Convergence Study Research Articles

Expert CONsensus on Visual Evaluation in Retinal disease manaGEment: the CONVERGE study

Background/AimsRecent decades have seen significant advances in both structural and functional testing of retinal disease. However, the current clinical value of specific testing modalities, as well as future trends, need...

Resolution analysis of magnetically arrested disc simulations

ABSTRACT Polarization measurements by the Event Horizon Telescope from M87* and Sgr A* suggest that there is a dynamically strong, ordered magnetic field, typical of what is expected of a magnetically arrested accretion disc (MAD). In such discs, the strong poloidal magnetic field can suppress the accretion flow and cause episodic flux eruptions. Recent work shows that general relativistic magnetohydrodynamic (GRMHD) MAD simulations feature dynamics of turbulence and mixing instabilities that are becoming resolved at higher resolutions. We perform a convergence study of MAD states exceeding the status quo by an order of magnitude in resolution. We use existing 3D simulations performed with the H-AMR code, up to a resolution of 5376 × 2304 × 2304 in a logarithmic spherical-polar grid. We find consistent time-averaged disc properties across all resolutions. However, higher resolutions reveal signs of inward angular momentum transport attributed to turbulent convection, particularly evident when mixing instabilities occur at the surfaces of flux tubes during flux eruptions. Additionally, we see wave-like features in the jet sheath, which become more prominent at higher resolutions, that may induce mixing between the jet and disc. At higher resolutions, we observe the sheath to be thinner, resulting in increased temperature, reduced magnetization, and greater variability. Those differences could affect the dissipation of energy, which would eventually result in distinct observable radiative emission from high-resolution simulations. With higher resolutions, we can delve into crucial questions about horizon-scale physics and its impact on the dynamics and emission properties of larger-scale jets.

Lifestyles associated with malaria in pregnancy in northwest Colombia: a mixed study from Latin American critical epidemiology

BackgroundIn the scientific literature on Malaria in Pregnancy (MiP), no studies have been conducted on lifestyles based on critical theory. The objective of this study was to analyse the lifestyles or singular processes of social determination of health in MiP in northwestern Colombia.MethodsMixed QUAN-QUAL convergent triangulation study. In the quantitative component, a psychometric evaluation and a cross-sectional design were conducted in 400 pregnant women to whom the Pender-Walker lifestyle scale and a survey on MiP prevention were applied. In the qualitative study, a critical ethnography was conducted with 46 pregnant women in whom their narratives and practices regarding lifestyles at home and healthcare were described.ResultsThe frequency of MiP was 9%, and a higher occurrence of the disease was identified in those who did not control stagnant water (29%), did not use insecticide-treated net (16%) and went to the hospital (14%) or the microscopist (20%) when they had fever. This coincides with the presence of unhealthy lifestyles, little knowledge about malaria, and a low perception of the risk of getting sick, as well as meanings and experiences about MiP, maternity, and pregnancy that show a high clinical, cultural, and socioeconomic burden for the women studied.ConclusionThis epidemiological profile and the approach to lifestyles based on the postulates of critical theory in health evidence that pregnant women exposed to malaria suffer serious social, cultural and health injustices that are not possible to impact with the current health model of malaria control in Colombia guided by aetiopathogenic, biomedical, positivist and utilitarian theories.

Instrument to evaluate the perception of abuse and/or disrespectful treatment during childbirth: A validation study

AimTo design and validate a tool to assess a woman's perception of whether she has experienced a situation of abuse or disrespect during childbirth attendance: “Childbirth Abuse and Respect Evaluation-Maternal Questionnaire” (CARE-MQ). MethodsMultidisciplinary panel of experts (gynecologists, midwives, mothers) participated in creating CARE-MQ. A cross-sectional study was carried out on 901 Spanish women who had given birth between 1 and 3 months before to determine psychometric characteristics. Finally, an exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and a convergent validity study were carried out with the Quality Questionnaire from the Patient's Perspective-Intrapartum (QPP-I), and a reliability study using internal consistency (Cronbach's α) and coefficient of intraclass correlation (CCI). FindingsThe KMO test gave a value of 0.935, and Bartlett's sphericity test was <0.001. The EFA identified four components (“Emotional Abuse”, “Inadequate Professionalism”, “Physical Abuse” y “Lost contact”) that explained 55.16 % of variance. In the CFA, a good fit was observed for most of the evaluated indicators. CARE-MQ correlated negatively with QPP-I (Spearman's rho = −0.641, 95 % CI: −0.679, −0.600; p < 0.001) and was statistically associated with variables related to childbirth experience (p < 0.005) such as the use of a birth plan, use of regional analgesia, type of birth, episiotomy, presence of severe tears, skin-to-skin contact, length of hospital stay and postpartum surgical intervention. Cronbach's α value was 0.903. The ICC of absolute agreement after administering the questionnaire one week after was 0.927 (95 % CI: 0.85–0.97). ConclusionsCARE-MQ is a valid and reliable instrument to evaluate the perception of a woman regarding the situation of abuse and/or disrespect that she may have experienced during birth in a population of Spanish postpartum women.

