Virtual Care: Perspectives From Family Physicians.

BACKGROUND: During the COVID-19 pandemic, virtual care expanded rapidly at Michigan Medicine and other health systems. From family physicians' perspectives, this shift to virtual care has the potential to affect workflow, job satisfaction, and patient communication. As clinics reopened and care delivery models shifted to a combination of in-person and virtual care, the need to understand physician experiences with virtual care arose in order to improve both patient and provider experiences. This study investigated Michigan Medicine family medicine physicians' perceptions of virtual care through qualitative interviews to better understand how to improve the quality and effectiveness of virtual care for both patients and physicians. METHODS: We employed a qualitative descriptive design to examine physician perspectives through semistructured interviews. We coded and analyzed transcripts using thematic analysis, facilitated by MAXQDA (VERBI) software. RESULTS: The results of the analysis identified four major themes: (a) chief concerns that are appropriate for virtual evaluation, (b) physician perceptions of patient benefits, (c) focused but contextually enriched patient-physician communication, and (d) structural support needed for high-quality virtual care. CONCLUSIONS: These findings can help further direct the discussion of how to make use of resources to improve the quality and effectiveness of virtual care.

Impact of a resilience-building energy management intervention for people with systemic sclerosis: a mixed methods study.

Objectives: People with SSc often experience fatigue, which significantly affects daily life functioning and quality of life. We aimed to explore participants' experiences of a peer health-coached resilience-building energy management to enhance well-being (RENEW) intervention on symptoms and well-being and to use mixed methods to compare how SSc duration influenced the experiences of participants who had clinically significant fatigue improvement vs those who did not. Methods: Semi-structured interviews were conducted with 21 participants from the parent clinical trial randomized to the RENEW intervention. Data were analysed using the rigorous and accelerated data reduction technique combined with thematic content analysis. A mixed methods approach used a joint display to identify themes related to the impact of SSc duration on fatigue improvement status. Participants were categorized into short/improvement, short/limited improvement, long/improvement, and long/limited improvement. Results: Our team generated four themes: participant and peer health-coach relationship, physical and psychological well-being improvement, need for a tailored approach and easy program access through technology. Mixed methods analysis revealed that, regardless of SSc duration, participants with improved fatigue reported increasing self-awareness of SSc-related symptoms and learning coping strategies to manage fatigue. Participants in the short/improvement group reported preferences for slower pacing of the program and pairing with a coach with similar symptom severity. Participants in the long/limited improvement group sought SSc-specific symptom management information. Conclusion: Incorporating peer health coaches and technology is beneficial for self-management interventions for people with SSc. Future tailoring of RENEW based on SSc duration and symptom severity is needed. Clinical trial registration number: clinicatrials.gov, NCT04908943.

Grand rounds in methodology: designing for integration in mixed methods research.

Mixed methods research is a popular approach used to understand persistent and complex problems related to quality and safety, such as reasons why interventions are not implemented as intended or explaining differential outcomes. However, the quality and rigour of mixed methods research proposals and publications often miss opportunities for integration, which is the core of mixed methods. Achieving integration remains challenging, and failing to integrate reduces the benefits of a mixed methods approach. Therefore, the purpose of this article is to guide quality and safety researchers in planning and designing a mixed methods study that facilitates integration. We highlight how meaningful integration in mixed methods research can be achieved by centring integration at the following levels: research question, design, methods, results and reporting and interpretation levels. A holistic view of integration through all these levels will enable researchers to provide better answers to complex problems and thereby contribute to improvement of safety and quality of care.

"Better at home": Mixed methods report of intricacies in pediatric febrile neutropenia management.

