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Kerry A Spitzer, 1 Mihaela S Stefan, 1–3 Aubri A Drake, 1 Quinn R Pack, 1– 4 Tara Lagu, 1, 2 Kathleen M Mazor, 5 Victor Pinto-Plata, 6 Peter K Lindenauer 1, 3, 7 1Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA, USA; 2Department of Internal Medicine, Baystate Medical Center, Springfield, MA, USA; 3Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA, USA; 4Division of Cardiovascular Medicine, Baystate Medical Center, Springfield, MA, USA; 5Meyers Primary Care Institute, a Joint Endeavor of the University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA; 6Pulmonary and Critical Care Medicine Division, Baystate Medical Center, Springfield, MA, USA; 7Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USACorrespondence: Kerry A SpitzerInstitute for Healthcare Delivery and Population Science University of Massachusetts Medical School-Baystate, 3601 Main Street, Springfield, MA 01199, USATel +1 413-794-7909Email Kerry.Spitzer@baystatehealth.orgRationale: Current guidelines recommend that patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease (COPD) initiate pulmonary rehabilitation (PR) shortly after discharge from the hospital. However, fewer than 2 percent of Medicare beneficiaries do so. Few studies have examined hospitalized patients’ perceptions of the barriers and facilitators to enroll in PR. The aim of this study was to develop an understanding of these factors by interviewing patients.Methods: We conducted semi-structured interviews with patients during a hospitalization for COPD exacerbation in a large teaching hospital. Directed content analysis was used to code and analyze interview transcripts.Results: Of the 15 patients we interviewed, 9 had participated in PR prior to their hospitalization, 10 were women; 4 were black, and 1 was Hispanic. Facilitators of enrollment included a desire to learn more about the disease, social support, and trust in the health-care provider recommending PR. Barriers to enrollment included lack of awareness, family obligations, lack of motivation, and transportation. For those who had previous experience with PR, but who did not complete the program, another barrier was not feeling well enough. Facilitators to adherence included the educational component of the program; feeling better through exercise; and a social connection with both participants and staff. For some patients. PR contributed to a renewed sense of hope or meaning. Most interviewees expressed interest in a peer coaching program.Conclusion: Our results highlight the importance of increasing awareness of PR and building trust between the provider and patients to facilitate initial enrollment. Future interventions to improve enrollment and adherence should address the need for education about the benefits of PR and the value of social support.Keywords: chronic obstructive pulmonary disease, COPD, pulmonary rehabilitation, hospitalization, patient perspectives

ContextPatient reported outcomes (PROs) are one means of systematically gathering meaningful subjective information for patient care, population health, and patient centered outcomes research. However, optimal data management for effective PRO applications is unclear.Case descriptionDelivery systems associated with the Health Care Systems Research Network (HCSRN) have implemented PRO data collection as part of the Medicare annual Health Risk Assessment (HRA). A questionnaire assessed data content, collection, storage, and extractability in HCSRN delivery systems.FindingsResponses were received from 15 (83.3 percent) of 18 sites. The proportion of Medicare beneficiaries completing an HRA ranged from less than 10 to 42 percent. Most sites collected core HRA elements and 10 collected information on additional domains such as social support. Measures for core domains varied across sites. Data were collected at and prior to visits. Modes included paper, clinician entry, patient portals, and interactive voice response. Data were stored in the electronic health record (EHR) in scanned documents, free text, and discrete fields, and in summary databases.Major themesPRO implementation requires effectively collecting, storing, extracting, and applying patient-reported data. Standardizing PRO measures and storing data in extractable formats can facilitate multi-site uses for PRO data, while access to individual PROs in the EHR may be sufficient for use at the point of care.ConclusionCollecting comparable PRO data elements, storing data in extractable fields, and collecting data from a higher proportion of eligible respondents represents an optimal approach to support multi-site applications of PRO information.

Objective: Guidelines on apology and disclosure after adverse events and errors have been in place for over 5 years. This study examines whether patients consider recommended responses to be appropriate and desirable, and whether clinicians' actions after adverse events are consistent with recommendations.Methods: Patients who believed that something had gone wrong during their cancer care were identified. During in-depth interviews, patients described the event, clinicians' responses, and their reactions.Results: 78 patients were interviewed. Patients' valued apology and expressions of remorse, empathy and caring, explanation, acknowledgement of responsibility, and efforts to prevent recurrences, but these key elements were often missing. For many patients, actions and evidence of clinician learning were most important.Conclusion: Patients' reports of apology and disclosure when they believe something has gone wrong in their care suggest that clinicians' responses continue to fall short of expectations.Practice Implications: Clinicians preparing to talk with patients after an adverse event or medical error should be aware that patients expect their actions to be congruent with their words of apology and caring. Healthcare systems need to support clinicians throughout the disclosure process, and facilitate both system and individual learning to prevent recurrences. [ABSTRACT FROM AUTHOR]

Health messages on television and other mass media have the potential to significantly influence the public's health-related knowledge and behaviors, but little is known about people's ability to comprehend such messages. To investigate whether people understood the spoken information in media messages about cancer prevention and screening, we recruited 44 adults from 3 sites to view 6 messages aired on television and the internet. Participants were asked to paraphrase main points and selected phrases. Qualitative analysis methods were used to identify what content was correctly and accurately recalled and paraphrased, and to describe misunderstandings and misconceptions. While most participants accurately recalled and paraphrased the gist of the messages used here, overgeneralization (e.g., believing preventative behaviors to be more protective than stated), loss of details (e.g., misremembering the recommended age for screening), and confusion or misunderstandings around specific concepts (e.g., interpreting "early stage" as the stage in one's life rather than cancer stage) were common. Variability in the public's ability to understand spoken media messages may limit the effectiveness of both pubic health campaigns and provider-patient communication. Additional research is needed to identify message characteristics that enhance understandability and improve comprehension of spoken media messages about cancer. [ABSTRACT FROM AUTHOR]

There is growing interest in public reporting of health care performance data relating to healthcare-associated infections (HAIs). This study evaluated different approaches for reporting hospital-level comparative data on HAIs and the extent to which such data might influence hospital choice. Eight versions of a report were developed, varying whether data were consistent across indicators, whether data were presented in text or graphs, and whether confidence intervals were included. A report and a questionnaire were mailed to a randomly selected sample of local residents. Findings provide no evidence that consistency of indicators, data presentation, report format, or inclusion of confidence intervals significantly impacted consumers' understanding. More educated consumers reported greater understanding of the reports. Responses suggested that public reporting of comparative data on HAIs could influence hospital choice, but other factors including prior experience, reputation, physicians' recommendations, and insurance coverage are also influential. Most consumers understand information on HAIs when it is presented in a short, simple report, and most correctly select the best or worst hospital. Consumers may be influenced by such data, but other factors are likely to be as or more important. (Am J Med Qual 2009;24:108-115). [ABSTRACT FROM AUTHOR]

BACKGROUND: A previous study described 7 elements of teacher identity: intrinsic satisfaction from teaching, knowledge and skill about teaching, belonging to a community of teachers, receiving rewards for teaching, believing that being a doctor means being a teacher, feeling a responsibility to teach, and sharing clinical expertise. PURPOSE: To conduct the initial testing of an instrument to measure the 7 elements of teacher identity in clinical educators and to consider the potential applications of such an instrument. METHODS: A 37-item questionnaire was mailed to 153 preceptors of preclinical students. Categories reflected the elements of teacher identity listed here. Demographic data were collected. Means, alphas, ANOVAs, and paired t tests were calculated. RESULTS: Of 153 preceptors, 127 (83%) completed the questionnaire. Cronbach's alpha for the overall scale and several subscales were high. Salaried physicians and those who had completed a faculty development program scored significantly higher on several subscales than physicians who volunteered to teach or who did not have faculty development. CONCLUSIONS: This study provides preliminary evidence that teacher identity can be measured and that preceptors do not respond as a homogeneous group. Assessing teacher identity may be helpful to medical schools looking to identify and support physicians who teach. [ABSTRACT FROM AUTHOR]

The purpose of this study was to determine whether print materials on stroke resulted in increased knowledge in a sample of lay people. One hundred and seventy-seven participants received (at random) one of five versions of a stroke information packet, or a control packet on colorectal cancer. Participants rated the materials on readability, understandability and usefulness immediately after reading. After a delay of 18 days on average, participants answered questions assessing stroke knowledge. Ratings of all packets were generally positive; however, stroke knowledge scores were significantly higher for the stroke information groups compared to the control group only for knowledge of causal mechanisms (stroke pathophysiology). While there was some indication that the fictionalized material on stroke was more effective than the expository materials, overall the impact of print materials on stroke knowledge, measured after a delay of at least 1 week, was minimal at best. Further research is needed to determine whether fictional contexts make some information more memorable. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Little is known about the best approaches and format for measuring physicians' communication skills in an online environment. This study examines the reliability and validity of scores from two Web-based communication skill assessment formats. METHODS: We created two online communication skill assessment formats: (a) MCQ (multiple-choice questions) consisting of video-based multiple-choice questions; (b) multi-format including video-based multiple-choice questions with rationales, Likert-type scales, and free text responses of what physicians would say to a patient. We randomized 100 general internists to each test format. Peer and patient ratings collected via the American Board of Internal Medicine (ABIM) served as validity sources. RESULTS: Seventy-seven internists completed the tests (MCQ: 38; multi-format: 39). The adjusted reliability was 0.74 for both formats. Excellent communicators, as based on their peer and patient ratings, performed slightly better on both tests than adequate communicators, though this difference was not statistically significant. Physicians in both groups rated test format innovative (4.2 out of 5.0). CONCLUSION: The acceptable reliability and participants' overall positive experiences point to the value of ongoing research into rigorous Web-based communication skills assessment. PRACTICE IMPLICATIONS: With efficient and reliable scoring, the Web offers an important way to measure and potentially enhance physicians' communication skills. [ABSTRACT FROM AUTHOR]

