Barriers and facilitators to implementation and sustainment of guideline-recommended depression screening for patients with breast cancer in medical oncology: a qualitative study.

OBJECTIVES: Implementation of guideline-recommended depression screening in oncology presents numerous challenges. Implementation strategies that are responsive to local context may be critical elements of adoption and sustainment. We evaluated barriers and facilitators to implementation of a depression screening program for breast cancer patients in a community medical oncology setting as part of a cluster randomized controlled trial. METHODS: Guided by the Consolidated Framework for Implementation Research, we employed qualitative methods to evaluate clinician, administrator, and patient perceptions of the program using semi-structured interviews. We used a team-coding approach for the data; thematic development focused on barriers and facilitators to implementation using a grounded theory approach. The codebook was refined through open discussions of subjectivity and unintentional bias, coding, and memo applications (including emergent coding), and the hierarchical structure and relationships of themes. RESULTS: We conducted 20 interviews with 11 clinicians/administrators and 9 patients. Five major themes emerged: (1) gradual acceptance and support of the intervention and workflow; (2) compatibility with system and personal norms and goals; (3) reinforcement of the value of and need for adaptability; (4) self-efficacy within the nursing team; and (5) importance of identifying accountable front-line staff beyond leadership "champions." CONCLUSIONS: Findings suggest a high degree of acceptability and feasibility due to the selection of appropriate implementation strategies, alignment of norms and goals, and a high degree of workflow adaptability. These findings will be uniquely helpful in generating actionable, real-world knowledge to inform the design, implementation, and sustainment of guideline-recommended depression screening programs in oncology. TRIAL REGISTRATION: ClinicalTrials.gov #NCT02941614.

Satisfaction With Telehealth Among Patients With Irritable Bowel Syndrome During COVID-19: Cross-Sectional Survey Findings.

INTRODUCTION: Coronavirus disease 2019 rapidly shifted health care toward telehealth. We assessed satisfaction with and preferences for telehealth among patients with irritable bowel syndrome (IBS). METHODS: We conducted a cross-sectional survey in an integrated healthcare system in Southern California with members aged 18-90 years with an International Classification of Diseases 9 and 10 codes for IBS from office-based encounters between June 1, 2018, and June 1, 2020. Eligible patients were emailed a survey assessing telehealth satisfaction overall and by patient-related factors, IBS characteristics, health and technologic literacy, utilization, and coronavirus disease 2019 perceptions. We identified perceived telehealth benefits and challenges. Multivariable logistic regression identified predictors of telehealth dissatisfaction. RESULTS: Of 44,789 surveys sent, 5,832 (13.0%) patients responded and 1,632 (3.6%) had Rome IV IBS. Among 1,314 (22.5%) patients with IBS and prior telehealth use (mean age 52.6 years [17.4]; 84.9% female; and 59.4% non-Hispanic White, 29.0% Hispanic, and 5.6% non-Hispanic Black), 898 (68.3%) were satisfied, 130 (9.9%) were dissatisfied, and 286 (21.8%) felt neutral. In addition, 78.6% would use telehealth again. Independent predictors of telehealth dissatisfaction include social media use of once a week or less (adjusted odds ratio [OR] = 2.1; 1.3-3.5), duration of IBS for <1 year (adjusted OR = 8.2; 1.9-35.8), and willingness to travel 60 plus minutes for face-to-face visits (adjusted OR = 2.6; 1.4-3.7). Patients' main concern with telehealth was a lack of physical examination. DISCUSSION: Most of the patients with IBS are satisfied with telehealth. Shorter duration of IBS diagnosis, comfort with technology, and increased willingness to travel were associated with telehealth dissatisfaction. These predictors may help identify a target population for a focused IBS-telehealth program.

Effect of a Community-Based Medical Oncology Depression Screening Program on Behavioral Health Referrals Among Patients With Breast Cancer: A Randomized Clinical Trial.

