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ABSTRACT Purpose To explore the opioid decision‐making process of prescribers in primary care, surgery, and subspecialty pain management. Methods This was a multistage qualitative‐qualitative study with clinicians involved in opioid prescribing and management from a single healthcare organization with locations in Minnesota, Florida, Arizona, and Wisconsin. Clinicians in this study included physicians, nurse practitioners (NPs), and physician assistants (PAs) practicing in primary care, surgery, or pain medicine. The interview guide was organized in three domains of a conceptual model for opioid use: (1) prescriber characteristics, (2) patient characteristics, and (3) practice environment characteristics. Individual interviews ( N = 20) were performed first, and data were summarized using a rapid template‐based approach. Subsequently, focus groups (FGs) ( N = 4) were conducted with an additional 21 clinicians to confirm and explore interview results. Data from interviews and FGs were analyzed using a common codebook. Results Findings were organized as decision factors into the three domains. Factors in the prescriber domain included characteristics such as formal pain management training, as well as factors that influenced knowledge and beliefs (e.g., advice from or observation of supervising clinicians and expert colleagues). Decision factors in the patient domain included patient pain etiology, comorbid medical or mental health conditions, and demographic characteristics. Clinicians' perceptions of these factors, such as viewing older age as having lesser risk for opioid misuse, influenced prescribing decisions. Clinicians also described challenges associated with “legacy patients” whose therapy was previously managed by a different clinician. Primary care clinicians, in particular, expressed difficulties managing post‐surgical or trauma‐related pain after care transition. Relevant decision factors reported by prescribers in the practice environment domain included guidelines and practice oversight. Most participants reported practicing in an environment that promoted conservative opioid use and having access to standardized institutional guidelines that reduced perceived decision‐making burden. Clinicians described how they used prescribing guidelines to help them communicate with patients about opioid use and prescribing decisions. Conclusions Intersecting prescriber, patient, and practice environment factors shape opioid analgesic prescribing decisions. Available resources in the practice environment, including peer input and institutional guidelines, may support clinician decision‐making and conversations with patients at the point of care, including in cases where patients have complex histories or personal characteristics that influence decision making.

Introduction: The COVID-19 pandemic has disproportionally affected historically marginalized populations and their access to resources and healthcare. In times of crisis, authentic community engagement is more important than ever. This study was Phase 1 of a larger 3-phase study to conduct timely community-engaged research with community members to understand the disproportionate impact of COVID-19 on historically underserved communities. The objective of this work was to conduct key informant (KI) interviews (1) to understand community organizations perspectives about the role that large academic health centers play as they interface with community organizations to support their work, (2) to leverage KI’s expertise to identify needs and assets within the community, and (3) to inform both Phase 2 (focus group qualitative research) and Phase 3 (survey) of the broader study. Methods: A total of 24 key informants were identified through purposeful sampling and one-on-one semi-structured interviews were conducted across 4 states using video conferencing. Results: Barriers to access and lack of transparency were highlighted as major issues requiring reform—in particular, aggressive billing practices and insurance barriers exacerbated local distrust of medical institutions. KIs recognized the health institution’s support for testing and vaccination during the COVID-19 pandemic, but noted other significant gaps in care, especially regarding mental health support. Although communication with the health institution was consistent for some KIs, others experienced unsustained communication efforts that hindered cooperation and relationship building. Conclusions: Leaders in the community as key stakeholders can provide unique insights into the challenges and potential solutions required to promote health equity, and foster understanding between local communities and healthcare institutions.

