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ObjectiveHemodialysis patients frequently experience dialysis therapy sessions complicated by intradialytic hypotension (IDH), a major patient safety concern. We investigate user-centered design requirements for a theory-informed, peer mentoring-based, informatics intervention to activate patients toward IDH prevention.MethodsWe conducted observations (156 hours) and interviews (n = 28) with patients in 3 hemodialysis clinics, followed by 9 focus groups (including participatory design activities) with patients (n = 17). Inductive and deductive analyses resulted in themes and design principles linked to constructs from social, cognitive, and self-determination theories.ResultsHemodialysis patients want an informatics intervention for IDH prevention that collapses distance between patients, peers, and family; harnesses patients' strength of character and resolve in all parts of their life; respects and supports patients' individual needs, preferences, and choices; and links "feeling better on dialysis" to becoming more involved in IDH prevention. Related design principles included designing for: depth of interpersonal connections; positivity; individual choice and initiative; and comprehension of connections and possible actions.DiscussionFindings advance the design of informatics interventions by presenting design requirements for outpatient safety and addressing key design opportunities for informatics to support patient involvement; these include incorporation of behavior change theories. Results also demonstrate the meaning of design choices for hemodialysis patients in the context of their experiences; this may have applicability to other populations with serious illnesses.ConclusionThe resulting patient-facing informatics intervention will be evaluated in a pragmatic cluster-randomized controlled trial in 28 hemodialysis facilities in 4 US regions.

PURPOSE Unlike in many community-based settings, benzodiazepine (BZD) prescribing to older veterans has decreased. We sought to identify health care system strategies associated with greater facility-level reductions in BZD prescribing to older adults. METHODS We completed an explanatory sequential mixed methods study of health care facilities in the Veterans Health Administration (N = 140). Among veterans aged [greater than or equal to]75 years receiving long-term BZD treatment, we stratified facilities into relatively high and low performance on the basis of the reduction in average daily dose of prescribed BZD from October 1, 2015 to June 30, 2017. We then interviewed key facility informants (n = 21) who led local BZD reduction efforts (champions), representing 11 high-performing and 6 low-performing facilities. RESULTS Across all facilities, the age-adjusted facility-level average daily dose in October 2015 began at 1.34 lorazepam-equivalent mg/d (SD 0.17); the average rate of decrease was -0.27 mg/d (SD 0.09) per year. All facilities interviewed, regardless of performance, used passive strategies primarily consisting of education regarding appropriate prescribing, alternatives, and identifying potential patients for discontinuation. In contrast, champions at high-performing facilities described leveraging >1 active strategies that included individualized recommendations, administrative barriers to prescribing, and performance measures to incentivize clinicians. CONCLUSIONS Initiatives to reduce BZD prescribing to older adults that are primarily limited to passive strategies, such as education and patient identification, might have limited success. Clinicians might benefit from additional recommendations, support, and incentives to modify prescribing practices. Key words: benzodiazepine reduction; veteran; mixed methods, INTRODUCTION The potential safety risks of benzodiazepine (BZD) use among older adults have been known for more than 30 years. (1,2) Whereas a variety of interventions have shown efficacy in [...]

PURPOSE Gastrointestinal (GI) bleeding is one of the most common serious adverse drug events. Guidelines recommend proton pump inhibitor (PPI) gastroprotection to prevent upper GI bleeding in high-risk patients, but this practice is underused. METHODS To explore prescribing practices and barriers to the use of PPI gastroprotection, including dynamics within and across specialties, we conducted semistructured interviews with physicians in 4 specialties at a single institution. We performed thematic analysis of barriers, organized around the theoretical domains framework. RESULTS The sample included 5 primary care physicians (PCPs), 4 cardiologists, 3 gastroenterologists, and 3 vascular surgeons. Most PCPs, gastroenterologists, and vascular surgeons seldom prescribed PPI gastroprotection. Cardiologists varied most in their use of PPI gastroprotection, with some prescribing it consistently and others never. Major barriers related to the following 3 themes: (1) knowledge, (2) decision processes, and (3) professional role. Knowledge of guidelines was greatest among cardiologists and gastroenterologists and low among PCPs and vascular surgeons, and PCPs tended to focus on adverse effects associated with PPIs, which made them reluctant to prescribe them. For cardiologists, prevention of bleeding was usually a priority, but they sometimes deferred prescribing to others. For the other 3 specialties, PPI gastroprotection was a low priority. There was unclear delineation of responsibility for prescribing gastroprotection between specialties. CONCLUSIONS Major barriers to PP1 gastroprotection relate to knowledge, decision processes, and professional role, which operate differentially across specialties. Multicomponent interventions will likely be necessary to improve guideline-based use of PPIs to prevent upper G1 bleeding. VISUAL ABSTRACT Key words: proton pump inhibitors; gastroprotection; gastrointestinal bleeding; prevention; barriers, INTRODUCTION Nonvariceal upper gastrointestinal bleeding (UGIB) affects nearly one quarter of a million patients in the United States annually and carries a 2% case fatality rate. (1,2) In the United [...]

We examined the effectiveness and safety of a walking program offered as part of cognitive behavioral therapy for chronic pain (CBT-CP). Participants were randomized to 10 weeks of CBT-CP, delivered either in person or by interactive voice response. Participants reported pedometer-measured step counts daily throughout treatment and received a weekly goal to increase their steps by 10% over the prior week's average. Walking-related adverse events (AEs) were assessed weekly. Participants (n = 125) were primarily male (72%), and white (80%) with longstanding pain (median: 11 years). There was no significant difference between treatment groups in rate of change in daily steps, but there was a significant increase in steps from baseline to treatment termination in the combined study sample (1648 steps (95% CI 1063-2225)). Participants classified as active doubled. AEs were mostly minor and temporary. Treatment was effective and safe whether the program was delivered in-person or remotely. Trial registration number: clinicaltrials.gov identifier: NCT01025752., Author(s): Alicia A. Heapy [sup.1] [sup.2] , Hallie Tankha [sup.3] , Diana M. Higgins [sup.4] [sup.5] , Mary Driscoll [sup.1] [sup.2] , Kathryn M. LaChappelle [sup.1] , Joseph L. Goulet [...]

