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To develop a new computer adaptive test that evaluates important aspects of medication adherence for persons with type 2 diabetes mellitus.Two hundred and twenty-five people with type 2 diabetes mellitus completed 41 items related to medication adherence.Exploratory analysis supported the essential unidimensionality of the initial item pool. Five items were deleted due to low item-adjusted total score correlations (resulting in 36 items). Confirmatory factor analysis supported the retention of 27 items. A graded response model identified no items for exclusion, based on misfit. No items were flagged for meaningful differential item functioning (DIF). The final item bank is comprised of 27 items; an associated 6-item short form was constructed that balanced both psychometric factors (e.g., item information values) and clinical input. Initial analysis of the simulated CAT and static short form supported both the reliability (i.e., internal consistency and test-retest reliability) and validity (i.e., convergent, discriminant, and known groups) of both administration formats.The new medication adherence item bank provides a reliable and valid assessment of the ability to take medications accurately among people with T2DM; it will be available in early 2023 through healthmeasures.net.

Objective We aim to explore how users’ experience of presence in a virtual world (VW) learning environment enhanced patient engagement in DSME/S programs conducted in an online VW platform with minority women with type 2 diabetes. Methods We conducted an embedded, mixed methods study, using a convergent study design to analyze qualitative field notes and interview data and quantitative survey data gathered from the Women in Control 2.0 (WIC2) clinical trial participants. The WIC2 clinical trial compared a diabetes group visit program delivered using an online VW platform versus an in-person approach. Result We enrolled 158 VW participants, of which 144 completed baseline data, 124 completed the post-intervention follow up survey, and 30 participated in key informant and focus group interviews. Overall, participants reported a sense of social (63.7%, mean 3.7/5.0), physical (63.1%, mean 3.6/5.0), and self (49.0%, mean 3.3/5.0) presence while engaged in VW group DSME/S. Three themes emerged from mixed methods analysis including, 1) Participants’ identification with their avatars enhances a sense of self presence in a VW, 2) physical presence enables visualization and imaginative play modalities of social learning, and 3) social presence cultivates meaningful social support and psychological safety. Conclusion Our research empirically supports the premise that participants’ experience of three domains of presence (self, physical and social) in a VW environment enhances participant engagement in DSME/S programs. Practice implications Further research is warranted to study optimal approaches to implementation and dissemination of this novel approach to patient education and engagement.

The purpose of this study was to develop a new measure, the Re-Engineered Discharge for Diabetes Computer Adaptive Test (REDD-CAT) Illness Burden item bank, to evaluate the impact that a chronic condition has on independent living, the ability to work (including working at home), social activities, and relationships.Semi-structured interviews were used to inform the development of an item pool (47 items) that captured patients' beliefs about how a diagnosis of type 2 diabetes interferes with different aspects of their lives. The Illness Burden item bank was developed and tested in 225 people with type 2 diabetes mellitus.No items had sparse response option cells or problems with monotonicity; two items were deleted due to low item-rest correlations. Factor analyses supported the retention of 29 items. With those 29 remaining items, a constrained (common slope) graded response model fit assessment indicated that two items had misfit; they were excluded. No items displayed differential item functioning by age, sex, education, or socio-economic status. The final item bank is comprised of 27 items. Preliminary data supported the reliability (internal consistency and test-retest reliability) and validity (convergent, discriminant, and known-groups) of the new bank.The Illness Burden item bank can be administered as a computer adaptive test or a 6-item short form. This new measure captures patients' perceptions of the impact that having type 2 diabetes has on their daily lives; it can be used in conjunction with the REDD-CAT measurement system to evaluate important social determinants of health in persons with type 2 diabetes mellitus.

The COVID-19 pandemic has exposed the medical and social vulnerability of an unprecedented number of people. Consequently, there has never been a more important time for clinicians to engage patients in advance care planning (ACP) discussions about their goals, values, and preferences in the event of critical illness. An evidence-based communication tool-the Serious Illness Conversation Guide-was adapted to address COVID-related ACP challenges using a user-centered design process: convening relevant experts to propose initial guide adaptations; soliciting feedback from key clinical stakeholders from multiple disciplines and geographic regions; and iteratively testing language with patient actors. With feedback focused on sharing risk about COVID-19-related critical illness, recommendations for treatment decisions, and use of person-centered language, the team also developed conversation guides for inpatient and outpatient use. These tools consist of open-ended questions to elicit perception of risk, goals, and care preferences in the event of critical illness, and language to convey prognostic uncertainty. To support use of these tools, publicly available implementation materials were also developed for clinicians to effectively engage high-risk patients and overcome challenges related to the changed communication context, including video demonstrations, telehealth communication tips, and step-by-step approaches to identifying high-risk patients and documenting conversation findings in the electronic health record. Well-designed communication tools and implementation strategies can equip clinicians to foster connection with patients and promote shared decision making. Although not an antidote to this crisis, such high-quality ACP may be one of the most powerful tools we have to prevent or ameliorate suffering due to COVID-19.

