Boehmer, Kasey R.

Background: Beta-lactam therapeutic drug monitoring (BL TDM; drug level testing) can facilitate improved outcomes in critically ill patients. However, only 10%–20% of hospitals have implemented BL TDM. This study aimed to characterize provider perceptions and key considerations for successfully implementing BL TDM. Methods: This was a sequential mixed-methods study from 2020 to 2021 of diverse stakeholders at 3 academic medical centers with varying degrees of BL TDM implementation (not implemented, partially implemented, and fully implemented). Stakeholders were surveyed, and a proportion of participants completed semistructured interviews. Themes were identified, and findings were contextualized with implementation science frameworks. Results: Most of the 138 survey respondents perceived that BL TDM was relevant to their practice and improved medication effectiveness and safety. Integrated with interview data from 30 individuals, 2 implementation themes were identified: individual internalization and organizational features. Individuals needed to internalize, make sense of, and agree to BL TDM implementation, which was positively influenced by repeated exposure to evidence and expertise. The process of internalization appeared more complex with BL TDM than with other antibiotics (ie, vancomycin). Organizational considerations relevant to BL TDM implementation (eg, infrastructure, personnel) were similar to those identified in other TDM settings. Conclusions: Broad enthusiasm for BL TDM among participants was found. Prior literature suggested that assay availability was the primary barrier to implementation; however, the data revealed many more individual and organizational attributes, which impacted the BL TDM implementation. Internalization should particularly be focused on to improve the adoption of this evidence-based practice.

Abstract Background Beta-lactam therapeutic drug monitoring (BL TDM; drug level testing) can facilitate improved outcomes in critically ill patients. Yet less than 20% of hospitals have implemented BL TDM. The purpose of this study was to characterize provider perceptions and key considerations for successful implementation of BL TDM. Methods This was a sequential mixed methods study from 2020 to 2021 of stakeholders at three academic medical centers with varying degrees of BL TDM implementation - Mayo Clinic (BL TDM not implemented), University of Florida Health Shands (partially implemented), and Royal Brisbane and Women’s Hospital (fully implemented). Stakeholders completed a survey to characterize their knowledge, perceptions, and experience with BL TDM. A diverse group of 30 respondents were then purposively sampled for semi-structured interviews. Results from the two strands were integrated, themes were identified, and findings were situated within implementation science frameworks. Results Among the 138 survey respondents (22% response rate), the majority were physicians (38%) and pharmacists (33%). 71% practiced in critical care and 21% in infectious diseases. The majority of respondents felt BL TDM was relevant to their practice and improved medication effectiveness and safety (Figure 1). Two implementation themes were identified: individual internalization and organizational features. Individuals needed to internalize, make sense of, and agree to BL TDM implementation which was positively influenced by repeated exposure to evidence and expertise. The process of internalization seemed more complex with BL TDM than with other antibiotics (i.e., vancomycin). Organizational considerations relevant to BL TDM implementation included adequate physical and informational infrastructure, access to trained personnel, supportive governance/leadership, and robust process and workflow development. Conclusion We found broad enthusiasm about the relevance and potential benefits of BL TDM among stakeholders. Prior literature suggested the primary barrier to implementation was assay availability, but we identified many more individual and organizational attributes which impacted the scale and spread of BL TDM. Disclosures Sara Ausman, PharmD, Gilead: Honoraria Christina G. Rivera, PharmD, Gilead: Grant/Research Support|Gilead: Honoraria|Insmed: Honoraria Jason Roberts, BPharm(Hons), PhD, FSHP, FISAC, British Society of Chemotherapy: Grant/Research Support|Cipla: Honoraria|Gilead: Advisor/Consultant|MSD: Advisor/Consultant|MSD: Honoraria|Pfizer: Board Member|Pfizer: Honoraria|Qpex: Grant/Research Support|Sandoz: Board Member|Summit: Advisor/Consultant|Wolters Kluwer: Advisor/Consultant Marc H. Scheetz, PharmD, MSc, Abbvie: Advisor/Consultant|Allecra: Grant/Research Support|Merck: Advisor/Consultant|Nevakar: Advisor/Consultant|Nevakar: Grant/Research Support|Premier Healthcare Solutions: Honoraria|Spero: Advisor/Consultant|SuperTrans Medical: Advisor/Consultant|SuperTrans Medical: Grant/Research Support|Takeda: Advisor/Consultant|Third Pole Therapeutics: Advisor/Consultant.

