A Communication Perspective on What Patient Advisory Boards Do: Action-Implicative Discourse Analysis and Negotiating Advice.

Stakeholder advisory boards are recognized as an essential and useful part of patient-centered research. However, such engagement can involve exchanges of diverse individual experiences, multiple opinions, and strong feelings in the face of researchers' limitations, deadlines, and agendas. Yet, little work examines how these potential tensions occur and are resolved in actual advisory board meetings. This perspective article describes and employs a communication framework for analyzing a patient advisory council (PAC) for a comparative effectiveness study on acupuncture and pain counseling for inpatients with cancer. The framework, Action-Implicative Discourse Analysis (AIDA), is an observational method that examines challenges through recorded and transcribed, naturally occurring interaction. Our analysis focused on two short excerpts from the first PAC meeting to demonstrate members' navigation of advice-giving and advice-receiving-one in which advice was ultimately implemented by the study team and another in which it was deemed unfeasible. Although advice is inherent to the work of all PACs, it often emerges unannounced as negotiated moments, made up of seemingly minor conversation moves. As a recurring event, advice can and should be analyzed and discussed within PACs to improve communication and team dynamics.

"It Gave Me Hope" Experiences of Diverse Safety Net Patients in a Group Acupuncture Intervention for Painful Diabetic Neuropathy.

Purpose: To explore the experiences of living with painful diabetic neuropathy (PDN) and with a group acupuncture intervention in a sample of low-income, diverse patients. Methods: We conducted a randomized clinical trial of a 12-week group acupuncture intervention for PDN. Data included validated measures of patient-reported outcomes, including pain and quality of life (QOL), as well as semistructured qualitative interviews about participants' experiences with PDN and the intervention. Interview transcripts were coded and analyzed using an inductive thematic framework. Results: We recruited 40 participants from diverse racial/ethnic backgrounds from a public hospital and conducted in-depth qualitative interviews with a subset of 17 participants. Participants randomized to acupuncture experienced greater decreases in pain compared with usual care as well as improved QOL. In interviews, they described a myriad of socioeconomic and personal life stressors that compounded the significant suffering and disability brought on by PDN. Those who received acupuncture were able to decrease reliance on pain medication, improve their sleep and daily function, reduce stress, and engage more with their own self-care. They noted that the acupuncture intervention also gave them hope in the face of their chronic disease. Conclusion: Acupuncture is a valuable adjunct treatment for low-income and marginalized populations with PDN. In addition to reducing pain and improving QOL, acupuncture may offer powerful benefits by increasing patient activation and hope.

Improving Access to Integrative Oncology Through Group Medical Visits: A Pilot Implementation Project.

Objectives: This article describes the implementation of a group medical visit (GMV) model to increase access to integrative oncology (IO) care. The most challenging and critical time to access high-quality IO care is while patients are receiving conventional cancer therapy. Often demand for individual IO clinic consultations precludes this from occurring. A three-session GMV program was designed to alleviate barriers to receiving integrative care during active cancer treatment. Design: A consolidated framework was used for implementation research and focused ethnography methods to describe the IO GMV implementation process. Data sources included patient evaluations, participant observation, and brief provider and patient interviews. Setting: A pilot program was created to assess the feasibility and acceptability of implementing IO GMVs at a comprehensive cancer center. Intervention: Each three-session GMV consisted of a didactic session, followed by individual visits with the integrative oncologist. Results: The setting, intervention, and implementation process of the IO GMV program were described. Thirty-two patients participated in the first five cohorts of the program. Twenty-two were women; 24 were White. The median age of participants was 52. Patient evaluations demonstrate high levels of satisfaction with the program with all scored aspects rated >4.0 on a five-point Likert scale. For the medical center, group visits are a financially viable alternative to individual IO visits; revenue from group visits exceeded the revenue potential of 6 h of individual visits by an average of 38%. Conclusion: GMVs are a feasible and promising model for increasing access to IO. Patients in active cancer treatment were able to participate in the program. Future research and implementation efforts could examine health outcomes over time after participation in GMVs, as well as the feasibility of using this model with more diverse patient populations.

A Randomized Clinical Trial of Group Acupuncture for Painful Diabetic Neuropathy Among Diverse Safety Net Patients.

