Application of a user experience design approach for an EHR-based clinical decision support system.

Objective: We applied a user experience (UX) design approach to clinical decision support (CDS) tool development for the specific use case of pediatric asthma. Our objective was to understand physicians' workflows, decision-making processes, barriers (ie, pain points), and facilitators to increase usability of the tool. Materials and methods: We used a mixed-methods approach with semi-structured interviews and surveys. The coded interviews were synthesized into physician-user journey maps (ie, visualization of a process to accomplish goals) and personas (ie, user types). Interviews were conducted via video. We developed physician journey maps and user personas informed by their goals, systems interactions, and experiences with pediatric asthma management. Results: The physician end-user personas identified were: efficiency, relationship, and learning. Features of a potential asthma CDS tool sought varied by physician practice type and persona. It was important to the physician end-user that the asthma CDS tool demonstrate value by lowering workflow friction (ie, difficulty or obstacles), improving the environment surrounding physicians and patients, and using it as a teaching tool. Customizability versus standardization were important considerations for uptake. Discussion: Different values and motivations of physicians influence their use and interaction with the EHR and CDS tools. These different perspectives can be captured by applying a UX design approach to the development process. For example, with the importance of customizability, one approach may be to build a core module with variations depending on end-user preference. Conclusion: A UX approach can drive design to help understand physician-users and meet their needs; ultimately with the goal of increased uptake.

Personal legacy and treatment choices for serious illness: a scoping review.

BACKGROUND: Legacy-how one hopes to be remembered after death-is an unexplored and important dimension of decision-making for people facing serious illness. OBJECTIVES: We conducted a scoping review to answer the following research questions: (1) How do people making treatment choices conceive of legacy? and (2) What treatment choices do people make with legacy in mind? ELIGIBILITY CRITERIA: Participants included people facing serious illness who discussed how they wanted to be remembered after their own death, or how they hoped to impact others, as they made treatment choices. Studies in English published between 1990 and 2022 were included. SOURCES OF EVIDENCE: We conducted searches in electronic databases including Medline/PubMed, CINAHL, PsycInfo, SocialWork, AnthropologyPlus, Web of Science, ProQuest and EMBASE databases. DATA SYNTHESIS: We used an electronic screening tool to screen abstracts and review full-text articles suitable for inclusion. We analysed included articles using Atlas.ti. We constructed tables and narratively synthesised the findings. RESULTS: We identified three major intersecting legacy goals that influence choices people facing serious illness make about their treatment and health behaviours, and the types of choices people make with legacy in mind. The three legacy goals are: remembrance of the individual self, remembrance of the social self and impact on others' well-being. CONCLUSIONS: We identify the importance of legacy to patient treatment choices. Understanding for whom this construct is important, what types of legacy goals people hold and how those goals impact treatment choices is necessary to provide patient-centred whole-person care to people facing serious illness.

Stressors and Silver Linings during COVID-19: Implications for Supporting Families with Young Children in a Post-Pandemic World.

OBJECTIVES: To better understand impacts of the COVID-19 pandemic and resulting economic and social disruptions on families, we analyzed qualitative data capturing perspectives from parents of young children. METHODS: This study analyzes interviews of parents of children aged 1-3.5 years at enrollment, recruited from four primary care systems serving mainly lower-income Hispanic families in Los Angeles, California. Interviews were conducted over 15 months beginning September 2020. Analyses focused on the open-ended question: Please describe in your own words how the COVID-19 pandemic has affected you and your family. We used iterative, multi-step processes to identify emergent qualitative themes. RESULTS: A total of 460 parent responses were collected and coded. Key themes and subthemes were tested for interrater reliability, with Kappa ranging from 0.74 to 0.91. Thematic analysis revealed two groups of responses, one emphasizing stress and one emphasizing "silver linings." Parents cited a range of stressors, from fear of COVID-19 to social isolation. Those emphasizing "silver linings" also referenced formal or informal supports - especially government/community assistance programs and childcare access - that enabled stronger family ties and positive lifestyle modifications. CONCLUSIONS FOR PRACTICE: Experiences of families with young children during COVID-19 were not uniform. Economic stability and reliable childcare may be critical mediators of family stress. Results affirm that the pandemic's impacts were distributed through channels largely built on, and possibly exacerbating, existing disparities. For lower-income families with young children, funding for public and private programs that target economic stability and childcare assistance may merit prioritization in future socio-economic disruptions.