Importance: Individuals with Alzheimer disease (AD) and Alzheimer disease-related dementias (ADRD) may be at increased risk for adverse outcomes relating to inappropriate prescribing of certain high-risk medications, including antipsychotics, sedative-hypnotics, and strong anticholinergic agents., Objective: To evaluate the effect of a patient/caregiver and prescriber-mailed educational intervention on potentially inappropriate prescribing to patients with AD or ADRD., Design, Setting, and Participants: This prospective, open-label, pragmatic randomized clinical trial, embedded in 2 large national health plans, was conducted from April 2022 to June 2023. The trial included patients with AD or ADRD and use of any of 3 drug classes targeted for deprescribing (antipsychotics, sedative-hypnotics, or strong anticholinergics)., Interventions: Patients were randomized to 1 of 3 arms: (1) a mailing of educational materials specific to the medication targeted for deprescribing to both the patient and their prescribing clinician; (2) a mailing to the prescribing clinician only; or (3) a usual care arm., Main Outcomes and Measures: Analysis was performed using a modified intention-to-treat approach. The primary study outcome was the dispensing of the medication targeted for deprescribing during a 6-month study observation period. Secondary outcomes included changes in medication-specific mean daily dose and health service utilization., Results: Among 12 787 patients included in the modified intention-to-treat analysis, 8742 (68.4%) were female, and the mean (SD) age was 77.3 (9.4) years. The cumulative incidence of being dispensed a medication targeted for deprescribing was 76.7% (95% CI, 75.4-78.0) in the patient and prescriber mailing group, 77.9% (95% CI, 76.5-79.1) in the prescriber mailing only group, and 77.5% (95% CI, 76.2-78.8) in the usual care group. Hazard ratios were 0.99 (95% CI, 0.94-1.04) for the patient and prescriber group and 1.00 (95% CI, 0.96-1.06) for the prescriber only group compared with the usual care group. There were no differences between the groups for secondary outcomes., Conclusions and Relevance: These findings suggest medication-specific educational mailings targeting patients with AD or ADRD and their clinicians are not effective in reducing the use of high-risk medications., Trial Registration: ClinicalTrials.gov Identifier: NCT05147428.

Background/objective: Hypertensive disorders of pregnancy (HDP) are a major cause of maternal morbidity and mortality in the US. Improved diagnosis and treatment of HDP may be achieved through home blood pressure monitoring (HBPM). However, there are challenges to effective HBPM during pregnancy. This qualitative study was conducted to explore patients' perspectives and experiences with HBPM., Methods: Pregnant or recently postpartum women with HDP (≥18 years) were recruited from an academic medical center to virtual focus groups from March to September 2023. The discussions centered on experiences with HDP and barriers and facilitators to HBPM. Qualitative thematic analysis was performed., Results: Among 20 participants, the mean age was 33.8 (SD 5.9) years, with 35% Hispanic and 35% Black/African-American. Facilitators to HBPM included understanding the parameters/purpose of HBPM, prior experience with healthcare/duration of hypertension, free access to HBPM equipment and decision support, creating a routine, external support/counseling (e.g., partner/healthcare/family), and technology support. Barriers to HBPM included uncertainty/lack of training about the HBPM process, accessing/using HBPM equipment, the belief that clinic monitoring was sufficient/achieving good control, and activation barriers to making HBPM a priority (e.g., fear of affirming the diagnosis, higher priorities/life stressors)., Conclusion: Many of the barriers to HBPM in pregnancy can be overcome through patient education/counseling, technology support, clinician/family reinforcement, and better access to validated blood pressure monitors. Given the importance of HBPM in improving outcomes for HDP, it is important for healthcare providers and policy makers to work to reduce barriers and amplify facilitators to HBPM for better adoption., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To describe primary care providers' (PCPs) perspectives on discussing COVID-19 vaccination with their patients., Methods: All PCPs from 11 primary care clinics at 3 health systems were invited to participate. Focus groups were conducted between December 2021-January 2022, and were recorded and transcribed. Participants were asked about their experience communicating about the COVID-19 vaccine. Themes and subthemes were inductively identified using thematic analysis., Results: 40 PCPs participated. All PCPs viewed discussing COVID-19 vaccination as high priority. Strategies for promoting COVID-19 vaccination included influencing what people think and feel, building trust and leveraging their relationship with patients, and practical strategies such as on-site vaccination. Most strategies aimed at influencing what people think and feel and leveraging relationships were viewed as generally ineffective. On-site vaccine availability was identified as the most influential factor. PCPs expressed frustration by their interactions with vaccine hesitant patients, leading them to truncate their communication with these patients., Conclusions: Despite using a broad range of strategies, most PCPs were unable to change the strongly held beliefs among the most vaccine hesitant patients that were often informed by misinformation and mistrust., Practice Implications: Promising strategies for promoting vaccination include social/relational (expressing empathy) and practical (on-site COVID-19 vaccine availability)., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Kimberly A. Fisher reports financial support was provided by National Institute on Minority Health and Health Disparities Division of Intramural Research. Kimberly A. Fisher reports a relationship with American Thoracic Society that includes: consulting or advisory. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

The ongoing hepatitis C virus (HCV) epidemic in the United States disproportionately affects rural people who inject drugs (PWID). This study explores the HCV risk environment in rural northern New England by examining PWID experiences and perceptions of HCV and injection equipment-sharing practices. We performed a thematic analysis on semi-structured interviews conducted with 21 adults with a history of injection drug use from rural New Hampshire, Vermont, and Massachusetts between April 2018 and August 2019. Salient themes included: (1) limited and varied access to sterile syringe sources; (2) syringe scarcity contributing to the use of informal syringe sources (e.g., secondary syringe exchange or syringe sellers who purchased syringes from out-of-state pharmacies); (3) syringe scarcity contributing to syringe sharing; (4) linkages among decisions about syringe sharing and perceptions of HCV risk, HCV status, and interpersonal trust; and (5) confusion and misconceptions about HCV, including difficulty learning one's HCV status, inadequate HCV education, and misconceptions regarding HCV transmission and treatment. Efforts to prevent and eliminate HCV among rural PWID should expand syringe access, increase awareness of HCV as a serious but preventable risk, and acknowledge social connections as potential influences on syringe access and syringe-sharing decisions.

Aim: To identify factors associated with willingness to participate in a COVID-19 clinical trial and reasons for and against participating. Materials & methods: We surveyed Massachusetts (MA, USA) residents online using the Dynata survey platform and via phone using random digit dialing between October and November 2021. Respondents were asked to imagine they were hospitalized with COVID-19 and invited to participate in a treatment trial. We assessed willingness to participate by asking, "Which way are you leaning" and why. We used multivariate logistic regression to model factors associated with leaning toward participation. Open-ended responses were analyzed using conventional content analysis. Results: Of 1071 respondents, 65.6% leaned toward participating. Multivariable analyses revealed college-education (OR: 1.59; 95% CI: 1.11, 2.27), trust in the healthcare system (OR: 1.32; 95% CI: 1.10, 1.58) and relying on doctors (OR: 1.77; 95% CI: 1.45, 2.17) and family or friends (OR: 1.31; 95% CI: 1.11, 1.54) to make health decisions were significantly associated with leaning toward participating. Respondents with lower health literacy (OR: 0.57; 95% CI: 0.36, 0.91) and who identify as Black (OR: 0.40; 95% CI: 0.24, 0.68), Hispanic (OR: 0.61; 95% CI: 0.38, 0.98), or republican (OR: 0.61; 95% CI: 0.38, 0.97) were significantly less likely to lean toward participating. Common reasons for participating included helping others, benefitting oneself and deeming the study low risk. Common reasons for leaning against were deeming the study high risk, disliking experimental treatments and not wanting to be a guinea pig. Conclusion: Our finding that vulnerable individuals and those with lower levels of trust in the healthcare system are less likely to be receptive to participating in a COVID-19 clinical trial highlights that work is needed to achieve a healthcare system that provides confidence to historically disadvantaged groups that their participation in research will benefit their community.

