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We explored experiences and perceptions surrounding the Self-Stewardship Time-Out Program (SSTOP) intervention across implementation sites to improve antimicrobial use. Semistructured qualitative interviews were conducted with Antibiotic Stewardship physicians and pharmacists, from which 5 key themes emerged. SSTOP may serve to achieve sustainable promotion of antibiotic use improvements.

Refugees experience high rates of food insecurity (FI) and its associated health outcomes, such as depression and hypertension. Prior research has identified barriers in accessing food among U.S. refugees. What remains unknown is when accessing food becomes a problem for U.S. refugees and what their preferred strategies are to address FI. Therefore, the objectives were to explore FI experiences among refugees to identify time points at which accessing food becomes a problem and to identify refugees' preferred strategies to address FI. In collaboration with one of the U.S. resettlement agencies in Utah, refugees were recruited for semi-structured interviews using convenience and snowball sampling. Thirty-six interviews were conducted between July and September 2024, in four different languages: English (4 interviews), Dari (6), Arabic (12), and Kinyarwanda (14). Interview transcripts were analyzed using thematic analysis. FI was at its peak among refugees at four time points. First, when they found their first job in the U.S. Second, after six months in the U.S., when they had to renew their Supplemental Nutrition Assistance Program (SNAP) application. Third, when they were no longer receiving caseworkers' support from resettlement agencies. Fourth, when they faced fluctuations in employment or household expenditures. Refugees' preferred strategies to address FI were addressing language barriers, providing a champion to check on them frequently and help when needed, providing information on addressing unmet needs, extending and expanding SNAP benefits, and providing gardens to grow food. Four time points when refugees are at higher risk of FI were identified. Community organizations, policymakers, and resettlement agencies should therefore develop interventions to address FI among refugees, specifically around these four time points and informed by refugees' preferred strategies.

Patient-centered care promotes the involvement of patients in decision-making related to their health care. The adoption and implementation of shared decision-making (SDM) into routine care are constrained by several obstacles, including technical and time constraints, clinician and patient attitudes and perceptions, and processes that exist outside the standardized clinical workflow. We aimed to understand the integration and implementation characteristics of reported SDM interventions integrated into an electronic health record (EHR) system. We conducted a scoping review using the methodological framework by Arksey and O'Malley with guidance from the Joanna Briggs Institute. Eligibility criteria included original research and reviews focusing on SDM situations in a real-world clinical setting and EHR integration of SDM tools and processes. We excluded retrospective studies, conference abstracts, simulation studies, user design studies, opinion pieces, and editorials. To identify eligible studies, we searched the following databases on January 11, 2021: MEDLINE, Embase, CINAHL Complete, Cochrane Library including CENTRAL, PsycINFO, Scopus, and Web of Science Core Collection. We systematically categorized descriptive data and key findings in a tabular format using predetermined data charting forms. Results were summarized using tables and associated narratives related to the review questions. Of the 2153 studies, 18 (0.84%) were included in the final review. There was a high degree of variation across studies, including SDM definitions, standardized measures, technical integration, and implementation strategies. SDM tools that targeted established health care processes promoted their use. Integrating SDM templates and tools into an EHR appeared to improve the targeted outcomes of most (17/18, 94%) studies. Most SDM interventions were designed for clinicians. Patient-specific goals and values were included in 56% (10/18) of studies. The 2 most common study outcome measures were SDM-related measures and SDM tool use. Understanding how to integrate SDM tools directly into a clinician's workflow within the EHR is a logical approach to promoting SDM into routine clinical practice. This review contributes to the literature by illuminating features of SDM tools that have been integrated into an EHR system. Standardization of SDM tools and processes, including the use of patient decision aids, is needed for consistency across SDM studies. The implementation approaches for SDM applications showed varying levels of planning and effort to promote SDM intervention awareness. Targeting accepted and established clinical processes may enhance the adoption and use of SDM tools. Future studies designed as randomized controlled trials are needed to expand the quality of the evidence base. This includes the study of integration methods into EHR systems as well as implementation methods and strategies deployed to operationalize the uptake of the SDM-integrated tools. Emphasizing patients' goals and values is another key area for future studies.