Importance: Implementation of guideline-recommended depression screening in medical oncology remains challenging. Evidence suggests that multicomponent care pathways with algorithm-based referral and management are effective, yet implementation of sustainable programs remains limited and implementation-science guided approaches are understudied. Objective: To evaluate the effectiveness of an implementation-strategy guided depression screening program for patients with breast cancer in a community setting. Design, Setting, and Participants: A pragmatic cluster randomized clinical trial conducted within Kaiser Permanente Southern California (KPSC). The trial included 6 medical centers and 1436 patients diagnosed with new primary breast cancer who had a consultation with medical oncology between October 1, 2017, through September 30, 2018. Patients were followed up through study end date of May 31, 2019. Interventions: Six medical centers in Southern California participated and were randomized 1:1 to tailored implementation strategies (intervention, 3 sites, n = 744 patients) or education-only (control, 3 sites, n = 692 patients) groups. The program consisted of screening with the 9-item Patient Health Questionnaire (PHQ-9) and algorithm-based scoring and referral to behavioral health services based on low, moderate, or high score. Clinical teams at tailored intervention sites received program education, audit, and feedback of performance data and implementation facilitation, and clinical workflows were adapted to suit local context. Education-only controls sites received program education. Main Outcomes and Measures: The primary outcome was percent of eligible patients screened and referred (based on PHQ-9 score) at intervention vs control groups measured at the patient level. Secondary outcomes included outpatient health care utilization for behavioral health, primary care, oncology, urgent care, and emergency department. Results: All 1436 eligible patients were randomized at the center level (mean age, 61.5 years; 99% women; 18% Asian, 17% Black, 26% Hispanic, and 37% White) and were followed up to the end of the study, insurance disenrollment, or death. Groups were similar in demographic and tumor characteristics. For the primary outcome, 7.9% (59 of 744) of patients at tailored sites were referred compared with 0.1% (1 of 692) at education-only sites (difference, 7.8%; 95% CI, 5.8%-9.8%). Referrals to a behavioral health clinician were completed by 44 of 59 patients treated at the intervention sites (75%) intervention sites vs 1 of 1 patient at the education-only sites (100%). In adjusted models patients at tailored sites had significantly fewer outpatient visits in medical oncology (rate ratio, 0.86; 95% CI, 0.86-0.89; P = .001), and no significant difference in utilization of primary care, urgent care, and emergency department visits. Conclusions and Relevance: Among patients with breast cancer treated in community-based oncology practices, tailored strategies for implementation of routine depression screening compared with an education-only control group resulted in a greater proportion of referrals to behavioral care. Further research is needed to understand the clinical benefit and cost-effectiveness of this program. Trial Registration: ClinicalTrials.gov Identifier: NCT02941614.

The Effectiveness of Neuromuscular Warmups for Lower Extremity Injury Prevention in Basketball: A Systematic Review.

BACKGROUND: Neuromuscular warmups have gained increasing attention as a means of preventing sports-related injuries, but data on effectiveness in basketball are sparse. The objective of this systematic review was to evaluate evidence of the effectiveness of neuromuscular warmup-based strategies for preventing lower extremity injuries among basketball athletes. METHODS: PubMed and Cochrane Library databases were searched in February 2019. Studies were included if they were English-language randomized controlled, non-randomized comparative, or prospective cohort trials, tested neuromuscular and/or balance-focused warmup interventions among basketball players, and assessed at least one type of lower extremity injury as a primary outcome. Criteria developed by the USPSTF were used to appraise study quality, and GRADE was used to appraise the body of evidence for each outcome. Due to heterogeneity in the included studies, meta-analyses could not be performed. RESULTS: In total, 825 titles and abstracts were identified. Of the 13 studies which met inclusion criteria for this review, five were balance interventions (3 randomized controlled trials) and eight were multicomponent interventions involving multiple categories of dynamic neuromuscular warmup (5 randomized controlled trials). Authors of four of the studies were contacted to obtain outcome data specific to basketball athletes. Basketball specific results from the studies suggest significant protective effects for the following lower extremity injuries: ankle injuries (significant in 4 out of the 9 studies that assessed this outcome); ACL injuries (2 of 4 studies); knee injuries generally (1 of 5 studies); and overall lower extremity injuries (5 of 7 studies). All but one of the non-significant results were directionally favorable. Evidence was moderate for the effect of multicomponent interventions on lower extremity injuries generally. For all other outcomes, and for balance-based interventions, the quality of evidence was rated as low. CONCLUSION: Overall, the evidence is supportive of neuromuscular warmups for lower extremity injury prevention among basketball players. However, most studies are underpowered, some used lower-quality research study designs, and outcome and exposure definitions varied. Due to the nature of the study designs, effects could not be attributed to specific intervention components. More research is needed to identify the most effective bundle of warmup activities.