Computational Fluid Dynamics Simulation on Blade Geometry of Novel Axial FlowTurbine for Wave Energy Extraction

Wave energy converters (WECs) utilizing the Oscillating Water Column (OWC) principle have gained prominence for harnessing kinetic energy from ocean waves. This study explores an innovative approach by transforming the pivoting Denniss–Auld turbine blades into a fixed configuration, offering a simplified alternative. The fixed-blade design emulates the maximum pivot points during the OWC’s exhalation and inhalation phases. Traditional Denniss–Auld turbines rely on complex hub systems to enable controllable blade rotation for performance optimization. This research examines the turbine’s efficiency without mechanical actuation. The simulations were conducted using ANSYS™ CFX 2023 R2 to solve the three-dimensional, incompressible, steady-state Reynolds-Averaged Navier–Stokes (RANS) equations, employing the k-ω SST turbulence model to close the system of equations. A grid convergence study was performed, and the numerical results were validated against available experimental and numerical data. An in-depth analysis of the intricate flow field around the turbine blades was also conducted. The modified Denniss–Auld turbine demonstrated a broad operating range, avoiding stalling at high flow coefficients and exhibiting performance characteristics like an impulse turbine. However, the peak efficiency was 12%, significantly lower than that of conventional Denniss–Auld and impulse turbines. Future research should focus on expanding the design space through parametric studies to enhance turbine efficiency and power output.

Convergence, sampling and total order estimator effects on parameter orthogonality in global sensitivity analysis.

Dynamical system models typically involve numerous input parameters whose "effects" and orthogonality need to be quantified through sensitivity analysis, to identify inputs contributing the greatest uncertainty. Whilst prior art has compared total-order estimators' role in recovering "true" effects, assessing their ability to recover robust parameter orthogonality for use in identifiability metrics has not been investigated. In this paper, we perform: (i) an assessment using a different class of numerical models representing the cardiovascular system, (ii) a wider evaluation of sampling methodologies and their interactions with estimators, (iii) an investigation of the consequences of permuting estimators and sampling methodologies on input parameter orthogonality, (iv) a study of sample convergence through resampling, and (v) an assessment of whether positive outcomes are sustained when model input dimensionality increases. Our results indicate that Jansen or Janon estimators display efficient convergence with minimum uncertainty when coupled with Sobol and the lattice rule sampling methods, making them prime choices for calculating parameter orthogonality and influence. This study reveals that global sensitivity analysis is convergence driven. Unconverged indices are subject to error and therefore the true influence or orthogonality of the input parameters are not recovered. This investigation importantly clarifies the interactions of the estimator and the sampling methodology by reducing the associated ambiguities, defining novel practices for modelling in the life sciences.

Transition from child to adult health services for young people with cerebral palsy in Ireland; implications from a mixed-methods study