Severe acute respiratory syndrome coronavirus 2, (SARS-CoV-2,) caused an influx of patients with acute disease characterized by a variety of symptoms termed COVID-19 disease, with some patients going on to develop post-acute COVID-19 syndrome. Individual factors like sex or coping styles are associated with a person's disease experience and quality of life. Individual differences in coping styles used to manage COVID-19 related stress correlate with physical and mental health outcomes. Our study sought to understand the relationship between COVID-19 symptoms, severity of acute disease, and coping profiles. An online survey to assess symptoms, functional status, and recovery in a large group of patients was nationally distributed online. The survey asked about symptoms, course of illness, and included the Brief-COPE and the adapted Social Relationship Inventory. We used descriptive and cluster analyses to characterize patterns of survey responses. 976 patients were included in the analysis. The most common symptoms reported by the patients were fatigue (72%), cough (71%), body aches/joint pain (66%), headache (62%), and fever/chills (62%). 284 participants reported PACS. We described three different coping profiles: outward, inward, and dynamic copers. Fatigue, cough, and body aches/joint pains were the most frequently reported symptoms. PACS patients were sicker, more likely to have been hospitalized. Of the three coping profiles, outward copers were more likely to be admitted to the hospital and had the healthiest coping strategies. Dynamic copers activated several coping strategies both positive and negative; they were also younger and more likely to report PACS. Cough, fatigue, and body aches/joint pain are common and most important to patients with acute COVID-19, while shortness of breath defined the experience for patients with PACS. Of the three coping profiles, dynamic copers were more likely to report PACS. Additional investigations into coping profiles in general, and the experience of COVID-19 and PACS is needed.

Background Food insecurity, poor nutrition, and diet-related diseases create major intersecting health challenges. The Veterans Health Administration (VHA) has identified food insecurity as a high-priority problem and established regular clinical screening. Veterans with identified food insecurity and diet-sensitive cardiometabolic health conditions will benefit from the successful implementation of effective Food is Medicine interventions. Methods This pragmatic, quasi-experimental intervention study of effectiveness and implementation of a produce-prescription program is conducted in 2 VA hospital health systems in Salt Lake City, Utah, and Houston, Texas. Eligible Veterans have (a) a diet-sensitive cardiometabolic health condition (obesity, hypertension, and/or diabetes) identified in the electronic health record (EHR) by diagnostic codes (ICD-10) and/or lab values and (b) low-income identified by priority status in administrative data. Program enrollment is pragmatically integrated within the VA clinical care process of food security screening and service referrals. Eligible Veterans who screen positive for food insecurity during clinical care processes are referred to the intervention. The Veterans Affairs FreshConnect Produce Prescription (VA FCPRx) intervention program includes 12 months of a produce prescription allowance for purchasing fresh fruits or vegetables, provided as $100 monthly on a pre-paid card for use at local grocery stores. The program also includes culinary education through cooking courses provided by VA nutritionists or nutritional consults provided one-on-one by a VA dietitian. Process and outcome measures will be evaluated using the PRISM RE-AIM framework. Health outcomes related to diet-sensitive chronic conditions (e.g., HbA1c levels for patients with diabetes) and healthcare costs (e.g., outpatient costs) are assessed using EHR data. VA FCPRx participant outcomes are assessed in comparison to a group of similar Veterans using intention-to-treat analyses. Patient-reported outcomes, implementation strategies and outcomes, and staff and Veteran experience are assessed with a combination of surveys, focus groups, and program administrative data. Discussion This pragmatic quasi-experimental intervention study will provide important new evidence about the impact of a produce prescription program for U.S. Veterans on health outcomes, healthcare costs, and patient-reported outcomes. The assessment of effectiveness and implementation processes and outcomes will inform the design and scaling of impactful, pragmatic, cost-effective programs for food insecure Veterans with diet-sensitive cardiometabolic conditions.

