption such as limited perceived need for SM may be more challenging to address and require different interventions than barriers related to patient self-efficacy or technical difficulties. CLINICALTRIAL ClinicalTrials.gov NCT02665468; https://clinicaltrials.gov/ct2/show/NCT02665468

Patients report their symptoms and subjective experiences in their own words. These expressions may be clinically meaningful yet are difficult to capture using automated methods. We annotated subjective symptom expressions in 750 clinical notes from the Veterans Affairs EHR. Within each document, subjective symptom expressions were compared to mentions of symptoms in clinical terms and to the assigned ICD-9-CM codes for the encounter. A total of 543 subjective symptom expressions were identified, of which 66.5% were categorized as mental/behavioral experiences and 33.5% somatic experiences. Only two subjective expressions were coded using ICD-9-CM. Subjective expressions were restated in semantically related clinical terms in 246 (45.3%) instances. Nearly one third (31%) of subjective expressions were not coded or restated in standard terminology. The results highlight the diversity of symptom descriptions and the opportunities to further develop natural language processing to extract symptom expressions that are unobtainable by other automated methods.