Clinician Focus Groups Research Articles

Qualitative Research in Palliative Care: Applications to Clinical Trials Work.

While vast opportunities for using qualitative methods exist within palliative care research, few studies provide practical advice for researchers and clinicians as a roadmap to identify and utilize such opportunities. To provide palliative care clinicians and researchers descriptions of qualitative methodology applied to innovative research questions relative to palliative care research and define basic concepts in qualitative research. Body: We describe three qualitative projects as exemplars to describe major concepts in qualitative analysis of early palliative care: (1) a descriptive analysis of clinician documentation in the electronic health record, (2) a thematic content analysis of palliative care clinician focus groups, and (3) a framework analysis of audio-recorded encounters between patients and clinicians as part of a clinical trial. This study provides a foundation for undertaking qualitative research within palliative care and serves as a framework for use by other palliative care researchers interested in qualitative methodologies.

A Novel Model for Predicting Rehospitalization Risk Incorporating Physical Function, Cognitive Status, and Psychosocial Support Using Natural Language Processing.

With the increasing focus on reducing hospital readmissions in the United States, numerous readmissions risk prediction models have been proposed, mostly developed through analyses of structured data fields in electronic medical records and administrative databases. Three areas that may have an impact on readmission but are poorly captured using structured data sources are patients' physical function, cognitive status, and psychosocial environment and support. The objective of the study was to build a discriminative model using information germane to these 3 areas to identify hospitalized patients' risk for 30-day all cause readmissions. We conducted clinician focus groups to identify language used in the clinical record regarding these 3 areas. We then created a dataset including 30,000 inpatients, 10,000 from each of 3 hospitals, and searched those records for the focus group-derived language using natural language processing. A 30-day readmission prediction model was developed on 75% of the dataset and validated on the other 25% and also on hospital specific subsets. Focus group language was aggregated into 35 variables. The final model had 16 variables, a validated C-statistic of 0.74, and was well calibrated. Subset validation of the model by hospital yielded C-statistics of 0.70-0.75. Deriving a 30-day readmission risk prediction model through identification of physical, cognitive, and psychosocial issues using natural language processing yielded a model that performs similarly to the better performing models previously published with the added advantage of being based on clinically relevant factors and also automated and scalable. Because of the clinical relevance of the variables in the model, future research may be able to test if targeting interventions to identified risks results in reductions in readmissions.

PPH Butterfly: a novel device to treat postpartum haemorrhage through uterine compression

ObjectivePostpartum haemorrhage (PPH) is a significant cause of maternal morbidity and mortality. The most common cause is an inability of the uterus to contract adequately after childbirth. In bimanual compression...

Polypharmacy and Adherence: Key Components of Integrated Care, The case of Catalonia

Introduction: Polypharmacy and medication adherence in the older population are significant public health issues throughout the European Union (EU), and are an important component of integrated care. SIMPATHY (Stimulating Innovation Management of Polypharmacy and Adherence in The Elderly) is a consortium of 10 organizations representing 8 EU countries and is working to address these issues by developing change management tools to facilitate EU policy makers in integrating polypharmacy and adherence into existing health care systems.Objectives: 1) Map existing components of polypharmacy and adherence programme in Catalonia and; 2) describe change management and implementation strategies used in the development, implementation, and scale up of the programme.Methods: We conducted a mixed-methods case study in Catalonia, Spain. Policies and practices of the Catalan Health Department and two clusters of healthcare institutions (one urban, one rural) including a teaching hospital, primary care centre, and long-term care facility were included for analysis. The study consisted of three phases: I) desk review of the polypharmacy and adherence policies at the government, regional and institutional level; II) key informant interviews with policymakers, managers, and clinicians responsible for developing and implementing the programme and; III) focus group of clinicians and managers familiar with the programme to validate preliminary results. Polypharmacy management involves multiple care providers and practice settings, so can be categorized as a complex intervention. Therefore, multiple theories and frameworks were used in the study design and analysis. Change management was assessed using Kotter’s 8 principles of leading change while the four main constructs of normalization process theory (NPT) were used to evaluate integration of the programme into daily practice (coherence, cognitive participation, collective action, and reflexive monitoring).Preliminary results: Two distinct programme types emerged in the analysis: a government sponsored programme lead by the Department of Health and targeted at primary care physicians, and an institutional sponsored programme lead by geriatrician clinicians and supported by department heads and hospital administrators. Participants in both programme types recognized the importance of polypharmacy in the older population and the need to take action on the issue, and both were guided by the regional health plan. The government programme utilized a top down or vertical approach to implementation with the primary focus on patient safety (preventing drug interactions, therapeutic duplications, or avoiding contraindicated drugs), individual physician prescribing, and had a goal of implementation throughout the entire healthcare system. The programme was supported by an extensive information technology system of electronic medical records and a pay for performance contract. A limited number of change management principles were identified, and implementation was limited by restricted personnel resources and lack of attention to integrating the new practice into daily work flow, as exemplified by the NPT analysis. The institutional programme employed a middle out, or horizontal implementation strategy with a global patient-centred focus, of which polypharmacy management was one component. It was driven by a small multidisciplinary team of physicians and pharmacists with the initial goal of creating a well-developed pilot that would be scaled up at a later point. Many change management principles and NPT constructs were identified. Key facilitators included a “culture of geriatrics” that supported the use of multidisciplinary teams and a culture of innovation within the hospital.Conclusion and future work: Catalonia has two examples of well-developed polypharmacy management programmes. The government sponsored approach had a narrower focus on patient safety and less use of multidisciplinary teams, but was able to be implemented throughout the healthcare system. Use of a more robust change management approach in the institutional setting facilitated the implementation, including the use of multidisciplinary teams. Both provide lessons for other health systems wanting to integrate management of polypharmacy into existing care models.

