Integrated health-system specialty pharmacies (IHSSP) have shown high medication access, adherence, and provider satisfaction. The goal of this study was to explore healthcare providers’ experiences ...with specialty medications distributed via Limited Distribution Networks (LDN) that do not include IHSSPs. We investigated healthcare providers’ perceived impact of LDNs on clinic workflow, clinical practice, and patient outcomes. Interviews and focus groups were conducted with fourteen healthcare providers from four outpatient specialty clinics at an academic health system with an IHSSP. Qualitative analysis using an iterative inductive/deductive approach of coded transcripts was used to identify themes. Participants discussed requirements and barriers to communicating with insurance providers, drug manufacturers, and external pharmacies; time and effort required to navigate LDNs and impact on workload and clinic workflow; financial awareness of medication costs and methods for communication about financial information with patients; and advocating for patients to ensure access to necessary therapy and avoid missed doses or treatment lapse. Participants reported barriers to navigating LDNs that can interfere with clinic workflow and patient care. IHSSPs may reduce clinic burden by helping patients access, afford, and remain on therapy.
Abstract
Study Objectives
Sleep duration can change over the life course; however, previous studies rarely investigated the association between socioeconomic status (SES) and individual sleep ...trajectories over time. We examined the association between baseline socioeconomic characteristics and long-term sleep trajectories among Black and White adults.
Methods
This study used data from the Southern Community Cohort Study (N = 45 035). Diverse trajectories of sleep duration were constructed using self-reported sleep duration at baseline and after ~10 years of follow-up. The associations between baseline socioeconomic characteristics and sleep trajectories were examined using multinomial logistic regression.
Results
Both Black and White participants experienced similar long-term individual sleep trajectories for baseline educational attainment and employment status albeit the associations appeared stronger among White participants. Lower education and unemployment were associated with higher odds of various suboptimal sleep trajectories suggesting worsening long-term sleep patterns among both racial groups. However, there were some racial differences in the experience of long-term sleep trajectories for household income and neighborhood SES. Household income was notably more important among White than Black individuals; lower household income was associated with higher odds of more suboptimal long-term sleep trajectories for White than Black individuals. Also, neighborhood SES was slightly more important among White than Black individuals; lower neighborhood SES was associated with higher odds of a few suboptimal long-term sleep trajectories for both racial groups.
Conclusions
Lower socioeconomic characteristics were associated with various suboptimal long-term sleep trajectories among Black and White participants. Substantial improvements in socio-economic characteristics may contribute to improved sleep patterns.
Graphical Abstract
Graphical Abstract
Antibiotics are frequently prescribed for children in the outpatient setting. Although sometimes necessary, antibiotic use is associated with important downstream effects including the development of ...antimicrobial resistance among human and environmental microorganisms. Current outpatient stewardship efforts focus on guiding appropriate antibiotic prescribing practices among providers, but little is known about parents' understanding of antibiotics and appropriate disposal of leftover antibiotics. To help bridge this gap, we conducted a qualitative study to assess parental understanding of their children's antibiotics, their adherence to antibiotic instructions, and their disposal practices. We conducted a semi-structured interview with parents of 13 children diagnosed with acute respiratory illnesses and prescribed antibiotics in an urban outpatient clinic. We found that parents had limited understanding of how antibiotics work. Although they received instructions about antibiotic use during the healthcare visit, adherence to the prescription and appropriate disposal of antibiotics was suboptimal. Limited baseline understanding of antibiotics, their prior experiences with antibiotics, perceptions about their social networks' antibiotic use, and information provided to them by healthcare providers may influence these behaviors. Our findings can inform educational efforts of outpatient stewardship programs to help optimize parental understanding of how to use and dispose of their children's antibiotics.
Adults with Tourette syndrome (TS) have worse mental health, physical health, and quality of life than the general population. The factors contributing to negative outcomes across multiple health ...domains in adults with TS remain uncertain, in part due to a lack of longitudinal studies in this population. In attempt to address these knowledge gaps, our center has initiated development of a regional registry for adults with TS. During the goal-setting and design phase of registry development, we conducted focus groups with adults with TS to identify research issues of greatest importance to this population and to obtain feedback on design and implementation of an adult TS registry.