The influence of patient-level factors on palliative and hospice care is unclear. We conducted a retrospective review of 2321 patients aged ≥18 that died within 6 months of admission to our institution between 2012 and 2017. Patients were included for analysis if their chart was complete, their length of stay was ≥48 hours, and if based on their diagnoses, they would have benefited from palliative care consultation (PCC). Bayesian regression with a weakly informative prior was used to find the odds ratio (OR) and 99% credible interval (CrI) of receiving PCC based on race/ethnicity, education, language, insurance status, and income. 730 patients fit our inclusion criteria and 30% (n = 211) received PCC. The OR of receiving PCC was 1.26 (99% CrI, 0.73-2.12) for Blacks, 0.81 (99% CrI, 0.31-1.86) for Hispanics, and 0.69 (99% CrI, 0.19-2.46) for other minorities. Less than high school education was associated with greater odds of PCC (OR 2.28, 99% CrI, 1.09-4.93) compared to no schooling. Compared to English speakers, non-English speakers had higher odds of receiving PCC when cared for by medical services (OR 3.01 [99% CrI, 1.44-5.32]) but lower odds of PCC when cared for by surgical services (0.22 [99% CrI

The purpose of this study was to assess the practice and perceptions of shared decision-making (SDM) by both faculty and residents at Boston Medical Center and explore barriers and facilitators to implementing SDM at our institution.We created and distributed an online survey assessing provider demographic and training characteristics, experiences with the informed consent process, practices in SDM, and perceptions about SDM. We used descriptive statistics to summarize provider characteristics and survey responses and univariate analysis to determine associations between them.Fifteen surgeons and 19 surgical residents completed the survey (49% response rate). Most respondents were aware of and had a positive attitude toward SDM (91% and 76%, respectively); 35% reported having SDM training. Providers had varying levels of engagement with different SDM practices, and there were inconsistent associations between provider characteristics and the use of SDM. Often providers thought the patient's health literacy, foreign primary language, clinical condition, and socioeconomic factors were barriers to the SDM process.Although most general surgery faculty and residents at our institution had a positive view of SDM, they engaged in SDM behaviors inconsistently, with no clear association between clinician characteristics and specific behaviors. We identified several barriers to SDM consistent with those identified by providers in other specialties. This highlights the need for further research to study live general surgery provider-patient interactions, as well as structured SDM education to train general surgery providers to reliably engage their patients in effective SDM.

Over 27 million Americans have type 2 diabetes mellitus (T2DM), accounting for >7.7 million hospital admissions. Social determinants of behavior, including medication adherence, play a critical role in their health outcomes. We developed a new patient-reported outcome (PRO) measure to evaluate medication adherence in people with T2DM, using established measurement development standards. An item pool was created that reflected important content related to medication adherence for people with T2DM. The item pool was then refined, using feedback from experts, a reading-level assessment (ensuring no >5th grade reading-level content was included), a translatability review (e.g., to allow future measure translation into Spanish), and feedback from T2DM patients. Next, 225 people with T2DM completed 58 self-report medication adherence items. Exploratory factor analysis supported the item pool’s essential unidimensionality. Five items were excluded due to low item-rest correlations. Confirmatory factor analysis supported retaining 27 items. All items fit the graded response model, and no items had meaningful differential item functioning for the factors age, sex, education, or socioeconomic status. The final item bank is comprised of 27 items and can be administered as a computer adaptive test or 6- item short form. Internal consistency reliability was excellent for all administration formats (α’s all ≥ .90). The new Medication Adherence item bank provides a reliable, content-relevant assessment of medication adherence for people with T2DM. It is part of the comprehensive Re-Engineered Discharge for Diabetes Computer Adaptive Test (REDD-CAT) measurement system, which is designed to capture important social determinants of behavior for people with T2DM. Work is underway to establish additional psychometric properties (e.g., test-retest reliability, validity) of this new measure. Disclosure S. Mitchell: Other Relationship; Self; See Yourself Health LLC, Speaker’s Bureau; Self; Merck Sharp & Dohme Corp. M. A. Kallen: None. A. Bragg: None. I. Moldovan: None. J. M. Howard: None. B. W. Jack: None. J. A. Miner: None. C. M. Graves: None. N. Carlozzi: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R21DK121092)

Introduction: Immersive online technologies, such as virtual world (VW) platforms, can increase patient engagement in DSME/S. The Women in Control 2.0 (WIC2) trial compared DSME/S delivered in a VW vs. in-person for minority women with uncontrolled type 2 diabetes (HbA1c ≥8.0). We hypothesize the sense of presence afforded by a VW platform fosters patient engagement. Presence in a virtual reality setting is defined as a feeling of being immersed in an environment despite its artificiality. Methods: We used a triangulation mixed-methods design embedded within the WIC2 clinical trial. For the 145 participants randomized to the VW study arm, we measured participant experience of physical, self and social “presence” in the VW using the validated Multimodal Presence Scale (MPS) and 63 participated in qualitative interviews. We analyzed participant experiences in the VW with qualitative data collected via direct observation, focus group, and key informant interviews. We calculated the MPS scores and conducted a qualitative thematic analysis of transcripts. Qualitative and quantitative data were collected independently and integrated using a conceptual mapping process to correlate participants’ experience of DSME/S in the VW. Results: Half of participants were over 56yo and had a mean baseline HbA1c of 9.9% (SD=1.75). Two-thirds of the VW participants reported a sense of social (63.7%) and physical (63.1%) presence, while half-experienced self (49.0%) presence in the VW. Data integration led to three themes related to “presence” in a VW: (1) Self-presence fosters user identification with the personalized avatar (2) Physical presence fosters a growth mindset through imaginative play and visualization, and (3) social presence fosters peer social support. Conclusion: Patient engagement in DSME/S is enhanced by the sense of physical, social and self- presence experienced by learners when using immersive technology software in a peer group context. Disclosure S. Mitchell: Other Relationship; Self; See Yourself Health LLC, Speaker's Bureau; Self; Merck Sharp & Dohme Corp. A. Bragg: None. M. Winter: None. P. Gardiner: None. J. M. Howard: None. L. D. Laird: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R01DK10653)