Development of a decision support aid to support goals of care conversation for hospitalized patients with cancer.

42 Background: Goals of care (GOC) conversations between oncologists and patients are often ill-defined due to poor physician and patient preparation and unclear goals. Hospitalization may further increase patients’ fear and confusion about GOC. Creating a tool to facilitate shared decision making is critical to support patients and their health care team in this process. In this study, we have collected data as the initial step in the development of a decision aid (DA) for GOC conversations with hospitalized patients with advanced cancer. Methods: A group of 14 content experts including diverse health professionals, patients and caregivers responded to a needs assessment to determine key questions to elicit involved stakeholders’ perceptions on relevant content for the DA. Questions were used to conduct semi-structured interviews with patients, a clinician focus group and a patient and caregiver focus group. All responses were audio-recorded and transcribed. Results: There were 30 participants: 10 patient interviews and 10 participants in each focus group. Patients generally wanted as much information as possible about prognosis and choices, but acknowledged they were often overwhelmed and frustrated at not receiving information sooner. Most were clear about who they would include in their GOC discussions. Clinicians’ concerns included not destroying patients’ hope and uncertainty about how to achieve the delicate balance of delivering bad news while preserving hope. Clinicians also felt challenged by the time needed to conduct GOC conversations and how to initiate them. Patient and caregivers emphasized the value of a multimodal approach to GOC conversations. Individually, they varied in their readiness for and the ideal timing of GOC conversations, noting these could be early or late in their illness trajectory. Conclusions: We see a need for personalization in a decision support aid to have clear goals of care. Patients differ in readiness to activate different parts of the decisional tree at different times. This will be used to guide design of a decision support aid to support hospitalized patients with advanced cancer to have a meaningful goals of care conversation with their clinicians.

Adoption of a Portal for the Primary Care Management of Pediatric Asthma: A Mixed-Methods Implementation Study.

BackgroundPatient portals may improve communication between families of children with asthma and their primary care providers and improve outcomes. However, the feasibility of using portals to collect patient-reported outcomes from families and the barriers and facilitators of portal implementation across diverse pediatric primary care settings have not been established.ObjectiveWe evaluated the feasibility of using a patient portal for pediatric asthma in primary care, its impact on management, and barriers and facilitators of implementation success.MethodsWe conducted a mixed-methods implementation study in 20 practices (11 states). Using the portal, parents of children with asthma aged 6-12 years completed monthly surveys to communicate treatment concerns, treatment goals, symptom control, medication use, and side effects. We used logistic regression to evaluate the association of portal use with child characteristics and changes to asthma management. Ten clinician focus groups and 22 semistructured parent interviews explored barriers and facilitators of use in the context of an evidence-based implementation framework.ResultsWe invited 9133 families to enroll and 237 (2.59%) used the portal (range by practice, 0.6%-13.6%). Children of parents or guardians who used the portal were significantly more likely than nonusers to be aged 6-9 years (vs 10-12, P=.02), have mild or moderate/severe persistent asthma (P=.009 and P=.04), have a prescription of a controller medication (P<.001), and have private insurance (P=.002). Portal users with uncontrolled asthma had significantly more medication changes and primary care asthma visits after using the portal relative to the year earlier (increases of 14% and 16%, respectively). Qualitative results revealed the importance of practice organization (coordinated workflows) as well as family (asthma severity) and innovation (facilitated communication and ease of use) characteristics for implementation success.ConclusionsAlthough use was associated with higher treatment engagement, our results suggest that achieving widespread portal adoption is unlikely in the short term. Implementation efforts should include workflow redesign and prioritize enrollment of symptomatic children.ClinicalTrialClinicaltrials.gov NCT01966068; https://clinicaltrials.gov/ct2/show/NCT01966068 (Archived by WebCite at http://www.webcitation.org/6i9iSQkm3)