INTRODUCTION: Many febrile neutropenia (FN) episodes are low risk (LR) for severe outcomes and can safely receive less aggressive management and early hospital discharge. Validated risk tools are recommended by the Children's Oncology Group to identify LR FN episodes. However, the complex dynamics of early hospital discharge and burdens faced by caregivers associated with the FN episode have been inadequately described. METHODS: An adapted quality-of-life (QoL) survey instrument was administered by a convergent mixed methods design; qualitative and quantitative data from two sources, the medical record and the mixed methods survey instrument, were independently analyzed prior to linkage and integration. Code book was informed by conceptual framework; open coding was used. Mixed methods analysis used joint display of results to determine meta-inferences. RESULTS: Twenty-eight patient-caregiver dyads participated with a response rate of 87%. Of the 27 FN episodes, 51.8% (14/27) were LR and 40.7% (11/27) had an early hospital discharge. The LR and early hospital discharge groups had higher mean QoL scores comparatively. Meta-inferences are reciprocal influencers and expand the complex situation; FN negatively affects the entire family, and the benefits of hospital management were outweighed by risks and worsened symptoms, so an individualized approach to management and care at home was preferred. CONCLUSION: Early discharge of LR FN episodes positively impacts QoL, yet risk-stratified management for FN is intricately complex. Optimal FN management should prioritize the patient's overall health; shared decision-making is recommended and can improve care delivery. These results should be confirmed in a larger, more heterogeneous population.

Integrating Transformative Considerations and Quantitative Results through a Participant Selection Joint Display in Explanatory Sequential Mixed Methods Studies.

Integrating philosophical or paradigmatic dimensions in mixed methods research studies facilitates the development of stronger meta-inferences. The transformative paradigm and the explanatory sequential mixed methods design share a focus on developing sampling criteria, but with different priorities. This article contributes to the field of mixed methods research by presenting a method of integrating transformative sampling considerations in explanatory sequential designs through a participant selection joint display. The approach presented addresses concerns regarding transparency of research decisions in mixed methods studies, while providing a method of centering the transformative paradigm in mixed methods integration procedures.

Implementing integrated hypertension and diabetes management using the World Health Organization's HEARTS model: protocol for a pilot study in the Guatemalan national primary care system.

BACKGROUND: The HEARTS technical package was developed by the World Health Organization to address the implementation gap in cardiovascular disease prevention in low- and middle-income countries. Guatemala is a middle-income country that is currently implementing HEARTS. National authorities in Guatemala are interested in exploring how hypertension and diabetes management can be integrated in HEARTS implementation. The objective of this study is to conduct a feasibility and acceptability pilot trial of integrated hypertension and diabetes management based on HEARTS in the publicly funded primary care system in Guatemala. METHODS: A single-arm pilot trial for 6 months will be carried out in 11 Ministry of Health primary care facilities starting in September 2023. A planned sample of 100 adult patients diagnosed with diabetes (n = 45), hypertension (n = 45), or both (n = 10) will be enrolled. The intervention will consist of HEARTS-aligned components: Training health workers on healthy-lifestyle counseling and evidence-based treatment protocols, strengthening access to medications and diagnostics, training on risk-based cardiovascular disease management, team-based care and task sharing, and systems monitoring and feedback, including implementation of a facility-based electronic monitoring tool at the individual level. Co-primary outcomes of feasibility and acceptability will be assessed using an explanatory sequential mixed-methods design. Secondary outcomes include clinical effectiveness (treatment with medication, glycemic control, and blood pressure control), key implementation outcomes (adoption, fidelity, usability, and sustainability), and patient-reported outcome measures (diabetes distress, disability, and treatment burden). Using an implementation mapping approach, a Technical Advisory Committee will develop implementation strategies for subsequent scale-up planning. DISCUSSION: This trial will produce evidence on implementing HEARTS-aligned hypertension and diabetes care in the MOH primary care system in Guatemala. Results also will inform future HEARTS projects in Guatemala and other low- and middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov ID NCT06080451. The trial was prospectively registered on October 12, 2023.

Institutional Review Boards' Assessment of Local Context: A Mixed Methods Study.

The nature of the review of local context by institutional review boards (IRBs) is vague. Requirements for single IRB review of multicenter trials create a need to better understand interpretation and implementation of local-context review and how to best implement such reviews centrally. We sought a pragmatic understanding of IRB local-context review by exploring stakeholders' attitudes and perceptions. Semistructured interviews with 26 IRB members and staff members, institutional officials, and investigators were integrated with 80 surveys of similar stakeholders and analyzed with qualitative theme-based text analysis and descriptive statistical analysis. Stakeholders described what they considered to be local context, the value of local-context review, and key processes used to implement review of local context in general and for emergency research conducted with an exception from informed consent. Concerns and potential advantages of centralized review of local context were expressed. Variability in perspectives suggests that local-context review is not a discrete process, which presents opportunities for defining pathways for single IRB review.

