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"Balboni, Tracy"
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Spirituality As A Determinant Of Health: Emerging Policies, Practices, And Systems
Reimagining public health's future should include explicitly considering spirituality as a social determinant of health that is linked to human goods and is deeply valued by people and their communities. Spirituality includes a sense of ultimate meaning, purpose, transcendence, and connectedness. With that end in mind, we assessed how recommendations recently issued by an expert panel for integrating spiritual factors into public health and medicine are being adopted in current practice in the United States. These recommendations emerged from a systematic review of empirical evidence on spirituality, serious illness, and population health published between 2000 and 2022. For each recommendation, we reviewed current federal, state, and local policies and practices recognizing spiritual factors, and we considered the ways in which they reflected the panel's recommendations. In this article, we highlight opportunities for broader application and scale while also noting the potential harms and benefits associated with incorporating these recommendations in various contexts. This analysis, while respecting the spiritual and religious diversity of the US population, identifies promising approaches for strengthening US public health by integrating spiritual considerations to inform person- and community-centered policy and practice.
Journal Article
Building towards common psychosocial measures in U.S. cohort studies: principal investigators’ views regarding the role of religiosity and spirituality in human health
Background
The goal of this study was to understand prospective cohort study Principal Investigators’ (PIs’) attitudes regarding the importance of religion and spirituality (R/S) on disease etiology in order to identify barriers and opportunities for greater inclusion of these domains in high-quality epidemiological research.
Methods
One-hour, semi-structured qualitative interviews were conducted with 20 PIs, who represent 24 different National Institutes of Health (NIH)-funded prospective cohort studies in the U.S. Collectively, these PIs collect detailed health data on approximately 1.25 of every 100 adult Americans. Sample size was calculated to achieve thematic saturation.
Results
The majority of PIs we interviewed viewed R/S as potentially important factors influencing disease etiology, particularly among minority communities that report higher levels of religiosity. Yet nearly all PIs interviewed felt there was not yet a compelling body of evidence elucidating R/S influences on health, and the potential mechanisms through which R/S may be operating to affect health outcomes. PIs identified 5 key areas that would need to be addressed before they would be persuaded to collect more R/S measures in their cohorts: (1) high-quality, prospective studies that include all appropriate covariates for the outcome under study; (2) studies that posit a plausible biological mechanism of effect; (3) well-validated R/S measures, collected in common across multiple cohorts; (4) the need to address bias against R/S research among investigators; and (5) NIH funding for R/S research.
Conclusions
Results of this study provide a roadmap for future R/S research investigating the impact of R/S influences on disease etiology within the context of U.S. prospective cohort studies. Identifying significant R/S influences on health could inform novel interventions to improve population health. Given the higher levels of religiosity/spirituality among minority communities, R/S research may also provide new leverage points for reducing health disparities.
Journal Article
Advance care planning and hospital outcomes in solid tumour oncology inpatients
ObjectivesTo assess the association between advance care planning (ACP) and outcomes of in-hospital mortality, 30-day hospital readmission and 30-day emergency department (ED) visits among patients with cancer.MethodsThis observational cohort analysis included patients with solid tumour malignancies receiving oncology care and admitted at Yale New Haven Hospital between 1 January 2018 and 31 December 2021.ResultsAmong 19 422 patients, 1283 (6.6%) had a documented ACP note. Compared with patients without an ACP, patients with an ACP tended to be older, have longer LOS, be admitted to an oncology inpatient team, subsequently admitted to intensive care unit and have a lower Rothman Index. Multivariable logistic regression identified ACP as independently associated with decreased 30-day readmission (OR=0.70 (95% CI: 0.60 to 0.82)) and 30-day ED visit (OR=0.79 (95% CI: 0.68 to 0.91)), adjusting for in-hospital mortality and patient characteristics.ConclusionACP documentation is associated with decreased readmissions and ED visits, independent of hospice utilisation.
Journal Article
Whose role? Oncology practitioners’ perceptions of their role in providing spiritual care to advanced cancer patients
Purpose
The purpose of this study is to determine how oncology nurses and physicians view their role in providing spiritual care (SC), factors influencing this perception, and how this belief affects SC provision.