Moving upstream: healthcare partnerships addressing social determinants of health through community wealth building.

BACKGROUND: Healthcare-based interventions addressing social needs such as food and housing generally fail to impact the upstream wealth and power inequities underlying those needs. However, a small number of US healthcare organizations have begun addressing these upstream inequities by partnering with community wealth building initiatives. These initiatives include community land trusts, resident-owned communities, and worker cooperatives, which provide local residents ownership and control over their housing and workplaces. While these partnerships represent a novel, upstream approach to the social determinants of health, no research has yet evaluated them. METHODS: To assess the current state and key aspects of healthcare-community wealth building partnerships, we conducted a multiple case study analysis using semi-structured interviews with thirty-eight key informants across ten partnerships identified through the Healthcare Anchor Network. To analyze the interviews, we used a two-stage coding process. First, we coded responses based on the phase of the intervention to which they corresponded: motivation, initiation, implementation, or evaluation. Then we assessed responses within each aspect for common themes and variation on salient topics. RESULTS: Partnerships were generally motivated by a combination of community needs, such as affordable housing and living wage jobs, and health system interests, such as workforce housing and supply chain resilience. Initiating projects required identifying external partners, educating leadership, and utilizing risk mitigation strategies to obtain health system buy-in. Implementation took various forms, with healthcare organizations providing financial capital in the form of grants and loans, social capital in the form of convening funders and other stakeholders, and/or capacity building support in the form of strategic planning or technical assistance resources. To evaluate projects, healthcare organizations used more process and community-level metrics rather than metrics based on individual health outcomes or returns on investment. Based on best practices from each partnership phase, we provide a roadmap for healthcare organizations to develop effective community wealth building partnerships. CONCLUSIONS: Assessing healthcare partnerships with community wealth building organizations yields key strategies healthcare organizations can use to develop more effective partnerships to address the upstream causes of poor health.

Experiences of Sleep Problems Among Older Korean Immigrants.

Despite poor sleep among older adults, little is known about the sleep habits of older immigrants living in the United States. The current pragmatic qualitative descriptive study explored sleep among older Korean immigrants, using a focus group with six participants and individual phone interviews with 22 Korean immigrants aged ≥60 years. Transcripts were coded to identify underlying themes. Several thematic categories were identified under six domains: daytime function, getting ready for bed, falling asleep, awakenings during sleep, going back to sleep, and seeking advice from peers. Unhealthy sleep behaviors were found during daytime and bedtime, particularly among those who were retired/unemployed or living alone. Seeking advice from peers was common but none of the advice helped participants sleep. Sleep education programs in Korean-speaking communities can be used to target those who are socially isolated and may benefit older Korean immigrants with sleep difficulties. [Research in Gerontological Nursing, 15(4), 193-202.].

Beyond housing: Understanding community integration among homeless-experienced veteran families in the United States.

Community integration is important to address among homeless-experienced individuals. Little is known about helping veteran families (families with a parent who is a veteran) integrate into the community after homelessness. We sought to understand the experiences of community integration among homeless-experienced veteran families. We used a two-stage, community-partnered approach. First, we analysed 16 interviews with homeless-experienced veteran parents (parents who served in the military; n = 9) living in permanent housing and providers of homeless services (n = 7), conducted from February to September 2016, for themes of community integration. Second, we developed a workgroup of nine homeless-experienced veteran parents living in a permanent housing facility, who met four times from December 2016 to July 2017 to further understand community integration. We audio-recorded, transcribed and analysed the interviews and workgroups for community integration themes. For the analysis, we developed community integration categories based on interactions outside of the household and built a codebook describing each topic. We used the codebook to code the individual interviews and parent workgroup sessions after concluding that the workgroup and interview topics were consistent. Findings were shared with the workgroup. We describe our findings across three stages of community integration: (a) first housed, (b) adjusting to housing and the community, and (c) housing maintenance and community integration. We found that parents tended to isolate after transitioning into permanent housing. After this, families encountered new challenges and were guarded about losing housing. One facilitator to community integration was connecting through children to other parents and community institutions (e.g. schools). Although parents felt safe around other veterans, many felt judged by non-veterans. Parents and providers reported a need for resources and advocacy after obtaining housing. We share implications for improving community integration among homeless-experienced veteran families, including providing resources after obtaining housing, involving schools in facilitating social connections, and combating stigma.