"You get what you need when you need it": A mixed methods examination of the feasibility and acceptability of a tailored digital tool to promote physical activity among women in midlife.

During midlife (ages 40-60), women experience myriad changes that elevate their risk for cardiovascular disease (CVD), including decreased physical activity (PA). Women cite lack of social support for PA and lack of active peers who can serve as role models as key barriers. Digital tools such as web applications can provide exposure to these social inputs; they are also accessible in daily life and require modest time investment. However, as few tools have been designed to meet the unique needs of women in midlife with CVD risk, our research team previously built a web application that is tailored for this population. In the present study, we used a convergent mixed methods design to develop a deep understanding of the feasibility, usability, and acceptability of this web application in a sample of identified end users. Participants (N = 27, MAge = 53 years, MBMI = 32.6 kg/m2) used the web application at the start of each day for 7 days and completed a 1-hour qualitative interview at the end of this test period. Integration of findings from two-level multilevel models (quantitative) and thematic analysis (qualitative) indicated support for the feasibility, usability, and acceptability of the new web application among women in midlife with CVD risk conditions and identified critical opportunities for improving the user experience. Findings also speak to the utility of options for content selection that can meet women's needs in daily life and highlight women's desire for PA resources that prioritize their perspectives.

Developing a survey instrument to assess flood health beliefs among residents of river flood zones in the Heartland.

INTRODUCTION: Flooding represents a significant health risk to residents of states bordering the Missouri and Missis-sippi Rivers. In Nebraska and Iowa, nearly 280,000 individuals live in floodplains that put them at higher risk for expe-riencing a flood. In Nebraska, 8.60 percent of residents live within floodplains, while in Iowa, 3.83 percent of residents live in floodplains.1 Flooding poses immediate risks including injury and loss of life, but it additionally threatens long-er-term impacts due to increased exposure to environmental health risks and damage to physical and social infrastruc-ture.2,3 Health education interventions depend on risk communication based on accurate knowledge of the health beliefs of at-risk individuals. This paper outlines the development of a survey instrument designed to solicit flooding health beliefs of individuals living in river flood zones. METHODS: This study developed the survey instrument through a series of revisions designed to increase the con-struct validity of the data collected. These steps included item sourcing and modification, expert review, and cognitive interviewing. Content for the initial survey draft was sourced from existing flood risk survey instruments and other standardized demographic surveys.4-8 This study then validated the instrument through sequential expert review and cognitive interviewing, collecting and conducting qualitative analysis of data collected through each phase. RESULTS: Themes from the expert review include (1) improvement of the user experience through revision of re-sponse categories and removal of unnecessary structural elements, (2) improvement of construct representativity through attentiveness to existing flood preparedness policies in the Heartland, and (3) streamlining of data analysis through revision and clarification of item prompts and responses. Themes from the cognitive interviewing include (1) the addition of items soliciting respondents' awareness of their flood risk as well as open-ended items soliciting respond-ents' existing personal flood plan components, (2) revision of existing demographic items to solicit respondents' esti-mated-rather than exact-household income, and (3) clarification of our definition of a flooding event. DISCUSSION: This study adapted existing survey items into an instrument designed to gather data on respondents' flood health beliefs and relevant demographic characteristics, producing a developed instrument that can be used to measure a population's flood health beliefs with reasonable evidence of validity. This instrument may be further tested by gathering baseline data and conducting psychometric testing to determine which items wield significant influence over respondents' decision to develop a personal or household flood plan.9 Additionally, this study provides a model for risk communication professionals seeking to adapt existing survey items to develop instruments designed to gather data on locally relevant health outcomes.10.

A cross-stakeholder approach to improving out-of-hospital cardiac arrest survival.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) affects over 300,000 individuals per year in the United States with poor survival rates overall. A remarkable 5-fold difference in survival-to-hospital discharge rates exist across United States communities. METHODS: We conducted a study using qualitative research methods comparing the system of care across sites in Michigan communities with varying OHCA survival outcomes, as measured by return to spontaneous circulation with pulse upon emergency department arrival. RESULTS: Major themes distinguishing higher performing sites were (1) working as a team, (2) devoting resources to coordination across agencies, and (3) developing a continuous quality improvement culture. These themes spanned the chain of survival framework for OHCA. By examining the unique processes, procedures, and characteristics of higher- relative to lower-performing sites, we gleaned lessons learned that appear to distinguish higher performers. The higher performing sites reported being the most collaborative, due in part to facilitation of system integration by progressive leadership that is willing to build bridges among stakeholders. CONCLUSIONS: Based on the distinguishing features of higher performing sites, we provide recommendations for toolkit development to improve survival in prehospital systems of care for OHCA.