Designing User-Centric Patient Portals: Clinician and Patients' Uses and Gratifications.

Legislation mandates that clinicians make patients' medical information available digitally. This has resulted in hurriedly installing patient portals that do not fully meet the needs of patients or clinicians. This study examined a specific portal, MyPreventiveCare (MPC), a patient-centered portal designed to promote preventive care to consumers, to elicit recommendations from patients and clinicians about how it could be more beneficial by uncovering their uses and gratifications (U&G). In-depth interviews with 31 patients and two clinician focus groups were conducted. Multiple methods were utilized, such as grounded theory coding to develop themes and content analysis to classify responses according to the U&G framework. Four main categories emerged that users desire to be included in health portals: integration with technology (27%), coordination of care (27%), incorporation of lifestyle (26%), and increased control (20%). Additional analysis revealed that health portals are mainly utilized to fulfill cognitive and affective needs, with over 80% of recommendations related to the U&G categories of cognitive and affective needs. Cognitive (60%), affective (21%), social integrative (10%), personal integrative (9%), and tension release (0%). Portals will continue to evolve and become important health communication tools if they address the user's perspective and are inclusive of new technological advances. Specifically, portals must become more user centric and incorporate aspects of the patients' lifestyle and integrate health information technology.

Applying Multiple Methods to Comprehensively Evaluate a Patient Portal's Effectiveness to Convey Information to Patients.

BackgroundPatient portals have yet to achieve their full potential for enhancing health communication and improving health outcomes. Although the Patient Protection and Affordable Care Act in the United States mandates the utilization of patient portals, and usage continues to rise, their impact has not been as profound as anticipated.ObjectiveThe objective of our case study was to evaluate how well portals convey information to patients. To demonstrate how multiple methodologies could be used to evaluate and improve the design of patient-centered portals, we conducted an in-depth evaluation of an exemplar patient-centered portal designed to promote preventive care to consumers.MethodsWe used 31 critical incident patient interviews, 2 clinician focus groups, and a thematic content analysis to understand patients’ and clinicians’ perspectives, as well as theoretical understandings of the portal’s use.ResultsWe gathered over 140 critical incidents, 71.8% (102/142) negative and 28.2% (40/142) positive. Positive incident categories were (1) instant medical information access, (2) clear health information, and (3) patient vigilance. Negative incident categories were (1) standardized content, (2) desire for direct communication, (3) website functionality, and (4) difficulty interpreting laboratory data. Thematic analysis of the portal’s immediacy resulted in high scores in the attributes enhances understanding (18/23, 78%), personalization (18/24, 75%), and motivates behavior (17/24, 71%), but low levels of interactivity (7/24, 29%) and engagement (2/24, 8%). Two overarching themes emerged to guide portal refinements: (1) communication can be improved with directness and interactivity and (2) perceived personalization must be greater to engage patients.ConclusionsResults suggest that simple modifications, such as increased interactivity and personalized messages, can make portals customized, robust, easily accessible, and trusted information sources.

Behavioral activation group therapy for reducing depressive symptoms and improving quality of life: a feasibility study.