In recent years, a growing body of research has established that social determinants of health influence the health outcomes of patients, especially those with T2DM. We developed a new patient-reported outcome (PRO) measure of an important social determinant of behavior that is specific to persons with T2DM: illness burden. Qualitative and quantitative methods informed the development of this new PRO. A literature review and semi-structured key informant interviews guided the establishment of an initial item pool. Expert and patient review, reading level assessment (to ensure no item had >5th grade reading-level language), and a translatability review were all used to refine the original item pool to 47 items. The refined item pool was then tested in 225 patients with T2DM. No items had sparse response option cells or problems with monotonicity; two items were deleted due to low item-rest correlations. Factor analyses (exploratory and confirmatory) supported the retention of 29 items. With those 29 remaining items, a constrained (common slope) graded response model (GRM) fit assessment indicated that two items had misfit and were excluded. No items displayed differential item functioning by age, sex, education, or socio-economic status. Thus, the final item bank is comprised of 27 items. Psychometric considerations (based on item information values) were used, in conjunction with expert content review, to select a 6-item static short form. IRT-based item parameters were employed to make this new measure available as a computer adaptive test. Internal consistency of the new PRO was excellent (α ≥ .90 for all administration formats). The new Illness Burden item bank captures patients’ perceptions of the impact that having T2DM has on their daily lives. It can be used in conjunction with the broader measurement system, the Re-Engineered Discharge for Diabetes Computer Adaptive Test, to evaluate important social determinants of behavior in persons with T2DM. Disclosure S. Mitchell: Other Relationship; Self; See Yourself Health LLC, Speaker’s Bureau; Self; Merck Sharp & Dohme Corp. M. A. Kallen: None. A. Bragg: None. I. Moldovan: None. J. M. Howard: None. B. W. Jack: None. J. A. Miner: None. C. M. Graves: None. N. Carlozzi: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (1R21DK121092)

Background: Comorbid depression is associated with poor diabetes control. DMGVs improve glycemic control and depressive symptoms among patients with type 2 diabetes (T2DM). The WIC2 study compared the effectiveness of an eight-week DGMV conducted in a virtual world platform vs. an in-person format to improve diabetes outcomes for 288 minority women with uncontrolled T2DM (HbA1c ≥8.0%). Objective: We conducted a secondary data analysis of the WIC2 clinical trial data to examine the association between improvements in depressive symptom burden (PHQ-8) and improvements in HbA1c among participants enrolled in the WIC2 study. Methods: We measured mean changes in PHQ-8 and HbA1c at baseline, 9-weeks, and 6-months post-enrollment among 288 WIC2 participants. We performed logistic regression to examine the association between a reduction in depressive symptoms per PHQ-8 (-5 points) and reduction in HbA1c (-0.4%) at 9-weeks and 6-months. We used multivariable logistic regression to adjust for potential confounders, including age, education, and study arm. Results: At baseline, nearly half of WIC enrollees reported mild (29.5%), moderate (17.4), or severe (1.7%) depressive symptoms. Their mean PHQ-8 score was 5.5 (SD 5.0) and mean A1c was 9.93% (SD 1.74). From baseline to 6-months, 17.4% (n=41) achieved a 5-point decrease in PHQ-8; among this subset, the mean PHQ-8 score was 10.49 (SD 4.69), indicative of moderate depression at baseline. Of these 41 participants, 68.3% (n=28) also achieved the threshold A1c improvement at 6-months. After controlling for study arm, education, and age, participants with 5-pt or greater reduction in PHQ-8 score from baseline to 6-months had 2.45 times the odds (CI: 1.16, 5.18) of achieving 0.4% or greater reduction in A1c. Conclusion: Improvements in depressive symptom burden correlate with improvements in diabetes management among women with uncontrolled T2DM. Disclosure P. Gardiner: None. B. M. Cruz: None. A. Bragg: None. M. Winter: None. K. Melo: None. J. M. Howard: None. S. Mitchell: Other Relationship; Self; See Yourself Health LLC, Speaker’s Bureau; Self; Merck Sharp & Dohme Corp. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R01DK10653)

There is a paucity of data regarding the utilization of palliative care consultation (PCC) in surgical specialties. We conducted a retrospective review of 2321 adult patients (age ≥18) who died within 6 months of admission to Boston Medical Center from 2012 to 2017. Patients were included for analysis if their length of stay was more than 48 hours and if, based on their diagnoses as determined by literature review and expert consensus, they would have benefited from PCC. Bayesian regression was used to estimate the odds ratio (OR) and 99% credible intervals (CrI) of receiving PCC adjusted for age, sex, race, insurance status, median income, and comorbidity status. Among the 739 patients who fit the inclusion criteria, only 30% (n = 222) received PCC even though 664 (90%) and 75 (10%) of these patients were identified as warranting PCC on medical and surgical services, respectively. Of the 222 patients who received PCC, 214 (96%) were cared for by medical services and 8 (4%) were cared for by surgical services. Patients cared for primarily by surgical were significantly less likely to receive PCC than primary patients of medical service providers (OR, 0.19, 99% CrI, 0.056-0.48). At our institution, many surgical patients appropriate for PCC are unable to benefit from this service due to low consultation numbers. Further investigation is warranted to examine if this phenomenon is observed at other institutions, elucidate the reasons for this disparity, and develop interventions to increase the appropriate use of PCC throughout all medical specialties.