Identifying Inequities in Video and Audio Telehealth Services for Primary Care Encounters During COVID-19: Repeated Cross-Sectional, Observational Study.

BACKGROUND: The COVID-19 pandemic resulted in rapid changes in how patient care was provided, particularly through the expansion of telehealth and audio-only phone-based care. OBJECTIVE: The goal of this study was to evaluate inequities in video and audio-only care during various time points including the initial wave of the COVID-19 pandemic, later stages of the pandemic, and a historical control. We sought to understand the characteristics of care during this time for a variety of different groups of patients that may experience health care inequities. METHODS: We conducted a retrospective analysis of electronic health record (EHR) data from encounters from 34 family medicine and internal medicine primary care clinics in a large, Midwestern health system, using a repeated cross-sectional, observational study design. These data included patient demographic data, as well as encounter, diagnosis, and procedure records. Data were obtained for all in-person and telehealth encounters (including audio-only phone-based care) that occurred during 3 separate time periods: an initial COVID-19 period (T2: March 16, 2020, to May 3, 2020), a later COVID-19 period (T3: May 4, 2020, to September 30, 2020), and a historical control period from the previous year (T1: March 16, 2019, to September 30, 2019). Primary analysis focused on the status of each encounter in terms of whether it was completed as scheduled, it was canceled, or the patient missed the appointment. A secondary analysis was performed to evaluate the likelihood of an encounter being completed based on visit modality (phone, video, in-person). RESULTS: In total, there were 938,040 scheduled encounters during the 3 time periods, with 178,747 unique patients, that were included for analysis. Patients with completed encounters were more likely to be younger than 65 years old (71.8%-74.1%), be female (58.8%-61.8%), be White (75.6%-76.7%), and have no significant comorbidities (63.2%-66.8%) or disabilities (53.2%-61.1%) in all time periods than those who had only canceled or missed encounters. Effects on different subpopulations are discussed herein. CONCLUSIONS: Findings from this study demonstrate that primary care utilization across delivery modalities (in person, video, and phone) was not equivalent across all groups before and during the COVID-19 pandemic and different groups were differentially impacted at different points. Understanding how different groups of patients responded to these rapid changes and how health care inequities may have been affected is an important step in better understanding implementation strategies for digital solutions in the future.

Equity in virtual care: A mixed methods study of perspectives from physicians.

BACKGROUND: Virtual care expanded rapidly during the COVID-19 pandemic, and how this shift affected healthcare disparities among subgroups of patients is of concern. Racial and ethnic minorities, older adults, individuals with less education, and lower-income households have lower rates of home broadband, smartphone ownership, and patient portal adoption, which may directly affect access to virtual care. Because primary care is a major access point to healthcare, perspectives of primary care providers are critical to inform the implementation of equitable virtual care. OBJECTIVE: The aim of this mixed methods study was to explore primary care physician experiences and perceptions of barriers and facilitators to equitable virtual care. DESIGN: We used an explanatory sequential mixed methods design, which consists of first collecting and analyzing quantitative survey data, then using those results to inform a qualitative follow-up phase to explain and expand on results. PARTICIPANTS: Primary care physicians in a family medicine department at an academic medical center responded to surveys (n = 38) and participated in interviews (n = 16). APPROACH: Participants completed a survey concerning frequency and preferences about video visits, pros and cons of video visits, communication aspects, and sufficiency of the technology. A purposeful sample of participants completed semi-structured interviews about their virtual care experiences with a focus on equity for subpopulations. KEY RESULTS: The results indicated that physicians have observed equity issues for unique patient populations. The results add to the understanding of nuanced ways in which virtual care can increase and decrease healthcare access for unique populations. Patients with limited English proficiency were particularly affected by inequity in virtual care access. CONCLUSION: Additional research and interventions are needed to improve portal access for those with limited English proficiency. Improvements should focus on health system interventions that expand access without requiring increased patient burden.