Background Individuals with high risk for lung cancer may benefit from lung cancer screening, but there are associated risks as well as benefits. Shared decision‐making (SDM) tools with personalized information may provide key support for patients. Understanding patient perspectives on educational tools to facilitate SDM for lung cancer screening may support tool development. Aim This study aimed to explore patient perspectives related to a SDM tool for lung cancer screening using a qualitative approach. Methods We elicited patient perspectives by showing a provider‐facing SDM tool. Focus group interviews that ranged in duration from 1.5 to 2 h were conducted with 23 individuals with high risk for lung cancer. Data were interpreted inductively using thematic analysis to identify patients' thoughts on and desires for a patient‐facing SDM tool. Results The findings highlight that patients would like to have educational information related to lung cancer screening. We identified several key themes to be considered in the future development of patient‐facing tools: barriers to acceptance, preference against screening and seeking empowerment. One further theme illustrated effects of patient–provider relationship as a limitation to meeting lung cancer screening information needs. Participants also noted several suggestions for the design of technology decision aids. Conclusion These findings suggest that patients desire additional information on lung cancer screening in advance of clinical visits. However, there are several issues that must be considered in the design and development of technology to meet the information needs of patients for lung cancer screening decisions. Patient or Public Contribution Patients, service users, caregivers or members of the public were not involved in the study design, conduct, analysis or interpretation of the data. However, clinical experts in health communication provided detailed feedback on the study protocol, including the focus group approach. The study findings contribute to a better understanding of patient expectations for lung cancer screening decisions and may inform future development of tools for SDM.

Background In this study we sought to explore the possibility of using patient centered care (PCC) documentation as a measure of the delivery of PCC in a health system. Methods We first selected 6 VA medical centers based on their scores for a measure of support for self-management subscale from a national patient satisfaction survey (the Survey for Healthcare Experience-Patients). We accessed clinical notes related to either smoking cessation or weight management consults. We then annotated this dataset of notes for documentation of PCC concepts including: patient goals, provider support for goal progress, social context, shared decision making, mention of caregivers, and use of the patient's voice. We examined the association of documentation of PCC with patients’ perception of support for self-management with regression analyses. Results Two health centers had < 50 notes related to either tobacco cessation or weight management consults and were removed from further analysis. The resulting dataset includes 477 notes related to 311 patients total from 4 medical centers. For a majority of patients (201 out of 311; 64.8%) at least one PCC concept was present in their clinical notes. The most common PCC concepts documented were patient goals (patients n = 126; 63% clinical notes n = 302; 63%), patient voice (patients n = 165, 82%; clinical notes n = 323, 68%), social context (patients n = 105, 52%; clinical notes n = 181, 38%), and provider support for goal progress (patients n = 124, 62%; clinical notes n = 191, 40%). Documentation of goals for weight loss notes was greater at health centers with higher satisfaction scores compared to low. No such relationship was found for notes related to tobacco cessation. Conclusion Providers document PCC concepts in their clinical notes. In this pilot study we explored the feasibility of using this data as a means to measure the degree to which care in a health center is patient centered. Practice Implications: clinical EHR notes are a rich source of information about PCC that could potentially be used to assess PCC over time and across systems with scalable technologies such as natural language processing.

Importance The effectiveness of public health measures implemented to mitigate the spread and impact of SARS-CoV-2 relies heavily on honesty and adherence from the general public. Objective To examine the frequency of, reasons for, and factors associated with misrepresentation and nonadherence regarding COVID-19 public health measures. Design, Setting, and Participants This survey study recruited a national, nonprobability sample of US adults to participate in an online survey using Qualtrics online panels (participation rate, 1811 of 2260 [80.1%]) from December 8 to 23, 2021. The survey contained screening questions to allow for a targeted sample of one-third who had had COVID-19, one-third who had not had COVID-19 and were vaccinated, and one-third who had not had COVID-19 and were unvaccinated. Main Outcomes and Measures The survey assessed 9 different types of misrepresentation and nonadherence related to COVID-19 public health measures and the reasons underlying such behaviors. Additional questions measured COVID-19–related beliefs and behaviors and demographic characteristics. Results The final sample included 1733 participants. The mean (SD) participant age was 41 (15) years and the sample predominantly identified as female (1143 of 1732 [66.0%]) and non-Hispanic White (1151 of 1733 [66.4%]). Seven hundred twenty-one participants (41.6%) reported misrepresentation and/or nonadherence in at least 1 of the 9 items; telling someone they were with or about to be with in person that they were taking more COVID-19 preventive measures than they actually were (420 of 1726 [24.3%]) and breaking quarantine rules (190 of 845 [22.5%]) were the most common manifestations. The most commonly endorsed reasons included wanting life to feel normal and wanting to exercise personal freedom. All age groups younger than 60 years (eg, odds ratio for those aged 18-29 years, 4.87 [95% CI, 3.27-7.34]) and those who had greater distrust in science (odds ratio, 1.14 [95% CI, 1.05-1.23]) had significantly higher odds of misrepresentation and/or nonadherence for at least 1 of the 9 items. Conclusions and Relevance In this survey study of US adults, nearly half of participants reported misrepresentation and/or nonadherence regarding public health measures against COVID-19. Future work is needed to examine strategies for communicating the consequences of misrepresentation and nonadherence and to address contributing factors.

