Pragmatic Intervention Research Articles

Abstract 14430: The Corcare Heart Function Optimization Protocol: A Structured Quality Improvement Intervention to Improve Goal Directed Targets for Patients With Reduced Ejection Fraction

Introduction: Reduced ejection fraction (REF) in patients is prevalent, utilizing substantial health care resources. Goal Directed Therapy (GDT) reduces hospitalization, morbidity, and mortality but use is suboptimal. Care in subspecialty clinics following discharge reduces readmission, but is not scaled for longitudinal care of the larger REF population. Canadian guidelines support integration of primary, specialist, and non-physician care in systems to improve outcomes. Hypothesis: A protocol-guided intervention will achieve high rates of GDT for REF patients in a community health care setting. Goal: To evaluate a pragmatic quality-of-care intervention to achieve GDT for REF patients and assess barriers to GDT. Methods: Patients referred for imaging and cardiology consultation at a community facility (Jan 1/15-Dec 31/22) were screened. Patients with LVEF <41% on echocardiogram were included if their cardiologist consented to study protocol GDT and were enrolled at the next scheduled, usual care cardiologist visit. 2 project nurses confirmed patient status and assisted GDT management using medical directives at 9 protocol-specified visits between usual care visits over 32 weeks. The primary target was achieving GDT or maximally tolerated GDT (>0 mg). A secondary endpoint, clinical inertia, was defined as not achieving GDT due to physician or patient choice. Results: 864 patients (13 cardiologists) participated: median age 71 (28-102) years, diabetes 25%, hypertension 60%, atrial fibrillation 22%. At intake: NYHA class ≥2 (60%), EF <30% (45%), 30-35% (27%), 36-40% (29%), REF etiology ischemic (47%), non-ischemic (43%), mixed (10%). The majority achieved GDT in each class; inertia, not intolerance predominantly accounted for those who did not achieve GDT. Conclusion: This pragmatic community-based intervention achieved high rates of GDT that could improve longitudinal care for REF patients, and is potentially scalable and generalizable.

Enhancing Intrinsic Capacity and Related Biomarkers in Community-Dwelling Multimorbid Older Adults Through Integrated Multidomain Interventions: Ancillary Findings From the Taiwan Integrated Geriatric (TIGER) Trial

ObjectiveThis study aimed to evaluate the efficacy of integrated multidomain interventions and primary health care on intrinsic capacity (IC) and related biomarkers. DesignAn ancillary analysis from the Taiwan Integrated Geriatric Care (TIGER) study: a randomized controlled trial. Setting and ParticipantsA total of 398 community-dwelling older adults aged ≥65 years with ≥3 chronic conditions. MethodsParticipants were randomized into the 12-month pragmatic multidomain intervention or usual care groups. The primary outcome was the change in IC and its subdomains (locomotion, cognition, vitality, psychological, and sensory) at baseline and 3-, 6-, 9-, and 12-month follow-ups. Generalized linear mixed models were used to evaluate the multidomain intervention effects on these changes. ResultsThe intervention arm had greater improvement in IC than the usual care arm (overall difference 1.5; 95% CI 0.5–2.5; P = .005), mainly from subdomains of locomotion (overall difference 1.4; 95% CI 0.5–2.4; P = .004) and cognition (2.9; 95% CI 2.1–3.7; P < .001). Changes in neutrophil-to-lymphocyte ratio (NLR −2.4; 95% CI −3.9 to −0.8, P = .003), serum levels of albumin (35.1; 95% CI 23.1–47.2; P < .001), dehydroepiandrosterone sulfate (DHEA-S 2.8; 95% CI 1.9–3.8; P < .001), free androgen index (FAI 1.5; 95% CI 1.1–1.9; P < .001), and vitamin D (4.0; 95% CI 2.0–6.1; P < .001) were associated with changes in IC over time. Conclusions and ImplicationsThe incorporation of multidomain interventions into primary health care significantly enhanced IC over the 12-month program. Changes in NLR, FAI, and serum levels of albumin, DHEA-S, vitamin D were associated with changes in IC over time. Trial registrationClinicalTrials.gov Identifier: NCT03528005.