Background Despite antibiotic stewardship programs existing in most acute care hospitals, there continues to be variation in appropriate antibiotic use. While existing research examines individual prescriber behavior, contextual reasons for variation are poorly understood. Methods We conducted an explanatory, sequential mixed-methods study of a purposeful sample of 7 hospitals with varying discharge antibiotic overuse. For each hospital, we conducted surveys, document analysis, and semi-structured interviews with antibiotic stewardship and clinical stakeholders. Data were analyzed separately and mixed during the interpretation phase, where each hospital was examined as a case, with findings organized across cases using a strengths, weaknesses, opportunities, and threats framework to identify factors accounting for differences in antibiotic overuse across hospitals. Results Surveys included 85 respondents. Interviews included 90 respondents (31 hospitalists, 33 clinical pharmacists, 14 stewardship leaders, 12 hospital leaders). On surveys, clinical pharmacists at hospitals with lower antibiotic overuse were more likely to report feeling: respected by hospitalist colleagues (P =.001), considered valuable team members (P =.001), and comfortable recommending antibiotic changes (P =.02). Based on mixed-methods analysis, hospitals with low antibiotic overuse had 4 distinguishing characteristics: (1) robust knowledge of and access to antibiotic stewardship guidance; (2) high-quality clinical pharmacist–physician relationships; (3) tools and infrastructure to support stewardship; and (4) highly engaged infectious diseases physicians who advocated stewardship principles. Conclusions This mixed-methods study demonstrates the importance of organizational context for high performance in stewardship and suggests that improving antimicrobial stewardship requires attention to knowledge, interactions, and relationships between clinical teams and infrastructure that supports stewardship and team interactions. [ABSTRACT FROM AUTHOR]

BackgroundPatients on hemodialysis receive dialysis thrice weekly for about 4 hours per session. Intradialytic hypotension (IDH)—low blood pressure during hemodialysis—is a serious but common complication of hemodialysis. Although patients on dialysis already participate in their care, activating patients toward IDH prevention may reduce their risk of IDH. Interactive, technology-based interventions hold promise as a platform for patient activation. However, little is known about the usability challenges that patients undergoing hemodialysis may face when using tablet-based informatics interventions, especially while dialyzing. ObjectiveThis study aims to test the usability of a patient-facing, tablet-based intervention that includes theory-informed educational modules and motivational interviewing–based mentoring from patient peers via videoconferencing. MethodsWe conducted a cross-sectional, mixed methods usability evaluation of the tablet-based intervention by using think-aloud methods, field notes, and structured observations. These qualitative data were evaluated by trained researchers using a structured data collection instrument to capture objective observational data. We calculated descriptive statistics for the quantitative data and conducted inductive content analysis using the qualitative data. ResultsFindings from 14 patients cluster around general constraints such as the use of one arm, dexterity issues, impaired vision, and lack of experience with touch screen devices. Our task-by-task usability results showed that specific sections with the greatest difficulty for users were logging into the intervention (difficulty score: 2.08), interacting with the quizzes (difficulty score: 1.92), goal setting (difficulty score: 2.28), and entering and exiting videoconference rooms (difficulty score: 2.07) that are used to engage with peers during motivational interviewing sessions. ConclusionsIn this paper, we present implications for designing informatics interventions for patients on dialysis and detail resulting changes to be implemented in the next version of this intervention. We frame these implications first through the context of the role the patients’ physical body plays when interacting with the intervention and then through the digital considerations for software and interface interaction.

BackgroundOf the 150,000 patients annually undergoing coronary artery bypass grafting, 35% develop complications that increase mortality 5 fold and expenditure by 50%. Differences in patient risk and operative approach explain only 2% of hospital variations in some complications. The intraoperative phase remains understudied as a source of variation, despite its complexity and amenability to improvement. ObjectiveThe objectives of this study are to (1) investigate the relationship between peer assessments of intraoperative technical skills and nontechnical practices with risk-adjusted complication rates and (2) evaluate the feasibility of using computer-based metrics to automate the assessment of important intraoperative technical skills and nontechnical practices. MethodsThis multicenter study will use video recording, established peer assessment tools, electronic health record data, registry data, and a high-dimensional computer vision approach to (1) investigate the relationship between peer assessments of surgeon technical skills and variability in risk-adjusted patient adverse events; (2) investigate the relationship between peer assessments of intraoperative team-based nontechnical practices and variability in risk-adjusted patient adverse events; and (3) use quantitative and qualitative methods to explore the feasibility of using objective, data-driven, computer-based assessments to automate the measurement of important intraoperative determinants of risk-adjusted patient adverse events. ResultsThe project has been funded by the National Heart, Lung and Blood Institute in 2019 (R01HL146619). Preliminary Institutional Review Board review has been completed at the University of Michigan by the Institutional Review Boards of the University of Michigan Medical School. ConclusionsWe anticipate that this project will substantially increase our ability to assess determinants of variation in complication rates by specifically studying a surgeon’s technical skills and operating room team member nontechnical practices. These findings may provide effective targets for future trials or quality improvement initiatives to enhance the quality and safety of cardiac surgical patient care. International Registered Report Identifier (IRRID)PRR1-10.2196/22536