Associations of Self-Reported Sleep Quality with Demographic and Other Characteristics in Older Korean Immigrants.

Poor sleep is common among older adults, affecting a wide range of health outcomes. However, little is known about sleep issues among older Korean immigrants, the fastest growing Asian American subgroup in the United States. We aimed to explore multiple factors associated with sleep among this group. We analyzed cross-sectional survey data from 43 older immigrants living in two large Korean communities in Southern California. Perceived sleep quality was significantly associated with gender, living arrangement, employment status, mental health, and sleep-related beliefs (all p-values < 0.05). Living with someone and being employed for wages were significantly uniquely associated with better sleep quality, accounting for demographic and health-related factors (R2 = 51.8%, adjusted R2 = 38.7%, p = 0.002). These findings suggest a potential role of sociocultural factors on sleep. Further studies are needed to confirm these findings and to inform a sleep intervention program tailored to the characteristics of older Korean immigrants.

Income as a Predictor of Self-Efficacy for Managing Pain and for Coping With Symptoms Among Patients With Chronic Low Back Pain.

OBJECTIVES: The purpose of this study was to evaluate pain self-efficacy (PSE) and coping self-efficacy (CSE) for people with chronic low back pain (CLBP), and to assess whether lower income may be associated with less PSE and CSE in the United States. METHODS: We conducted a cross-sectional study using survey data collected between June 2016 and February 2017 from n = 1364 patients with CLBP from chiropractic clinics in the United States to measure the relationship between income and both types of self-efficacy. We created 4 multivariate models predicting PSE and CSE scores. We used both a parsimonious set of covariates (age, sex) and a full set (age, sex, education, neck pain comorbidity, catastrophizing, and insurance). We also calculated effect sizes (Cohen's d) for unadjusted differences in PSE and CSE score by income. RESULTS: Lower income was associated with lower PSE and CSE scores across all 4 models. In the full models, the highest-income group had an average of 1 point (1-10 scale) higher PSE score and CSE score compared to the lowest income group. Effect sizes for the unadjusted differences in PSE and CSE scores between the highest and lowest income groups were 0.94 and 0.84, respectively. CONCLUSIONS: Our findings indicate that people with lower income perceive themselves as less able to manage their pain, and that this relationship exists even after taking into account factors like health insurance and educational attainment. There is a need to further investigate how practitioners and policymakers can best support low-income patients with chronic pain.

Barriers and Facilitators to Implementation of Health System Interventions Aiming to Welcome and Protect Immigrant Patients: a Qualitative Study.

BACKGROUND: At the same time that federal policymakers have enforced restrictive immigration policies, healthcare systems across the USA are developing, and have implemented, interventions aimed at addressing immigration-related stressors faced by immigrant communities. Yet, little is known about the contextual determinants that influence their implementation success. Using the Consolidated Framework for Implementation Research (CFIR), this study identifies factors enabling or challenging the implementation of interventions aimed at mitigating immigration-related stressors in the healthcare context. METHODS: We used a qualitative research design to conduct 38 semi-structured interviews with stakeholders involved in implementation of interventions at 25 healthcare facilities across 5 states with the highest undocumented immigrant populations (California, Texas, New York, Florida, and Illinois). Interviews were conducted from May through August 2018. Constant comparative analysis was used to identify barrier and facilitator themes. Deductive coding was thereafter used to categorize themes according to CFIR domain. RESULTS: Barriers to implementation included perceptions of legal complexity and challenges to adopting such systemic strategies. Facilitators included a national policy climate that had brought immigrant health to the forefront, allowing for leveraging momentum towards institutional change; communication among healthcare personnel; existing community partnerships with immigrant rights and service organizations; and a shared sense of mission centering health equity. Local variation in immigration-related policies (e.g., local law agencies enforcing federal immigration laws) and heterogeneity of local immigrant communities also impacted implementation. Champions and informal leaders were integral to institutional efforts but not sufficient for sustainability. Perceived urgency to act superseded evaluation considerations, with all interventions in initial phases of implementation. Future iterations and evaluations of these interventions are needed to establish best practices and implementation determinants. CONCLUSION: This is the first systematic study describing implementation determinants of immigration-related interventions across health systems. Identifying these determinants provides guidance to other healthcare organizations to effectively strategize and ensure implementation success.