A multi- and mixed-method adaptation study of a patient-centered perioperative mental health intervention bundle

BackgroundAnxiety and depression are common among older adults and can intensify during perioperative periods, but few mental health interventions are designed for older surgical patients’ unique needs. As part of the feasibility trial, we developed and adapted a perioperative mental health (PMH) bundle for older patients comprised of behavioral activation (BA) and medication optimization (MO) to ameliorate anxiety and depressive symptoms before, during, and after cardiac, orthopedic, and oncologic surgery.MethodsWe used mixed-methods including workshop studios with patients, caregivers, clinicians, researchers, and interventionists; intervention refinement and reflection meetings; patient case review meetings; intervention session audio-recordings and documentation forms; and patient and caregiver semi-structured interviews. We used the results to refine our PMH bundle. We used multiple analytical approaches to report the nature of adaptations, including hybrid thematic analysis and content analysis informed by the Framework for Reporting Adaptations and Modifications – Expanded.ResultsAdaptations were categorized by content (intervention components), context (how the intervention is delivered, based on the study, target population, intervention format, intervention delivery mode, study setting, study personnel), training, and evaluation. Of 51 adaptations, 43.1% involved content, 41.2% involved context, and 15.7% involved training and evaluation. Several key adaptations were noted: (1) Intervention content was tailored to patient preferences and needs (e.g., rewording elements to prevent stigmatization of mental health needs; adjusting BA techniques and documentation forms to improve patient buy-in and motivation). (2) Cohort-specific adaptations were recommended based on differing patient needs. (3) Compassion was identified by patients as the most important element.ConclusionsWe identified evidence-based mental health intervention components from other settings and adapted them to the perioperative setting for older adults. Informed by mixed-methods, we created an innovative and pragmatic patient-centered intervention bundle that is acceptable, feasible, and responsive to the needs of older surgical populations. This approach allowed us to identify implementation strategies to improve the reach, scalability, and sustainability of our bundle, and can guide future patient-centered intervention adaptations.Clinical trials RegistrationNCT05110690 (11/08/2021).

Reduction in mortality from HIV-related CNS infections in routine care in Africa (DREAMM): a before-and-after, implementation study

Four decades into the HIV epidemic, CNS infection remains a leading cause of preventable HIV-related deaths in routine care. The Driving Reduced AIDS-associated Meningo-encephalitis Mortality (DREAMM) project aimed to develop, implement, and evaluate pragmatic implementation interventions and strategies to reduce mortality from HIV-related CNS infection. DREAMM took place in five public hospitals in Cameroon, Malawi, and Tanzania. The main intervention was a stepwise algorithm for HIV-related CNS infections including bedside rapid diagnostic testing and implementation of WHO cryptococcal meningitis guidelines. A health system strengthening approach for hospitals was adopted to deliver quality care through a co-designed education programme, optimised clinical and laboratory pathways, and communities of practice. DREAMM was led and driven by local leadership and divided into three phases: observation (including situational analyses of routine care), training, and implementation. Consecutive adults (aged ≥18 years) living with HIV presenting with a first episode of suspected CNS infection were eligible for recruitment. The primary endpoint was the comparison of 2-week all-cause mortality between observation and implementation phases. This study completed follow-up in September, 2021. The project was registered on ClinicalTrials.gov, NCT03226379. From November, 2016 to April, 2019, 139 eligible participants were enrolled in the observation phase. From Jan 9, 2018, to March 25, 2021, 362 participants were enrolled into the implementation phase. 216 (76%) of 286 participants had advanced HIV disease (209 participants had missing CD4 cell count), and 340 (69%) of 494 participants had exposure to antiretroviral therapy (ART; one participant had missing ART data). In the implementation phase 269 (76%) of 356 participants had a probable CNS infection, 203 (76%) of whom received a confirmed microbiological or radiological diagnosis of CNS infection using existing diagnostic tests and medicines. 63 (49%) of 129 participants died at 2 weeks in the observation phase compared with 63 (24%) of 266 in the implementation phase; and all-cause mortality was lower in the implementation phase when adjusted for site, sex, age, ART exposure (adjusted risk difference -23%, 95% CI -33 to -13; p<0·001). At 10 weeks, 71 (55%) died in the observation phase compared with 103 (39%) in the implementation phase (-13%, -24 to -3; p=0·01). DREAMM substantially reduced mortality from HIV-associated CNS infection in resource-limited settings in Africa. DREAMM scale-up is urgently required to reduce deaths in public hospitals and help meet Sustainable Development Goals. European and Developing Countries Clinical Trials Partnership, French Agency for Research on AIDS and Viral Hepatitis. For the French and Portuguese translations of the abstract see Supplementary Materials section.