Background Poor transition from child- to adult-oriented healthcare may lead to negative outcomes and dissatisfaction with services in adulthood. The aim of the study was to examine how transition is provided to and experienced by young people with CP in Ireland. This report provides integrated quantitative and qualitative findings and implications based on the totality of knowledge generated. Methods A convergent parallel mixed-methods study was conducted. Data were collected from people with CP aged 16-22 years, parents, and health professionals using surveys and semi-structured interviews, informed by a framework of nine key transition practices. Quantitative and qualitative findings were integrated at the interpretation stage of the research using integration through joint displays. Implications were developed through discussions with health professionals, young people, and parents. Results Surveys were completed by 75 young people/parents and 108 health professionals. Interviews were conducted with 13 young people, 14 parents, and 27 health professionals. There was complementarity between quantitative and qualitative findings indicating lack of a named worker, limited information provision, insufficient self-management support, no opportunity to meet the adult team, limited contact with the GP, and no opportunity for attending formal life skills training. There was dissonance between quantitative and qualitative findings regarding appropriate level of parental involvement. There was silence between quantitative and qualitative findings for promotion of health self-efficacy and senior manager responsible for transition, with quantitative findings indicating these were not present for most young people, but qualitative findings not describing these practices Conclusion Implications of integrated findings include the need for a standardised transition pathway, intentional actions to enable parents and young people to adapt to changing roles, provision of information in a collaborative and phased approach, a common understanding of self-management between young people, parents and health professionals, and the need to involve adults’ services and GPs in transition.

Determining what matters most to Marfan syndrome (MFS) patients: a convergent mixed method study of the health-related quality of life and psychosocial effects of MFS aortovascular manifestations

Abstract Background Marfan Syndrome (MFS) affects multiple organ systems but the aortovascular manifestations are the most serious and life-threatening. However, there is no available evidence on the effect of the aortovascular manifestations on health-related quality of life (HRQoL) and psychosocial wellbeing of MFS patients. Purpose This study aims to determine the HRQoL and the psychosocial effects of the aortovascular manifestation of MFS. Methods A convergent mixed-method design was used in this single site study. Specifically, the quantitative study (S1) is an observational exploratory study using seven validated questionnaires relating to HRQoL (SF36, EQ-5D-5L) and psychosocial health (depression [CESD], illness perception [IPQ], fatigue [FSS], self-esteem [RSES], stigma [PSQ]), previously used in MFS research. The qualitative study (S2) is an exploratory study using semi-structured interviews. Analysis consisted of descriptive and inferential statistics and Framework method1 for S1 and S2, respectively. Joint display was used for data integration. Results A total of 75 participants completed the questionnaires (S1) and 20 were interviewed (S2). The mean age was 43 years (S1) and 40 years (S2) and the majority (S1: 54 (72%); S2: 17 (85%)) were white British. S1 found the majority of MFS participants experienced depression, anxiety, pain and fatigue. These areas were confirmed in S2. A positive self-esteem was generally reported in S1, but this is not supported by S2, which highlighted patients experience a loss of self-esteem due to perceived body image disturbance. Finally, S2 generated new areas not identified in S1 including health anxiety, loss of personal efficacy, self-stigma and ‘invisible disability’ affecting work and socio-economic condition. Overall, the joint display generated three confirmed, seven expanded and one discordant finding. Conclusion MFS patients with aortovascular manifestations experienced several HRQoL and psychosocial issues related to their condition. Collaborative efforts are needed to develop multifaceted interventions and programs to address their needs and provide a holistic and comprehensive service for MFS patients. Finally, four new areas were identified in S2, which added important new evidence in this body of knowledge.

By the numbers and in their own words: A mixed methods study of unmet needs and humanitarian inclusion of older Syrian refugees in Lebanon.

Older people constitute an overlooked vulnerable population in humanitarian crises. Lebanon is a small country that hosts the largest number of refugees per capita in the world. With exacerbating socioeconomic conditions, exclusionary policies against refugees, and a fragmented humanitarian system, the status of older Syrian refugees (OSRs) requires special attention. This study aimed to explore OSRs' unmet needs, coping strategies, available humanitarian services, and some indicators of the humanitarian inclusion standards focusing on the shelter, health, nutrition and food security, and water, sanitation and hygiene sectors. We conducted a convergent mixed-methods study between December 2021 and March 2022 in the North and Bekaa, including a cross-sectional survey with 461 participants and 14 semi-structured interviews. Results show that OSRs lived in inappropriate shelters (cold, leaking rainwater), especially in informal tented settlements. High rent prices pushed refugee households with elderly to prioritize paying rent at the expense of other needs such as food and medication, particularly when food cash transfer is the sole source of income, jeopardizing food security and intake. Access to dignifying and accessible bathing facilities was compromised in ITSs with shared facilities. Substantial medical costs hindered OSRs access to healthcare such as surgeries. Due to the crisis, chronic medications are not always available in dispensaries for subsidized cost, pushing OSRs to non-compliance and selling food assistance to buy medications. Soaring fuel prices hindered OSRs access to heating and transportation to receive healthcare. No efforts were reported in collecting data on OSRs' needs, targeting them with information on services, or soliciting feedback for programming, especially in the absence of any age-tailored interventions. Findings shed light on the precarious living conditions of OSRs in Lebanon and add to the body of evidence documenting their invisibility to the humanitarian response. An age-inclusive response is needed through holistic, tailored, and sustainable interventions.