Importance: Residents must prepare for effective communication with patients after medical errors. The video-based communication assessment (VCA) is software that plays video of a patient scenario, asks the physician to record what they would say, engages crowdsourced laypeople to rate audio recordings of physician responses, and presents feedback to physicians., Objective: To evaluate the effectiveness of VCA feedback in resident error disclosure skill training., Design, Setting, and Participants: This single-blinded, randomized clinical trial was conducted from July 2022 to May 2023 at 7 US internal medicine and family medicine residencies (10 total sites). Participants were second-year residents attending required teaching conferences. Data analysis was performed from July to December 2023., Intervention: Residents completed 2 VCA cases at time 1 and were randomized to the intervention, an individual feedback report provided in the VCA application after 2 weeks, or to control, in which feedback was not provided until after time 2. Residents completed 2 additional VCA cases after 4 weeks (time 2)., Main Outcomes and Measures: Panels of crowdsourced laypeople rated recordings of residents disclosing simulated medical errors to create scores on a 5-point scale. Reports included learning points derived from layperson comments. Mean time 2 ratings were compared to test the hypothesis that residents who had access to feedback on their time 1 performance would score higher at time 2 than those without feedback access. Residents were surveyed about demographic characteristics, disclosure experience, and feedback use. The intervention's effect was examined using analysis of covariance., Results: A total of 146 residents (87 [60.0%] aged 25-29 years; 60 female [41.0%]) completed the time 1 VCA, and 103 (70.5%) completed the time 2 VCA (53 randomized to intervention and 50 randomized to control); of those, 28 (54.9%) reported reviewing their feedback. Analysis of covariance found a significant main effect of feedback between intervention and control groups at time 2 (mean [SD] score, 3.26 [0.45] vs 3.14 [0.39]; difference, 0.12; 95% CI, 0.08-0.48; P = .01). In post hoc comparisons restricted to residents without prior disclosure experience, intervention residents scored higher than those in the control group at time 2 (mean [SD] score, 3.33 [0.43] vs 3.09 [0.44]; difference, 0.24; 95% CI, 0.01-0.48; P = .007). Worse performance at time 1 was associated with increased likelihood of dropping out before time 2 (odds ratio, 2.89; 95% CI, 1.06-7.84; P = .04)., Conclusions and Relevance: In this randomized clinical trial, self-directed review of crowdsourced feedback was associated with higher ratings of internal medicine and family medicine residents' error disclosure skill, particularly for those without real-life error disclosure experience, suggesting that such feedback may be an effective way for residency programs to address their requirement to prepare trainees for communicating with patients after medical harm., Trial Registration: ClinicalTrials.gov Identifier: NCT06234085.

Introduction: The COVID-19 pandemic has been characterized by disparities in disease burden and medical care provision. Whether these disparities extend to long COVID awareness and receipt of medical care is unknown. We aimed to characterize awareness of long COVID and receipt of medical care for long COVID symptoms among populations who experience disparities in the United States (US)., Methods: We conducted a cross-sectional survey among a national sample of US adults between January 26-February 5, 2023. We surveyed approximately 2,800 adults drawn from the Ipsos probability-based KnowledgePanel® who identify as White, Black, or Hispanic, with over-sampling of Black, Hispanic, and Spanish-proficient adults. Awareness of long COVID was assessed with the question, "Have you heard of long COVID? This is also referred to as post-COVID, Long-haul COVID, Post-acute COVID-19, or Chronic COVID." Respondents reporting COVID-19 symptoms lasting longer than 1 month were classified as having long COVID and asked about receipt of medical care., Results: Of the 2,828 respondents, the mean age was 50.4 years, 52.8% were female, 40.2% identified as Hispanic, 29.8% as Black, and 26.7% as White. 18% completed the survey in Spanish. Overall, 62.5% had heard of long COVID. On multivariate analysis, long COVID awareness was lower among respondents who identified as Black (OR 0.64; 95% CI 0.51, 0.81), Hispanic and completed the survey in English (OR 0.59; 95% CI 0.46, 0.76), and Hispanic and completed the survey in Spanish (OR 0.31, 95% C.I. 0.23, 0.41), compared to White respondents (overall p < 0.001). Long COVID awareness was also associated with educational attainment, higher income, having health insurance, prior history of COVID-19 infection, and COVID-19 vaccination. Among those reporting symptoms consistent with long COVID ( n = 272), 26.8% received medical care. Older age, longer symptom duration and greater symptom impact were associated with receipt of medical care for long COVID symptoms. Of those who received care, most (77.8%) rated it as less than excellent on a 5-point scale., Discussion: This survey reveals limited awareness of long COVID and marked disparities in awareness according to race, ethnicity, and language. Targeted public health campaigns are needed to raise awareness., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer RS declared a shared parent affiliation, with the authors JM and BL to the handling editor at the time of the review., (Copyright © 2024 Fisher, Mazor, Epstein, Goldthwait, Abu Ghazaleh, Zhou, Crawford, Marathe and Linas.)

Background: Effective primary care necessitates follow-up actions by the patient beyond the visit. Prior research suggests room for improvement in patient adherence., Objective: This study sought to understand patients' views on their primary care visits, the plans generated therein, and their self-reported adherence after 3 months., Methods: As part of a large multisite cluster randomized pragmatic trial in 3 health care organizations, patients completed 2 surveys-the first within 7 days after the index primary care visit and another 3 months later. For this analysis of secondary outcomes, we combined the results across all study participants to understand patient adherence to care plans. We recorded patient characteristics and survey responses. Cross-tabulation and chi-square statistics were used to examine bivariate associations, adjusting for multiple comparisons when appropriate. We used multivariable logistic regression to assess how patients' intention to follow, agreement, and understanding of their plans impacted their plan adherence, allowing for differences in individual characteristics. Qualitative content analysis was conducted to characterize the patient's self-reported plans and reasons for adhering (or not) to the plan 3 months later., Results: Of 2555 patients, most selected the top box option (9=definitely agree) that they felt they had a clear plan (n=2011, 78%), agreed with the plan (n=2049, 80%), and intended to follow the plan (n=2108, 83%) discussed with their provider at the primary care visit. The most common elements of the plans reported included reference to exercise (n=359, 14.1%), testing (laboratory, imaging, etc; n=328, 12.8%), diet (n=296, 11.6%), and initiation or adjustment of medications; (n=284, 11.1%). Patients who strongly agreed that they had a clear plan, agreed with the plan, and intended to follow the plan were all more likely to report plan completion 3 months later (P<.001) than those providing less positive ratings. Patients who reported plans related to following up with the primary care provider (P=.008) to initiate or adjust medications (P≤.001) and to have a specialist visit were more likely to report that they had completely followed the plan (P=.003). Adjusting for demographic variables, patients who indicated intent to follow their plan were more likely to follow-through 3 months later (P<.001). Patients' reasons for completely following the plan were mainly that the plan was clear (n=1114, 69.5%), consistent with what mattered (n=1060, 66.1%), and they were determined to carry through with the plan (n=887, 53.3%). The most common reasons for not following the plan were lack of time (n=217, 22.8%), having decided to try a different approach (n=105, 11%), and the COVID-19 pandemic impacted the plan (n=105, 11%)., Conclusions: Patients' initial assessment of their plan as clear, their agreement with the plan, and their initial willingness to follow the plan were all strongly related to their self-reported completion of the plan 3 months later. Patients whose plans involved lifestyle changes were less likely to report that they had "completely" followed their plan., Trial Registration: ClinicalTrials.gov NCT03385512; https://clinicaltrials.gov/study/NCT03385512., International Registered Report Identifier (irrid): RR2-10.2196/30431., (©Cheryl D Stults, Kathleen M Mazor, Michael Cheung, Bernice Ruo, Martina Li, Amanda Walker, Cassandra Saphirak, Florin Vaida, Sonal Singh, Kimberly A Fisher, Rebecca Rosen, Robert Yood, Lawrence Garber, Christopher Longhurst, Gene Kallenberg, Edward Yu, Albert Chan, Marlene Millen, Ming Tai-Seale. Originally published in Journal of Participatory Medicine (https://jopm.jmir.org), 14.03.2024.)