Using Wearable Passive Sensing to Predict Binge Eating in Response to Negative Affect Among Individuals With Transdiagnostic Binge Eating: Protocol for an Observational Study.

BACKGROUND: Binge eating (BE), characterized by eating a large amount of food accompanied by a sense of loss of control over eating, is a public health crisis. Negative affect is a well-established antecedent for BE. The affect regulation model of BE posits that elevated negative affect increases momentary risk for BE, as engaging in BE alleviates negative affect and reinforces the behavior. The eating disorder field's capacity to identify moments of elevated negative affect, and thus BE risk, has exclusively relied on ecological momentary assessment (EMA). EMA involves the completion of surveys in real time on one's smartphone to report behavioral, cognitive, and emotional symptoms throughout the day. Although EMA provides ecologically valid information, EMA surveys are often delivered only 5-6 times per day, involve self-report of affect intensity only, and are unable to assess affect-related physiological arousal. Wearable, psychophysiological sensors that measure markers of affect arousal including heart rate, heart rate variability, and electrodermal activity may augment EMA surveys to improve accurate real-time prediction of BE. These sensors can objectively and continuously measure biomarkers of nervous system arousal that coincide with affect, thus allowing them to measure affective trajectories on a continuous timescale, detect changes in negative affect before the individual is consciously aware of them, and reduce user burden to improve data completeness. However, it is unknown whether sensor features can distinguish between positive and negative affect states, given that physiological arousal may occur during both negative and positive affect states. OBJECTIVE: The aims of this study are (1) to test the hypothesis that sensor features will distinguish positive and negative affect states in individuals with BE with >60% accuracy and (2) test the hypothesis that a machine learning algorithm using sensor data and EMA-reported negative affect to predict the occurrence of BE will predict BE with greater accuracy than an algorithm using EMA-reported negative affect alone. METHODS: This study will recruit 30 individuals with BE who will wear Fitbit Sense 2 wristbands to passively measure heart rate and electrodermal activity and report affect and BE on EMA surveys for 4 weeks. Machine learning algorithms will be developed using sensor data to distinguish instances of high positive and high negative affect (aim 1) and to predict engagement in BE (aim 2). RESULTS: This project will be funded from November 2022 to October 2024. Recruitment efforts will be conducted from January 2023 through March 2024. Data collection is anticipated to be completed in May 2024. CONCLUSIONS: This study is anticipated to provide new insight into the relationship between negative affect and BE by integrating wearable sensor data to measure affective arousal. The findings from this study may set the stage for future development of more effective digital ecological momentary interventions for BE. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/47098.

Faculty and Resident Perspectives of the Complexity of Wellness Program Implementation: A Qualitative Exploration.

Introduction: Developing and implementing a wellness curriculum in a family medicine residency program is a complex process. We developed and implemented a new wellness curriculum in line with the national wellness conversation with a focus on the allocation of dedicated resources, the use of evidence-informed interventions, and the goal to be responsive to the feedback of both residents and residency leadership. Our research aim was to better understand the complexity of wellness curriculum implementation with a focus on identification of challenges to implementation. Methods: We developed a wellness program with structured curricular elements initially focused on evidence-informed skill development that iterated after year 1 to include more process-oriented elements. For the years 2016-2019 we collected and analyzed qualitative, open-ended survey questions, anonymous resident curriculum feedback, and faculty observation forms to assess resident and faculty perspectives on the new curriculum. Results: One hundred eighty-three survey invitations were sent with 122 total responses (66.7% response rate). Forty-eight of 56 residents responded to at least one survey. We analyzed responses along with the additional qualitative data that revealed several themes impacting the work of residency wellness curriculum implementation. These included how to manage curricular time, where the locus of control for the curricular content resides, and how residents and faculty differ in their definitions of wellness. Conclusions: We believe programs will be well positioned if they further investigate the complex structures at play that influence residency wellness, including both systemic factors and individual and community level interventions, and design curriculum that is well-defined, includes essential elements, and is informed by resident participation.

Enhancing Nonverbal Communication Through Virtual Human Technology: Protocol for a Mixed Methods Study.