A Sector Wheel Approach to Understanding the Needs and Barriers to Services among Homeless-Experienced Veteran Families.

BACKGROUND: Veteran family homelessness is a significant issue, yet little is known about the needs and barriers to services of veteran families experiencing homelessness. This qualitative study examined the experiences, needs, and barriers to services among homeless-experienced veteran families to inform providers for this important population. METHODS: Twenty-five semi-structured interviews were conducted from February through September 2016 with 18 veteran parents with a recent history of homelessness (9 mothers, 9 fathers), and 7 homeless service providers throughout Los Angeles County. The "Sector Wheel for Under-Resourced Populations" data elicitation approach was used to conduct the interviews, which allowed the participant to guide the interview by discussing different sectors of a family's life affected by homelessness. The interviews were audio-recorded, transcribed, and themes were coded with Atlas.ti. RESULTS: Interviews revealed parenting stress and worsening family mental health during homelessness. Participants described barriers to navigating housing, social, and health services with children, including not knowing where to seek help, difficulty connecting to health and social services in the community, and a lack of family-focused services. Parents encountered discrimination by landlords and lack of access to permanent housing in safe neighborhoods. CONCLUSIONS: Findings demonstrate a need for delivering family-centered and comprehensive services to homeless-experienced veteran families that recognize the multifaceted needs of this population. Advocacy initiatives are needed to address discrimination against veterans experiencing family homelessness and increase access to affordable permanent housing in safe neighborhoods for families.

Deficits in Advance Care Planning for Patients With Decompensated Cirrhosis at Liver Transplant Centers.

Importance: The burden of end-of-life care for patients with cirrhosis is increasing in the US, and most of these patients, many of whom are not candidates for liver transplant, die in institutions receiving aggressive care. Advance care planning (ACP) has been associated with improved end-of-life outcomes for patients with other chronic illnesses, but it has not been well-characterized in patients with decompensated cirrhosis. Objective: To describe the experience of ACP in patients with decompensated cirrhosis at liver transplant centers. Design, Setting, and Participants: For this multicenter qualitative study, face-to-face semistructured interviews were conducted between July 1, 2017, and May 30, 2018, with clinicians and patients with decompensated cirrhosis at 3 high-volume transplant centers in California. Patient participants were adults and had a diagnosis of cirrhosis, at least 1 portal hypertension-related complication, and current or previous Model for End-Stage Liver Disease with sodium score of 15 or higher. Clinician participants were health care professionals who provided care during the illness trajectory. Main Outcomes and Measures: Experiences with ACP reported by patients and clinicians. Participants were asked about the context, behaviors, thoughts, and decisions concerning elements of ACP, such as prognosis, health care preferences, values and goals, surrogate decision-making, and documentation. Results: The study included 42 patients (mean [SD] age, 58.2 [11.2] years; 28 men [67%]) and 46 clinicians (13 hepatologists [28%], 11 transplant coordinators [24%], 9 hepatobiliary surgeons [20%], 6 social workers [13%], 5 hepatology nurse practitioners [11%], and 2 critical care physicians [4%]). Five themes that represent the experiences of ACP were identified: (1) most patient consideration of values, goals, and preferences occurred outside outpatient visits; (2) optimistic attitudes from transplant teams hindered the discussions about dying; (3) clinicians primarily discussed death as a strategy for encouraging behavioral change; (4) transplant teams avoided discussing nonaggressive treatment options with patients; and (5) surrogate decision makers were unprepared for end-of-life decision-making. Conclusions and Relevance: This study found that, despite a guarded prognosis, patients with decompensated cirrhosis had inadequate ACP throughout the trajectory of illness until the end of life. This finding may explain excessively aggressive life-sustaining treatment that patients receive at the end of life.

Comparing the Recruitment of Research Participants With Chronic Low Back Pain Using Amazon Mechanical Turk With the Recruitment of Patients From Chiropractic Clinics: A Quasi-Experimental Study.

