Race Dialogues and Potential Application in Clinical Environments: A Scoping Review.

BACKGROUND: Race dialogues, conversations about race and racism among individuals holding different racial identities, have been proposed as one component of addressing racism in medicine and improving the experience of racially minoritized patients. Drawing on work from several fields, we aimed to assess the scope of the literature on race dialogues and to describe potential benefits, best practices, and challenges of conducting such dialogues. Ultimately, our goal was to explore the potential role of race dialogues in medical education and clinical practice. METHODS: Our scoping review included articles published prior to June 2, 2022, in the biomedicine, psychology, nursing and allied health, and education literatures. Ultimately, 54 articles were included in analysis, all of which pertained to conversations about race occurring between adults possessing different racial identities. We engaged in an interactive group process to identify key takeaways from each article and synthesize cross-cutting themes. RESULTS: Emergent themes reflected the processes of preparing, leading, and following up race dialogues. Preparing required significant personal introspection, logistical organization, and intentional framing of the conversation. Leading safe and successful race dialogues necessitated trauma-informed practices, addressing microaggressions as they arose, welcoming participation and emotions, and centering the experience of individuals with minoritized identities. Longitudinal experiences and efforts to evaluate the quality of race dialogues were crucial to ensuring meaningful impact. DISCUSSION: Supporting race dialogues within medicine has the potential to promote a more inclusive and justice-oriented workforce, strengthen relationships amongst colleagues, and improve care for patients with racially minoritized identities. Potential levers for supporting race dialogues include high-quality racial justice curricula at every level of medical education and valuation of racial consciousness in admissions and hiring processes. All efforts to support race dialogues must center and uplift those with racially minoritized identities.

Improving Care Beyond Birth: A Qualitative Study of Postpartum Care After High-Risk Pregnancy.

Background: The postpartum period is a window to engage birthing people in their long-term health and facilitate connections to comprehensive care. However, postpartum systems often fail to transition high-risk patients from obstetric to primary care. Exploring patient experiences can be helpful for optimizing systems of postpartum care. Methods: This is a qualitative study of high-risk pregnant and postpartum individuals. We conducted in-depth interviews with 20 high-risk pregnant or postpartum people. Interviews explored personal experiences of postpartum care planning, coordination of care between providers, and patients' perception of ideal care transitions. We performed thematic analysis using the Capability, Opportunity, Motivation, Behavior (COM-B) model of behavior change as a framework. COM-B allowed for a formal structure to assess participants' ability to access postpartum care and primary care reengagement after delivery. Results: Participants universally identified difficulty accessing primary care in the postpartum period, with the most frequently reported barriers being lack of knowledge and supportive environments. Insufficient preparation, inadequate prenatal counseling, and lack of standardized care transitions were the most significant barriers to primary care reengagement. Participants who most successfully engaged in primary care had postpartum care plans, coordination between obstetric and primary care, and access to material resources. Conclusions: High-risk postpartum individuals do not receive effective counseling on the importance of primary care engagement after delivery. System-level challenges and lack of care coordination also hinder access to primary care. Future interventions should include prenatal education on the benefits of primary care follow-up, structured postpartum planning, and system-level improvements in obstetric and primary care provider communication.

Testing the What Matters to Me workbook in a diverse sample of seriously ill patients and caregivers.

Objectives: We evaluated the What Matters to Me Workbook, a patient-facing version of the Serious Illness Conversation Guide co-created by Ariadne Labs and The Conversation Project. Methods: We purposively recruited diverse seriously ill patients and caregivers in the US. Participants completed the Workbook, a survey, and a semi-structured in-depth interview about their experience. Qualitative analysis of interviews and notes was employed to extract themes. Simple descriptive statistics were employed to analyze eight investigator authored questions. Results: Twenty-nine study participants completed twenty-one interviews and twenty-five surveys. Ratings for safety (3.87/4, SD = 0.43) and acceptability (3.59/4, SD = 0.956) were higher than ratings for ease of use (3.30/4, SD = 0.97) and usefulness (3.24/4, SD = 0.80). Qualitative analysis identified that while the workbook was safe, acceptable, easy to use, and useful, it is more important who is recommending it and how they are explaining it. Conclusion: If presented in the right way by a trustworthy person, the What Matters to Me Workbook can be an easy to use, useful, and safe resource for patients with serious illness and their caregivers. Innovation: The Workbook focuses on serious illness rather than end-of-life and meshes with a clinician-facing conversation guide and a health-system level intervention.

The Patient Safety Adoption Framework: A Practical Framework to Bridge the Know-Do Gap.