Benefits, risks, barriers, and facilitators to cycling: a narrative review.

There is large potential to increase cycling participation worldwide. Participation in cycling is associated with lower risk of mortality from any cause, and incidence of cardiovascular disease and type 2 diabetes, as well as positive mental health and well-being. The largest potential for health gains likely to come from increasing participation amongst those who do not currently cycle regularly, rather than encouraging those who already cycle regularly to cycle more. Replacing car journeys with cycling can lead to reductions in air pollution emissions and lower pollutant exposure to the general population. Important gaps and uncertainties in the existing evidence base include: the extent to which the health benefits associated with cycling participation are fully causal due to the observational nature of much of the existing evidence base; the real-world economic cost-benefits of pragmatic interventions to increase cycling participation; and the most effective (combination of) approaches to increase cycling participation. To address these uncertainties, large-scale, long-term randomised controlled trials are needed to: evaluate the effectiveness, and cost-effectiveness, of (combinations of) intervention approaches to induce sustained long-term increases in cycling participation in terms of increases in numbers of people cycling regularly and number of cycling journeys undertaken, across a range of population demographic groups; establish the effects of such interventions on relevant outcomes related to health and wellbeing, economic productivity and wider societal impacts; and provide more robust quantification of potential harms of increasing cycling participation, such as collision risks.

141 Perspectives of key stakeholders on an adaptive physical activity mHealth intervention in the prevention of secondary stroke: a qualitative study

Abstract Background Engaging in regular Physical Activity (PA) is associated with lower mortality post-stroke, and PA reduces the chance of recurrent stroke. Despite recent guidelines to optimise PA post-stroke, people with stroke are known to be less active than their age-matched counterparts. Given the heterogenous nature of stroke, PA interventions, which are adaptive to individual performance, are recommended. Empirical data is lacking on the design and delivery of adaptive PA interventions post-stroke. Suggested strategies recommend the use of mobile health (mHealth) interventions. The aim of this study is to explore the perspectives of key stakeholders on the design and development of an adaptive mHealth PA intervention post-stroke. Methods People with stroke, healthcare professionals and carers participated in semi-structured one-to-one or focus group interviews. A reflexive thematic analysis was undertaken on transcribed interviews and key themes and sub-themes were developed. Results Twenty-eight interviews were conducted across stakeholder groups including people with stroke (n = 12, mean age 55 years), healthcare professionals (n = 10) and carers (n = 6, mean age 67 years). Three main themes relevant to the design and development of the intervention were identified: (1) Key features of a mHealth PA intervention, (2) Pragmatic intervention delivery, (3) Challenges to development and use. Conclusion There was widespread agreement across stakeholder groups that an adaptive mHealth PA intervention post-stroke would be beneficial following discharge from acute care. Our data supports the development of individually adapted programs, to increase PA post-stroke. These findings present new perspectives across stakeholder groups on the design and delivery of an adaptive, mHealth PA post-stroke. Taken together with existing quantitative evidence, these findings will inform the development of a feasibility trial, examining patient and process outcomes, to increase PA levels post-stroke.

Assessing the effect of regular swimming exercise on the micro- and macrovascular physiology of older adults (ACELA II study).

Introduction: Cardiovascular disease (CVD) remains the main cause of death in the Western world. Our recent findings demonstrate potential CVD risk reduction in older adults who undertake regular swimming exercise. Nevertheless, it remains unknown whether an exercise intervention based on swimming is feasible and effective prior to a wider implementation of a CVD risk prevention strategy. Methods: This was a pragmatic, two-group, randomised controlled trial. A total of 40 older adults were randomly split into two groups (n = 20 per group). The swimming exercise group consisted of participants who engaged in swimming exercise (2-3days/week, for 8weeks). The control group did not perform any exercise. Flow-mediated dilation (%FMD) was the primary outcome. Secondary outcomes included raw cutaneous vascular conductance. Feasibility outcomes (e.g., recruitment, adherence, and attrition rates) were also assessed. Results: Statistically significant macrovascular (%FMD; swimming group: 9.8% ± 4.2%, p <0.001; control group: 4.6% ± 2.5%) and microvascular function (raw cutaneous vascular conductance; swimming group: 4.1 ± 0.9, p <0.01; control group: 3.2 ± 1.1) improvements were observed in the swimming group compared to the control group. Compliance to twice and thrice weekly in an 8-week swimming exercise was 92.6% and 88.4%, respectively, with no dropouts. Conclusion: Our 8-week, community-based, pragmatic swimming exercise intervention is a feasible and effective exercise programme that could be implemented in older adults for the prevention of age-related CVD. These findings suggest that swimming exercise could significantly reduce CVD risk in older adults, and a large research clinical trial is warranted to establish these findings.