Context: Potentially inappropriate prescribing of medications in older adults, particular those with dementia, can lead to adverse drug events including falls and fractures, worsening cognitive impairment, emergency department visits, and hospitalizations. Educational mailings from health plans to patients and their providers to encourage deprescribing conversations may represent an effective, low-cost, "light touch", approach to reducing the burden of potentially inappropriate prescription use in older adults with dementia., Objectives: The objective of the Developing a PRogram to Educate and Sensitize Caregivers to Reduce the Inappropriate Prescription Burden in Elderly with Alzheimer's Disease (D-PRESCRIBE-AD) trial is to evaluate the effect of a health plan based multi-faceted educational outreach intervention to community dwelling patients with dementia who are currently prescribed sedative/hypnotics, antipsychotics, or strong anticholinergics., Methods: The D-PRESCRIBE-AD is an open-label pragmatic, prospective randomized controlled trial (RCT) comparing three arms: 1) educational mailing to both the health plan patient and their prescribing physician (patient plus physician arm, n = 4814); 2) educational mailing to prescribing physician only (physician only arm, n = 4814); and 3) usual care (n = 4814) among patients with dementia enrolled in two large United States based health plans. The primary outcome is the absence of any dispensing of the targeted potentially inappropriate prescription during the 6-month study observation period after a 3-month black out period following the mailing. Secondary outcomes include dose-reduction, polypharmacy, healthcare utilization, mortality and therapeutic switching within targeted drug classes., Conclusion: This large pragmatic RCT will contribute to the evidence base on promoting deprescribing of potentially inappropriate medications among older adults with dementia. If successful, such light touch, inexpensive and highly scalable interventions have the potential to reduce the burden of potentially inappropriate prescribing for patients with dementia. ClinicalTrials.gov Identifier: NCT05147428., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Singh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Hepatitis C virus (HCV) disproportionately affects rural communities, where health services are geographically dispersed. It remains unknown whether proximity to a syringe services program (SSP) is associated with HCV infection among rural people who inject drugs (PWID)., Methods: Data are from a cross-sectional sample of adults who reported injecting drugs in the past 30 days recruited from rural counties in New Hampshire, Vermont, and Massachusetts (2018-2019). We calculated the road network distance between each participant's address and the nearest fixed-site SSP, categorized as ≤ 1 mile, 1-3 miles, 3-10 miles, and > 10 miles. Staff performed HCV antibody tests and a survey assessed past 30-day injection equipment sharing practices: borrowing used syringes, borrowing other used injection equipment, and backloading. Mixed effects modified Poisson regression estimated prevalence ratios (aPR) and 95% confidence intervals (95% CI). Analyses were also stratified by means of transportation., Results: Among 330 PWID, 25% lived ≤ 1 mile of the nearest SSP, 17% lived 1-3 miles of an SSP, 12% lived 3-10 miles of an SSP, and 46% lived > 10 miles from an SSP. In multivariable models, compared to PWID who lived within 1 mile of an SSP, those who lived 3 to 10 miles away had a higher prevalence of HCV seropositivity (aPR: 1.25, 95% CI 1.06-1.46), borrowing other used injection equipment (aPR: 1.23, 95% CI 1.04-1.46), and backloading (aPR: 1.48, 95% CI 1.17-1.88). Similar results were observed for PWID living > 10 miles from an SSP: aPR [HCV]: 1.19, 95% CI 1.01-1.40; aPR [borrowing other used equipment]:1.45, 95% CI 1.29-1.63; and aPR [backloading]: 1.59, 95% CI 1.13-2.24. Associations between living 1 to 3 miles of an SSP and each outcome did not reach statistical significance. When stratified by means of transportation, associations between distance to SSP and each outcome (except borrowing other used injection equipment) were only observed among PWID who traveled by other means (versus traveled by automobile)., Conclusions: Among PWID in rural New England, living farther from a fixed-site SSP was associated with a higher prevalence of HCV seropositivity, borrowing other used injection equipment, and backloading, reinforcing the need to increase SSP accessibility in rural areas. Means of transportation may modify this relationship., (© 2023. The Author(s).)

Context: Pseudohypoparathyroidism type IA (PHPIA) is a rare genetic disorder characterized by hormone resistance and a typical phenotype named Albright hereditary osteodystrophy. Unawareness of this rare disease leads to delays in diagnosis., Objective: The aims of this study were to describe the clinical and molecular characteristics of patients with genetically confirmed GNAS mutations and to evaluate their long-term outcomes., Methods: A retrospective search for all patients diagnosed with PHPIA in 2 referral centers in Israel was conducted., Results: Nine children (8 females) belonging to 6 families were included in the study. Five patients had GNAS missense mutations, 2 had deletions, and 2 had frameshift mutations. Four mutations were novel. Patients were referred at a mean age of 2.4 years due to congenital hypothyroidism (5 patients), short stature (2 patients), or obesity (2 patients), with a follow-up duration of up to 20 years. Early obesity was observed in the majority of patients. Elevated parathyroid hormone was documented at a mean age of 3 years; however, hypocalcemia became evident at a mean age of 5.9 years, about 3 years later. All subjects were diagnosed with mild to moderate mental retardation. Female adult height was very short (mean -2.5 SD) and 5 females had primary or secondary amenorrhea., Conclusion: Long-term follow-up of newborns with a combination of congenital hypothyroidism, early-onset obesity, and minor dysmorphic features associated with PHPIA is warranted and molecular analysis is recommended since the complete clinical phenotype may develop a long time after initial presentation., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background Accountable care organizations (ACOs) aim to improve health care quality and reduce costs, including among patients with heart failure (HF). However, variation across ACOs in admission rates for patients with HF and associated factors are not well described. Methods and Results We identified Medicare fee-for-service beneficiaries with HF who were assigned to a Medicare Shared Savings Program ACO in 2017 and survived ≥30 days into 2018. We calculated risk-standardized acute admission rates across ACOs, assigned ACOs to 1 of 3 performance categories, and examined associations between ACO characteristics and performance categories. Among 1 232 222 beneficiaries with HF, 283 795 (mean age, 81 years; 54% women; 86% White; 78% urban) were assigned to 1 of 467 Medicare Shared Savings Program ACOs. Across ACOs, the median risk-standardized acute admission rate was 87 admissions per 100 people, ranging from 61 (minimum) to 109 (maximum) admissions per 100 beneficiaries. Compared to the overall average, 13% of ACOs performed better on risk-standardized acute admission rates, 72% were no different, and 14% performed worse. Most ACOs with better performance had fewer Black beneficiaries and were not hospital affiliated. Most ACOs that performed worse than average were large, located in the Northeast, had a hospital affiliation, and had a lower proportion of primary care providers. Conclusions Admissions are common among beneficiaries with HF in ACOs, and there is variation in risk-standardized acute admission rates across ACOs. ACO performance was associated with certain ACO characteristics. Future studies should attempt to elucidate the relationship between ACO structure and characteristics and admission risk.

Objectives: COVID-19 vaccines are widely available, but uptake is suboptimal. To develop strategies to increase vaccination rates, we sought to (1) characterize adults initially hesitant to be vaccinated for COVID-19 who later received the vaccine and (2) identify factors associated with their vaccination decision., Methods: In January 2021, we conducted an online survey of US adults via Prolific that assessed vaccination intent, COVID-19-related knowledge and attitudes, and demographic characteristics. In May 2021, we recontacted respondents to assess vaccination status and factors influencing their vaccination decision. We used χ 2 statistics and t tests to examine associations between respondents' vaccination status and their characteristics, knowledge, and attitudes. We analyzed reasons for vaccination using thematic analysis., Results: Of 756 initially vaccine-hesitant respondents, 529 (70.0%) completed the follow-up survey. Nearly half of those initially not sure about vaccination (47.3%, 112 of 237) were vaccinated at follow-up, while 21.2% (62 of 292) of those initially planning not to be vaccinated were vaccinated at follow-up. Of those initially not sure, higher educational attainment, greater knowledge of COVID-19, and a doctor's recommendation were associated with vaccination. Of those initially intending not to be vaccinated, male sex, Democratic political affiliation, receipt of an influenza shot within 5 years, being more worried about COVID-19, and having greater COVID-19 knowledge were associated with increased likelihood of being vaccinated. Of 167 respondents who gave reasons for vaccination, protecting oneself and others (59.9%), practical issues (29.9%), social influences (17.4%), and vaccine safety (13.8%) were the main reasons., Conclusion: Providing information on the protective value of vaccination, implementing rules that make remaining unvaccinated burdensome, making vaccination easy, and providing social support may influence vaccine-hesitant adults to accept vaccination.

Background: Regional, facility, and racial variability in intensity of care provided to nursing home (NH) residents with advanced dementia is poorly understood., Materials and Methods: Assessment of Disparities and Variation for Alzheimer's disease NH Care at End of life (ADVANCE) is a multisite qualitative study of 14 NHs from four hospital referral regions providing varied intensity of advanced dementia care based on tube-feeding and hospital transfer rates. This report explored the perceptions and experiences of Black and White proxies (N = 44) of residents with advanced dementia to elucidate factors driving these variations. Framework analyses revealed themes and subthemes within the following a priori domains: understanding of advanced dementia and care decisions, preferences related to end-of-life care, advance care planning, decision-making about managing feeding problems and acute illness, communication and trust in NH providers, support, and spirituality in decision-making. Matrix analyses explored similarities/differences by proxy race. Data were collected from June 1, 2018 to July 31, 2021., Results: Among 44 proxies interviewed, 19 (43.1%) were Black, 36 (81.8%) were female, and 26 (59.0%) were adult children of residents. In facilities with the lowest intensity of care, Black and White proxies consistently reported having had previous conversations with residents about wishes for end-of-life care and generally better communication with providers. Black proxies held numerous misconceptions about the clinical course of advanced dementia and effectiveness of treatment options, notably tube-feeding and cardiopulmonary resuscitation. Black and White proxies described mistrust of NH staff but did so towards different staffing roles. Religious and spiritual beliefs commonly thought to underlie preferences for more intense care among Black residents, were rarely, but equally mentioned by race., Conclusions: This report refuted commonly held assumptions about religiosity and spirituality as drivers of racial variations in advanced dementia care and revealed several actionable facility-level factors, which may help reduce these variations., (© 2023 The American Geriatrics Society.)