Research Objectives To detail the development of patient-reported outcome measures (PROs) that capture social determinants of health (SDOH) among individuals with Type 2 diabetes mellitus (T2DM). Design Observational survey study. Setting Academic medical center. Participants 225 individuals with T2DM. Interventions N/A. Main Outcome Measures Participants completed five item pools: Healthcare Access (54 items), Medication Adherence (58 items), Illness Burden (47 items), Health-seeking Behavior (56 items), Housing Stability (22 items). Classical test and item response theory analyses were used to develop item banks, computer adaptive tests (CATs), and short forms (SFs). Results Eight new measures were established: Healthcare Access (44 items); Medication Adherence (27 items); Illness Burden (27 items); Housing Stability (20 items); and four Health-Seeking Behavior instruments: Primary Care Provider-Specific (6-item SF), General Beliefs (13 items), Family/Friends-Specific (5-item SF), and Internet-Specific (4-item SF). Exploratory and confirmatory factor analysis (EFA/CFA) supported unidimensionality for all measures. For EFAs, eigenvalue 1-to-2 ratio was >4 and proportion of variance accounted for by eigenvalue 1 was >0.40. Model fit criteria for CFAs (e.g., CFI ≥0.90, TLI ≥0.90, RMSEA Conclusions These PROs are part of the REDD-CAT comprehensive measurement system for SDOH and are candidates for inclusion as standard outcomes measures for use with discharge planning to mitigate readmission risk in people with T2DM. Author(s) Disclosures The authors have no conflicts of interest.

Background The purpose of this study was to develop and administer surveys that assess patient and family caregiver experiences with care transitions and examine the psychometric properties of the surveys. The surveys were designed to ask about 1) the transitional care services that matter most to patients and their caregivers and 2) care outcomes, including the overall quality of transitional care they received, patient self-reported health, and caregiver effort/stress. Methods Survey items were developed based on a review of the literature, existing surveys, focus groups, site visits, stakeholder and expert input, and patient and caregiver cognitive interviews. We administered mail surveys with telephone follow up to patients recently discharged from 43 U.S. hospitals. Patients identified the caregivers who helped them during their hospital stay (Time 1 caregiver) and when they were home (Time 2 caregiver). Time 1 and Time 2 caregivers were surveyed by telephone only. The psychometric properties of the survey items and outcome composite measures were examined for each of the three surveys. Items that performed poorly across multiple analyses, including those with low variability and/or a high missing data, were dropped except when they were conceptually important. Results The analysis datasets included responses from 9282 patients, 1245 Time 1 caregivers and 1749 Time 2 caregivers. The construct validity of the three proposed outcome composite measures—Overall Quality of Transitional Care (patient and caregiver surveys), Patient Overall Health (patient survey) and Caregiver Effort/Stress (caregiver surveys) —was supported by acceptable exploratory factor analysis results and acceptable internal consistency reliability. Site-level reliability was acceptable for the two patient outcome composite measures, but was low for Caregiver Effort/Stress ( Conclusions Overall, the final patient and caregiver surveys are psychometrically sound and can be used by health systems, hospitals, and researchers to assess the quality of care transitions and related outcomes. Results from these surveys can be used to improve care transitions, focusing on what matters most to patients and their family caregivers.

BACKGROUND The development of evidence-based care geared towards Black and Latina women living with uncontrolled type 2 diabetes is contingent upon their active recruitment into clinical interventions. Well-documented impediments to recruitment include a historical mistrust of the research community and socioeconomic factors that limit awareness and access to research studies. Although sociocultural and socioeconomic factors deter minorities from participating in clinical research, it is equally important to consider the role of stigma in chronic disease intervention studies. OBJECTIVE We aim to share our discovery of diabetes-related stigma as an underrecognized impediment to recruitment for the Women in Control 2.0 virtual diabetes self-management education study. METHODS Our initial recruitment plan used traditional strategies to recruit minority women with uncontrolled type 2 diabetes, which included letters and phone calls to targeted patients, referrals from clinicians, and posted flyers. After engaging a patient advisory group and consulting with experts in community advocacy, diabetes-related stigma emerged as a prominent barrier to recruitment. The study team reviewed and revised recruitment scripts and outreach material in order to better align with the lived experience and needs of potential enrollees. RESULTS Using a more nuanced, community-centered recruitment approach, we achieved our target recruitment goal, enrolling 309 participants into the study, exceeding our target of 212. CONCLUSIONS There is a need for updated recruitment methods that can increase research participation of patients who experience internalized diabetes stigma. To address disparities in minority health, further research is needed to better understand diabetes-related stigma and devise strategies to avert or address it.

Background Many pregnant people find no bridge to ongoing specialty or primary care after giving birth, even when clinical and social complications of pregnancy signal need. Black, indigenous, and all other women of color are especially harmed by fragmented care and access disparities, coupled with impacts of racism over the life course and in health care. Methods We launched the initiative “Bridging the Chasm between Pregnancy and Health across the Life Course” in 2018, bringing together patients, advocates, providers, researchers, policymakers, and systems innovators to create a National Agenda for Research and Action. We held a 2-day conference that blended storytelling, evidence analysis, and consensus building to identify key themes related to gaps in care and root causes of inequities. In 2019, more than 70 stakeholders joined six working groups to reach consensus on strategic priorities based on equity, innovation, effectiveness, and feasibility. Findings Working groups identified six key strategic areas for bridging the chasm. These include: 1) progress toward eliminating institutional and interpersonal racism and bias as a requirement for accreditation of health care institutions, 2) infrastructure support for community-based organizations, 3) extension of holistic team-based care to the postpartum year and beyond, with integration of doulas and community health workers on the team, 4) extension of Medicaid coverage and new quality and pay-for-performance metrics to link maternity care and primary care, 5) systems to preserve maternal narratives and data across providers, and 6) alignment of research with women's lived experiences. Conclusions The resulting agenda presents a path forward to remedy the structural chasms in women's health care, with key roles for advocates, policymakers, researchers, health care leaders, educators, and the media.