OBJECTIVE: Existing pharmacologic approaches for painful diabetic neuropathy (PDN) are limited in efficacy and have side effects. We examined the feasibility, acceptability, and effects of group acupuncture for PDN. DESIGN AND SETTING: We randomized patients with PDN from a public safety net hospital to 1) usual care, 2) usual care plus 12 weeks of group acupuncture once weekly, or 3) usual care plus 12 weeks of group acupuncture twice weekly. METHODS: The primary outcome was change in weekly pain intensity (daily 0-10 numerical rating scale [NRS] averaged over seven days) from baseline to week 12. We also assessed health-related quality of life and related symptoms at baseline and weeks 6, 12, and 18. RESULTS: We enrolled 40 patients with PDN (baseline pain = 5.3). Among participants randomized to acupuncture, 92% attended at least one treatment (mean treatments = 10.1). We observed no significant differences between once- vs twice-weekly acupuncture and combined those groups for the main analyses. Compared with usual care, participants randomized to acupuncture experienced greater decreases in pain during the 12-week intervention period (between-group differences from baseline = -2.06, 95% confidence interval [CI] = -3.01 to -1.10), but benefits were not maintained after acupuncture ended (baseline to week 18 = -0.61, 95% CI = -1.46 to 0.24). Quality of life improved for acupuncture participants (baseline to week 12 difference = 11.79, 95% CI = 1.92 to 21.66), but group differences were not significant compared with usual care (25.58, 95% CI = -3.90 to 55.06). CONCLUSIONS: Group acupuncture is feasible and acceptable among linguistically and racially diverse safety net patients. Findings suggest clinically relevant reduction in pain from PDN and quality of life improvements associated with acupuncture, with no differences based on frequency.

Adjunctive acupuncture for pain and symptom management in the inpatient setting: protocol for a pilot hybrid effectiveness-implementation study.

BACKGROUND: Effective pain management among hospitalized patients is an important aspect of providing quality care and achieving optimal clinical outcomes and patient satisfaction. Common pharmacologic approaches for pain, though effective, have serious side effects and are not appropriate for all inpatients. Findings from randomized controlled trials (RCTs) support the efficacy of acupuncture for many symptoms relevant to inpatients including postoperative pain, cancer-related pain, nausea and vomiting, and withdrawal from narcotic use. However, the extent to which findings from RCTs translate to real-world implementation of acupuncture in typical hospital settings is unknown. METHODS/DESIGN: In partnership with the launch of a clinical program offering acupuncture services to inpatients at the University of California San Francisco's Mount Zion Hospital, we are conducting a pilot study using a hybrid effectiveness-implementation design to: (1) assess the effectiveness of acupuncture to manage pain and other symptoms and improve patient satisfaction; and (2) evaluate the barriers and facilitators to implementing an on-going acupuncture service for inpatients. During a two-month pre-randomization phase, we evaluated and adapted clinical scheduling and treatment protocols with acupuncturists and hospital providers and pretested study procedures including enrollment, consent, and data collection. During a six-month randomization phase, we used a two-tiered consent process in which inpatients were first consented into a study of symptom management, randomized to be offered acupuncture, and consented for acupuncture if they accepted. We are also conducting in-depth interviews and focus groups to assess evidence, context, and facilitators of key provider and hospital administration stakeholders. DISCUSSION: Effectiveness research in "real-world" practice settings is needed to inform clinical decision-making and guide implementation of evidence-based acupuncture practices. To successfully provide clinical acupuncture services and maintain a rigorous research design, practice-based trials of acupuncture require careful planning and attention to setting-specific, contextual factors. TRIAL REGISTRATION: This trial has been registered in ClinicalTrials.gov. The identifier is NCT01988194, registered on November 5, 2013.

Applying the RE-AIM Framework to Evaluate Integrative Medicine Group Visits Among Diverse Women with Chronic Pelvic Pain.

The purpose of this study was to evaluate group medical visits using an integrative health approach for underserved women with chronic pelvic pain (CPP). We implemented an integrative medicine program to improve quality of life among women with CPP using Centering, a group-based model that combines healthcare assessment, education, and social support. Patients were from university-affiliated and public hospital-affiliated clinics. We evaluated the program with qualitative and quantitative data to address components of the RE-AIM framework: Reach, Effectiveness, Adoption, Implementation, and Maintenance. Participants of the Centering CPP Program participants (n = 26) were demographically similar to a sample of women with CPP who sought care at Bay Area hospitals (n = 701). Participants were on average 40 years of age, a majority of whom were racial/ethnic minorities with low household income (76%). Women who attended four or more sessions (n = 16) had improved health-related quality of life, including decreases in average number of unhealthy days in the past month (from 24 to 18, p < .05), depressive symptoms (from 11.7 to 9.0, p < .05), and symptom severity (from 4.2 to 3.1, p < .01). Sexual health outcomes also improved (30.5 to 50.3, p = .02). No improvements were observed for pain catastrophizing. Our pilot program provides preliminary data that an integrative health approach using a group-based model can be adapted and implemented to reach diverse women with CPP to improve physical and psychological well-being. Given these promising findings, rigorous evaluation of implementation and effectiveness of this approach compared with usual care is warranted.