OBJECTIVES: Many patient safety initiatives fail to be adopted and implemented, even when proven effective. This creates the well-recognized know-do gap, referring to the discrepancy between what healthcare workers know should be done based on evidence and what takes place in practice. We aimed to develop a framework to improve the adoption and implementation of patient safety initiatives. METHODS: We conducted a background literature review followed by qualitative interviews with patient safety leaders to identify barriers and facilitators to adoption and implementation. Inductive thematic analysis was used to generate themes that informed the development of the framework. We used a consensus-building approach to co-create the framework and guidance tool with an Ad Hoc Committee made up of subject-matter experts and patient family advisors. The framework was tested for utility, feasibility, and acceptability through qualitative interviews. RESULTS: The Patient Safety Adoption Framework contains 5 domains and 6 subdomains. The domains are leadership (subdomains: prioritization, accountability, governance), culture and context, process (subdomains: co-creation, high reliability, engagement), meaningful measurement, and person-centeredness. A guidance tool was developed to provide practical guidance for improvement teams using the framework. Testing affirmed the framework and guidance tool with a high degree of acceptability, feasibility, and utility among implementers and subject-matter experts. CONCLUSIONS: The Patient Safety Adoption Framework provides the essential components necessary to facilitate the adoption and implementation of patient safety initiatives. The framework offers a roadmap for healthcare organizations striving to close the know-do gap.

Perceptions of Mobile Health Technology in Elective Surgery: A Qualitative Study of North American Surgeons.

OBJECTIVES: To explore the surgeon-perceived added value of mobile health technologies (mHealth), and determine facilitators of and barriers to implementing mHealth. BACKGROUND: Despite the growing popularity of mHealth and evidence of meaningful use of patient-generated health data in surgery, implementation remains limited. METHODS: This was an exploratory qualitative study following the Consolidated Criteria for Reporting Qualitative Research. Purposive sampling was used to identify surgeons across the United States and Canada. The Consolidated Framework for Implementation Research informed development of a semistructured interview guide. Video-based interviews were conducted (September-November 2020) and interview transcripts were thematically analyzed. RESULTS: Thirty surgeons from 8 specialties and 6 North American regions were interviewed. Surgeons identified opportunities to integrate mHealth data pre- operatively (eg, expectation-setting, decision-making) and during recovery (eg, remote monitoring, earlier detection of adverse events) among higher risk patients. Perceived advantages of mHealth data compared with surgical and patient-reported outcomes included easier data collection, higher interpretability and objectivity of mHealth data, and the potential to develop more patientcentered and functional measures of health. Surgeons identified a variety of implementation facilitators and barriers around surgeon- and patient buy-in, integration with electronic medical records, regulatory/reimbursement concerns, and personnel responsible for mHealth data. Surgeons described similar considerations regarding perceptions of mHealth among patients, including the potential to address or worsen existing disparities in surgical care. CONCLUSIONS: These findings have the potential to inform the effective and equitable implementation of mHealth for the purposes of supporting patients and surgical care teams throughout the delivery of surgical care.

Convergence of Service Providers and Managers' Perspectives on Strengths, Gaps, and Priorities for Rural Health System Redesign: A Whole-Systems Qualitative Study in Washington County, Maine.

INTRODUCTION: Both rural residents and state government leaders describe a need to redesign rural health care systems. Community members should be at the center of this effort. METHODS: We conducted 46 in-depth interviews of direct service providers between September and November 2020 in Washington County, Maine. Data were analyzed using a thematic analysis approach. RESULTS: Existing strengths included collaboration between government and health systems, and community-based services. Gaps included insufficient workforce, restricted scope of licensing and poor reimbursement, lack of coordination between health systems, and limited paramedicine capacity. Strategies for health system redesign included addressing maldistribution of services and resource optimization, changing federal and state legislation around insurance and scope of practice, and moving toward value-based purchasing models. CONCLUSIONS: Participants provided pragmatic recommendations based on their deep understanding of the community context. Lessons learned are likely to be salient in areas with similar profiles regarding rurality and poverty.

Women's Pathways to Abortion Care in South Carolina: A Qualitative Study of Obstacles and Supports.

CONTEXT: Women seeking timely and affordable abortion care may face myriad challenges, including high out-of-pocket costs, transportation demands, scheduling difficulties and stigma. State-level regulations may exacerbate these burdens and impede women's access to a full range of care. Women's reports of their experiences can inform efforts to improve pathways to abortion care. METHODS: In 2014, semistructured qualitative interviews were conducted with 45 women obtaining abortions in South Carolina, which has a restrictive abortion environment. Interviews elicited information about women's pathways to abortion, including how they learned about and obtained care, whether they received professional referrals, and the supports and obstacles they experienced. Transcripts were examined using thematic analysis to identify key themes along the pathways, and a process map was constructed to depict women's experiences. RESULTS: Twenty participants reported having had contact with a health professional or crisis pregnancy center staff for pregnancy confirmation, and seven of them received an abortion referral. Women located abortion clinics through online searches, previous experience, and friends or family. Financial strain was the most frequently cited obstacle, followed by transportation challenges. Women reported experiencing emotional strain, stress and stigma, and described the value of receiving social support. Because of financial pressures, the regulation with the greatest impact was the one prohibiting most insurance plans from covering abortion care. CONCLUSIONS: Further research on experiences of women seeking abortion services, and how these individuals are affected by evolving state policy environments, will help shape initiatives to support timely, affordable and safe abortion care in a climate of increasing restrictions.