Abstract Background: Venous thromboembolism (VTE) in pregnancy is an important cause of maternal morbidity and mortality. Low-molecular-weight heparin (LMWH) is the cornerstone of prophylaxis and treatment of thrombotic events during pregnancy. LMWH has fewer adverse effects than other anticoagulants, does not cross the placenta, and is safe for the fetus. However, the use of LMWH during pregnancy is sensitive to womens’ underlying preferences. The objective of this review is to systematically assess women’s values and preferences research evidence on this topic.Methods: We searched four electronic databases from inception to March 2022, and included studies examining values and preferences of using LMWH among pregnant women at risk of VTE. We followed a convergent integrated mixed-methods design to compare and contrast quantitative (utility and non-utility measures) and qualitative findings. We assessed the certainty of the values and preferences evidence with the GRADE approach for quantitative findings, and with GRADE-CERqual for qualitative evidence. Results were presented in a conjoint display.Results: We screened 3,393 references and identified seven eligible studies. The mixed methods analysis resulted in four themes. Datasets confirmed each other in that: 1) the majority of women consider that benefits of treatment outweigh the inconveniences of daily injections; and 2) main concerns around medication are safety and injections administration. Quantitative outcomes expanded on the qualitative findings in that: 3) participants who perceived a higher risk of VTE were more willing to take LMWH. Finally, we found a discrepancy between the datasets around: 4) the amount of information preferred to make the decision; however, qualitative data expanded to clarify that women prefer making informed decisions and receive support from their clinician in their decision-making process.Conclusions: We are moderately confident that in the context of pregnancy, using LMWH is preferred by women given its net beneficial balance. Integrating data from different sources of evidence, and representing them in a jointly manner helps to identify patient’s values and preferences. Our results may inform clinical practice guidelines and support shared decision-making process in the clinical encounter for the management of VTE in the context of pregnancy.

CSCW has previously investigated the "information work" that patients do in relation to their health, illnesses, and treatments. Our study contributes to this ongoing stream of work by investigating the information work that chronically ill patients do in relation to their physical bodily experiences. We use an interpretivist approach and qualitative methods (semi-structured interviews and observations) to examine how patients in a midwestern U.S. city carry out information work related to their bodily experiences of Chronic Kidney Disease (CKD). Our findings highlight four themes related to such work: bodily experiences of CKD; making meaning of bodily experiences through experiential learning; communicating bodily experiences; and attuning daily life around bodily experiences. In so doing, we show how patients continuously engage in information work in relation to their bodily experiences. For example, we found participants experienced physical sensations such as pain, cramping, and extreme fatigue, which elicited complex labor, yet most patients received little education from health care professionals about what bodily sensations they might have and what these physical experiences might mean. While patients and clinicians worked collaboratively to adjust treatment based on bodily information, such collaborative adjustment often did not occur until patients learned to interpret and communicate bodily experiences through a difficult and physically painful "trial and error" learning process. Our empirical insights extend on the literature of information work that chronically ill patients do and inform design of information technologies and care processes for patients with chronic disease.

Known gaps exist between what patients value and institutions prioritize. We sought to incorporate patients’ reasons for valuing family medicine into a new Mission and Vision statement by deploying brief surveys to a convenience sample of patients. We conducted descriptive quantitative analyses of demographics and inductive content analysis of written responses. Patients returned 92 (20%) of 450 questionnaires. Responders were 63% female, mean age of 47 years. Patients noted distinguishing features of family medicine were (1) continuity of care, (2) all-encompassing care, and (3) trusted referrals. Some patients reported not knowing there was a distinction between family medicine and other primary care.

Abstract Purpose: Diabetes care has largely focused on reducing the risk of complications by achieving hemoglobin A1c (HbA1c) targets; yet, whole-person care may be more effective and desirable. We sought to determine the nature of discussions about quality of life, burden of treatment, hypoglycemia, sexual function, and social support during diabetes-focused clinical encounters.Methods: We analyzed 41 previously recorded clinical encounters with patients with type 2 diabetes from the control arms of practice-based trials of shared decision making. Two coders evaluated videos for discussions about aspects of life with diabetes: quality of life, burden of treatment, hypoglycemia, sexual function, and social supports. When an aspect was raised, coders evaluated the nature of the conversation, clinician responses, and time spent on discussing the aspect. Results: Median length of the encounter was 15 minutes, 6 seconds (IQR: 11:16 – 20:23 minutes). Thirty five of 41 encounters (85.4%), included some discussion of quality of life (58.5%), burden of treatment (51.2%), social support (2.4%), or hypoglycemia (9.8%). Sexual function was not discussed. On average, 4.5% (1.4%-5.5%) of the encounter time involved conversations about HbA1c whereas 15.0% (0%-25%) of the encounter was spent on some aspect of quality of life, burden of treatment, social support, or hypoglycemia. If a topic related to quality of life was raised, clinicians most often responded by acknowledging patient’s concern without providing a solution (45.8%). Conclusions: A significant part of the patient-clinician encounter involves discussion of quality of life and burden of treatment, but clinicians rarely address these issues by providing solutions.