High School Basketball Coach and Player Perspectives on Warm-Up Routines and Lower Extremity Injuries.

BACKGROUND: While participation in sports-related activities results in improved health outcomes, high school athletes are at risk for lower extremity injuries, especially ankle, knee, and thigh injuries. Efforts to promote the adoption and implementation of evidence-driven approaches to reduce injury risk among school-aged athletes are needed. However, there is limited research regarding the perceived barriers, facilitators, and adherence factors that may influence the successful implementation of effective warm-up routines among this population. METHODS: We conducted a qualitative study using semi-structured interviews and focus groups to assess high school basketball coach and player current practices, knowledge, and perspectives about warm-ups and lower-extremity injuries (LEIs). We interviewed coaches (n = 12) and players (n = 30) from May to October 2019. Participants were recruited from public high schools in a joint school district in Southern California. Multiple coders employed thematic analysis of the data using validated methods. RESULTS: Coaches and players reported regular engagement (e.g., daily) in warm-up routines, but the time dedicated (range 5-45 min), types of exercises, and order varied substantially. Players often co-lead the warm-up practice with the coach or assistant coach. Despite regular engagement in warm-up, players and coaches report multiple challenges, including (1) limited time and space to warm-up effectively at games, (2) a perception that young players are not prone to injury, (3) competing demands for coaches' time during practice, and (4) coaches' lack of knowledge. Coaches and players perceive that warming up before practice will result in fewer injuries, and many players are motivated to warm up as a result of their personal injury experience; however, they desire guidance on the ideal exercises for preventing injury and training on the proper form for each exercise. CONCLUSIONS: Regular involvement in basketball warm-up routines is common among high school teams, but the methods and time dedicated to these practices varied. Players and coaches are eager for more information on warm-up programs shown to reduce LEIs.

Recruitment and baseline characteristics of the Community of Voices choir study to promote the health and well-being of diverse older adults.

OBJECTIVE: To describe the recruitment and baseline results of the Community of Voices study that aims to examine the effect of a community choir intervention on the health and well-being of older adults from diverse racial/ethnic and socioeconomic backgrounds. METHOD: Using community-based participatory research methods, we recruited adults age 60 and over from 12 Administration on Aging-supported senior centers in San Francisco into a 2-arm cluster-randomized controlled trial of the community choir intervention. Multiple outreach methods were used. We tracked outreach, screening, and recruitment metrics and collected demographics and baseline outcomes via community-based, interviewer-administered surveys and performance measures of cognition, physical function, and psychosocial variables. RESULTS: The study contacted 819 individuals, screened 636, and enrolled 390 diverse older adults over a 42-month, phased recruitment period. The mean age was 71.2 (SD = 7.3), and the majority were women. Two-thirds of the sample are non-white, and 20% of participants reported having financial hardship. DISCUSSION: Outreach and recruitment methods used in the Community of Voices trial facilitated enrollment of a large proportion of minority and lower-SES older adults in the final sample. Similar recruitment approaches could serve as a model for recruiting diverse racial/ethnic and socioeconomic older adults into research.