Background: Physical activity (PA) prevents cardiovascular (CV) disease and maintains health. It is unclear which factors predict the adoption or maintenance of PA at a worksite wellness center. Methods: To assess the predictors of increase in PA we conducted a retrospective study on 7237 adults attending a worksite wellness center between September 2008 and October 2011. Upon joining the wellness center, participants completed an electronic or paper survey that assessed for the presence of CV risk factors, height, weight, self-perceived health behaviors and psychosocial factors using eleven validated 0-10 point scale. We included 1927 participants who completed the standard survey at the time of enrollment and at 12 months (+/- 90 days). For logistic regression analysis PA increase at 12 months was defined as an increase of ≥2 points of self-reported PA, on a 0 to 10 point scale, or maintenance of a high level of PA at follow up (FU). Results: Mean (SD) age was 38 (11) yr., BMI was 26.93 (6.06) kg/m 2 and 32% were men. From the study sample, 717 (37%) participants increased their PA level or maintained a high level of PA at FU. When comparing people who increased or maintained a high level of PA with the group without improvement or a decline in PA, there were differences in age and BMI: age [39 (11) vs. 38 (11) yr.; p=0.04] and BMI [27.37 (5.92) vs. 26.68 (5.92) kg/m 2 ; p=0.024]. The Table reports the results of the multivariate logistic regression model. While CV risk factors (tobacco use, hyperglycemia/diabetes mellitus, and high blood cholesterol), perceived stress level and self-perception of being overweight were not significant predictors of increase PA, low muscular strength and flexibility and interactions with close friends were significantly associated with PA. Conclusion: A significant proportion of people, over one-third, enrolled in a wellness center increase their PA level or maintain high levels of PA at 12 months after enrollment. Increasing age and BMI, and a measure of social support; interaction with close friends, and perceived muscular strength and flexibility, predict increase in PA. Presence of CV risk factors do not predict increase in PA. Tailoring programs to address these domains may help younger, less fit, and those with less social support improve their PA level.

Background: Individuals with brachial plexus injuries (BPIs) can be prescribed assistive devices, including myoelectric elbow orthoses (MEOs), for rehabilitation or functional use after failed treatment for elbow flexion restoration. Although recent case studies indicate potential for clinical improvements after using an MEO after BPI, the patients' perspectives on such use are still unknown. Objective: To explore patient perspectives on the use of an MEO after surgical treatment for a traumatic BPI. Study design: Qualitative using both a focus group and semistructured interviews. Methods: Patients with BPI that used an MEO were recruited. Five patients participated in an in-person focus group, whereas three patients participated in individual phone interviews. Themes that emerged from the focus group were compared against those that emerged from the personal interviews. Results: Feedback was grouped into three themes: device usage, hardware performance, and device design. Within each theme, positive elements, areas for improvement, and additional considerations emerged. Patients indicated a positive attitude toward using an MEO as a rehabilitation tool. They desired a streamlined, stronger device to support them and assist during activities of daily living. Conclusions: For patients with BPI, a well-designed MEO that meets their needs could assist with rehabilitation and increase independence in daily activities. Continued patient engagement in the evaluation and development of both medical devices and treatment plans offers the best opportunity for improved outcomes that are important to the patient.

Background: Regular exercise is considered a key element to maintain weight loss, but its role to induce weight loss has been controversial. Methods: In this retrospective study of 7237 individuals attending a worksite wellness center from September 2008 to October 2011 to assess predictors of weight loss at 12 months after joining. Upon joining the wellness center, participants completed a survey that assessed for the presence of cardiovascular risk factors, height, weight, self-perceived health behaviors and psychosocial factors using validated 11-point scale items. We limited the sample to 1927 overweight (25 < BMI ≤ 30) and obese (BMI > 30) participants who completed the survey in full at baseline and at 12 months (+/- 90 days). The outcome variable was weight change at 12 months after enrollment. Weight loss was defined as a loss of > 1kg. Results: Of 1927 participants, 998 (52%) were either overweight (n=573; 57%) or obese (n=425; 43%), and 60% were women. Mean (SD) age was 41 (11.5) yr, BMI 30.7 (5.5) kg/m 2 and they visited the wellness center 49 (90) times/year. At 12 months, 416 (42%) of the participants had lost >1 kg and 19% had lost > 5kg. The predictors of weight loss were: baseline BMI, [Odds Ratio (OR)= 1.56 (1.15-2.13); p < .0044] and [OR= 1.75 (1.26-2.44); p < .0010] for BMI between 30-35 and BMI ≥35, vs BMI between 25-29, respectively. In addition, visits/year [OR= 1.60 (1.19-2.16); p < .0010] and [OR= 1.85 (1.37-2.61); p < .0001] for those attending 13-52 sessions and > 52 visits/year, vs ≤ 12 visits/year, respectively. The association persisted after controlling for all covariates (ie, cardiovascular risk factors, self-perceived health behavior and psychosocial factors). The Table shows the results of the multivariate analysis assessing predictors for >1kg weight loss. Neither age, gender, perceived stress, self-perception of being overweight, following a healthy diet, nor history of hypertension, high blood cholesterol or diabetes predicted weight loss. Conclusions: A significant percentage of overweight or obese individuals lose weight after enrolling in a worksite wellness center. Frequency of attendance, baseline BMI, and support for maintaining a healthy living are associated with weight loss. These results suggest interventions to promote usage of wellness centers maybe be beneficial for the obese adult.