Background: The prevalence of obesity (body mass index ≥ 30) among nursing home residents has been increasing, but there has been little research on weight change in this population. We examined resident characteristics associated with substantial weight loss among nursing home residents with obesity., Methods: Using data from the Minimum Data Set 3.0, this retrospective study included long-stay nursing home residents with obesity newly admitted to a facility in 2014 who had annual assessments in 2015. Substantial weight loss was defined as a loss of ≥10% body weight within a year. Multivariate regression analyses were conducted to identify factors associated with weight loss, including demographic characteristics, medical conditions, and functional limitations in activities of daily living (ADL)., Results: Among 59782 newly admitted nursing home residents with obesity, 23% experienced substantial weight loss during their first year in the nursing home. Moderate ADL dependency (odds ratio [OR] = 1.42, 95% confidence interval [CI]: 1.31-1.53), severe ADL dependency (OR = 1.83; 95% CI: 1.67-1.99), severe mobility impairment (OR = 1.15; 95% CI: 1.04-1.23), and severe cognitive impairment (OR = 1.13; 95% CI: 1.07-1.19), as well as cancer (OR = 1.10; 95% CI: 1.01-1.20), heart failure (OR = 1.06; 95% CI: 1.01-1.11), end-stage renal disease (OR = 1.17; 95% CI: 1.11-1.23), and bowel incontinence (OR = 1.19; 95% CI: 1.14-1.25) were associated with weight loss., Conclusion: Substantial weight loss is common among nursing home residents with obesity over a 1-year period following admission, and these residents have a greater burden of functional and cognitive impairment and specific medical conditions. These findings suggest the need to further elucidate the clinical implications of weight loss among this population., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: Monoclonal gammopathy of undetermined significance (MGUS) is the precursor of multiple myeloma. This qualitative study described patient (n = 14) experiences and healthcare providers' (n = 8) opinions and practices concerning care for patients with MGUS in the US., Methods: Semi-structured, in-depth interviews were analyzed using thematic analysis., Results: We identified six overarching themes related to the care pathway for patients with MGUS: (1) Process of MGUS diagnosis, (2) Providers' explanations, (3) Patients' understanding, (4) Impact of the diagnosis, (5) Follow-up/management, and (6) Factors influencing healthcare utilization. Patients demonstrated a basic understanding of MGUS. However, some patients felt anxiety around the diagnosis, which may affect other aspects of their lives. Non-hematologist providers report having less MGUS-specific knowledge. Older age, high-risk MGUS, and insurance coverage/healthcare costs influenced healthcare utilization., Conclusion: Patients with MGUS may have difficulty processing this premalignant diagnosis. Non-hematologist providers may have gaps in knowledge around specific care for patients with MGUS., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Objective: Low health literacy is a concern among US Veterans. In this study, we evaluated NoteAid, a system that provides lay definitions to medical jargon terms in EHR notes to help Veterans comprehend EHR notes. We expected that low initial scores for Veterans would be improved by using NoteAid., Materials and Methods: We recruited Veterans from the Amazon Mechanical Turk crowd work platform (MTurk). We also recruited non-Veterans from MTurk as a control group for comparison. We randomly split recruited MTurk Veteran participants into control and intervention groups. We recruited non-Veteran participants into mutually exclusive control or intervention tasks on the MTurk platform. We showed participants de-identified EHR notes and asked them to answer comprehension questions related to the notes. We provided participants in the intervention group with EHR note content processed with NoteAid, while NoteAid was not available for participants in the control group., Results: We recruited 94 Veterans and 181 non-Veterans. NoteAid leads to a significant improvement for non-Veterans but not for Veterans. Comparing Veterans recruited via MTurk with non-Veterans recruited via MTurk, we found that without NoteAid, Veterans have significantly higher raw scores than non-Veterans. This difference is not significant with NoteAid., Discussion: That Veterans outperform a comparable population of non-Veterans is a surprising outcome. Without NoteAid, scores on the test are already high for Veterans, therefore, minimizing the ability of an intervention such as NoteAid to improve performance. With regards to Veterans, understanding the health literacy of Veterans has been an open question. We show here that Veterans score higher than a comparable, non-Veteran population., Conclusion: Veterans on MTurk do not see improved scores when using NoteAid, but they already score high on the test, significantly higher than non-Veterans. When evaluating NoteAid, population specifics need to be considered, as performance may vary across groups. Future work investigating the effectiveness of NoteAid on improving comprehension with local Veterans and developing a more difficult test to assess groups with higher health literacy is needed., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Patient education of high-risk medications such as direct oral anticoagulants (DOACs) is limited in ambulatory care settings. Clinical pharmacists are uniquely equipped to educate patients about DOACS but seldom interact with patients in those settings where patient education and satisfaction are often overlooked. Recently, the Anticoagulation Forum endorsed a checklist (DOAC Checklist) to guide and educate patients initiating or resuming DOACs. We assessed the impact on knowledge and satisfaction of an intervention framed around the checklist. Randomized clinical trial. Ambulatory patients starting a DOAC or resuming one after setback (bleeding, stroke, or transient ischemic attack) in an ambulatory setting (office, emergency department, or short stay hospitalization). Three educational clinical pharmacist tele-visits, hotline access to the pharmacist, and coordination with continuity providers in 3 months. Patient knowledge scores from a 15-item DOAC-related questionnaire and satisfaction scores from an abbreviated version of the Duke Anticoagulation Satisfaction Survey (DASS). Of 561 randomized patients, 436 completed our follow-up surveys. Knowledge scores were similar for the 233 intervention patients vs. 203 control patients (63.7% vs 62.2% correct). Satisfaction scores on the 7-point Likert scale were virtually identical (6.24 and 6.22). Our pharmacist-led intervention framed around the DOAC checklist had little impact on knowledge and satisfaction. Delays between intervention end and completion of the follow-up questionnaires may have obscured benefits experienced earlier. More intensive education or strategies other than telephone-based consultation may be required to produce sustained knowledge.TRN: NCT04068727 retrospectively registered on August 22, 2019., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To test the impact of varied physician recommendations on COVID-19 vaccine hesitancy., Methods: We conducted a vignette-based experimental survey on Prolific, an online research platform. COVID-19 vaccine hesitant, adult panel members were assigned to one of five messages that varied by recommendation style (participatory vs explicit) and strategy (acknowledgement of concerns; comparison to the flu shot; statement that millions of people have already received it; emphasis on protecting others). Vaccine hesitancy was re-assessed with the question, "Would you get vaccinated at this visit?"., Results: Of the 752 participants, 60.1% were female, 43.4% Black, 23.6% Latino, and 33.0% White; mean age was 35.6 years. Overall, 33.1% of the initially "not sure" and 13.1% of the initially "no" participants became less hesitant following any recommendation. Among the "not sure" participants, 20.3% of those who received a participatory recommendation became less hesitant compared with 34.3%- 39.5% for the explicit recommendations. The "protect others" message was most effective among initially "no" participants; 19.8% become less hesitant, compared to 8.7% for the participatory recommendation., Conclusion: A physician recommendation may reduce COVID-19 vaccine hesitancy., Practice Implications: An explicit recommendation and "protect others" message appear to be important elements of a physician recommendation for COVID-19 vaccination., Competing Interests: Declaration of Competing Interest The authors have no competing interests to report., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Physician delivered weight management counseling (WMC) occurs infrequently and physicians report lack of training and poor self-efficacy. The purpose of this study was to develop and test the Video-based Communication Assessment (VCA) for weight management counseling (WMC) training in medical residents., Methods: This study was a mixed methods pilot conducted in 3 phases. First, we created five vignettes based on our prior data and expert feedback, then administered the vignettes via the VCA to Internal Medicine categorical residents (n = 16) from a University Medical School. Analog patients rated responses and also provided comments. We created individualized feedback reports which residents were able to view on the VCA. Lastly, we conducted debriefing interviews with the residents (n = 11) to obtain their feedback on the vignettes and personalized feedback. Interviews were transcribed, and we used thematic analysis to generate and apply codes, followed by identifying themes., Results: Descriptive statistics were calculated and learning points were created for the individualized feedback reports. In VCA debriefing interviews with residents, five themes emerged: 1) Overall the VCA was easy to use, helpful and more engaging than traditional learning and assessment modes, 2) Patient scenarios were similar to those encountered in the clinic, including diversity, health literacy and different stages of change, 3) The knowledge, skills, and reminders from the VCA can be transferred to practice, 4) Feedback reports were helpful, to the point and informative, including the exemplar response of how to best respond to the scenario, and 5) The VCA provide alternatives and practice scenarios to real-life patient situations when they aren't always accessible., Conclusions: We demonstrated the feasibility and acceptability of the VCA, a technology delivered platform, for delivering WMC to residents. The VCA exposed residents to diverse patient experiences and provided potential opportunities to tailor providers responses to sociological and cultural factors in WMC scenarios. Future work will examine the effect of the VCA on WMC in actual clinical practice., (© 2022. The Author(s).)