Pathophysiological changes of muscle after ischemic stroke: a secondary consequence of stroke injury.

Sufficient clinical evidence suggests that the damage caused by ischemic stroke to the body occurs not only in the acute phase but also during the recovery period, and that the latter has a greater impact on the long-term prognosis of the patient. However, current stroke studies have typically focused only on lesions in the central nervous system, ignoring secondary damage caused by this disease. Such a phenomenon arises from the slow progress of pathophysiological studies examining the central nervous system. Further, the appropriate therapeutic time window and benefits of thrombolytic therapy are still controversial, leading scholars to explore more pragmatic intervention strategies. As treatment measures targeting limb symptoms can greatly improve a patient's quality of life, they have become a critical intervention strategy. As the most vital component of the limbs, skeletal muscles have become potential points of concern. Despite this, to the best of our knowledge, there are no comprehensive reviews of pathophysiological changes and potential treatments for post-stroke skeletal muscle. The current review seeks to fill a gap in the current understanding of the pathological processes and mechanisms of muscle wasting atrophy, inflammation, neuroregeneration, mitochondrial changes, and nutritional dysregulation in stroke survivors. In addition, the challenges, as well as the optional solutions for individualized rehabilitation programs for stroke patients based on motor function are discussed.

Efficacy of a novel patient-focused intervention aimed at increasing adherence to guideline-based preventive measures in asplenic patients: the PrePSS trial

PurposeTo determine whether a novel intervention improves the adherence to guideline-based preventive measures in asplenic patients at risk of post-splenectomy sepsis (PSS).MethodsWe used a prospective controlled, two-armed historical control group design to compare a novel, health action process approach (HAPA)-based telephonic intervention involving both patients and their general practitioners to usual care. Eligible patients were identified in cooperation with the insurance provider AOK Baden-Wuerttemberg, Germany. Patients with anatomic asplenia (n = 106) were prospectively enrolled and compared to a historical control group (n = 113). Comparisons were done using a propensity-score-based overlap-weighting model. Adherence to preventive measures was quantified by the study-specific ‘Preventing PSS score’ (PrePSS score) which includes pneumococcal and meningococcal vaccination status, the availability of a stand-by antibiotic and a medical alert card.ResultsAt six months after the intervention, we estimated an effect of 3.96 (95% CI 3.68–4.24) points on the PrePSS score scale (range 0–10) with mean PrePSS scores of 3.73 and 7.70 in control and intervention group, respectively. Substantial improvement was seen in all subcategories of the PrePSS score with the highest absolute gains in the availability of stand-by antibiotics. We graded the degree of participation by the general practitioner (no contact, short contact, full intervention) and noted that the observed effect was only marginally influenced by the degree of physician participation.ConclusionsPatients who had received the intervention exhibited a significantly higher adherence to guideline-based preventive measures compared to the control group. These data suggest that widespread adoption of this pragmatic intervention may improve management of asplenic patients. Health insurance provider-initiated identification of at-risk patients combined with a patient-focused intervention may serve as a blueprint for a wide range of other preventive efforts leading to patient empowerment and ultimately to better adherence to standards of care.

Efficacy of a training programme for the management of diabetes mellitus in the hospital: A randomized study (stage 2 of GOVEPAZ healthcare).