Objectives: To describe the feasibility of a chaplain-led spiritually focused life review interview and the development of a spiritual legacy document (SLD) for patients with advanced diseases and to describe changes in spiritual well-being (SWB), spiritual coping strategies (SC), and quality of life (QOL) after receiving the SLD. Patients and Methods: In all, 130 patients and support person (SP) pairs were recruited from July 2012 to January 2019. Following enrollment, demographic information was gathered and baseline questionnaires were administered. Functional Assessment of Chronic Illness Therapy–Spiritual Well-Being Scale (FACIT-Sp-12) and a linear analog scale assessment (LASA) measured SWB. LASAs also measured QOL and emotional well-being (EWB). Positive Religious Coping Scale (RCOPE) measured SC. After completion of baseline forms, participants were interviewed (individually) by a chaplain. Interviews were digitally recorded, transcribed, and verified. Transcripts were edited and participants were given the opportunity to make adaptations. The participant-approved draft was then developed into a professionally printed SLD. Follow-up questionnaires were administered to assess change. Results: Significant improvements from baseline to post-SLD follow-up were found for patients on the LASAs: SWB (average 7.7-8.3, P = .01), QOL (average 6.7-7.3, P = .03), EWB (average 6.9-7.5, P = .01), and on the positive RCOPE (average 1.8-2.0, P = .007). Effect sizes were approximately 0.25. Considering any improvement, 61.0% improved their positive RCOPE score, 46.6% improved EWB, and 39.7% improved SWB. No significant changes were found on the FACIT-Sp-12. No significant changes were found for SPs. Conclusion: The results suggest that the primary participants who completed the study benefited by significantly increasing their QOL, SWB, EWB, and SC.

Objective There exists a paucity of work in the development and testing of theoretical models specific to childhood health disparities even though they have been linked to the prevalence of adult health disparities including high rates of chronic disease. We conducted a systematic review and thematic analysis of existing models of health disparities specific to children to inform development of a unified conceptual framework. Methods We systematically reviewed articles reporting theoretical or explanatory models of disparities on a range of outcomes related to child health. We searched Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus (database inception to 9 July 2015). A metanarrative approach guided the analysis process. Results A total of 48 studies presenting 48 models were included. This systematic review found multiple models but no consensus on one approach. However, we did discover a fair amount of overlap, such that the 48 models reviewed converged into the unified conceptual framework. The majority of models included factors in three domains: individual characteristics and behaviours (88%), healthcare providers and systems (63%), and environment/community (56%), . Only 38% of models included factors in the health and public policies domain. Conclusions A disease-agnostic unified conceptual framework may inform integration of existing knowledge of child health disparities and guide future research. This multilevel framework can focus attention among clinical, basic and social science research on the relationships between policy, social factors, health systems and the physical environment that impact children's health outcomes.

Increased prenatal diagnoses of sex chromosome aneuploidies (SCAs) amid limited knowledge of their prognoses heighten the need to understand how families contend with the implications of an SCA. To explore the experiences of parents and individuals who received a genetic diagnosis of an SCA (excluding Turner syndrome), we conducted semistructured qualitative telephone interviews with 43 participants affected by these conditions. Parents (n = 35) and individuals (n = 8) expressed almost unanimous interest in more optimistic portrayals of their condition from their providers, even when the prognosis is uncertain. While some participants reported success in receiving accurate information from their provider and identifying supportive resources, numerous families received outdated or misleading information about their condition and lacked direction in accessing follow-up care and support. Parents desire greater coordination of their child’s medical care and access to care that approaches an SCA holistically. Opportunities remain to improve the diagnosis and care of individuals with SCAs.