Background: DSME improves diabetes outcomes, however participation is low. Virtual world (VW) technology is a scalable and engaging platform for DSME. The WIC study compared the effectiveness of DSME Medical Group Visits conducted in a VW platform vs. in-person to improve diabetes outcomes for minority women with uncontrolled type 2 diabetes (T2DM). Objective: To assess the impact of WIC DSME intervention on hospital use and associated costs (inpatient, observation stays, ED visits). Methods: Hospital utilization and billing data of the WIC-DSME intervention was analyzed 6-months pre-to-post enrollment for the study cohort and by study arm for a subset of 142 minority women with T2DM who completed the study. The percent change in the number of hospital utilizations from pre-to-post enrollment was calculated and associated costs were estimated from billing data and compared by study arm, utilization type and for the cohort as a whole. Results: Total utilization among all 142 WIC program completers decreased by 25% from 114 events (57 events per arm) in the 6-months prior to WIC enrollment to 86 events (n=38 in-person; n=48 VW) in the 6-months post-enrollment. Hospital charges also decreased from $767,730 to $601,446 (22%). Among VW DSME participants, there was a 16% reduction in total utilization compared to a 33% reduction in the in-person DSME arm. Among VW participants, there was a 46% decrease in the number of high cost utilizations (observations and inpatient) and a 36% decrease in Emergency Department (ED) visits post-enrollment. Among in-person participants, there was no change in total high cost utilizations and a 68% decrease in ED visits. Total hospital charges for the WIC in-person DSME arm decreased by $24,625 (-6%) and $141,659 (-37%) for the WIC virtual world arm. Conclusion: Both in-person and VW DSME are associated with lower hospital utilization and costs among minority women with uncontrolled T2DM. Disclosure S. Mitchell: Speaker’s Bureau; Self; Merck Sharp & Dohme Corp. Stock/Shareholder; Self; See Yourself Health, LLC. A. Bragg: None. J.M. Howard: None. P. Gardiner: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R01DK106531)

Purpose: To characterize Latina experiences of a Spanish-language DSME program delivered in the VW versus a F2F format. Methods: Qualitative analysis of transcripts from three semi-structured focus groups conducted with 22 randomly selected Latina women enrolled in the Women in Control (WIC) DSME comparative effectiveness study. Two researchers coded the data and conducted a qualitative thematic analysis. Audio recordings were transcribed verbatim. Results: A total of 73 Latinas living with uncontrolled type 2 diabetes enrolled in the WIC study with an average age of 52yo, ∼75% had less than a high school diploma and more than 40% reported low health literacy. Four overarching themes were identified and applied to both VW and F2F formats, including (1) the impact of depression on diabetes self-care, (2) strong desire for actionable education (3) high value on peer coaching and positive group culture. One additional theme was identified among VW participants - (4) Positive Technological Development (PTD) - the sense of agency developed through learning to use technology for DSME. Conclusion: Latina women with diabetes with low health and computer literacy were positively impacted by the Women in Control DSME program both in F2F and in a VW. The VW platform facilitated PTD even among those with very low literacy and computer experience. Disclosure K. Melo: None. A. Bragg: None. L.D. Laird: None. P. Gardiner: None. J.M. Howard: None. S. Mitchell: Speaker’s Bureau; Self; Merck Sharp & Dohme Corp. Stock/Shareholder; Self; See Yourself Health, LLC. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R01DK106531-05S1)

Background: Research is needed to improve diabetes care of minority women who are disproportionately affected by type 2 diabetes. Yet, barriers exist that hinder efforts to include minority women in research. Evidence suggests that successful study enrollment requires multiple recruitment strategies. Little is known about the correlation between recruitment strategy and retention. We aim to examine the relationship between Women in Control (WIC) recruitment strategies, enrollment rates, and retention. Methods: We utilized multiple strategies to recruit minority women, including culturally-tailored invitation letters and phone calls to targeted Boston Medical Center patients, referrals from clinicians and WIC participants, word of mouth, social media, and posted flyers. We analyzed WIC recruitment data to determine the proportion of participants recruited by each method. We then assessed the proportion of WIC participants who adhered to the Diabetes Self-Management Education (DSME) study protocol by recruitment method. Results: Overall, targeted recruitment methods (letters and phone calls) yielded the highest number of screens and enrollments with a total of 975 screened, 207 found eligible, 195 enrolled - with 75% of those enrolled, attending 5 out 8 DSME medical group visits (MGV). Recruitment flyers generated the second most potential participants with a total of 73 screened, 18 found eligible and enrolled - with 83% attending 5 out of 8 MGV. All other recruitment methods (clinician or participant referral, word of mouth, social media and unknown source) combined yielded a total of 85 screened, 23 found eligible, 23 enrolled - with 78% attending 5 out of 8 MGV. Conclusion: Although we used multiple methods to recruit minority women, our data shows that targeted recruitment - using culturally tailored messaging - was the most effective recruitment method. There was no relationship between recruitment method and retention in the intervention. Disclosure A. Bragg: None. P. Gardiner: None. S.B. Woods: None. J.M. Howard: None. S. Mitchell: Speaker’s Bureau; Self; Merck Sharp & Dohme Corp. Stock/Shareholder; Self; See Yourself Health, LLC. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R01DK106531)