Methods
This is a survey-based, multisite study conducted from October 2008 to January 2009. All oncology physicians and nurses caring for advanced cancer patients at four Boston, MA cancer centers were invited to participate; 339 participated (response rate = 63 %).
Results
Nurses were more likely than physicians to report that it is the role of medical practitioners to provide SC, including for doctors (69 vs. 49 %,
p
< 0.001), nurses (73 vs. 49 %,
p
< 0.001), and social workers (81 vs. 63 %,
p
= 0.001). Among nurses, older age was the only variable that was predictive of this belief [adjusted odds ratio (AOR) 1.08; 1.01–1.16,
p
= 0.02]. For nurses, role perception was not related to actual SC provision to patients. In contrast, physicians’ role perceptions were influenced by their intrinsic religiosity (AOR, 1.44; 95 % CI, 1.09–1.89;
p
= 0.01) and spirituality (AOR, 6.41; 95 % CI, 2.31–17.73,
p
< 0.001). Furthermore, physicians who perceive themselves as having a role in SC provision reported greater SC provision to their last advanced cancer patients seen in clinic, 69 % compared to 31 %,
p
< 0.001.
Conclusions
Nurses are more likely than physicians to perceive medical practitioners as having a role in SC provision. Physicians’ perceptions of their role in SC provision are influenced by their religious/spiritual characteristics and are predictive of actual SC provision to patients. Spiritual care training that includes improved understanding of clinicians’ appropriate role in SC provision to severely ill patients may lead to increased SC provision.
Journal Article
Quantitative-qualitative analyses of patient-reported pain response after palliative radiation therapy
PurposeWhile the 0–10 pain scale is often used to assess treatment response, it may not accurately reflect change in pain over time. The purpose of this study is to correlate pain improvement using the 0–10 pain scale to patients’ perceived improvement in pain following palliative radiation therapy (RT), and to qualitatively characterize themes of pain assessment.MethodsPatients age ≥ 20 receiving RT for spinal metastases were enrolled. Patients rated their pain (0–10) at the treatment site at RT start, and 1 and 4 weeks post-RT completion. At 1 and 4 weeks post-RT, patients reported their perceived percent improvement in pain (pPIP) (0–100%), which was compared to calculated percent improvement in pain (cPIP) based on the 0–10 pain scores. At 4 weeks post-RT, 20 randomly selected patients participated in a qualitative pain assessment.ResultsSixty-four patients treated at 1–2 sites were analyzed. At 1 week post-RT completion, 53.7% (36/67) reported pPIP within 10 percentage points of cPIP, 32.8% (22/67) reported pPIP > 10 percentage points higher than cPIP, and 13.4% (9/67) reported pPIP > 10 percentage points lower than cPIP. Similar degrees of discordance were seen at 4 weeks post-RT. Qualitative analysis revealed five themes: pain quality (n = 19), activities (n = 9), function (n = 7), medication use (n = 2), and radiation side effects (n = 1).ConclusionsAbout half of patients reported a pPIP substantially disparate from their cPIP, and the change in pain measured by the 0–10 scale tended to underestimate the degree of perceived pain improvement. Multiple themes were identified in qualitative analysis of pain response.