Integrated group antenatal and pediatric care in Haiti: A comprehensive care accompaniment model.

The J9 Plus (J9) maternal-child accompaniment program is based on four pillars: group antenatal care (GANC), group pediatric care, psychosocial support, and community-based care. We aimed to evaluate the impact of the J9 model of care on perinatal outcomes. We conducted a convergent mixed methods study of maternal-newborn dyads born in 2019 at Hôpital Universitaire de Mirebalais. Quantitative data was collected retrospectively to compare dyads receiving J9 care to usual care. A secondary analysis of qualitative data described patient perspectives of J9 care. Antenatal care attendance was significantly higher among women in J9 (n = 524) compared to usual care (n = 523), with 490(93%) and 189(36%) having >4 visits, respectively; p <0.001, as was post-partum visit attendance [271(52%) compared to 84(16%), p<0.001] and use of post-partum family planning methods [98(19%) compared to 47(9%), p = 0.003]. Incidence of pre-eclampsia with severe features was significantly lower in the J9 group [44(9%)] compared to the usual care group [73(14%)], p <0.001. Maternal and neonatal mortality and low birth weight did not differ across groups. Cesarean delivery [103(20%) and 82(16%), p<0.001] and preterm birth [118 (24%)] and 80 (17%), p <0.001] were higher in the J9 group compared to usual care, respectively. In the qualitative analysis, ease of access to high-quality care, meaningful social support, and maternal empowerment through education were identified as key contributors to these outcomes. Compared to usual care, the J9 Plus maternal-child accompaniment model of care is associated with increased engagement in antenatal and postpartum care, increased utilization of post-partum family planning, and lower incidence of pre-eclampsia with severe features, which remains a leading cause of maternal mortality in Haiti. The J9 accompaniment approach to care is an empowering model that has the potential to be replicated in similar settings to improve quality of care and outcomes globally.

The managers' perspectives on service providing in women's harm reduction centers during the COVID-19 pandemic: mixed method study

BackgroundThe COVID-19 pandemic posed significant challenges for managers overseeing women's harm reduction centers. This study seeks to capture managers' perspectives on the service providing in women's harm reduction centers during the COVID-19 pandemic.MethodsThis convergent mixed-method study conducted in three provinces of Iran: Tehran, Khuzestan, and Kermanshah. The study was carried out between January and May 2023. In the quantitative part, the researchers utilized reports from 10 center managers. A researcher-designed questionnaire was employed to collect data on a wide range of services and referrals provided by the centers. The qualitative part of the research involved conventional content analysis and included 12 individual interviews. Two directors from the Ministry of Health and ten managers of women’s harm reduction centers participated in the interviews. During the interpretation phase, the researchers compared the quantitative and qualitative findings to obtain a comprehensive understanding of the topic.ResultsDuring the quantitative stage of the study, it was observed that all the managers were women, with an average age of 40.7 ± 7 years. More than half of the managers had obtained a postgraduate education (n = 6, 60%), and a majority of them were married (n = 7, 70%). Additionally, 40% of the managers (n = 4) were working as contractors. During the non-COVID-19 period, there were higher coverage by centers and residents, more referrals of non-injecting drug users and sex workers, and a higher number of group counseling sessions in all three provinces compared to the COVID-19 period. The qualitative analysis revealed two primary themes: "challenges" and "capabilities."ConclusionsDuring the COVID-19 pandemic, providing some services and client referrals decreased in the centers, and center managers faced increased challenges. Many of these challenges were in the communication, executive, management, structure, education, financial, civilization, facilities, and socio-cultural sectors. Managers used their skills to manage and control these challenges. It is important to focus on these challenges and managerial capabilities to effectively handle future crises.