ObjectivesThe Serious Illness Care Programme (SICP) is a multicomponent evidence-based intervention that improves communication about patients’ values and goals in serious illness. We aim to characterise implementation strategies for programme delivery and the contextual factors that influence implementation in three ‘real-world’ health system SICP initiatives.MethodsWe employed a qualitative thematic framework analysis of field notes collected during the first 1.5 years of implementation and a fidelity survey.ResultsAnalysis revealed empiric evidence about implementation and institutional context. All teams successfully implemented clinician training and an electronic health record (EHR) template for documentation of serious illness conversations. When training was used as the primary strategy to engage clinicians, however, clinician receptivity to the programme and adoption of conversations remained limited due to clinical culture-related barriers (eg, clinicians’ attitudes, motivations and practice environment). Visible leadership involvement, champion facilitation and automated EHR-based data feedback on documented conversations appeared to improve adoption. Implementing these strategies depended on contextual factors, including leadership support at the specialty level, champion resources and capacity, and EHR capabilities.ConclusionsHealth systems need multifaceted implementation strategies to move beyond the limited impact of clinician training in driving improvement in serious illness conversations. These include EHR-based data feedback, involvement of specialty leaders to message the programme and align incentives, and local champions to problem-solve frontline challenges longitudinally. Implementation of these strategies depended on a favourable institutional context. Greater attention to the influence of contextual factors and implementation strategies may enable sustained improvements in serious illness conversations at scale.

PURPOSE Despite concerted actions to streamline care transitions, the journey from hospital to home remains hazardous for patients and caregivers. Remarkably little is known about the patient and caregiver experience during care transitions, the services they need, or the outcomes they value. The aims of this study were to (1) describe patient and caregiver experiences during care transitions and (2) characterize patient and caregiver desired outcomes of care transitions and the health services associated with them. METHODS We interviewed 138 patients and 110 family caregivers recruited from 6 health networks across the United States. We conducted 34 homogenous focus groups (103 patients, 65 caregivers) and 80 key informant interviews (35 patients, 45 caregivers). Audio recordings were transcribed and analyzed using principles of grounded theory to identify themes and the relationship between them. RESULTS Patients and caregivers identified 3 desired outcomes of care transition services: (1) to feel cared for and cared about by medical providers, (2) to have unambiguous accountability from the health care system, and (3) to feel prepared and capable of implementing care plans. Five care transition services or provider behaviors were linked to achieving these outcomes: (1) using empathic language and gestures, (2) anticipating the patient’s needs to support self-care at home, (3) collaborative discharge planning, (4) providing actionable information, and (5) providing uninterrupted care with minimal handoffs. CONCLUSIONS Clear accountability, care continuity, and caring attitudes across the care continuum are important outcomes for patients and caregivers. When these outcomes are achieved, care is perceived as excellent and trustworthy. Otherwise, the care transition is experienced as transactional and unsafe, and leaves patients and caregivers feeling abandoned by the health care system.

Objectives Little is known about the acceptance of non-pharmacological group strategies delivered to low income racially diverse patients with chronic pain and depression. This paper examines how the Integrative Medical Group Visit (IMGV) addresses many of the deficits identified with usual care. Design and setting Six IMGVs cohorts were held at a safety net hospital and two federally funded community health centres. Data was gathered through focus groups. Transcripts were analysed using both a priori codes and inductive coding. Intervention The intervention included ten sessions of Integrative Medical Group Visits with a primary care provider and a meditation instructor. The curriculum uses principles of Mindfulness Based Stress Reduction and evidence based integrative medicine. The visit is structured similarly to other group medical visits. Main outcome measures Data was gathered through four focus groups held after the cohorts were completed. Results Participants (N = 20) were largely low income minority adults with chronic pain and comorbid depression. Six themes emerged from the coding including: chronic pain is isolating; group treatment contributes to better coping with pain; loss of control and autonomy because of the unpredictability of pain as well as dependence on medication and frequent medical appointments; groups improve agency and control over one’s health condition; navigating the healthcare system and unsatisfactory treatment options; and changes after the IMGV due to non-pharmacological health management. Conclusions The IMGV is a promising format of delivering integrative care for chronic pain and depression which addresses many of the problems identified by patients in usual care.

Background: Hospitalized patients are frequently unprepared to care for themselves after discharge often leading to unplanned hospital readmission. One strategy to reduce readmission rates is improving the quality of patient education and preparation before hospital discharge. The ReEngineered Discharge (RED) is a standardized hospital-based program designed to provide patients and caregivers the information they need to continue care at home. Objectives: We sought to study the impact of the RED intervention on posthospitalization adult patient experience scores in an urban academic safety-net hospital. Methods: We conducted a descriptive study of a pilot program that compared posthospitalization survey responses to the Press Ganey survey item “Instructions were given about how to care for yourself at home.” We compared the survey results for 3 groups of adult patients: those receiving the RED program, those receiving a standard discharge on the same hospital unit, and those receiving a standard discharge on other hospital units. Results: A greater percentage of adult patients who received the RED discharge program rated the quality of their discharge as “very good” as compared to those receiving a standard discharge on the same hospital unit and those receiving a standard discharge on other hospital units (61%, 35%, and 41%, respectively, P = .0001). Conclusion: Delivery of a standardized hospital discharge program resulted in a larger proportion of top-box “very good” responses on a Press Ganey posthospitalization survey. Future research should examine whether hospital-based transition programs can sustain improvement in patient experience measures and whether these improvements can be observed in other patient populations.