Abstract Background: Chronic conditions are placing a serious burden on individuals as well as the health care system. Health coaching (HC) has emerged as a promising approach that can support effective lifestyle interventions for chronic conditions. However, until now there is no particularly comprehensive systematic review of HC impact on a chronic condition from the angle of patient improvement and detail coaching characteristics reported. Objective: To synthesize available studies on the efficacy and current status of HC interventions on the health of chronically ill adult patients. Methods: The literature search will be conducted for trials published in English within the past four years. Electronic databases CINAHL, Cochrane Library, Embase, MEDLINE, and Scopus will be searched with keywords describing HC for chronic diseases. Randomized controlled trials that compare HC interventions to conventional care or other alternative therapies will be included. Data extraction will be conducted by two reviewers independently, and enrolled trials will be evaluated for quality and bias assessment. If appropriate, meta-analysis will be conducted on the last stage of the review; otherwise, the study findings will be described narratively. The software Review Manager (Revman version 5.3.5.) provided by the Cochrane Collaboration will be applied for the meta-analysis. Results: This is the first study to comprehensively explore the effectiveness and current status of HC intervention for patients with chronic conditions. Discussion: Study findings from this review will advance the appropriate utilization of coaching practice by determining whether HC is effective and feasible among patients with chronic disease. If proven effective, this approach may be applied more broadly through public health interventions. The current status findings will also provide evidence to inform decisions for integrating HC interventions into the current management pathway for individuals with chronic conditions. Systematic review registration: PROSPERO CRD42020153280.

Background Leadership Saves Lives (LSL) was a prospective, mixed methods intervention to promote positive change in organisational culture across 10 diverse hospitals in the USA and reduce mortality for patients with acute myocardial infarction (AMI). Despite the potential impact of complex interventions such as LSL, descriptions in the peer-reviewed literature often lack the detail required to allow adoption and adaptation of interventions or synthesis of evidence across studies. Accordingly, here we present the underlying design principles, overall approach to intervention design and core content of the intervention. Methods of intervention development Hospitals were selected for participation from the membership of the Mayo Clinic Care Network using random sampling with a purposeful component. The intervention was designed based on the Assess, Innovate, Develop, Engage, Devolve model for diffusion of innovation, with attention to pressure testing of the intervention with user groups, creation of a think tank to develop a comprehensive assessment of the landscape, and early and continued engagement with strategically identified stakeholders in multiple arenas. Results We provide in-depth descriptions of the design and delivery of the three intervention components (three annual meetings of all hospitals, four rounds of in-hospital workshops and an online community), designed to equip a guiding coalition within each site to identify and address root causes of AMI mortality and improve organisational culture. Conclusions This detailed practical description of the intervention may be useful for healthcare practitioners seeking to promote organisational culture change in their own contexts, researchers seeking to compare the results of the intervention with other leadership development and organisational culture change efforts, and healthcare professionals committed to understanding complex interventions across healthcare settings.

Purpose To pilot test the impact of the ICAN Discussion Aid on clinical encounters. Methods A pre–post study involving 11 clinicians and 100 patients was conducted at two primary care clinics within a single health system in the Midwest. The study examined clinicians’ perceptions about ICAN feasibility, patients’ and clinicians’ perceptions about encounter success, videographic differences in encounter topics, and medication adherence 6 months after an ICAN encounter. Results 39/40 control encounters and 45/60 ICAN encounters yielded usable data. Clinicians reported ICAN use was feasible. In ICAN encounters, patients discussed diet, being active and taking medications more. Clinicians scored themselves poorer regarding visit success than their patients scored them; this effect was more pronounced in ICAN encounters. ICAN did not improve 6-month medication adherence or lengthen visits. Conclusion This pilot study suggests that using ICAN in primary care is feasible, efficient and capable of modifying conversations. With lessons learned in this pilot, we are conducting a randomised trial of ICAN versus usual care in diverse clinical settings. Trial registration number NCT02390570 .

AbstractObjectiveThis study assesses the attitudes and preferences of Chinese clinicians toward their involvement in shared decision making (SDM).MethodsFrom May 2014 to May 2015, 200 Chinese clinicians from two hospitals were enrolled to complete a survey on their attitude towards SDM. We conducted the survey via face‐to‐face interviews before and after an educational intervention on SDM among young Chinese clinicians. The clinicians were asked to give the extent of agreement to SDM. They also gave the extent of difficulty in using decision aids (DAs) during the SDM process. The variation in the range of responses to each question before and after the SDM intervention was recorded. The frequency of changed responses was analyzed by using JMP 6.0 software. Data were statistically analyzed using Chi‐square and Mann–Whitney U tests, as appropriate to the data type. Multiple logistic regressions were used to test for those factors significantly and independently associated with preference for an approach for each scenario.ResultsOf the 200 young Chinese clinicians sampled, 59.0% indicated a preference for SDM and a desire to participate in SDM before receiving education or seeing the DA, and this number increased to 69.0% after seeing the DA with the sample video of the SDM process on Statin Choice. However, 28.5% of the respondents still reported that, in their current practice, they make clinical decisions on behalf of their patients. The clinicians who denied a desire to use the DA stated that the main barriers to implement SDM or DA use in China are lack of time and knowledge of SDM.ConclusionsMost young Chinese clinicians want to participate in SDM. However, they state the main barriers to perform SDM are lack of experience and time. The educational intervention about SDM that exposes clinicians to DAs was found to increase their receptivity.