To assess the efficacy of a structured educational intervention for health professionals on the appropriateness of inpatient diabetes care and on some clinical outcomes in hospitalised subjects. A multicentre (6 regional hospitals) cluster-randomized (2:1) two parallel-group pragmatic intervention trials, as a part of the GOVEPAZ study, was conducted in three clinical settings, that is, Internal Medicine, Surgery and Intensive Care. Intervention consisted of a 2-month structured education of clinical staff to inpatient diabetes care. Twelve wards - 2 for each hospital - and 6 wards - 1 for each hospital - were randomized to usual care and to the intervention arm, respectively. Consecutively hospitalised diabetic subjects (n=524, age 74±14years, 57% males, median HbA1C 57mmol/mol) were included. The clinical appropriateness of inpatient diabetes management was assessed by a previously validated multi-domain performance score (PS). Clinical outcomes included hypoglycemia, glucose control biomarkers, clinical conditions at discharge and inpatient mortality rate. A numerically, but not statistically significant, higher PS (+0.94; 95% C.I.: -0.53 - +2.4) was achieved in the intervention than in the usual care wards. Hypoglycemias (p=0.32), glucose control (p=0.89) and survival rates (p=0.71) were similar in the two experimental arms. Plasma glucose on admission (OR=1.52 per 1 SD; C.I. 1.07-2.17; p=0.021) and the number of hypoglycemic events per patient (OR=1.55 per 1 SD; C.I.:1.11-2.16; p=0.011) were independently associated with the inpatient mortality rate. Structured education of the clinical staff failed to improve the inpatient appropriateness of diabetes care or clinical outcomes. In-hospital hypoglycemia was confirmed to be an independent indicator of death risk.

Barriers to and Facilitators of Providing Care for Adolescents Suffering from Rare Diseases: A Mixed Systematic Review.

Rare Diseases (RDs) in adolescents are characterized by low frequency and clinical heterogeneity, are chronic and deliberating and demand a multidisciplinary approach as well as costly and specialized treatments. Comprehending patients' and parents' needs through a mixed systematic review is essential for healthcare system planning. This mixed systematic review explored barriers to and facilitators of effective care for adolescents with RDs as perceived by patients and their parents. Three databases (2008-2023) were searched and twenty-five articles were selected and critically appraised with the Mixed Methods Appraisal Tool (MMAT; version 2018). The review followed a convergent integrated approach for data extraction according to Joanna Briggs Institute's (JBI) mixed method systematic review (MMSR) methodology. Subsequent reflexive thematic analysis categorized the barriers and facilitators into five levels (intrapersonal, interpersonal, institutional, community and public policy) following the conceptual framework of the socio-ecological model for healthcare promotion. Barriers on the institutional and public policy level stood out as the most frequently reported, resulting in unmet care needs and frustrating family dynamics. National and regional healthcare policies are rarely actually linked to pragmatic intervention programs with a measurable impact on patients' welfare. Targeted strategies involving primary care infrastructure and personnel for better coordination and management of the disease are discussed.

A qualitative evaluation of a telehealth healthy lifestyle intervention for people with serious mental illness.

There are high levels of nutritional and metabolic, cardiovascular, and respiratory tract diseases among people diagnosed with serious mental illness (SMI). Consequently, we developed a pragmatic, affordable nutritional and exercise intervention: Choices4Health. Due to the COVID-19 pandemic, we modified this intervention so it could be delivered online. The aim of this study was to explore the experience of participating in online Choices4Health, in a real-world clinical setting, from the perspectives of service users with SMI. The study aim was addressed using thematic analysis. Service users who had attended online Choices4Health, received a SMI diagnosis (defined as a schizophrenia spectrum disorder or an affective disorder), and resided in a South Dublin catchment were invited to participate. Nine participants were purposefully sampled. Semi-structured interviews were conducted by telephone. Data analysis was guided by thematic analysis procedures. Six themes were generated: Being ready and not overburdened (Engagement); Gaining knowledge and implementing it (Learning and doing); Viewing the intervention as appropriate and effective (Targeted impact); Being at home with others online (Belonging); Having a positive affective attitude towards the intervention (Feeling); and Perceiving problems with intervention delivery (Recommended change). Findings suggest that online Choices4Health is, broadly speaking, acceptable from a service user perspective, but that further refinement is required to address specific issues participants identified. These relate to follow-up or programme extension, technology access, in-person contact preference, and participant inclusion criteria. Further research is required into online Choices4Health efficacy, innovations to reduce digital exclusion, and managing group dynamics in telehealth interventions.