Journal Article
A Roadmap for conducting psychosocial research in epidemiological studies: perspectives of cohort study principal investigators
BackgroundPsychosocial adversity disproportionately affects racial/ethnic and socioeconomic minorities in the USA, and therefore understanding the mechanisms through which psychosocial stress and resilience influence human health can provide meaningful insights into addressing US health disparities. Despite this promise, psychosocial factors are infrequently and unsystematically collected in the US prospective cohort studies.MethodsWe sought to understand prospective cohort principal investigators’ (PIs’) attitudes regarding the importance of psychosocial influences on disease aetiology, in order to identify barriers and opportunities for greater inclusion of these domains in high-quality epidemiological research. One-hour, semi-structured qualitative interviews were conducted with 20 PIs representing 24 US prospective cohort studies funded by the National Institutes of Health (NIH), collectively capturing health data on 1.25 of every 100 American adults. A hypothesis-free, grounded theory approach was used to analyse and interpret interview data.ResultsMost cohort PIs view psychosocial factors as an important research area to further our understanding of disease aetiology and agree that this research will be crucial for future public health innovations. Virtually all PIs emphasised that future psychosocial research will need to elucidate biological and behavioural mechanisms in order to be taken seriously by the epidemiological community more broadly. A lack of pertinent funding mechanisms and a lack of consensus on optimal scales and measures of psychosocial factors were identified as additional barriers to advancing psychosocial research.ConclusionsOur interviews emphasised the need for: (1) high-quality, longitudinal studies that investigate biological mechanisms and pathways through which psychosocial factors influence health, (2) effort among epidemiological cohorts to broaden and harmonise the measures they use across cohorts, to facilitate replication of results and (3) the need for targeted funding opportunities from NIH and other grant-making institutions to study these domains.
Journal Article
Non-operative management of spinal metastases: A prognostic model for failure
•We identified factors associated with non-operative failure in spinal metastases.•9% of the population treated non-operatively received surgery within 1-year.•Risk factors for surgery included neurologic symptoms and pathologic fracture.
To describe patient-specific characteristics associated with non-operative failure leading to surgery.
We conducted a retrospective review of patients treated for spinal metastases from 2005 to 2017. We deemed patients as failures if they were treated non-operatively and then received a surgical intervention within one year of starting a non-operative regimen. We used multivariable Poisson regression to identify factors associated with non-operative failure. We conducted internal validation using bootstrapping with 1000 replications.
We identified 1205 patients with spinal metastases, of whom 834 were initially treated non-operatively and constituted the analytic sample. Of these 77 (9%) went on to have surgery within 1-year of presentation and were deemed non-operative treatment failures. We identified vertebral body collapse and/or pathologic fracture (adjusted Risk Ratio [RR] 1.75; 95% Confidence Interval [CI] 1.11, 2.76) and neurologic signs or symptoms at presentation (RR 1.90; 95% CI 1.19, 3.03) as factors independently associated with an increased risk of non-operative failure. Platelet-lymphocyte ratio >155, a marker for inflammatory state, was also associated with an increased risk of failure (RR 2.32; 95% CI 1.15, 4.69). Failure rates among those with 0, 1, 2 or all three of these risk factors were 5%, 7%, 12% and 20%, respectively (p = 0.004).
We found that 9% of patients with spinal metastases initially treated non-operatively received surgery within 1-year of commencing care. The likelihood of surgery increased with the number of risk factors. These results can be used in counseling and shared decision making at the time of initial presentation.
Journal Article
Training Community Clergy in Serious Illness: Balancing Faith and Medicine
Community-based clergy are highly engaged in helping seriously ill patients address spiritual concerns at the end of life (EOL). While they desire EOL training, no data exist in guiding how to conceptualize a clergy-training program. The objective of this study was used to identify best practices in an EOL training program for community clergy. As part of the National Clergy Project on End-of-Life Care, the project conducted key informant interviews and focus groups with active clergy in five US states (California, Illinois, Massachusetts, New York, and Texas). A diverse purposive sample of 35 active clergy representing pre-identified racial, educational, theological, and denominational categories hypothesized to be associated with more intensive utilization of medical care at the EOL. We assessed suggested curriculum structure and content for clergy EOL training through interviews and focus groups for the purpose of qualitative analysis. Thematic analysis identified key themes around curriculum structure, curriculum content, and issues of tension. Curriculum structure included ideas for targeting clergy as well as lay congregational leaders and found that clergy were open to combining resources from both religious and health-based institutions. Curriculum content included clergy desires for educational topics such as increasing their medical literacy and reviewing pastoral counseling approaches. Finally, clergy identified challenging barriers to EOL training needing to be openly discussed, including difficulties in collaborating with medical teams, surrounding issues of trust, the role of miracles, and caution of prognostication. Future EOL training is desired and needed for community-based clergy. In partnering together, religious–medical training programs should consider curricula sensitive toward structure, desired content, and perceived clergy tensions.
Journal Article