BACKGROUND: Communication is a critical component of the patient-provider relationship; however, limited research exists on the role of nonverbal communication. Virtual human training is an informatics-based educational strategy that offers various benefits in communication skill training directed at providers. Recent informatics-based interventions aimed at improving communication have mainly focused on verbal communication, yet research is needed to better understand how virtual humans can improve verbal and nonverbal communication and further elucidate the patient-provider dyad. OBJECTIVE: The purpose of this study is to enhance a conceptual model that incorporates technology to examine verbal and nonverbal components of communication and develop a nonverbal assessment that will be included in the virtual simulation for further testing. METHODS: This study will consist of a multistage mixed methods design, including convergent and exploratory sequential components. A convergent mixed methods study will be conducted to examine the mediating effects of nonverbal communication. Quantitative (eg, MPathic game scores, Kinect nonverbal data, objective structured clinical examination communication score, and Roter Interaction Analysis System and Facial Action Coding System coding of video) and qualitative data (eg, video recordings of MPathic-virtual reality [VR] interventions and student reflections) will be collected simultaneously. Data will be merged to determine the most crucial components of nonverbal behavior in human-computer interaction. An exploratory sequential design will proceed, consisting of a grounded theory qualitative phase. Using theoretical, purposeful sampling, interviews will be conducted with oncology providers probing intentional nonverbal behaviors. The qualitative findings will aid the development of a nonverbal communication model that will be included in a virtual human. The subsequent quantitative strand will incorporate and validate a new automated nonverbal communication behavior assessment into the virtual human simulation, MPathic-VR, by assessing interrater reliability, code interactions, and dyadic data analysis by comparing Kinect responses (system recorded) to manually scored records for specific nonverbal behaviors. Data will be integrated using building integration to develop the automated nonverbal communication behavior assessment and conduct a quality check of these nonverbal features. RESULTS: Secondary data from the MPathic-VR randomized controlled trial data set (210 medical students and 840 video recordings of interactions) were analyzed in the first part of this study. Results showed differential experiences by performance in the intervention group. Following the analysis of the convergent design, participants consisting of medical providers (n=30) will be recruited for the qualitative phase of the subsequent exploratory sequential design. We plan to complete data collection by July 2023 to analyze and integrate these findings. CONCLUSIONS: The results from this study contribute to the improvement of patient-provider communication, both verbal and nonverbal, including the dissemination of health information and health outcomes for patients. Further, this research aims to transfer to various topical areas, including medication safety, informed consent processes, patient instructions, and treatment adherence between patients and providers. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46601.

Early changes in hospital resuscitation practices during the COVID-19 pandemic.

Background: The coronavirus disease 2019 (COVID-19) pandemic resulted in many disruptions in care for patients experiencing in-hospital cardiac arrest (IHCA). We sought to identify changes made in hospital resuscitation practices during progression of the COVID-19 pandemic. Methods: We conducted a descriptive qualitative study using in-depth interviews of clinical staff leadership involved with resuscitation care at a select group of U.S. acute care hospitals in the national American Heart Association Get With The Guidelines-Resuscitation registry for IHCA. We focused interviews on resuscitation practice changes for IHCA since the initiation of the COVID-19 pandemic. We used rapid analysis techniques for qualitative data summarization and analysis. Results: A total of 6 hospitals were included with interviews conducted with both physicians and nurses between November 2020 and April 2021. Three topical themes related to shifts in resuscitation practice through the COVID-19 pandemic were identified: 1) ensuring patient and provider safety and wellness (e.g., use of personal protective equipment); 2) changing protocols and training for routine educational practices (e.g., alterations in mock codes and team member roles); and 3) goals of care and end of life discussions (e.g., challenges with visitor and family policies). We found advances in leveraging technology use as an important topic that helped institutions address challenges across all 3 themes. Conclusions: Early on, the COVID-19 pandemic resulted in many changes to resuscitation practices at hospitals placing an emphasis on enhanced safety, training, and end of life planning. These lessons have implications for understanding how systems may be better designed for resuscitation efforts.

General Practitioners' Perspectives on Appropriate Use of Ultrasonography in Primary Care in Denmark: A Multistage Mixed Methods Study.

