Caregivers' Role in In-Home Video Telehealth: National Survey of Occupational Therapy Practitioners.

BACKGROUND: Older adults face barriers to specialty care, such as occupational therapy (OT), and these challenges are worse for rural older adults. While in-home video telehealth may increase access to OT, older adults' health- and technology-related challenges may necessitate caregiver assistance. OBJECTIVE: This study examines caregiver assistance with in-home OT video telehealth visits from the perspectives of OT practitioners at Veterans Health Administration (VHA). METHODS: A web-based national survey of VHA OT practitioners about caregivers' role in video telehealth was conducted between January and February 2022. Survey items were developed with input from subject matter experts in geriatrics and OT and identified patient factors that necessitate caregiver participation; the extent to which caregivers assist with different types of tasks (technological and clinical tasks); and the perceived facilitators of, benefits of, and barriers to caregiver involvement. RESULTS: Of approximately 1787 eligible VHA OT practitioners, 286 (16% response rate) participated. Not all survey items required completion, resulting in different denominators. Most respondents were female (183/226, 81%), White (163/225, 72.4%), and occupational therapists (275/286, 96.2%). Respondents were from 87 VHA medical centers, the catchment areas of which served a patient population that was 34% rural, on average (SD 0.22). Most participants (162/232, 69.8%) had >10 years of OT experience serving a patient cohort mostly aged ≥65 years (189/232, 81.5%) in primarily outpatient rehabilitation (132/232, 56.9%). The top patient factors necessitating caregiver involvement were lack of technical skills, cognitive impairment, and advanced patient age, with health-related impairments (eg, hearing or vision loss) less frequent. Technological tasks that caregivers most frequently assisted with were holding, angling, moving, repositioning, or operating the camera (136/250, 54.4%) and enabling and operating the microphone and setting the volume (126/248, 50.8%). Clinical tasks that caregivers most frequently assisted with were providing patient history (143/239, 59.8%) and assisting with patient communication (124/240, 51.7%). The top facilitator of caregiver participation was clinician-delivered caregiver education about what to expect from video telehealth (152/275, 55.3%), whereas the top barrier was poor connectivity (80/235, 34%). Increased access to video telehealth (212/235, 90.2%) was the top-rated benefit of caregiver participation. Most respondents (164/232, 70.7%) indicated that caregivers were at least sometimes unavailable or unable to assist with video telehealth, in which case the appointment often shifted to phone. CONCLUSIONS: Caregivers routinely assist VHA patients with in-home OT video visits, which is invaluable to patients who are older and have complex medical needs. Barriers to caregiver involvement include caregivers' challenges with video telehealth or inability to assist, or lack of available caregivers. By elucidating the caregiver support role in video visits, this study provides clinicians with strategies to effectively partner with caregivers to enhance older patients' access to video visits.

Caregiver Support Role in Occupational Therapy Video Telehealth: A Scoping Review.

Caregiver involvement may facilitate patient participation in occupational therapy (OT) video telehealth. However, little is known about the extent to which caregivers participate and what they do. This scoping review aims to, 1) describe the caregiver role supporting patient participation in OT video telehealth, and, 2) identify barriers and facilitators to caregiver involvement. Findings reveal caregiver involvement in a range of OT evaluation and intervention processes, with details on what caregivers did overall lacking. Barriers and facilitators are also described. This study underscores the need for clear and robust descriptions of caregiver participation to increase best practices in video telehealth.

Using Nudges to Reduce Missed Appointments in Primary Care and Mental Health: a Pragmatic Trial.

BACKGROUND: Missed appointments ("no-shows") are a persistent and costly problem in healthcare. Appointment reminders are widely used but usually do not include messages specifically designed to nudge patients to attend appointments. OBJECTIVE: To determine the effect of incorporating nudges into appointment reminder letters on measures of appointment attendance. DESIGN: Cluster randomized controlled pragmatic trial. PATIENTS: There were 27,540 patients with 49,598 primary care appointments, and 9420 patients with 38,945 mental health appointments, between October 15, 2020, and October 14, 2021, at one VA medical center and its satellite clinics that were eligible for analysis. INTERVENTIONS: Primary care (n = 231) and mental health (n = 215) providers were randomized to one of five study arms (four nudge arms and usual care as a control) using equal allocation. The nudge arms included varying combinations of brief messages developed with veteran input and based on concepts in behavioral science, including social norms, specific behavioral instructions, and consequences of missing appointments. MAIN MEASURES: Primary and secondary outcomes were missed appointments and canceled appointments, respectively. STATISTICAL ANALYSIS: Results are based on logistic regression models adjusting for demographic and clinical characteristics, and clustering for clinics and patients. KEY RESULTS: Missed appointment rates in study arms ranged from 10.5 to 12.1% in primary care clinics and 18.0 to 21.9% in mental health clinics. There was no effect of nudges on missed appointment rate in primary care (OR = 1.14, 95%CI = 0.96-1.36, p = 0.15) or mental health (OR = 1.20, 95%CI = 0.90-1.60, p = 0.21) clinics, when comparing the nudge arms to the control arm. When comparing individual nudge arms, no differences in missed appointment rates nor cancellation rates were observed. CONCLUSIONS: Appointment reminder letters incorporating brief behavioral nudges were ineffective in improving appointment attendance in VA primary care or mental health clinics. More complex or intensive interventions may be necessary to significantly reduce missed appointments below their current rates. TRIAL NUMBER: ClinicalTrials.gov, Trial number NCT03850431.