The Intensive Care Unit (ICU) is a stressful environment for families of critically ill patients and these individuals are at risk to develop persistent psychological morbidity. Our study objective was to identify individual differences in coping with stress and information presentation preferences of respondents exposed to a simulated ICU experience. Participants were recruited from a university and two community populations. Participants completed questionnaires that measured demographic information and characteristics that may be relevant to an individual's ICU experience. Quality of life was measured by the EQ-5D, personality dimensions were examined with the abbreviated Big Five inventory, coping with stress was assessed with Brief COPE. Shared decision making preferences were assessed by the Degner Control Preferences Scale (CPS) and information seeking style was assessed with the Miller Behavioral Style Scale (MBSS). Social support was examined using an abbreviated version of the Social Relationship Index. Participants also completed a vignette-based simulated ICU experience, in which they made a surrogate decision on behalf of a loved one in the ICU. Three hundred forty-three participants completed the study. Three distinct coping profiles were identified: adaptive copers, maladaptive copers, and disengaged copers. Profiles differed primarily on coping styles, personality, quality of their closest social relationship, and history of anxiety and depression. Responses to the simulated ICU decision making experience differed across profiles. Disengaged copers (15%) were more likely to elect to refuse dialysis on behalf of an adult sibling compared to adaptive copers (7%) or maladaptive copers (5%) (p = 0.03). Notably, the MBSS and the CPS did not differ by coping profile. Distinct coping profiles are associated with differences in responses to a simulated ICU experience. Tailoring communication and support to specific coping profiles may represent an important pathway to improving ICU experience for patients and families.

OBJECTIVES/GOALS: The Clinical Implementation stage in the translational pipeline is hampered by the tension between formal evidence and clinician perceptions. For instance, when guidelines are translated into electronic clinical decision support alerts, they are often ignored. Using advances in LLMs we present a framework to quantify these discrepancies. METHODS/STUDY POPULATION: We hypothesize that ignoring guideline-based alerts may be driven by discordances between clinical guidelines’ deterministic realities and clinician’ perception of clinical reality. Until now this has been very difficult to measure using quantitative methods. We argue that advances in Large Language Models (LLM) provide an avenue for exploring this quantitatively. Here we present the method and preliminary results comparing the responses of BioBERTT from a carefully designed set of questions when the LLM is fine-tuned using either formal guidelines or transcripts of clinicians discussing guidelines and clinical care in the parallel domain. The formal “distance” between the LLM responses is evaluated using quantitative metrics like the Hamming Distance. RESULTS/ANTICIPATED RESULTS: We present a description of the architecture used to prove or disprove our hypothesis. We will present results obtained when training the architecture with data that could be used to test the limits of our hypothesis, by fine-tuning BioBERT with diverse synthetic clinical views, either in agreement or disagreement with the formal guidelines. Results comparing sepsis guideline text with transcripts of interviews with Emergency Department clinicians discussing care practices for sepsis in the ED transcripts will also be considered. Our current emphasis is on securing a wider range of transcripts of clinicians interviewed from different clinical specialties and different clinical settings. While here we focus on clinical guidelines, the framework supports any intervention in the Clinical Implementation stage. DISCUSSION/SIGNIFICANCE: Leveraging recent advances in LLMs, we develop a framework that can quantitatively measure the differences between guidelines and clinician perception of best practices. We demonstrated the functionality of this approach using synthetic data and initiated the collection of clinician transcripts to test the framework in real clinical situations.