Effects of deductive and explicit‐inductive instruction on tertiary‐level Chinese learners’ use of English subjunctive as a pragmatic mitigator

AbstractThis quasi‐experimental study investigates the immediate and long‐term effects of deductive instruction and explicit‐inductive instruction to L2 learners on the use of the English subjunctive as a pragmatic mitigator. Two intact classes of tertiary‐level Chinese EFL (English as a Foreign Language) learners, labeled as the deductive group and the explicit‐inductive group, respectively, received two 45‐min sessions of pragmatic intervention, whereas a third intact class serving as the control group was given grammatical instruction. The immediate post‐test and delayed post‐test administered to the three groups shows that the deductive group had an immediate edge but not a long‐term one over the explicit‐inductive group, in terms of appropriateness and linguistic accuracy; however, the gain of the explicit‐inductive group was better retained than in the deductive group. This study contributes to the expansion of instructional targets within the field of L2 pragmatics. It also highlights the relative advantage of deductive and explicit‐inductive instruction methods.

Dietary intake during a pragmatic cluster-randomized weight loss trial in an underserved population in primary care

BackgroundCurrently there are limited data as to whether dietary intake can be improved during pragmatic weight loss interventions in primary care in underserved individuals.MethodsPatients with obesity were recruited into the PROPEL trial, which randomized 18 clinics to either an intensive lifestyle intervention (ILI) or usual care (UC). At baseline and months 6, 12, and 24, fruit and vegetable (F/V) intake and fat intake was determined. Outcomes were analyzed by repeated-measures linear mixed-effects multilevel models and regression models, which included random cluster (clinic) effects. Secondary analyses examined the effects of race, sex, age, and food security status.ResultsA total of 803 patients were recruited. 84.4% were female, 67.2% African American, 26.1% received Medicaid, and 65.5% made less than $40,000. No differences in F/V intake were seen between the ILI and UC groups at months 6, 12, or 24. The ILI group reduced percent fat at months 6, 12, and 24 compared to UC. Change in F/V intake was negatively correlated with weight change at month 6 whereas change in fat intake was positively associated with weight change at months 6, 12, and 24 for the ILI group.ConclusionsThe pragmatic weight loss intervention in primary care did not increase F/V intake but did reduce fat intake in an underserved population with obesity. F/V intake was negatively associated with weight loss at month 6 whereas percent fat was positively correlated with weight loss throughout the intervention. Future efforts better targeting both increasing F/V intake and reducing fat intake may promote greater weight loss in similar populations.Trial registrationNCT Registration: NCT02561221

Enabling dads and improving First Nations adolescent mental health: a pragmatic randomised controlled study

IntroductionThere are few empirically supported social and emotional well-being programmes for First Nations adolescents, and we found none targeting those living in Aboriginal communities in remote areas of Australia. The...

Understanding primary care diagnosis and management of sleep disturbance for people with dementia or mild cognitive impairment: a realist review.

Sleep disturbance (SD) is common among people living with dementia (PLwD) or mild cognitive impairment (MCI). It has a significant impact on the wellbeing of PLwD and caregivers, and makes care at home more difficult. Within primary care, assessment and management of SD for this population is complex and challenging. To identify what works, how, and for whom, in the assessment and management of SD for PLwD or MCI in primary care. We conducted a realist review to develop explanations of causal relationships, using context-mechanism-outcome configurations (CMOCs). An initial programme theory was iteratively tested and refined, using data from relevant literature and stakeholder feedback. The study followed RAMESES reporting quality. In total, 71 papers from OECD countries were included for analysis, generating 19 CMOCs. Low awareness of SD and assessment methods resulted in underdiagnosis in primary care. Assessment and treatment of PLwD/MCI were, respectively, more challenging when people were unable to accurately report concerns or implement interventions independently. Sedative medication was commonly used to manage SD, often driven by low confidence in nonpharmacological strategies. Long-term medication use was common despite guidelines indicating limited efficacy, which was driven by perceived pressures to prescribe or concerns of relapse. In nursing homes, environments and routines could exacerbate SD. Increasing awareness, knowledge, and confidence in diagnosis and assessment of SD is needed. Primary care-specific assessment tools may help. Long-term medication use is the default option in absence of pragmatic and effective non-pharmacological interventions that can be easily incorporated into routine general practice.