BackgroundDepression is associated with a loss of productivity and noticeable personal, social, and economic decline; it affects more than 350 million people worldwide. Behavioral activation (BA), derived from cognitive behavioral therapy, has drawn increasingly more interest as a means of treatment for major depressive disorder due to its relative cost-effectiveness and efficacy. In this study, we disseminate findings from a feasibility study evaluating barriers to implementing a group BA program for major depressive disorder. The purpose of this feasibility study is to assess both patient and clinician perceptions on components of a group-based behavioral activation (BA) program. In particular, this feasibility study provides in-depth evaluation of the acceptability of BA prior to the design and implementation of a randomized trial to investigate BA effectiveness. Findings from this study directly informed decisions regarding the design and implementation of BA during the pilot trial. Specific components of BA were assessed and modified based on the results of this study.MethodsThis qualitative study was completed through the Mood Disorders Program at St. Joseph’s Healthcare Hamilton. The authors of this study used data from two focus group sessions, one consisting of an interdisciplinary group of clinicians working in the Mood Disorders Program, and the other of registered outpatients of the Mood Disorders Program with a confirmed clinical diagnosis of depression. The benefits of offering this program in a group format, mainly social skill development opportunities and the use of technology such as activity tracking device, smart phones, and tablets during the therapy sessions, are a major focus of both the clinician and patient groups. Both groups emphasized the importance of offering sustainable activation.ResultsDifferences in opinions existed between staff and patient groups regarding the use of technology in the program, though ultimately it was agreed upon that technology could be useful as a therapeutic aid. All participants agreed that behavioral activation was essential to the development of positive habits and routines necessary for recovery from depression. Patients agreed the program looked sustainable and stressed the potential benefit for improving depressive symptoms.ConclusionsDiscussions from clinician and patient-centered focus groups directly informed decisions regarding the design and implementation of BA during the pilot trial. Specific components of BA were assessed and modified based on the results of this study. These findings provide insight for clinicians providing behavioral activation programming, and will serve as a framework for the development of the Out of the Blues program, a group-based BA program to be piloted in the Mood Disorders Program at St. Joseph’s Healthcare Hamilton.Trial registrationClinical Trials registration number NCT02045771

Concordance of Nurses and Physicians on Whether Critical Care Patients are Receiving Futile Treatment.

Nurses and physicians often describe critical care that is not expected to provide meaningful benefit to a patient as futile, and providing treatments perceived as futile is associated with moral distress. To explore concordance of physicians' and nurses' assessments of futile critical care. A focus group of clinicians developed a consensus definition of "futile" critical care. Daily for 3 months, critical care physicians and nurses in a health care system identified patients perceived to be receiving futile treatment. Assessments and patients' survival were compared between nurses and physicians. Nurses and physicians made 6254 shared assessments on 1086 patients. Nurses and physicians assessed approximately the same number of patients as receiving futile treatment (110 for nurses vs 113 for physicians, P = .82); however, concordance was low as to which patients were assessed as receiving futile treatment (κ = 0.46). The 110 patients categorized by nurses as receiving futile treatment had lower 6-month mortality than did the 113 patients so assessed by physicians (68% vs 85%, P = .005). Patients who were assessed as receiving futile treatment by both providers were more likely to die in the hospital than were patients assessed as receiving futile treatment by the nurse alone (76% vs 32%, P < .001) or by the physician alone (76% vs 57%, P = .04). Interprofessional concordance on provision of critical care perceived to be futile is low; however, joint predictions between physicians and nurses were most predictive of patients' outcomes, suggesting value in collaborative decision making.

Using a mobile health application to support self-management in chronic obstructive pulmonary disease: a six-month cohort study.

BackgroundSelf-management strategies have the potential to support patients with chronic obstructive pulmonary disease (COPD). Telehealth interventions may have a role in delivering this support along with the opportunity to monitor symptoms and physiological variables. This paper reports findings from a six-month, clinical, cohort study of COPD patients’ use of a mobile telehealth based (mHealth) application and how individually determined alerts in oxygen saturation levels, pulse rate and symptoms scores related to patient self-initiated treatment for exacerbations.MethodsThe development of the mHealth intervention involved a patient focus group and multidisciplinary team of researchers, engineers and clinicians. Individual data thresholds to set alerts were determined, and the relationship to exacerbations, defined by the initiation of stand-by medications, was measured. The sample comprised 18 patients (age range of 50–85 years) with varied levels of computer skills.ResultsPatients identified no difficulties in using the mHealth application and used all functions available. 40 % of exacerbations had an alert signal during the three days prior to a patient starting medication. Patients were able to use the mHealth application to support self- management, including monitoring of clinical data. Within three months, 95 % of symptom reporting sessions were completed in less than 100 s.ConclusionsHome based, unassisted, daily use of the mHealth platform is feasible and acceptable to people with COPD for reporting daily symptoms and medicine use, and to measure physiological variables such as pulse rate and oxygen saturation. These findings provide evidence for integrating telehealth interventions with clinical care pathways to support self-management in COPD.