Background Project Re-Engineered Discharge (RED) is an evidence-based strategy to reduce readmissions disseminated and adapted by various health systems across the country. To date, little is known about how adapting Project RED from its original protocol impacts RED implementation and/or sustainability. The goal of this study was to identify and characterize contextual factors influencing how five California hospitals adapted and implemented RED and the subsequent impact on RED program sustainability. Methods Participant observation and key informant and focus group interviews with 64 individuals at five California hospitals implementing RED in 2012 and 2013 were conducted. These involved hospital leadership, personnel responsible for Project RED implementation, hospital staff, and clinicians. Interview transcripts were coded and analyzed using a modified grounded theory approach and constant comparative analysis. Results Both internal and external contextual factors were identified that influenced hospitals’ decisions on RED adaptation and implementation. These also impacted RED sustainability. External factors included: impending federal penalties for hospitals with high readmission rates targeting specific diagnoses, and access to external funding and technical support to help hospitals implement RED. Internal or organizational level contextual factors included: committed leadership prioritizing Project RED; RED adaptations; depth, accountability and influence of the implementation team; sustainability planning; and hospital culture. Only three of the five hospitals continued Project RED beyond the implementation period. Conclusions The sustainability of RED in participating hospitals was only possible when hospitals approached RED implementation as a transformational process rather than a patient safety project, maintained a high level of fidelity to the RED protocol, and had leadership and an implementation team who embraced change and failure in the pursuit of better patient care and outcomes. Hospitals who were unsuccessful in implementing a sustainable RED process lacked all or most of these components in their approach. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2242-z) contains supplementary material, which is available to authorized users.

Introduction In the U.S. about 450,000 people per year receive medical burn care through hospital emergency departments, hospital outpatient clinics, free-standing urgent care centers and private physician offices. Burns are generally classified in terms of depth and severity. Outpatient management of partial thickness burns normally involves the application of an ointment, which may contain an antibiotic and is widely used in burn care. This clinical study has been designed to prospectively evaluate potential benefits of an enzymatic debrider in partial thickness burn wounds compared to antibiotic only treatment. The primary purpose of this study is to compare an enzymatic debrider with a topical antibiotic ointment in the proportion healed at 3 weeks after initiation of treatment, and time to healing (in weeks). Methods A convenience sample of 20 subjects, aged 19–56, with an acute thermal burn injury less than 72 hours old, and less than 10% TBSA were randomly assigned to outpatient treatment with an enzymatic debrider or a topical antibiotic. The proportion of subjects healed after 3 weeks of treatment was analyzed using ANOVA. In addition, a t-test comparison between the enzymatic debrider and the topical antibiotic was performed. Results For partial thickness burns, the mean time to heal using an enzymatic debrider was 18 days compared to 28 days for the topical antibiotic. However, there was no statistical significance in burn wound closure between subjects receiving an enzymatic debrider compared to a topical antibiotic, t (13) = .677; p = .510. An analysis of variance comparing an enzymatic debrider and a topical antibiotic also showed no statistical significance in time to heal (F=.849, p=374). Conclusions Due to the small sample size, the results from this study do not support the use of an enzymatic debrider versus a topical antibiotic in treating partial thickness burn injuries to advance wound closure or shorten time to heal. The results of this study show clinical significance, with burn wounds healed in 18 days when an enzymatic debrider was used compared to 28 days when a topical antibiotic was used. The lack of statistical significance was due to an under-powered study. Furthermore, partial thickness burns should spontaneously heal within 7–14 days, regardless of the topical treatment, excluding concomitant co-morbidities. Applicability of Research to Practice Continued research is necessary, employing larger sample sizes to adequately compare the use of an enzymatic debrider compared to topical antibiotics in deep partial thickness burn wounds. In addition, outpatient management of deep thickness and full-thickness burn injuries, utilizing sharp debridement in conjunction with enzymatic debridement, in patients who decline surgical treatment of burn wounds should be explored, analyzing time to heal, scar evaluation, and cost analysis

Introduction Accurate burn assessment is crucial to prescribing appropriate treatment and is dependent upon the experience of the provider and the timing of diagnosis relative to the burn injury evaluation. Differentiating between a deep partial thickness and full thickness burn may not be easily discernible. To augment the clinical diagnosis of burn depth, a laser doppler image measures the microvascular blood flow of injured tissue to predict burn wound healing. The aim of this study is to evaluate the clinical assessment of burn wounds by experienced burn providers compared to the laser doppler image assessment in predicting which burn wounds should heal spontaneously in 3 weeks. Methods A retrospective chart review from 2012–2016, included 54 subjects. The clinical assessment included a description of burn variables relevant to the determination of spontaneous burn wound healing (burn depth, total body surface area, mechanism of injury, anatomical location, clinical burn depth diagnosis, and laser doppler image). A chi-square analysis compared the clinical diagnosis and the laser doppler assessment of burn wound depth, as well as the correlation between clinical diagnosis versus laser doppler image in predicting spontaneous burn wound healing. Results Comparing partial thickness burn injuries, there were 38 clinically diagnosed partial thickness injuries (by experienced burn providers) and 38 partial thickness burn injures diagnosed via LDI. Deep partial thickness burn injuries were diagnosed clinically in 9 subjects, compared to 10 via LDI. Full thickness burn injuries were diagnosed clinically in 7 subjects and 6 via LDI. A chi-square test was performed to examine the relationship between clinical diagnosis of burn depth and laser doppler image. The relation between these variables was significant,X2= 26.884, p< .000. Comparing clinically diagnosed burn depth to LDI, each approach (clinical or LDI) diagnosed 42 subjects with partial thickness or deep partial thickness burn injuries and all healed spontaneously. Two of the clinically diagnosed full thickness burn injuries required skin grafting. Six patients were lost to follow-up (X2= 17.745, p < .001). Conclusions This study confirms there is no difference between an experienced burn provider’s clinical diagnosis of burn wound depth and prognosis for spontaneous healing compared to a laser doppler image prognosis of burn wound healing. Applicability of Research to Practice In an era of advanced technologies, expert clinical bedside assessment is the standard of care.