OBJECTIVE: The purpose of this study was to compare the crowdsourcing platform Amazon Mechanical Turk (MTurk) with in-person recruitment and web-based surveys as a method to (1) recruit study participants and (2) obtain low-cost data quickly from chiropractic patients with chronic low back pain in the United States. METHODS: In this 2-arm quasi-experimental study, we used in-person clinical sampling and web-based surveys from a separate study (RAND sample, n = 1677, data collected October 2016 to January 2017) compared with MTurk (n = 310, data collected November 2016) as a sampling and data collection tool. We gathered patient-reported health outcomes and other characteristics of adults with chronic low back pain receiving chiropractic care. Parametric and nonparametric tests were run. We assessed statistical and practical differences based on P values and effect sizes, respectively. RESULTS: Compared with the RAND sample, the MTurk sample was statistically significantly younger (mean age 35.4 years, SD 9.7 vs 48.9, SD 14.8), made less money (24% vs 17% reported less than $30,000 annual income), and reported worst mental health than the RAND sample. Other differences were that the MTurk sample had more men (37% vs 29%), fewer White patients (87% vs 92%), more Hispanic patients (9% vs 5%), fewer people with a college degree (59% vs 68%), and patients were more likely to be working full time (62% vs 58%). The MTurk sample was more likely to have chronic low back pain (78% vs 66%) that differed in pain frequency and duration. The MTurk sample had less disability and better global health scores. In terms of efficiency, the surveys cost $2.50 per participant in incentives for the MTurk sample. Survey development took 2 weeks and data collection took 1 month. CONCLUSION: Our results suggest that there may be differences between crowdsourcing and a clinic-based sample. These differences range from small to medium on demographics and self-reported health. The low incentive costs and rapid data collection of MTurk makes it an economically viable method of collecting data from chiropractic patients with low back pain. Further research is needed to explore the utility of MTurk for recruiting clinical samples, such as comparisons to nationally representative samples.

Experiences With Chiropractic Care for Patients With Low Back or Neck Pain.

BACKGROUND: Musculoskeletal disorders are the second leading cause of disability worldwide. OBJECTIVE: Examine experiences of chiropractic patients in the United States with chronic low back or neck pain. METHOD: Observational study of 1853 chronic low back pain and neck pain patients (74% female) who completed an online questionnaire at the 3-month follow-up that included Consumer Assessment of Healthcare Providers and Systems (CAHPS) items assessing their experiences with care. RESULTS: We found similar reports of communication for the chiropractic sample and patients in the 2016 CAHPS National Database, but 85% in the database versus 79% in the chiropractic sample gave the most positive response to the time spent with provider item. More patients in the CAHPS database rated their provider at the top of the scale (8 percentage points). More chiropractic patients reported always getting answers to questions the same day (16 percentage points) and always being seen within 15 minutes of their appointment time (29 percentage points). CONCLUSIONS: The positive experiences of patients with chronic back and neck pain are supportive of their use of chiropractic care.

Assessment of Perspectives on Health Care System Efforts to Mitigate Perceived Risks Among Immigrants in the United States: A Qualitative Study.

Importance: Increases in the enforcement of immigration policies, deportations, and rhetoric critical of immigration during and after the 2016 US presidential election have been associated with a decrease in health-seeking behaviors and an increase in adverse health outcomes among immigrants. Efforts to address the health care needs of immigrants after the 2016 presidential election have centered on individual-level patient-practitioner strategies or federal- and state-level policy changes. However, these approaches have not captured the role of health care systems and the range of health care facilities encompassed within them. Objective: To characterize policies and actions implemented by health care facilities to address immigration status-related stressors. Design, Setting, and Participants: This exploratory qualitative study involved semistructured interviews in a purposive sample of health care facilities across 5 states (California, Texas, New York, Florida, and Illinois) with the largest populations of individuals with undocumented immigration status. Data from media sources and informational interviews with local immigration advocacy leaders were used to identify health care facilities that had implemented welcoming policies and strategies. Stakeholders, including administrators, frontline clinicians involved in policy implementation, and senior executive leaders, were interviewed. Interviews were conducted between May 1 and August 9, 2018, and were recorded, transcribed, and coded using constant comparative analysis. Data analysis was performed from June 29, 2018, to February 5, 2019. Main Outcomes and Measures: Stakeholder perspectives on the range, scope and content of policies and actions implemented to address immigration-related stressors at health care facilities. Results: A total of 38 in-depth interviews were conducted spanning 25 health care facilities in 5 states; these facilities included 13 federally qualified health centers, 7 academic or private hospitals, and 5 public institutions. Interviewees described policies and actions that mitigated one or more of the following perceived risks: (1) risk of exposure to immigration enforcement personnel at or near facilities, (2) risk of immigration status-related information disclosure, (3) risk associated with patient-level stressors, (4) risk associated with practitioner-level stressors, and (5) coordination of risk mitigation. Most personnel at health care facilities emphasized that their policies and actions fit within a larger mission and history of addressing the social needs of diverse patients and mitigating risks for patients. Conclusions and Relevance: Health care facilities can implement both active and reactive measures to address perceived immigration-associated risks among patients and practitioners. Population health and immigration policies are at the forefront of current policy debates. An understanding of the ways in which health care facilities can serve to mitigate perceived risks among their patients and employees can be one step toward optimizing health care for immigrants.