What clinicians want: findings from a psychotherapy practice research network survey.

Practice research networks may be one way of advancing knowledge translation and exchange (KTE) in psychotherapy. In this study, we document this process by first asking clinicians what they want from psychotherapy research. Eighty-two psychotherapists in 10 focus groups identified and discussed psychotherapy research topics relevant to their practices. An analysis of these discussions led to the development of 41 survey items. In an online survey, 1,019 participants, mostly practicing clinicians, rated the importance to their clinical work of these 41 psychotherapy research topics. Ratings were reduced using a principal components analysis in which 9 psychotherapy research themes emerged, accounting for 60.66% of the variance. Two postsurvey focus groups of clinicians (N = 22) aided in interpreting the findings. The ranking of research themes from most to least important were-Therapeutic Relationship/Mechanisms of Change, Therapist Factors, Training and Professional Development, Client Factors, Barriers and Stigma, Technology and Adjunctive Interventions, Progress Monitoring, Matching Clients to Therapist or Therapy, and Treatment Manuals. Few differences were noted in rankings based on participant age or primary therapeutic orientation. Postsurvey focus group participants were not surprised by the top-rated items, as they were considered most proximal and relevant to therapists and their work with clients during therapy sessions. Lower ranked items may be perceived as externally imposed agendas on the therapist and therapy. We discuss practice research networks as a means of creating new collaborations consistent with KTE goals. Findings of this study can help to direct practitioner-researcher collaborations.

Interunit Handoffs of Patients and Transfers of Information: A Survey of Current Practices

We describe the current state of emergency department to inpatient handoffs and assess handoff best practices between emergency physicians and hospitalist medicine physicians. A survey was distributed electronically to emergency medicine and internal medicine physicians at 10 hospitals across the United States. Descriptive and quantitative analysis was performed on survey results. Additionally, qualitative data were obtained from an expert focus group of both emergency medicine and hospital medicine clinicians. Seven hundred fifty of 1,799 physicians (42.2%) responded to our Web-based survey. Attending physicians (45%) described themselves as practicing emergency medicine (51%) or internal medicine (56%). Responding residents were 55% internal medicine, 43% emergency medicine, and 13% dual emergency medicine/internal medicine. Of the responding departments, use of standardized tools was reported by less than 20% and only one third of residents reported formal handoff training. Handoff factors identified as important include identifying "high-risk" patients, designating uninterrupted time to perform the handoff, and standardizing information provided during the handoff. Qualitative results mirrored these themes and acknowledged the importance of bedside handoffs. To our knowledge, this is the largest multispecialty survey to date, including both resident and attending physicians in emergency medicine and hospital medicine. Standardized tools are rarely used and training of residents in this critical task is uncommon. Physicians in both specialties agree on the important content and structure of handoff, including the ideal situation of face-to-face bedside discussion. A curriculum and assessment tool for this practice should be developed.

The Frequency and Cost of Treatment Perceived to Be Futile in Critical Care

Physicians often perceive as futile intensive care interventions that prolong life without achieving an effect that the patient can appreciate as a benefit. The prevalence and cost of critical care perceived to be futile have not been prospectively quantified. To quantify the prevalence and cost of treatment perceived to be futile in adult critical care. To develop a common definition of futile care, we convened a focus group of clinicians who care for critically ill patients. On a daily basis for 3 months, we surveyed critical care specialists in 5 intensive care units (ICUs) at an academic health care system to identify patients whom the physicians believed were receiving futile treatment. Using a multivariate model, we identified patient and clinician characteristics associated with patients perceived to be receiving futile treatment. We estimated the total cost of futile treatment by summing the charges of each day of receiving perceived futile treatment and converting to costs. Prevalence of patients perceived to be receiving futile treatment. During a 3-month period, there were 6916 assessments by 36 critical care specialists of 1136 patients. Of these patients, 904 (80%) were never perceived to be receiving futile treatment, 98 (8.6%) were perceived as receiving probably futile treatment, 123 (11%) were perceived as receiving futile treatment, and 11 (1%) were perceived as receiving futile treatment only on the day they transitioned to palliative care. The patients with futile treatment assessments received 464 days of treatment perceived to be futile in critical care (range, 1-58 days), accounting for 6.7% of all assessed patient days in the 5 ICUs studied. Eighty-four of the 123 patients perceived as receiving futile treatment died before hospital discharge and 20 within 6 months of ICU care (6-month mortality rate of 85%), with survivors remaining in severely compromised health states. The cost of futile treatment in critical care was estimated at $2.6 million. In 1 health system, treatment in critical care that is perceived to be futile is common and the cost is substantial.