How to investigate differences in indoor environmental comfort and adaptation? Mixed methods research with patients

ABSTRACT Ensuring hospitalized patients’ comfort requires understanding differences in comfort and adaptation to discomfort, as well as the role of the built environment therein. Shortcomings in this understanding result from limitations of existing research methods. Therefore the potential of a mixed methods research design to investigate when and why experiences of and adaption to (dis)comfort differ among hospitalized patients was explored. A convergent mixed methods case study was conducted in two hospital wards of a Belgian hospital. Qualitative data included interviews with 19 patients about their experiences and information about the patients at the two wards during the fieldwork; quantitative data included sensor measurements of indoor environmental quality parameters (i.e. illuminance and indoor temperature), a questionnaire among 238 patients about their assessment of the indoor conditions, and simulations of these conditions. Joint displays allowed comparing situations in which characteristics related to the patients or their setting differed in an integrated way. The displays provide an intermediate step between purely qualitative descriptions of comfort and adaptation and purely quantitative models that predict both. Scenarios that the joint displays allow identifying inform about characteristics that could improve these models, and about roles of the built environment in experiences.

Lifestyles and Academic Stress in University Students of Health Sciences: A Mixed-Methodology Study.

The global health emergency generated by the COVID-19 pandemic (caused by the SARS-CoV-2 virus) led to the implementation of extraordinary measures such as confinement and isolation in many countries to mitigate the spread of the virus. (1) This study analyzes the lifestyles and academic and perceived stresses of university students of health sciences during the period of online learning due to the COVID-19 pandemic. The relationship between lifestyles and academic stress was examined. (2) A parallel mixed-method convergent study was conducted, with a correlational non-experimental design. Quantitative and qualitative data were collected and analyzed in parallel, with parametric and nonparametric testing for quantitative data and Miles and Huberman's approach to qualitative analysis. The qualitative findings complemented the quantitative results. The number of students who participated in this study was 2734, from six programs in health, nursing, medicine, clinical laboratory, physiotherapy, dentistry, and clinical psychology at the University of Chimborazo, Ecuador. (3) Overall, the health science students had "Unhealthy or health-compromising lifestyles", medical students being the ones who have healthier lifestyles. However, more than 80% experienced and perceived stress during the period of online learning and social isolation due to the pandemic, women being the ones who experienced it at a higher level. (4) The online learning modality during the COVID-19 pandemic modified lifestyles and generated stress in health science students, due to changes in daily routines, sedentary lifestyle, and stress, as a result of social isolation. Therefore, the students prefer face-to-face teaching, perceived as enabling more enriching interactions with their teachers and peers and the opportunity to develop essential practical skills in their health practice.

Finite Element Analysis of Functionally Graded Sandwich Plates

Computational methods become a necessity at places where the fields of testing as well as lab model testing poses problems or situations demanding large number of test results at low cost. The accuracy of the computational model can be adjusted by convergence study. The present study uses finite element method for finding static behaviour of sandwich plates having functionally graded core. Power law is employed for quantification of the material properties and zig-zag theory is utilized for the analysis. Hamilton’s theorem is exploited for deriving the equation which is resolved by FEM by taking nine-node C-0 iso-parametric FE having 11 DOF/node. Aspect ratio, power law coefficient and skewness of plate are used as variables to study the bending response of the plate. Present results are found to be consistent with the published ones and new results are also presented.

The Connections among Interacting with Nature, Nature Relatedness and Dietary Choices: A Pilot Mixed Methods Study.

Interacting with nature and a connection to nature (Nature Relatedness [NR]) have been associated with better mental and physical health as well as higher levels of physical activity. However, limited research has explored how interacting with nature and NR may promote healthful dietary behaviors. The purpose of this pilot convergent mixed methods study was to explore the connections between interacting with nature, NR, and dietary choices. For descriptive purposes, we measured participants' (n = 25) interactions with nature, NR (total, experience, perspective, and self) scores, physical activity, and Healthy Eating Index-2020 scores. In-depth interviews (n = 13) explored the factors that influence interacting with nature and food choices. Quantitative and qualitative data were analyzed separately, and later integrated to yield a more complete understanding of the research inquiry than either form of data would have provided alone. The results from this pilot mixed methods study indicate that there are connections between the variables of interest and that NR may play a pivotal role in how interacting with nature may promote sustainable dietary behaviors. These findings could promote the potential for utilizing nature-based experiences to improve dietary intake.