PURPOSE: Researchers aimed to describe general practitioners' understanding of appropriate ultrasound use, to record actual scanning practices of early adopters in general practice, and to identify differences between attitudes and actual practice via a mixed methods analysis. METHODS: This study was part of a larger multistage mixed methods research framework exploring the use of ultrasound in general practice in Denmark. We used an exploratory sequential approach in the data collection with initial qualitative findings from an interview study applied to building a quantitative questionnaire utilized in a cohort study. In addition, we merged the qualitative and quantitative data using joint display analysis to compare and contrast the results from the 2 stages of the study. RESULTS: In the interviews, general practitioners described appropriate ultrasound use as point-of-care examinations with a clear purpose and limited to predefined specific conditions within delimited anatomic areas. They stated that general practitioners should receive formalized ultrasound training and be skilled in the examinations they perform. In the cohort study, general practitioners performed ultrasound examinations of anatomic areas with or without a defined clinical suspicion. Some performed ultrasound examinations for which they had no previous training or skills. CONCLUSIONS: We found a difference between the ideas about the appropriate uses for ultrasound in general practice and the actual use by early adopters in clinical practice. Our findings suggest a need for evidence-based guidelines to support general practitioners in choosing which examinations to perform and strategies for developing and maintaining scanning competency.

Patient, caregiving partner, and clinician recommendations for improving heart failure care in the Veterans Health Administration.

OBJECTIVE: Heart Failure (HF) care requires substantial care coordination between patients, patients' informal caregivers, and clinicians, but few studies have examined recommendations from all three perspectives. The objective of this study was to understand and identify shared recommendations to improve HF self-care from the perspective of VA persons with HF, their caregiving partners, and clinicians. METHODS: Secondary data analysis from a study of semi-structured interviews with 16 couples (persons with HF and their caregiving partners) and 13 clinicians (physicians, nurses, other specialists) from a large Veterans Affairs (VA) hospital. Interviews were double-coded, and analyzed for themes around commonly used or recommended self-care strategies. RESULTS: Three themes emerged: (1) Couples and clinicians believe that improvements are still needed to existing HF education, especially the need to be tailored to learning style and culture, (2) Couples and clinicians believe that technology can facilitate better HF self-care, and (3) Couples and clinicians believe that caregiving partners are part of the self-care team, and should be involved in care management to support the person with HF. DISCUSSION: Recommendations from couples and clinicians address barriers to HF self-care and encourage patient-centered care.

The Burden of Caring for and Treating Glaucoma: The Patient Perspective.

PURPOSE: To understand the treatment burden experienced by patients receiving care for primary open-angle glaucoma. DESIGN: Semistructured, one-on-one, qualitative interviews. PARTICIPANTS: Patients with primary open-angle glaucoma and age ≥40 years who were scheduled for a follow-up glaucoma appointment at the Kellogg Eye Center. Researchers used purposeful sampling to ensure that there was representation of a range of ages, disease stages, total number of medical conditions, distance traveled to clinic, history of glaucoma surgery, employment, and education. Interviews were conducted until thematic saturation was obtained. METHODS: Participants were interviewed using a semi-structured interview guide that addressed aspects of glaucoma care that give them burden, how this burden impacts their lives, and factors that influence the burden and its impact. Researchers analyzed the transcripts using inductive thematic analysis and grounded theory to generate themes that emerged from the interviews and to map these themes into a conceptual model of glaucoma treatment burden. MAIN OUTCOME MEASURES: Themes related to glaucoma treatment burden generated by qualitative analysis. RESULTS: A total of 22 patients participated in the study. Study participants described 10 categories of glaucoma care activities that cause treatment burden, 8 themes for consequences of glaucoma treatment burden, and 25 themes of factors that influenced the workload created by the various glaucoma care activities and the consequences that they experienced because of these activities. CONCLUSIONS: Participants expressed that the treatment of glaucoma creates a burden for patients that is distinct from the burden of the disease process itself and that this burden negatively affects their quality of life and can potentially cause vision-threatening issues with medication and appointment adherence. We observed considerable variation in the extent to which participants experienced this burden and its consequences, much of which was explained by the influencing factors the participants described. Understanding glaucoma treatment burden and its influencing factors is important as we work to deliver patient-centered care and prevent vision loss.