By 2050, the older Latino population will reach 17.5 million and constitute 20% of the nation’s seniors; correspondingly, the Alzheimer’s disease rate among Latinos is projected to increase 1.3 million. Consequently, there is growing interest in delivering culturally sensitive health care services to this population, Although a significant body of research exists exploring how personal resources may moderate the impact of caregiving stressors on caregiving well-being; there is relatively little research on the role of religiosity and religious coping in influencing caregiver mental health outcomes. This knowledge gap is significant given evidence suggests that Latinos more often use religion and spirituality as a coping mechanism than Anglos. In this study, we explored the association of religiosity and religious coping with measures of caregiver depression and anxiety among 67 Latino Alzheimer’s caregivers through in depth interviews conducted in Spanish in the caregiver’s home. Our core measures included the Duke Religiosity Index; Pargament’s Brief RCOPE which taps positive and negative religious coping methods, the CES-D Depression Scale and the State Anxiety Inventory-State Scale (STAI-S). Our regression analysis revealed that, after controlling for caregiver and care recipients demographic and health variables, negative religious coping predicted greater levels of depression and anxiety. The study suggests that religion provides some persons with a framework for interpreting the challenges associated with caregiving and that negative religious coping methods can have deleterious effects on psychological well-being. The implications for primary care providers regarding how to address the spiritual concerns of Latinos and other ethnic minorities are discussed.

To gain a better understanding of the patient and caregiver experience during care transitions and to describe the desired outcomes of transitions in care, 138 patients and 110 family caregivers participated in focus groups or interviews at six health networks across the U.S. Principles of grounded theory were used to analyze transcripts. Overall, patients and caregivers preferences were to: (1) feel prepared and capable of implementing the care plan, (2) know who was accountable for their care, and (3) feel cared for/about by medical providers. Five care transitional care elements were linked to achieving the preferred outcomes: a) providing actionable information; b) collaborative discharge planning; c) using empathic language and gestures; d) anticipating the patient’s needs to support self-care at home, and e) providing uninterrupted care with minimal handoffs. Clear accountability, care continuity and caring attitudes across the care continuum are important outcomes for patients and caregivers.

Care transitions between and across settings are often fragmented and place older adults at high risk for poor outcomes. Finding ways to improve care transitions for patients and their family caregivers across the continuum of settings is necessary. Therefore, we conducted site visits across the United States at 45 health care organizations—community hospitals, academic medical centers, integrated health systems, and broader community partnerships—using a combination of qualitative techniques—including observation, document review, and semi-structured interviews. Over 1,000 participants representing management and leadership, transitional care team members, internal stakeholders, community partners, patients, and family caregivers participated. Common facilitators of effective care transitions included: strong collaboration within and beyond the organization, staff buy-in, and patient and family centered care.

BackgroundCurrent treatment options for chronic pain and depression are largely medication-based, which may cause adverse side effects. Integrative Medical Group Visits (IMGV) combines mindfulness techniques, evidence based integrative medicine, and medical group visits, and is a promising adjunct to medications, especially for diverse underserved patients who have limited access to non-pharmacological therapies.ObjectiveDetermine the effectiveness of IMGV compared to a Primary Care Provider (PCP) visit in patients with chronic pain and depression.Design9-week single-blind randomized control trial with a 12-week maintenance phase (intervention-medical groups; control-primary care provider visit).SettingAcademic tertiary safety-net hospital and 2 affiliated federally-qualified community health centers.Participants159 predominantly low income racially diverse adults with nonspecific chronic pain and depressive symptoms.InterventionsIMGV intervention- 9 weekly 2.5 hour in person IMGV sessions, 12 weeks on-line platform access followed by a final IMGV at 21 weeks.MeasurementsData collected at baseline, 9, and 21 weeks included primary outcomes depressive symptoms (Patient Health Questionnaire 9), pain (Brief Pain Inventory). Secondary outcomes included pain medication use and utilization.ResultsThere were no differences in pain or depression at any time point. At 9 weeks, the IMGV group had fewer emergency department visits (RR 0.32, 95% CI: 0.12, 0.83) compared to controls. At 21 weeks, the IMGV group reported reduction in pain medication use (Odds Ratio: 0.42, CI: 0.18-0.98) compared to controls.LimitationsAbsence of treatment assignment concealment for patients and disproportionate group attendance in IMGV.ConclusionResults demonstrate that low-income racially diverse patients will attend medical group visits that focus on non-pharmacological techniques, however, in the attention to treat analysis there was no difference in average pain levels between the intervention and the control group.Trial registrationclinicaltrials.gov NCT02262377.

Background Care transitions between clinicians or settings are often fragmented and marked by adverse events. To increase patient safety and deliver more efficient and effective health care, new ways to optimize these transitions need to be identified. A study was conducted to delineate facilitators and barriers to implementation of transitional care services at health systems that may have been adopted or adapted from published evidence-based models. Methods From March 2015 through December 2015, site visits were conducted across the United States at 22 health care organizations—community hospitals, academic medical centers, integrated health systems, and broader community partnerships. At each site, direct observation and document review were conducted, as were semistructured interviews with a total of 810 participants (5 to 57 participants per site) representing various stakeholder groups, including management and leadership, transitional care team members, internal stakeholders, community partners, patients, and family caregivers. Results Facilitators of effective care transitions included collaborating within and beyond the organization, tailoring care to patients and caregivers, and generating buy-in among staff. Commonly reported barriers included poor integration of transitional care services, unmet patient or caregiver needs, underutilized services, and lack of physician buy-in. Conclusion True community partnership, high-quality communication, patient and family engagement, and ongoing evaluation and adaptation of transitional care strategies are ultimately needed to facilitate effective care transitions. Health care organizations can strategically prioritize transitional care service delivery through staffing decisions, by making transitional care part of the organization's formal board agenda, and by incentivizing excellence in providing transitional care services.