How care decisions are made among interdisciplinary providers caring for critically injured patients: A qualitative study.

BACKGROUND: Injury is the leading cause of death in people under 45 years of age in the United States; however, how care decisions occur in critical injury is poorly understood. This exploratory study sought to generate hypotheses about how care decisions are made among interdisciplinary providers caring for patients who have been critically injured. METHODS: This was a qualitative study conducted at two intensive care units in a level 1 trauma center in an urban, teaching, safety-net hospital. Semistructured interviews consisted of case scenarios with competing clinical priorities presented to 25 interdisciplinary providers, elucidating how decisions are approached. Responses were recorded, transcribed, and coded. Thematic analysis was conducted to discover central themes. Category formulation and sorting was done for data reduction and thematic structuring of the data. The range and central tendency of these themes are reported. RESULTS: The central theme for how care decisions are made among interdisciplinary providers was through the distribution of shared responsibility. The distribution of shared responsibility depended on interdisciplinary communication to navigate the two subthemes of time and roles. Time had to be navigated carefully, because it was both an opportunity for data acquisition and consensus building but also a pressure to decisively progress care. Roles were distinct but interchangeable and consisted of experts, actualizers, and questioners. CONCLUSION: Care decisions are made in the context of shared responsibility among interdisciplinary providers. Interdisciplinary communication is a means of establishing roles and navigating time to distribute shared responsibility among interdisciplinary providers.

The impact of patient preferences and costs on the appropriateness of spinal manipulation and mobilization for chronic low back pain and chronic neck pain.

BACKGROUND: Although the delivery of appropriate healthcare is an important goal, the definition of what constitutes appropriate care is not always agreed upon. The RAND/UCLA Appropriateness Method is one of the most well-known and used approaches to define care appropriateness from the clinical perspective-i.e., that the expected effectiveness of a treatment exceeds its expected risks. However, patient preferences (the patient perspective) and costs (the healthcare system perspective) are also important determinants of appropriateness and should be considered. METHODS: We examined the impact of including information on patient preferences and cost on expert panel ratings of clinical appropriateness for spinal mobilization and manipulation for chronic low back pain and chronic neck pain. RESULTS: The majority of panelists thought patient preferences were important to consider in determining appropriateness and that their inclusion could change ratings, and half thought the same about cost. However, few actually changed their appropriateness ratings based on the information presented on patient preferences regarding the use of these therapies and their costs. This could be because the panel received information on average patient preferences for spinal mobilization and manipulation whereas some panelists commented that appropriateness should be determined based on the preferences of individual patients. Also, because these therapies are not expensive, their ratings may not be cost sensitive. The panelists also generally agreed that preferences and costs would only impact their ratings if the therapies were considered clinically appropriate. CONCLUSIONS: This study found that the information presented on patient preferences and costs for spinal mobilization and manipulation had little impact on the rated appropriateness of these therapies for chronic low back pain and chronic neck pain. Although it was generally agreed that patient preferences and costs were important to the appropriateness of M/M for CLBP and CNP, it seems that what would be most important were the preferences of the individual patient, not patients in general, and large cost differentials.

Coping and Management Techniques Used by Chronic Low Back Pain Patients Receiving Treatment From Chiropractors.