Can a redesign of emergency pharmacist roles improve medication management? A prospective study in three Australian hospitals

Emergency departments (EDs) face increasing service demands and the imposition of treatment targets which has led to continual process redesign and changes in staff skill mix and functions. To identify extended ED pharmacist roles that could improve medication management and to implement and evaluate one such role change. A focus group of clinicians sought to redesign processes around ED medication management. Preparation of medication charts for patients admitted from ED was selected. Baseline data were obtained to define elements of existing medication charting processes. Suitably trained ED pharmacists' trialled the effectiveness of making therapeutic suggestions on a medication chart 'sticker' or by direct 'consultation' with medical staff. At the conclusion of the study focus groups at each site evaluated clinical staff perceptions of the change. Focus group participants thought that ED pharmacists could undertake extended roles in analgesia, nausea control, antibiotic cover, addiction management and preparation of medication charts for admitted patients. In the pre-intervention audit (n = 140), 74% required at least one intervention by the ward pharmacists to address medication discrepancies. Ward pharmacists detected 292 medication discrepancies (median 1, IQR 0-3). In the 'sticker' intervention the ED pharmacist made 84 therapeutic suggestions of which 66 (78.6%) were accepted by medical staff. In the 'consultation' intervention 230 therapeutic suggestions were made of which 219 (95.2%) were accepted. The qualitative evaluation found that pharmacist-prepared medication charts within the processes established were deemed safe, timely, accurate, complete and legible. Support exists for ED pharmacists to expand their medication-related roles. ED pharmacists can safely prepare medication charts in a timely fashion and their therapeutic suggestions within a 'consultative' framework are more beneficial than written advice. However, issues relating to resourcing, hours of service, service focus, statutory restrictions and training support for extended roles require resolution.

Development of Simple Clinical Criteria for the Definition of Inflammatory Arthritis, Enthesitis, Dactylitis, and Spondylitis: A Report from the GRAPPA 2012 Annual Meeting

Dermatologist and primary care clinicians are in an ideal position to identify the emergence of psoriatic arthritis (PsA) in patients with psoriasis. Yet these clinicians are not well trained to distinguish inflammatory musculoskeletal disease from other more common problems such as osteoarthritis, traumatic or degenerative tendonitis and back pain, or fibromyalgia. A simple set of clinical criteria to identify inflammatory disease would aid recognition of PsA. At its 2012 annual meeting, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) discussed development of evidence-based, practical, and reliable definitions of inflammatory arthritis, enthesitis, dactylitis, and spondylitis. This project will be a sequential process of expert clinician nominal-group technique, patient surveys and focus groups, and Delphi exercises to identify core features of inflammatory disease, testing these in a small group of patients with and without inflammatory disease, and finally validating these criteria in larger groups of patients.

Views of Women and Clinicians on Postpartum Preparation and Recovery

To explore important domains of women's postpartum experiences as perceived by postpartum mothers and obstetricians/midwives, and to investigate how postpartum care could enhance patient preparation for the postpartum period. Qualitative research study was conducted to explore women's and clinicians' perceptions of the postpartum experience. Four focus groups of postpartum women (n = 45) and two focus groups of obstetric clinicians (n = 13) were held at a large urban teaching hospital in New York City. All focus groups were audio recorded, transcribed, and analyzed using grounded theory. Four main themes were identified: lack of women's knowledge about postpartum health and lack of preparation for the postpartum experience, lack of continuity of care and absence of maternal care during the early postpartum period, disconnect between providers and postpartum mothers, and suggestions for improvement. Mothers did not expect many of the symptoms they experienced after childbirth and were disappointed with the lack of support by providers during this critical time in their recovery. Differences existed in the major postpartum concerns of mothers and clinicians. However, both mothers and clinicians agreed that preparation during the antepartum period could be beneficial for postpartum recovery. Results from this study indicate that many mothers do not feel prepared for the postpartum experience. Study findings raise the hypothesis that capturing patient-centered domains that define the postpartum experience and integrating these domains into patient care may enhance patient preparation for postpartum recovery and improve postpartum outcomes.