Background and Aim: Patients with lung cancer experience high rates of psychosocial distress. They are also more likely to have unresolved, unmet social needs which may contribute to psychosocial distress. Despite this, neighborhood-level social determinants of health (SDOH) in relation to psychosocial distress have not been adequately investigated in patients with lung cancer. The goal of this study is to examine the association between neighborhood-level SDOH and psychosocial distress among a sample of newly diagnosed patients with lung cancer., Methods: This cross-sectional study included newly diagnosed, adult lung cancer patients from an accredited cancer center. Psychosocial distress was measured with the Distress Thermometer. Neighborhood-level SDOH indicators for income and education were used to create a composite SDOH variable categorized into low, medium, and high deprivation levels. Covariates were age, gender, race/ethnicity, comorbidity index, cancer stage, and insurance status. Using multivariate logistic regression modeling, the association of psychosocial distress with the neighborhood-level SDOH was examined., Results: The prevalence of psychosocial distress in the sample was 58.4%. Neighborhood-level SDOH indicators were not significantly associated with psychosocial distress. Higher odds of psychosocial distress were significantly associated with being female and having distant or regional cancer versus localized cancer. The age group 66-75 years was significantly associated with lower distress compared with those aged <65 years., Conclusions: Psychosocial distress was consistently high across all the SDOH deprivation categories; but these neighborhood-level SDOH indicators do not appear to be predictive of psychosocial distress at the time of diagnosis of lung cancer., (© 2022 The Authors. Cancer Reports published by Wiley Periodicals LLC.)

Background: US residents require practice and feedback to meet Accreditation Council for Graduate Medical Education mandates and patient expectations for effective communication after harmful errors. Current instructional approaches rely heavily on lectures, rarely provide individualized feedback to residents about communication skills, and may not assure that residents acquire the skills desired by patients. The Video-based Communication Assessment (VCA) app is a novel tool for simulating communication scenarios for practice and obtaining crowdsourced assessments and feedback on physicians' communication skills. We previously established that crowdsourced laypeople can reliably assess residents' error disclosure skills with the VCA app. However, its efficacy for error disclosure training has not been tested., Objective: We aimed to evaluate the efficacy of using VCA practice and feedback as a stand-alone intervention for the development of residents' error disclosure skills., Methods: We conducted a pre-post study in 2020 with pathology, obstetrics and gynecology, and internal medicine residents at an academic medical center in the United States. At baseline, residents each completed 2 specialty-specific VCA cases depicting medical errors. Audio responses were rated by at least 8 crowdsourced laypeople using 6 items on a 5-point scale. At 4 weeks, residents received numerical and written feedback derived from layperson ratings and then completed 2 additional cases. Residents were randomly assigned cases at baseline and after feedback assessments to avoid ordinal effects. Ratings were aggregated to create overall assessment scores for each resident at baseline and after feedback. Residents completed a survey of demographic characteristics. We used a 2×3 split-plot ANOVA to test the effects of time (pre-post) and specialty on communication ratings., Results: In total, 48 residents completed 2 cases at time 1, received a feedback report at 4 weeks, and completed 2 more cases. The mean ratings of residents' communication were higher at time 2 versus time 1 (3.75 vs 3.53; P<.001). Residents with prior error disclosure experience performed better at time 1 compared to those without such experience (ratings: mean 3.63 vs mean 3.46; P=.02). No differences in communication ratings based on specialty or years in training were detected. Residents' communication was rated higher for angry cases versus sad cases (mean 3.69 vs mean 3.58; P=.01). Less than half of all residents (27/62, 44%) reported prior experience with disclosing medical harm to patients; experience differed significantly among specialties (P<.001) and was lowest for pathology (1/17, 6%)., Conclusions: Residents at all training levels can potentially improve error disclosure skills with VCA practice and feedback. Error disclosure curricula should prepare residents for responding to various patient affects. Simulated error disclosure may particularly benefit trainees in diagnostic specialties, such as pathology, with infrequent real-life error disclosure practice opportunities. Future research should examine the effectiveness, feasibility, and acceptability of VCA within a longitudinal error disclosure curriculum., (©Andrew A White, Ann M King, Angelo E D’Addario, Karen Berg Brigham, Suzanne Dintzis, Emily E Fay, Thomas H Gallagher, Kathleen M Mazor. Originally published in JMIR Medical Education (https://mededu.jmir.org), 03.10.2022.)

Introduction: Older adults with Alzheimer's disease and related dementias (ADRD) are at increased risk of harm due to prescribing of potentially inappropriate medications. Encouraging patients and caregivers to talk with their providers about potentially inappropriate medications could stimulate deprescribing. Our objective was to explore whether mailing educational materials to patients with ADRD might activate patients or caregivers to initiate a conversation with their provider about potentially inappropriate medications., Methods: We conducted semi-structured interviews with patients with ADRD, caregivers of patients with ADRD, and healthcare providers. All participants were shown educational materials referencing potentially inappropriate medications and suggestions to promote deprescribing. Interviews explored reactions to the materials, the idea of patients and caregivers initiating a conversation about deprescribing, and the deprescribing process. Interview transcripts were analyzed using inductive thematic analysis., Results: We conducted a total of 27 interviews: 9 with caregivers only, 2 with patients only, 3 with patient-caregiver dyads, and 13 with providers. Patients and caregivers reported that if a medication might cause harm, it would motivate them to talk to their provider about the medication. Trust in the provider could facilitate or inhibit such conversations; conversations would be more likely if there were prior positive experiences asking questions of the provider. Providers were receptive to patients and caregivers initiating conversations about their medications, as they valued deprescribing as part of their clinical practice and welcome informed patients and caregivers as participants in decision-making about medication., Conclusion: Mailing educational materials about potentially inappropriate medications to community-dwelling patients with ADRD may promote deprescribing conversations. Ongoing pragmatic trials will determine whether such interventions stimulate deprescribing conversations and achieve reductions in prescribing of inappropriate medications., Plain Language Summary: Encouraging patients with Alzheimer's disease to talk with their providers about medications that may cause harm Introduction: Older adults with Alzheimer's disease and related dementias (ADRD) are sometimes prescribed medications that may cause harm, especially when taken for extended periods of time. Patients and their caregivers may not know about the risks. Doctors know of the risks but may not address them due to competing priorities or other challenges in providing care to these patients with complex needs. Encouraging the patient or their caregiver to talk to their doctor about their medications might help to reduce the use of medications that are not beneficial. This study's goal was to explore whether sending educational materials to patients with ADRD might encourage patients or caregivers to ask their doctor about their medications. Methods: We interviewed patients with ADRD, caregivers, and doctors. We showed them educational materials that suggested patients and their caregivers talk to their doctor about reducing or stopping medications that may be harmful. We asked for reactions to the materials and to the idea of talking to the doctor about stopping the medication. Results: We conducted 27 interviews: 9 with caregivers only, 2 with patients only, 3 with patient-caregiver dyads, and 12 with doctors. Patients and caregivers said learning that a medication might cause harm would motivate them to talk to their doctor about the medication. Trust in their doctor was important. Some patients and caregivers were comfortable asking questions about medications, while others were reluctant to challenge the doctor. Doctors were open to patients and caregivers asking about medications and felt it was important that patients not take medications that are not needed. Conclusion: Sending educational materials to patients with ADRD and caregivers may encourage them to talk with their doctors about stopping or reducing medications. Studies are needed to learn whether such materials lead to reductions in prescribing of potential harmful medications., Competing Interests: Competing interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s), 2022.)

Understanding the progression of monoclonal gammopathy of undetermined significance (MGUS) to multiple myeloma (MM) is needed to identify patients who would benefit from closer clinical surveillance. Given that two of the defining criteria of MM are renal failure and anemia, we described the trajectories of creatinine (Cr) and hemoglobin (Hgb) over time in patients with a diagnosis of MGUS. Patients diagnosed with MGUS (n = 424) were identified by a previously validated case-finding algorithm using health claims and electronic health record data (2007-2015) and followed through 2018. Group-based trajectory modeling identified patients with distinct laboratory value trajectories of Cr (mg/dl) and Hgb (g/dl). Most patients were non-Hispanic White (97.6%) with a mean age of 75 years at MGUS diagnosis. Three multi-trajectory groups were identified: (1) Normal Cr/Hgb (n = 225; 53.1%)-stable serum Cr levels and decreasing, normal Hgb levels; (2) Normal Cr/lower-normal Hgb group (n = 188; 44.3%)-stable, slightly elevated levels of Cr and decreasing levels of Hgb; and (3) High Cr/borderline Hgb group (n = 11; 2.6%)-increased Cr levels and stable low levels of Hgb. Patients with MGUS in Group 2 were older than patients in other groups, and patients in group 3 had more comorbidities than participants in all other groups. Few patients developed MM during the study period. We were able to identify distinct biomarker trajectories in patients with MGUS over time. Future research should investigate how these trajectories may be related to the risk of progression to MM, including M-protein levels., (© 2022 John Wiley & Sons Ltd.)

