A socioecological qualitative analysis of barriers to care in colorectal surgery.

BACKGROUND: Although specific social determinants of health have been associated with disparities in surgical outcomes, there exists a gap in knowledge regarding the mechanisms of these associations. Gaining perspectives from multiple socioecological levels can help elucidate these mechanisms. Our study aims to identify social determinants of health that act as barriers or facilitators to surgical care among colorectal surgery stakeholders. METHODS: We recruited participants representing 5 socioecological levels: patients (individual); caregivers/surgeons (interpersonal); and leaders in hospitals (organizational), communities (community), and government (policy). Patients participated in focus groups, and the remaining participants underwent individual interviews. Semistructured interview guides were used to explore barriers and facilitators to surgical care at each socioecological level. Transcripts were analyzed by 3 coders in an inductive thematic approach with content analyses. The intercoder agreement was 93%. RESULTS: Six patient focus groups (total n = 18) and 12 key stakeholder interviews were conducted. The mean age of patients was 54.7 years, 66% were Black, and 61% were female. The most common diseases were colorectal cancer (28%), inflammatory bowel disease (28%), and diverticulitis (22%). Key social determinants of health impacting surgical care emerged at each level: individual (clear communication, mental stress), interpersonal (provider communication and trust, COVID-related visitation restrictions), organizational (multiple forms of contact, quality educational materials, scheduling systems, discrimination), community (community and family support and transportation), and policy (charity care, patient advocacy organizations, insurance coverage). CONCLUSION: Key social determinants of health-impacting care among colorectal surgery patients emerged at each socioecological level and may provide targets for interventions to reduce surgical disparities.

IBD AND THE PATIENT-PROVIDER RELATIONSHIP: DOES TRUST IMPACT TELEMEDICINE UTILIZATION?

BACKGROUND Telemedicine use has increased during the COVID-19 pandemic, but uptake among patient populations has not been equitable. Lack of access to technology or broadband connection contributes to the digital divide, but additional factors at the provider-level may contribute. We aimed to identify barriers and facilitators to inflammatory bowel disease (IBD) patient use of telemedicine with a focus on trust and the patient-provider relationship. METHODS Patients 18 years and older who were seen via telemedicine at a colorectal surgery clinic at a high-volume, tertiary care academic center were contacted for participation in this study. Patient demographics including age at surgery, race, sex, and diagnosis were recorded. Patient health literacy was evaluated using the BRIEF Health Literacy Screening Tool. The Wake Forest Physician Trust Scale (WFPTS) was used to measure patient trust in providers. Individual semi-structured interviews based on developed guides explored barriers and facilitators to telemedicine use. NVivo12 software was used for qualitative analysis and data organization. Coders reviewed each transcript independently, convening after initial review for discussion. Final themes were analyzed by disease process. RESULTS Among 29 participants, 24% of patients underwent colorectal surgery for treatment of IBD. 52% identified as female, 67% White, 30% Black, and 4% Latino, which closely mirrors the racial demographics of the study region. 33.3% of patients had limited health literacy (BRIEF score < 17) with an overall mean BRIEF score of 17.6 out of 20 (SD 3.33). The WFPTS scale ranged from 44 to 50, with a mean of 48.5 (SD 2.1) in IBD patients. Among IBD patients, three major themes were identified as important with respect to trust during telemedicine visits: trust in providers, trust in the institution, and trust in the surgical process. Of these, provider-level trust appeared to most influence patient trust in telemedicine. All participants noted that surgeon confidence and reputation affected trust in telemedicine. In the majority of IBD patients, a surgery referral from a trusted provider was an important factor in a patient’s trust and utilization of telemedicine pre and post operatively. Additionally, the duration of the patient encounter, pre-operative education, and the surgeon’s ability to answer questions appeared most relevant to IBD patients. LIMITATIONS The generalizability of our results may be limited because all patients were seen via telemedicine at a single institution. CONCLUSION Provider-level trust may have an increased role in IBD patients. To improve patient trust and telemedicine engagement in the IBD patient population, providers and healthcare systems should build and integrate interventions that enhance communication and interpersonal skills.