CAN ADVANCE CARE PLANNING BECOME PART OF USUAL COMMUNITY PALLIATIVE CARE? USING A MULTI-SITE ACTION RESEARCH APPROACH TO IDENTIFY CONDITIONS FOR SUCCESS

BackgroundInternationally the recommended system-wide approach to ACP has been successful in health care settings and communities with a homogenous population. A multi-faceted ACP was developed, trialled and evaluated in diverse...

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Introduction: Medicine is now able to keep patients alive for long periods of time in conditions such as permanent unconsciousness and permanent dependence on life-sustaining machines: conditions that nearly all people would not want. When a patient’s chance of survival is very low or the quality of life is markedly diminished, intensive care interventions that prolong life without achieving the goals of medicine are often considered “futile” by health care providers. We aimed to quantify and characterize the prevalence of futile treatment at one academic health system. Hypothesis: We hypothesize that futile treatment is common and patients who are identified by critical care doctors as receiving futile treatment have a poor outcome. Methods: A focus group of clinicians who provide care for critically ill patients was convened to develop a common definition of medical futility. On a daily basis from December 15, 2011 through March 15, 2012, we surveyed the critical care attending in five intensive care units (ICUs) in one healthcare system to identify which patients the clinicians identified as receiving futile treatment. Days receiving futile treatment while being transitioned to comfort care were excluded. Results: Thirty-six attendings made 6979 assessments on 1144 patients. Of the 1144 patients evaluated by an attending critical care physician, 135 (12%) were identified as receiving futile treatment on at least one ICU day. The majority of futility assessments were found in the Medical ICU and the Neuro-Critical Care Unit. These 135 patients together received 476 days of futile treatment (7% of all patient critical care days during this period). Of these 135 patients, 93 patients died in the hospital, another 12 patients died within 3 months of discharge, and 6 more patients were discharged on hospice. Of the remaining patients, 1 is still hospitalized, 3 were discharged home, 2 were transferred to another hospital’s ICU, and 18 were transferred to nursing homes or long term acute care facilities. Conclusions: Futile treatment at the studied academic medical center is common. Because the provision of critical care is resource-intensive and not in the best interest of dying patients and those in extremely compromised health states, we will explore the reasons why futile critical care occurs and how care might be re-oriented to better serve patients.

Development and preliminary validation of a patient‐reported outcome measure for swallowing after total laryngectomy (SOAL questionnaire)

To develop and validate a laryngectomee-specific questionnaire to investigate swallowing function. This paper describes the generation of questionnaire items, pretesting with laryngectomees and a preliminary validation. This study employed 2 phases: questionnaire development and questionnaire validation. Items were developed from patient (n = 10) and clinician (n = 6) focus groups. Content checking, acceptability and face validity were determined through pretesting with 10 laryngectomees and via consensus feedback from 35 speech and language therapists. During preliminary validation, the 17-item final questionnaire was administered to 3 different groups. Discrimination amongst groups was established by comparing questionnaire responses of a laryngectomee group (n = 19) with known dysphagic (n = 19) and non-dysphagic groups (n = 20). Questionnaire responses from the reference dysphagic group were compared with an instrumental assessment of swallowing, the modified barium swallow (MBS). Large urban teaching hospital. Speech and language therapists, laryngectomees, non-dysphagic volunteers, post-radiotherapy dysphagic patients. Preliminary validation of SOAL questionnaire. Normal, laryngectomee and dysphagic groups had significantly different SOAL scores, as did laryngectomees with different degrees of swallowing impairment (Kruskall Wallis, P << 0.001). The subjective SOAL score had a strong positive correlation with the reference measure of ratings on the MBS (r = 0.5; P = 0.03). The swallowing outcome after laryngectomy (SOAL) questionnaire is a simple, self-administered tool to assess swallowing function post-total laryngectomy. Further specific testing with a laryngectomy cohort is necessary for full validation. Its potential value lies in screening for dysphagia in clinics or during long-term follow-up of laryngectomees.