Transcription factor antagonism regulates heterogeneity in embryonic stem cell states.

Gene expression heterogeneity underlies cell states and contributes to developmental robustness. While heterogeneity can arise from stochastic transcriptional processes, the extent to which it is regulated is unclear. Here, we characterize the regulatory program underlying heterogeneity in murine embryonic stem cell (mESC) states. We identify differentially active and transcribed enhancers (DATEs) across states. DATEs regulate differentially expressed genes and are distinguished by co-binding of transcription factors Klf4 and Zfp281. In contrast to other factors that interact in a positive feedback network stabilizing mESC cell-type identity, Klf4 and Zfp281 drive opposing transcriptional and chromatin programs. Abrogation of factor binding to DATEs dampens variation in gene expression, and factor loss alters kinetics of switching between states. These results show antagonism between factors at enhancers results in gene expression heterogeneity and formation of cell states, with implications for the generation of diverse cell types during development.

Occupational Therapy Practitioner Perspectives of the Role of Caregivers in Video Telehealth.

The current article examines the role of caregivers to support patient participation in video telehealth, using data from interviews with occupational therapy practitioners at Veterans Health Administration. We found that caregiver participation allowed patients who might otherwise not be able to access video telehealth to do so, with patient factors, such as low technical literacy, contributing to caregiver involvement. In addition, caregiver participation varied by type of task performed. There were also benefits and barriers to caregiver participation. This study enhances our understanding of caregivers' role enabling patients to access video telehealth, which has implications for nursing professionals. [Journal of Gerontological Nursing, 48(10), 15-20.].

Applying user-centered design in the development of nudges for a pragmatic trial to reduce no-shows among veterans.

OBJECTIVE: To incorporate user-centered design processes into the refinement of nudges designed to reduce no-shows among healthcare appointments for military veterans in the Veterans Health Administration (VA). METHODS: We developed candidate nudges as brief messages based on four broad concepts in behavioral science. We then conducted iterative waves of multi-stage interviews (N = 27) that included a pile sorting task, a "think-aloud" review of each message, and prototype letter reviews. Rapid consensus analysis of each wave's feedback iteratively refined message language. RESULTS: Veterans rejected several theoretically plausible messages focusing on avoiding the burden of rescheduling missed appointments or the monetary cost of no-shows. Participants suggested framing calling to cancel an appointment as helping other veterans and emphasized a new motivational theme: expressing personal concern for the veteran. CONCLUSION: Use of iterative UCD methods allowed for early identification of both messages inappropriate for veterans and new veteran-generated nudges around non-judgmental validation that could be incorporated in the design of our pragmatic trial. PRACTICE IMPLICATIONS: Rapid team-based qualitative analysis, iterative material design, and space in the study design to incorporate entirely new insights from participants into study materials are all approaches that can improve communications of what matters most to a specific population.

Enhancing Usability of Appointment Reminders: Qualitative Interviews of Patients Receiving Care in the Veterans Health Administration.