Leadership Perspectives on Nursing Home Operations From Crisis to Control: A Mixed Methods Study

ObjectivesNursing home (NH) leaders remain challenged to deliver quality care, despite the COVID-19 transition to an endemic phase. This study describes NH leadership perspectives on preparing and maintaining quality care during times of diminishing resources as experienced through the COVID-19 pandemic to gain insight on how best to support NHs moving forward. DesignThis was a cross-sectional, parallel convergent mixed methods study. Setting and ParticipantsThis study reports quantitative data from N = 5001 NHs across 12 states along with qualitative data from a subsample of NH leaders (N = 15). MethodsPublicly reported survey data were analyzed using descriptive statistics. Individual in-depth interviews with NH leaders conducted at 12-month follow-up were analyzed using inductive thematic coding organized by a guiding framework. Data were integrated using convergent analysis and a joint display. ResultsNH leaders (licensed administrators, clinical directors, and managers) reported resident and staff infection rates, and access to resources (such as personal protective equipment and testing supplies) that aligned with national trends. Leaders described their NHs (n = 14; 43% rural; 71% not for profit) to be in varied states of operational readiness (standard, contingency, crisis) to support quality infection prevention and control (IPC) at the transition to the endemic COVID-19 phase. Leadership reported continued challenges in addressing resident and staff vaccinations, securing testing supplies, obtaining financial resources to maintain acceptable levels of personal protective equipment, continued staffing shortages, and issues in implementing isolation practices in current facilities. Conclusion and ImplicationsNH leaders continue to struggle delivering quality IPC care post-pandemic and require focused support in several areas. Clinical practice guidelines should include IPC practices to prevent the infection and spread of any COVID-19 variant in this endemic phase. Policies should support continued reporting of IPC-related metrics and adequate funding to account for the long-term financial burden NHs face.

Improved brain effective connectivity modelling by dynamic Bayesian networks

Background:If brain effective connectivity network modelling (ECN) could be accurately achieved, early diagnosis of neurodegenerative diseases would be possible. It has been observed in the literature that Dynamic Bayesian Network (DBN) based methods are more successful than others. However, DBNs have not been applied easily and tested much due to computational complexity problems in structure learning. New method:This study introduces an advanced method for modelling brain ECNs using improved discrete DBN (Improved- dDBN) which addresses the computational challenges previously limiting DBN application, offering solutions that enable accurate and fast structure modelling. Results:The practical data and prior sizes needed for the convergence to the globally correct network structure are proved to be much smaller than the theoretical ones using simulated dDBN data. Besides, Hill Climbing is shown to converge to the true structure at a reasonable iteration step size when the appropriate data and prior sizes are used. Finally, importance of data quantization methods are analysed. Comparison with existing methods:The Improved-dDBN method performs better and robust, when compared to the existing methods for realistic scenarios such as varying graph complexity, various input conditions, noise cases and non-stationary connections. The data used in these tests is the simulated fMRI BOLD time series proposed in the literature. Conclusions:Improved-dDBN is a good candidate to be used on real datasets to accelerate developments in brain ECN modelling and neuroscience. Appropriate data and prior sizes can be identified based on the approach proposed in this study for global and fast convergence.

A Mixed-Method Study of the Utilization and Determinants of Private Health Insurance Schemes in the Residents of Rural Communities in Central India: A Study Protocol.

Background Private health insurance plays a critical role in healthcare financing, yet its utilization and determinants in rural settings still need to be studied, particularly in Central India. This study aims to address this gap by investigating the utilization and determinants of private health insurance schemes among residents of rural communities in Central India. Materials and methods A convergent parallel mixed-method study design, consisting of quantitative and qualitative approaches, will be employed. Quantitative data will be collected through structured questionnaires administered to residents aged 18 and above within the field practice area of a tertiary medical college hospital. Qualitative data will be gathered through in-depth interviews with key stakeholders. Statistical analysis will include descriptive and inferential statistics, while thematic analysis will be employed for qualitative data (CTRI Number CTRI/2024/06/069155). Conclusion The findings of this study will provide valuable insights into the utilization and determinants of private health insurance schemes in rural communities of Central India. By identifying barriers and facilitators to insurance uptake, policymakers and healthcare providers can develop targeted interventions to improve healthcare access and affordability in rural areas. In addition, the study will contribute to the existing literature on private health insurance utilization in India, informing future research endeavors and policy initiatives.