OBJECTIVES: The purpose of this study was to describe coping strategies (eg, mechanisms, including self-treatment) that a person uses to reduce pain and its impact on functioning as reported by patients with chronic low back pain who were seen by doctors of chiropractic and how these coping strategies vary by patient characteristics. METHODS: Data were collected from a national sample of US chiropractic patients recruited from chiropractic practices in 6 states from major geographical regions of the United States using a multistage stratified sampling strategy. Reports of coping behaviors used to manage pain during the past 6 months were used to create counts across 6 domains: cognitive, self-care, environmental, medical care, social activities, and work. Exploratory analyses examined counts in domains and frequencies of individual items by levels of patient characteristics. RESULTS: A total of 1677 respondents with chronic low back pain reported using an average of 9 coping behaviors in the prior 6 months. Use of more types of behaviors were reported among those with more severe back pain, who rated their health as fair or poor and who had daily occurrences of pain. Exercise was more frequent among the healthy and those with less pain. Female respondents tended to report using more coping behaviors than men, and Hispanics more than non-Hispanics. CONCLUSION: Persons with chronic back pain were proactive in their coping strategies and frequently used self-care coping strategies like those provided by chiropractors in patient education. In alignment with patients' beliefs that their condition was chronic and lifelong, many patients attempted a wide range of coping strategies to relieve their pain.

Prevalence and Characteristics of Chronic Spinal Pain Patients with Different Hopes (Treatment Goals) for Ongoing Chiropractic Care.

Objectives: The treatment goals of patients successfully using ongoing provider-based care for chronic spinal pain can help inform health policy related to this care. Design: Multinomial logistical hierarchical linear models were used to examine the characteristics of patients with different treatment goals for their ongoing care. Settings/Location: Observational data from a large national sample of patients from 125 chiropractic clinics clustered in 6 U.S. regions. Subjects: Patients with nonwork-injury-related nonspecific chronic low-back pain (CLBP) and chronic neck pain (CNP). Interventions: All were receiving ongoing chiropractic care. Outcome measures: Primary outcomes were patient endorsement of one of four goals for their treatment. Explanatory variables included pain characteristics, pain beliefs, goals for mobility/flexibility, demographics, and other psychological variables. Results: Across our sample of 1614 patients (885 with CLBP and 729 with CNP) just under one-third endorsed a treatment goal of having their pain go away permanently (cure). The rest had goals of preventing their pain from coming back (22% CLBP, 16% CNP); preventing their pain from getting worse (14% CLBP, 12% CNP); or temporarily relieving their pain (31% CLBP, 41% CNP). In univariate analysis across these goals, patients differed significantly on almost all variables. In the multinomial logistic models, a goal of cure was associated with shorter pain duration and more belief in a medical cure; a goal of preventing pain from coming back was associated with lower pain levels; and those with goals of preventing their pain from getting worse or temporarily relieving pain were similar, including in having their pain longer. Conclusions: Although much of health policy follows a curative model, the majority of these CLBP and CNP patients have goals of pain management (using ongoing care) rather than "cure" (care with a specific end) for their chiropractic care. This information could be useful in crafting policy for patients facing provider-based nonpharmacologic care for chronic pain.

Researching the Appropriateness of Care in the Complementary and Integrative Health Professions Part 5: Using Patient Records: Selection, Protection, and Abstraction.

OBJECTIVES: The purpose of this paper is to describe the 4-step process (consent, selection, protection, and abstraction) of acquiring a large sample of chiropractic patient records from multiple practices and subsequent data abstraction. METHODS: From April 2017 to December 2017, RAND acquired patient records from 99 chiropractic practices across the United States. The records included patients enrolled in a survey e-study (prospective sample) and a random sample of all clinic patients (retrospective sample) with chronic back or neck pain. Clinic staff were trained to collect the sample, scan, and transfer the records. We designed an online data collection tool for abstraction. Protocols were instituted to protect patient confidentiality. Doctors of chiropractic were selected and trained as abstractors, and a system was established to monitor data collection. RESULTS: In compliance with data protection protocols, 3603 patient records were scanned, including 1475 in the prospective sample and 2128 in the random sample. A total of 1716 patients (prospective sample) consented to having their records scanned, but only 1475 could be retrieved. Of records scanned, 19% were unusable owing to illegibility, no care during the period of interest, or poor scanning. The abstractor interrater reliability for appropriateness of care decisions was fair to moderate (κ .38-.48). CONCLUSION: The acquisition, handling, and abstraction of a large sample of chiropractic records was a complex task with challenges that necessitated adapting planned approaches. Of the records abstracted, many revealed incomplete provider documentation regarding the details of and rationale for care. Better documentation and more standardized record keeping would facilitate future research using patient records.