BACKGROUND: No-shows are a persistent and costly problem in all healthcare systems. Because forgetting is a common cause of no-shows, appointment reminders are widely used. However, qualitative research examining appointment reminders and how to improve them is lacking. OBJECTIVE: To understand how patients experience appointment reminders as part of intervention development for a pragmatic trial of enhanced appointment reminders. DESIGN: Qualitative content analysis PARTICIPANTS: Twenty-seven patients at a single Department of Veterans Affairs hospital and its satellite clinics APPROACH: We conducted five waves of interviews using rapid qualitative analysis, in each wave continuing to ask veterans about their experience of reminders. We double-coded all interviews, used deductive and inductive content analysis to identify themes, and selected quotations that exemplified three themes (limitations, strategies, recommendations). KEY RESULTS: Interviews showed four limitations on the usability of current appointment reminders which may contribute to no-shows: (1) excessive information within reminders; (2) frustrating telephone systems when calling in response to an appointment reminder; (3) missing or cryptic information about clinic logistics; and (4) reminder fatigue. Patients who were successful at keeping appointments often used specific strategies to optimize the usability of reminders, including (1) using a calendar; (2) heightening visibility; (3) piggybacking; and (4) combining strategies. Our recommendations to enhance reminders are as follows: (1) mix up their content and format; (2) keep them short and simple; (3) add a personal touch; (4) include specifics on clinic location and contact information; (5) time reminders based on the mode of delivery; and (6) hand over control of reminders to patients. CONCLUSIONS: Appointment reminders are vital to prevent no-shows, but their usability is not optimized for patients. There is potential for healthcare systems to modify several aspects of the content, timing, and delivery of appointment reminders to be more effective and patient-centered.

Changes in Fatigue Are the Same for Trained Men and Women after Resistance Exercise.

PURPOSE: To measure changes in fatigue and knee-extensor torque in the 48 h after trained men and women completed a full-body resistance exercise session. METHODS: Eight trained women (mean ± SD: age, 25.6 ± 5.9 yr; height, 1.68 ± 0.06 m; mass, 71.0 ± 8.6 kg) and eight trained men (age, 25.5 ± 6.2 yr; height, 1.79 ± 0.05 m; mass, 86.4 ± 9.8 kg) performed a full-body resistance exercise session based on real-world athletic practice. Measurements were performed before and after the exercise session, as well as 1, 24, and 48 h after the session. Fatigue and pain were measured with standardized self-report measures. Maximal isometric contractions with the knee extensors and superimposed femoral nerve stimulation were performed to examine maximal torque, rate of torque development, voluntary activation, and muscle contractility. Two sets of 10 isokinetic contractions (60°·s) with the knee extensors were performed during the protocol with use of near-infrared spectroscopy to assess muscle oxygenation. EMG were recorded from two quadriceps muscles during all isometric and isokinetic contractions. RESULTS: Fatigue was increased from baseline for both sexes until 48 h after training (P < 0.001). Maximal torque and evoked twitch amplitudes were similarly reduced after exercise for men and women (P < 0.001). Voluntary activation and EMG amplitudes were unchanged after the training session. Muscle oxygenation was 13.3% ± 17.4% (P = 0.005) greater for women during the isokinetic repetitions, and the values were unchanged after the training session. CONCLUSIONS: This is the first study to show similar changes in the fatigue reported by trained men and women in the 48 h after a training session involving full-body resistance exercises. Sex differences in muscle oxygenation during exercise do not influence the reductions in muscle force, activation, or contractility after the training session.

Trained females exhibit less fatigability than trained males after a heavy knee extensor resistance exercise session.

PURPOSE: We examined differences between trained males and females in measures of muscular fatigability and central motor output after a resistance exercise session. METHODS: Sixteen trained males (n = 8) and females (n = 8) participated in the study. Knee extensor maximal torque and rate of torque development were measured before and after the exercise session, and the twitch interpolation technique was used during the maximal efforts to derive measures of voluntary activation and muscle contractility by supramaximal stimulation of the femoral nerve using 10 and 100 Hz doublets. Surface electromyograms were recorded during all maximal efforts to examine maximal and rate of quadriceps muscle activation. RESULTS: After exercise, maximal torque was reduced for both sexes by 26.3 ± 12.5% (p < 0.001). Absolute and relative vRTD was reduced only for males after exercise (p < 0.05). The early (0-50 ms) rate of muscle activation rise was similarly reduced for both sexes between 2.6 and 16.4% s-1 (p < 0.01), but males experienced an average decrease of 82.5 ± 72.1% s-1 for the maximal rate of muscle activation compared to no change for females (p = 0.02). Males had greater reductions (p < 0.05) for maximal twitch amplitudes and rate of twitch development (- 51.1 ± 21.5% and - 49.9 ± 22.8%, respectively) compared to females (- 35.8 ± 13.7% and - 31.5 ± 14.0%, respectively). CONCLUSIONS: These findings suggest that trained females are resistant to reductions in rapid torque development, despite similar reductions in maximal torque, after resistance exercise, with this result explained by better-maintained muscle contractility and maximal rate of muscle activation compared to males.