Objectives: Intensity of care, such as hospital transfers and tube feeding of residents with advanced dementia varies by nursing home (NH) within and across regions. Little work has been done to understand how these 2 levels of influence relate. This study's objectives are to identify facility factors associated with NHs providing high-intensity care to residents with advanced dementia and determine whether these factors differ within and across hospital referral regions (HRRs)., Design: Cross-sectional analysis., Setting and Participants: 1449 NHs., Methods: Nationwide 2016-2017 Minimum Data Set was used to categorize NHs and HRRs into 4 levels of care intensity based on rates of hospital transfers and tube feeding among residents with advanced dementia: low-intensity NH in a low-intensity HRR, high-intensity NH in a low-intensity HRR, low-intensity NH in a high-intensity HRR, and a high-intensity NH in a high-intensity HRR., Results: In high-intensity HRRs, high-vs low-intensity NHs were more likely to be urban, lack a dementia unit, have a nurse practitioner or physician (NP or PA) on staff, and have a higher proportion of residents who were male, aged <65 years, Black, had pressure ulcers, and shorter hospice stays. In low-intensity HRRs, higher proportion of Black residents was the only characteristic associated with being a high-intensity NH., Conclusions and Implications: These findings suggest that within high-intensity HRRs, there are potentially modifiable factors that could be targeted to reduce burdensome care in advanced dementia, including having a dementia unit, palliative care training for NPs and PAs, and increased use of hospice care., (Copyright © 2021 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Physicians' abilities to address obesity in routine care may be affected by their own health behaviors, skills in and attitudes toward weight management counseling (WMC). Gender differences have been noted amongst these factors as well. We examined gender differences in personal health behaviors and predictors of perceived WMC skills and attitudes of medical students enrolled in a WMC trial. Enrollment took place in 2020 and consisted of students from eight U.S. medical schools. Baseline measures included demographics, exercise, and weight management behaviors, WMC attitudes and perceived skills. Descriptive statistics were calculated, and linear mixed models used to assess the effect of personal health behaviors on outcomes of WMC attitudes and perceived skills. Complete data were available for 1145 medical students. More males reported exercising 4 or more days/week (58.6% v. 41.4%), being more likely to monitor their weight (75.6% v. 70.3%) and less likely to intentionally attempt weight loss in the past (50.3% v. 65.3%) compared to females (all p's < 0.05). Exercising 4 or more days per week was positively associated with perceived WMC skills in the adjusted model (β = 0.10, CI 0.06 to 0.14, p < 0.01). Exercise frequency was positively associated with perceived WMC skills, regardless of gender. WMC curriculum may consider focusing on personal health behaviors such as exercise to increase perceived WMC skills., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Author(s).)

An effective clinical research effort in nursing homes to address prevention and treatment of COVID-19 faced overwhelming challenges. Under the Health Care Systems Research Network-Older Americans Independence Centers AGING Initiative, a multidisciplinary Stakeholder Advisory Panel was convened to develop recommendations to improve the capability of the clinical research enterprise in US nursing homes. The Panel considered the nursing home as a setting for clinical trials, reviewed the current state of clinical trials in nursing homes, and ultimately developed recommendations for the establishment of a nursing home clinical trials research network that would be centrally supported and administered. This report summarizes the Panel's recommendations, which were developed in alignment with the following core principles: build on available research infrastructure where appropriate; leverage existing productive partnerships of researchers with groups of nursing homes and nursing home corporations; encompass both efficacy and effectiveness clinical trials; be responsive to a broad range of stakeholders including nursing home residents and their care partners; be relevant to an expansive range of clinical and health care delivery research questions; be able to pivot as necessary to changing research priorities and circumstances; create a pathway for industry-sponsored research as appropriate; invest in strategies to increase diversity in study populations and the research workforce; and foster the development of the next generation of nursing home researchers., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2022 Elsevier Inc., AMDA – the Society for Post-Acute and Long-Term Care Medicine, American Geriatrics Society. Published by Elsevier Inc. All rights reserved.)

Background: Residents may benefit from simulated practice with personalized feedback to prepare for high-stakes disclosure conversations with patients after harmful errors and to meet American Council on Graduate Medical Education mandates. Ideally, feedback would come from patients who have experienced communication after medical harm, but medical researchers and leaders have found it difficult to reach this community, which has made this approach impractical at scale. The Video-Based Communication Assessment app is designed to engage crowdsourced laypeople to rate physician communication skills but has not been evaluated for use with medical harm scenarios., Objective: We aimed to compare the reliability of 2 assessment groups (crowdsourced laypeople and patient advocates) in rating physician error disclosure communication skills using the Video-Based Communication Assessment app., Methods: Internal medicine residents used the Video-Based Communication Assessment app; the case, which consisted of 3 sequential vignettes, depicted a delayed diagnosis of breast cancer. Panels of patient advocates who have experienced harmful medical error, either personally or through a family member, and crowdsourced laypeople used a 5-point scale to rate the residents' error disclosure communication skills (6 items) based on audiorecorded responses. Ratings were aggregated across items and vignettes to create a numerical communication score for each physician. We used analysis of variance, to compare stringency, and Pearson correlation between patient advocates and laypeople, to identify whether rank order would be preserved between groups. We used generalizability theory to examine the difference in assessment reliability between patient advocates and laypeople., Results: Internal medicine residents (n=20) used the Video-Based Communication Assessment app. All patient advocates (n=8) and 42 of 59 crowdsourced laypeople who had been recruited provided complete, high-quality ratings. Patient advocates rated communication more stringently than crowdsourced laypeople (patient advocates: mean 3.19, SD 0.55; laypeople: mean 3.55, SD 0.40; P<.001), but patient advocates' and crowdsourced laypeople's ratings of physicians were highly correlated (r=0.82, P<.001). Reliability for 8 raters and 6 vignettes was acceptable (patient advocates: G coefficient 0.82; crowdsourced laypeople: G coefficient 0.65). Decision studies estimated that 12 crowdsourced layperson raters and 9 vignettes would yield an acceptable G coefficient of 0.75., Conclusions: Crowdsourced laypeople may represent a sustainable source of reliable assessments of physician error disclosure skills. For a simulated case involving delayed diagnosis of breast cancer, laypeople correctly identified high and low performers. However, at least 12 raters and 9 vignettes are required to ensure adequate reliability and future studies are warranted. Crowdsourced laypeople rate less stringently than raters who have experienced harm. Future research should examine the value of the Video-Based Communication Assessment app for formative assessment, summative assessment, and just-in-time coaching of error disclosure communication skills., (©Andrew A White, Ann M King, Angelo E D’Addario, Karen Berg Brigham, Suzanne Dintzis, Emily E Fay, Thomas H Gallagher, Kathleen M Mazor. Originally published in JMIR Medical Education (https://mededu.jmir.org), 29.04.2022.)

Background: Smartwatches can be used for atrial fibrillation (AF) detection, but little is known about how older adults at risk for AF perceive their usability., Methods: We employed a mixed-methods study design using data from the ongoing Pulsewatch study, a randomized clinical trial (NCT03761394) examining the accuracy of a smartwatch-smartphone app dyad (Samsung/Android) compared to usual care with a patch monitor (Cardea SOLO™ ECG System) for detection of AF among older stroke survivors. To be eligible to participate in Pulsewatch, participants needed to be at least 50 years of age, have had an ischemic stroke, and have no major contraindications to anticoagulation therapy should AF be detected. After 14 days of use, usability was measured by the System Usability Scale (SUS) and investigator-generated questions. Qualitative interviews were conducted, transcribed, and coded via thematic analysis., Results: Ninety participants in the Pulsewatch trial were randomized to use a smartwatch-smartphone app dyad for 14 days (average age: 65 years, 41% female, 87% White), and 46% found it to be highly usable (SUS ≥68). In quantitative surveys, participants who used an assistive device (eg, wheelchair) and those with history of anxiety or depression were more likely to report anxiety associated with watch use. In qualitative interviews, study participants reported wanting a streamlined system that was more focused on rhythm monitoring and a smartwatch with a longer battery life. In-person training and support greatly improved their experience, and participants overwhelmingly preferred use of a smartwatch over traditional cardiac monitoring owing to its comfort, appearance, and convenience., Conclusion: Older adults at high risk for AF who were randomized to use a smartwatch-app dyad for AF monitoring over 14 days found it to be usable for AF detection and preferred their use to the use of a patch monitor. However, participants reported that a simpler device interface and longer smartwatch battery life would increase the system's usability., (© 2022 Heart Rhythm Society.)