Participants were recruited from a tertiary care adult TS clinic and from institutional research registries. Focus groups were conducted online and were moderated by a qualitative research expert. Qualitative data analysis was performed using an iterative inductive/deductive approach.
Across four focus groups, adult TS participants (n=22) expressed a variety of research priorities, including developing more effective treatments for tics, identifying risk factors for tic persistence into adulthood, clarifying the interaction between TS symptoms and women's health, clarifying the relationships between TS and other mental and physical health disorders, and addressing day-to-day living issues. Focus group participants were generally enthusiastic about creation of an adult TS registry. They indicated that adults with TS are more likely to engage with a registry that logistically accommodates participants (eg, by offering a wide range of visit times, by providing telehealth options) and that fosters bidirectional interaction (eg, by disseminating results regularly, by involving participants in registry design and implementation, by notifying participants of support resources).
Focus group input clarifies the research priorities of adults with TS and will inform the ongoing development of an adult TS registry.
Despite efforts to enhance the quality of medication prescribing in outpatient settings, potentially inappropriate prescribing remains common, particularly in unscheduled settings where patients can ...present with infectious and pain-related complaints. Two of the most commonly prescribed medication classes in outpatient settings with frequent rates of potentially inappropriate prescribing include antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs). In the setting of persistent inappropriate prescribing, we sought to understand a diverse set of perspectives on the determinants of inappropriate prescribing of antibiotics and NSAIDs in the Veterans Health Administration.
We conducted a qualitative study guided by the Consolidated Framework for Implementation Research and Theory of Planned Behavior. Semi-structured interviews were conducted with clinicians, stakeholders, and Veterans from March 1, 2021 through December 31, 2021 within the Veteran Affairs Health System in unscheduled outpatient settings at the Tennessee Valley Healthcare System. Stakeholders included clinical operations leadership and methodological experts. Audio-recorded interviews were transcribed and de-identified. Data coding and analysis were conducted by experienced qualitative methodologists adhering to the Consolidated Criteria for Reporting Qualitative Studies guidelines. Analysis was conducted using an iterative inductive/deductive process.
We conducted semi-structured interviews with 66 participants: clinicians (N = 25), stakeholders (N = 24), and Veterans (N = 17). We identified six themes contributing to potentially inappropriate prescribing of antibiotics and NSAIDs: 1) Perceived versus actual Veterans expectations about prescribing; 2) the influence of a time-pressured clinical environment on prescribing stewardship; 3) Limited clinician knowledge, awareness, and willingness to use evidence-based care; 4) Prescriber uncertainties about the Veteran condition at the time of the clinical encounter; 5) Limited communication; and 6) Technology barriers of the electronic health record and patient portal.
The diverse perspectives on prescribing underscore the need for interventions that recognize the detrimental impact of high workload on prescribing stewardship and the need to design interventions with the end-user in mind. This study revealed actionable themes that could be addressed to improve guideline concordant prescribing to enhance the quality of prescribing and to reduce patient harm.
Objectives
To explore patient opinions and underlying values regarding overlapping surgery (OS) scenarios, specifically evaluating the effect of attending surgeon presence and availability, as well ...as trainee participation on patient comfort level and willingness to consent.
Study Design
Mixed methods.
Methods
Forty adults participated in semi‐structured interviews. Interviews included vignettes involving three scenarios of OS (1: attending present; 2: attending absent for wound closure; 3: attending absent and unavailable for wound closure, with covering attending), visual analog scale ratings of participants’ comfort with scenarios, and cognitive debriefing. Themes and subthemes were identified using hierarchical coding of transcripts, and quantitative and qualitative analyses were conducted.
Results
Quantitative analysis revealed anticipated decreases in comfort with decreasing attending presence/availability (mean comfort level 94% vs. 78% vs. 63% for scenarios 1 vs. 2 vs. 3, P < 0.005), although many patients reported improved comfort with scenario 3 if meeting the covering attending. Participants demonstrated a preference for less trainee involvement (P < 0.005, scenario 1) and greater trainee experience (P < 0.05, all scenarios). However, not all individuals were uncomfortable with attending absence or trainee independence. Themes important for decision making included trust in the surgeon, surgeon experience, trainee involvement, disease severity, cost, and wait time.