Barriers and Facilitators to Optimal Antibiotic Prescribing on Discharge from the Hospital to Nursing Homes

Background: Up to half of antibiotics used in nursing homes (NHs) are initiated in acute care hospitals prior to nursing home admission. Optimizing antibiotic prescribing on hospital discharge presents an opportunity to improve NH antibiotic use. We aimed to identify barriers and facilitators to optimal antibiotic prescribing on discharge from the hospital to NHs. Methods: This was a qualitative thread of a convergent parallel mixed methods study to identify high-value targets to optimize antibiotic prescribing on discharge from the hospital to NHs. We conducted 32 qualitative interviews: 16 with prescribers (9), pharmacists (6), and a care manager (1) from 3 acute care hospitals and 16 with advanced practice providers (12) and registered nurses/nurse managers (4) from 7 NHs in Oregon and Wisconsin. Interview participants were asked to describe their typical practice for prescribing antibiotics on discharge to NHs or admitting patients with antibiotic prescriptions from hospitals, and about barriers and facilitators for optimal antibiotic prescribing during these transitions. Interviews were audio recorded, transcribed verbatim, and analyzed by 3 investigators using the qualitative descriptive analysis Results: Hospital healthcare workers described that there are different practice flows for oral and intravenous (IV) antibiotic prescribing. IV antibiotic orders are typically routed to the infectious diseases (ID) specialists and ID pharmacists to review and verify appropriateness. There were minimal established workflows to review and verify oral antibiotic orders. Pharmacists appeared integral to optimal antibiotic prescribin; however, the high frequency of oral prescriptions and short turnaround times from discharge orders to transportation limited pharmacists’ abilities to review these orders. With limited pharmacist involvement, the quality of oral antibiotic prescription relied on the prescribers’ knowledge, and there was no systematic oversight for inexperienced prescribers or specialists who may not be familiar with the adequacy of antibiotic use for NH residents. NH participants perceived that most antibiotics prescribed from hospitals were appropriate. Yet, some commented that they occasionally observe inadequate or unusual prescriptions from newer prescribers or specialists. NH participants most common concern related to antibiotic prescriptions was missing information including unclear or lack of antibiotic indications or stop dates. NH participants also stated that the frequent need to contact the hospital to obtain missing information is challenging and burdensome. Conclusions: Qualitative interviews identified several barriers and facilitators to optimal antibiotic prescribing on discharge to NHs. These results will be used to develop an intervention to improve antibiotic prescribing during these transitions.

Uncertainty and Communication Preferences Among Patients Undergoing Lung Transplant Evaluation: A Mixed-Methods Study.

Higher uncertainty is associated with poorer quality of life and may be impacted by clinician communication about the future. We determined how patients undergoing lung transplant evaluation experience uncertainty and communication about the future from clinicians. We performed a convergent parallel mixed-methods study using a cross-sectional survey and semistructured interviews. Patients undergoing lung transplant evaluation at the University of Colorado and the University of Washington answered questions about future communication and completed the Mishel Uncertainty in Illness Scale-Adult (MUIS-A; range 33-165, higher scores indicate more uncertainty). Interviews were analyzed using content analysis. Integration of survey and interview results occurred during data interpretation. A total of 101 patients completed the survey (response rate: 47%). Twelve survey participants completed interviews. In the survey, most patients identified changing family roles as important (76%), which was infrequently discussed with clinicians (31%). Most patients (86%) worried about the quality of their life in the future, and 74% said that not knowing what to expect in the future prevented them from making plans. The mean MUIS-A score was 85.5 (standard deviation 15.3). Interviews revealed three themes: (1) uncertainty of the future distresses participants; (2) participants want practical information from clinicians; and (3) communication preferences vary among participants. Participants experienced distressing uncertainty and wanted information about the future. Communication topics that were important to participants were not always addressed by physicians. Clinicians should address how chronic lung disease and lung transplant can directly impact patients' lives and support patients to cope with uncertainty.