Background: The U.S. clinical research enterprise in nursing homes was unprepared to mount clinical trials in nursing homes to address urgent questions relevant to prevention and treatment during the COVID-19 pandemic. We identify priorities essential for establishing a supportive environment for future clinical trials in nursing homes., Methods: Two cross-sectional online questionnaires were administered between January and February 2021. One was administered to nursing home providers, researchers, and policymakers; respondents rated the importance of attributes of researchers, facilities, leaders and staff for conducting clinical trials in nursing homes. Because importance may depend on trial type, respondents rated each attribute for efficacy trials (testing an intervention in ideal circumstances) and effectiveness trials (testing an intervention in "real world" circumstances). We calculated the attribute rating means and standard deviations, and used content analysis to characterize open-ended responses. The second questionnaire for resident family members and advocates included open-ended questions about nursing home research, and factors influencing willingness to participate., Results: The attributes rated as most essential for conducting efficacy and effectiveness trials in nursing homes are research team attributes, that is, that researchers recognize regulatory constraints; understand and adapt to nursing home workflow; and work collaboratively with nursing home leaders to identify priorities. Resident and facility diversity emerged as essential for effectiveness trials; important dimensions included resident race, ethnicity and income, as well as nursing home urban/rural location, quality ratings, geography, staffing ratios, size, and profit status. Caregivers and resident advocates stressed the importance of communication among participants, researchers, and nursing home leadership and staff at all stages of a trial., Conclusion: Developing a robust U.S. clinical research enterprise capable of efficiently mounting future clinical trials in nursing homes will require a reimagining of the relationships that exist between researchers, facilities, nursing home leaders, and residents, with a research infrastructure specifically focused on supporting and fostering these connections., (© 2022 The American Geriatrics Society.)

Objective: To understand the impact of sharing clinic notes on communication and self-management among patients with COPD and to develop recommendations for writing patient-centered notes., Methods: Thirty patients with COPD participated in 'think-aloud' interviews in which they reviewed their COPD-specific clinic note. Interviews were coded using conventional content analysis, organized by the six-function communication framework., Results: Participants were predominantly White (93.3%), with a mean age of 65.5 years. More than half had a high school degree or less, half reported difficulty understanding spoken information, and nearly half sometimes need help reading medical materials. Patients indicated notes provided an opportunity to learn details of their condition and facilitated information sharing - strengthening information exchange. Reading notes enabled self-management through motivation, prompting information seeking, and reminding them of action steps. Patients reacted positively to statements suggesting the provider listened to them, saw them as a person, and was attentive to details, which fostered the relationship. Most patients reacted negatively to medical terminology, incorrect information, and wording that was perceived as disparaging., Conclusions: Sharing clinic notes with patients can promote information exchange, enable self-management, and strengthen the patient-provider relationship., Practice Implications: Incorporating patients' recommendations for writing notes could strengthen the benefits of sharing notes., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Importance: Regional, facility, and racial and ethnic variability in intensity of care provided to nursing home residents with advanced dementia is well documented but poorly understood., Objective: To assess the factors associated with facility and regional variation in the intensity of care for nursing home residents with advanced dementia., Design, Setting, and Participants: In the ADVANCE (Assessment of Disparities and Variation for Alzheimer Disease Nursing Home Care at End of Life) qualitative study, conducted from June 1, 2018, to July 31, 2021, nationwide 2016-2017 Medicare Minimum Data Set information identified 4 hospital referral regions (HRRs) with high (n = 2) and low (n = 2) intensity of care for patients with advanced dementia based on hospital transfer and tube-feeding rates. Within those HRRs, 14 facilities providing relatively high-intensity and low-intensity care were recruited. A total of 169 nursing home staff members were interviewed, including administrators, directors of nursing, nurses, certified nursing assistants, social workers, occupational therapists, speech-language pathologists, dieticians, medical clinicians, and chaplains., Main Outcomes and Measures: Data included 275 hours of observation, 169 staff interviews, and abstraction of public nursing home material (eg, websites). Framework analyses explored organizational factors and staff perceptions across HRRs and nursing homes in the following 4 domains: physical environment, care processes, decision-making processes, and implicit and explicit values., Results: Among 169 staff members interviewed, 153 (90.5%) were women, the mean (SD) age was 47.6 (4.7) years, and 54 (32.0%) were Black. Tube-feeding rates ranged from 0% in 5 low-intensity facilities to 44.3% in 1 high-intensity facility, and hospital transfer rates ranged from 0 transfers per resident-year in 2 low-intensity facilities to 1.6 transfers per resident-year in 1 high-intensity facility. The proportion of Black residents in facilities ranged from 2.9% in 1 low-intensity facility to 71.6% in 1 high-intensity facility, and the proportion of Medicaid recipients ranged from 45.3% in 1 low-intensity facility to 81.3% in 1 high-intensity facility. Factors distinguishing facilities providing the lowest-intensity care from those providing the highest-intensity care facilities included more pleasant physical environment (eg, good repair and nonmalodorous), standardized advance care planning, greater staff engagement in shared decision-making, and staff implicit values unfavorable to tube feeding. Many staff perceptions were ubiquitous (eg, adequate staffing needs), with no distinct pattern across nursing homes or HRRs. Staff in all nursing homes expressed assumptions that proxies for Black residents were reluctant to engage in advance care planning and favored more aggressive care. Except in nursing homes providing the lowest-intensity care, many staff believed that feeding tubes prolonged life and had other clinical benefits., Conclusions and Relevance: This study found that variability in the care of patients with advanced dementia may be reduced by addressing modifiable nursing home factors, including enhancing support for low-resource facilities, standardizing advance care planning, and educating staff about evidence-based care and shared decision-making. Given pervasive staff biases toward proxies of Black residents, achieving health equity for nursing home residents with advanced dementia must be the goal behind all efforts aimed at reducing disparities in their care.

Introduction: This study evaluated the impact of receiving a monoclonal gammopathy of undetermined significance (MGUS) diagnosis on healthcare utilization from patients at a community-based multispecialty provider organization., Methods: A cohort of patients with MGUS (n = 429) were matched on sex, age, and length of enrollment to a cohort of patients without MGUS (n = 1286). Healthcare utilization was assessed: 1-12 months before, 1 month before and after, and 1-12 months after diagnosis/index date. Multivariable conditional Poisson models compared change in utilization of each service in patients with and without MGUS., Results: During the 2 months around diagnosis/index date, the rates of emergency room, hospital and outpatient visits were higher for patients with MGUS than patients without MGUS. In the year before MGUS diagnosis, the association was still elevated, although attenuated., Conclusion: Understanding the care of MGUS patients is important given that multiple myeloma patients with a pre-existing MGUS diagnosis may have a better prognosis.

Objectives: Many patients with cancer believe that something has gone wrong in their care but are reluctant to speak up. This pilot study sought to evaluate the impact of an intervention of active outreach to patients undergoing cancer treatment, wherein patients were encouraged to speak up if they had concerns about their care and to describe the types of concerns patients reported., Methods: Patients receiving cancer care at two sites were randomly assigned to an intervention or control group. Intervention patients received a brochure encouraging them to speak up about any concerns and an outreach telephone call during which the interviewer explicitly asked about concerns. Participants in both groups received baseline and follow-up questionnaires assessing their perceptions of their care and whether anything had "gone wrong" and provided ratings of health care providers' communication and responsiveness. Qualitative content coding was used to categorize patient-reported concerns collected through the baseline and follow-up questionnaires (both groups) and during telephone outreach (intervention patients only). The primary outcome was the number of patients reporting a concern about their care. Communication and responsiveness ratings for intervention and control group patients were compared using t tests., Results: Of the 60 patients in the intervention group, 34 (56.7%) reported at least one problem or concern, compared with 16 (29.1%) of the 55 patients in the control group (P = 0.003). The telephone outreach in particular resulted in more than half of those reached reporting a new concern (55.3%). We detected no impact of the intervention on patients' ratings of communication or support for speaking up., Conclusions: Patients in this study reported a variety of concerns in response to active outreach, demonstrating that active outreach to patients can provide healthcare teams and systems the opportunity to offer a real-time response to the patient, identify where system improvements are needed, and implement policies, procedures, or programs to prevent recurrences., (Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.)

Rationale: Although clinical trials have found that pulmonary rehabilitation (PR) can reduce the risk of readmissions after hospitalization for a chronic obstructive pulmonary disease (COPD) exacerbation, less is known about PR's impact in routine clinical practice. Objectives: To evaluate the association between initiation of PR within 90 days of discharge and rehospitalization(s). Methods: We analyzed a retrospective cohort of Medicare beneficiaries (66 years of age or older) hospitalized for COPD in 2014 who survived at least 30 days after discharge. Measurements and Main Results: We used propensity score matching and estimated the risk of recurrent all-cause rehospitalizations at 1 year using a multistate model to account for the competing risk of death. Of 197,376 total patients hospitalized in 4,446 hospitals, 2,721 patients (1.5%) initiated PR within 90 days of discharge. Overall, 1,534 (56.4%) patients who initiated PR and 125,720 (64.6%) who did not were rehospitalized one or more times within 1 year of discharge. In the propensity-score-matched analysis, PR initiation was associated with a lower risk of readmission in the year after PR initiation (hazard ratio, 0.83; 95% confidence interval, 0.77-0.90). The mean cumulative number of rehospitalizations at 1 year was 0.95 for those who initiated PR within 90 days and 1.15 for those who did not ( P  < 0.001). Conclusions: After hospitalization for COPD, Medicare beneficiaries who initiated PR within 90 days of discharge experienced fewer rehospitalizations over 1 year. These results support findings from randomized controlled clinical trials and highlight the need to identify effective strategies to increase PR participation.