Conclusion
Patients varied highly in their willingness to consent to OS scenarios. In settings of trainee independence and covering surgeons, many patients desired meeting these members of the treatment team, which improved comfort for some. For some patients, tradeoffs and incentives of timeliness, cost, and convenience modified their willingness to have OS.
Level of Evidence
4
Laryngoscope, 129:1337–1346, 2019
Engaging communities in research increases its relevance and may speed the translation of discoveries into improved health outcomes. Many researchers lack training to effectively engage stakeholders, ...whereas academic institutions lack infrastructure to support community engagement.
In 2009, the Meharry-Vanderbilt Community-Engaged Research Core began testing new approaches for community engagement, which led to the development of the Community Engagement Studio (CE Studio). This structured program facilitates project-specific input from community and patient stakeholders to enhance research design, implementation, and dissemination. Developers used a team approach to recruit and train stakeholders, prepare researchers to engage with stakeholders, and facilitate an in-person meeting with both.
The research core has implemented 28 CE Studios that engaged 152 community stakeholders. Participating researchers, representing a broad range of faculty ranks and disciplines, reported that input from stakeholders was valuable and that the CE Studio helped determine project feasibility and enhanced research design and implementation. Stakeholders found the CE Studio to be an acceptable method of engagement and reported a better understanding of research in general. A tool kit was developed to replicate this model and to disseminate this approach.
The research core will collect data to better understand the impact of CE Studios on research proposal submissions, funding, research outcomes, patient and stakeholder engagement in projects, and dissemination of results. They will also collect data to determine whether CE Studios increase patient-centered approaches in research and whether stakeholders who participate have more trust and willingness to participate in research.
The World Health Organization created the Age-Friendly Environment (AFE) framework to design communities that support healthy aging and equitable decision-making. This framework's resource domains ...may account for disparately lower advance care planning (ACP) among older adults with limited incomes compared to those with high incomes. We aimed to describe and examine associations of AFE factors with ACP.
We recruited and conducted cross-sectional surveys among older adults with limited incomes in seven community-based settings in Nashville, Tennessee. ACP and AFE item scales were dichotomized and analyzed with unadjusted phi correlation coefficients.
Survey participants (N=100) included 59 women, 70 Black/African American, and 70 ≥60 years old. Most participants agreed that their community was age-friendly (≥58%) and varied in ACP participation (22-67%). Participants who perceived easy travel and service access and sufficient social isolation outreach were more likely to have had family or doctor quality-of-life discussions (phi=.22 to .29, p<.05). Having a healthcare decision-maker was positively associated with age-friendly travel, housing, and meet-up places (phi=.20-.26, p<.05).
The AFE Framework is useful for exploring the environmental factors of ACP, but further research is warranted to identify specific and immediate resources to support successful ACP among populations with socioeconomic disadvantage.
Increased sedentary behavior and lack of physical activity are associated with increased risk for many chronic diseases. Differences in leisure-time physical activity between African American and ...white adults have been suggested to partially explain racial disparities in chronic disease outcomes, but expanding the definition of physical activity to include household and occupational activities may reduce or even eliminate racial differences in total physical activity. The objective of this study was to describe patterns of active and sedentary behaviors in black and white adults and to examine these behaviors across demographic measures. Sedentary and physically active behaviors were obtained from a validated physical activity questionnaire in 23,021 black men, 9,899 white men, 32,214 black women, and 15,425 white women (age 40-79) at enrollment into the Southern Community Cohort Study. Descriptive statistics for sedentary time; light, moderate, and vigorous household/occupational activity; sports/exercise; total activity; and meeting current physical activity recommendations via sports/exercise were examined for each race-sex group. Adjusted means were calculated using multiple linear regression models across demographic measures. Study participants spent approximately 60% of waking time in sedentary behaviors. Blacks reported more television viewing time than whites (45 minutes for females, 15 minutes for males), but when sitting time was expressed as a proportion of overall awake time, minimal racial differences were found. Patterns of light, moderate, and vigorous household/occupational activity were similar in all race/sex groups. 2008 Physical Activity Guidelines for Americans were followed by 16% of women and 25% of men independent of race. Overall, black and white men and women in this study spent the majority of their daily time in sedentary behaviors and less than one-fourth followed current guidelines for physical activity. These results indicate that public health campaigns should focus on both reducing sedentary behavior and increasing physical activity in all adult US populations.
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