571-P: Theory-Based Design of a Nutrition-Focused Approach at CGM Initiation for People with T2D

Background: CGM can improve glycemic outcomes and has the potential to help people with T2D adopt evidence-based nutrition recommendations. Effective interventions using CGM data to guide food choices that align with nutrition recommendations are sparse. The objective of this work is to describe development of a nutrition-focused approach (NFA) at CGM initiation using the behavior change wheel (BCW), a theory-based intervention development framework. Methods: The BCW process included 3 parts: 1) specifying the target behavior and existing barriers according to the Capability Opportunity Motivation-Behavior (COM-B) Model and Theoretical Domains Framework (TDF); 2) identifying intervention content to address the barriers (e.g. broad strategies for behavior change and specific behavior change techniques (BCTs)); and 3) assessing feasibility of the intervention and selecting ways to implement content. Rapid literature review, stakeholder discussion, and content analysis were used to achieve these steps. Results: The target behavior was defined as using CGM data to guide dietary changes that align with current nutrition recommendations and improve TIR. Via content analysis, 80 barriers were coded according to the COM-B and TDF constructs. After feasibility assessment and stakeholder discussions, 12 barriers were selected (e.g. an opportunity barrier is lack of tools supporting use of CGM data to guide food choices). These barriers were mapped to 5 behavior change strategies (i.e. intervention functions; such as training and enablement) and associated BCTs (e.g. habit formation and reframing). The final intervention includes three components: a 1-hr in-person session, a 30-min telehealth session, and nutrition-focused CGM-initiation materials. Conclusion: Use of the BCW led to the development of a rigorous but pragmatic theory-driven intervention. Effectiveness of the nutrition-focused approach at CGM initiation intervention will be tested in clinical trials. Disclosure H.Willis: Other Relationship; Abbott Diabetes, Dexcom, Inc., Research Support; Abbott Diabetes. M.Jaka: None. E.A.Johnson: Speaker's Bureau; Medtronic, Medscape. Funding American Diabetes Association (7-22-JDFN-27 to H.W.)

Combining data and mathematical models for the design of personalised light interventions to improve sleep timing in aging

AbstractBackgroundMore than 70% of people living with dementia (PLWD) experience sleep disturbances (e.g., early bedtime, long time in bed) even in the early stages of cognitive decline. Light interventions have been proposed as a promising non‐pharmacological approach to improve sleep timing, but current implementations are burdensome and not personalised. Quantitative tools for designing pragmatic light interventions for the home‐setting could benefit PLWD and their carers.Here, we report on a quantitative computational tool which combines readily collectable data with a new mathematical model to provide personalised advice on light interventions. Our focus is on designing low‐burden interventions requiring minimal changes to lifestyle or sleep‐wake routines.MethodEighteen older adults (65‐80 y) monitored their light exposure and sleep for a period of 7‐10 days at home using a wristworn monitor (Actiwatch Spectrum) and a sleep diary from which we calculated daily sleep timing and duration.We constructed a new mechanistic mathematical model for sleep timing that incorporates sleep homeostasis, circadian rhythmicity and light data (HCL). For each participant, we fitted the model to their sleep timing and duration data. We then used simulations to predict the effect of different light interventions on sleep timing and used optimisation to determine light exposure patterns that promote a target sleep onset time.ResultIndividuals varied in their sleep duration (07:18 ± 0:56 hh:mm; mean ± SD) and mid‐sleep timing (03:22 ± 01:00 hh:mm). We successfully retrieved ‘personal’ model parameters that accurately captured sleep duration and timing for 17 of the 18 participants. Our simulations indicated that the effect of a given light exposure pattern on sleep timing depends on the personalised model parameters, suggesting that an intervention that works for one person may not work for someone else. We were able to propose light exposure patterns requiring minimal behavioural change, facilitating adherence.ConclusionIt is possible to extract individual physiological parameters for sleep‐wake regulation from data collected in the field. These individual parameters can be used to design personalised light interventions. Our fully‐documented code could be combined with passive sleep monitors and environmental light sensors to unobtrusively recommend personalised light exposure patterns in close‐to real time.

Professional learning promoting agency in challenging practice contexts

ABSTRACT This study promoted professional learning and agency through a pragmatic formative intervention. Participants sought to change professional practices in classrooms in response to critical reflection on pedagogic practices and wider social concerns. Australian researchers collaborated with teachers and teacher educators from Nepal, informed by cultural-historical activity theory (CHAT). Change Laboratory methods identified a contradiction between heavy curriculum content and pedagogies that were regarded as educationally desirable and socially just. Participants developed eight principles to help teachers enact high-quality, inclusive pedagogies. One group linked this to the idea of MicroProjects, a solution for time-pressed teachers that could embody all eight principles. They worked with teachers in a nearby school to develop and implement MicroProjects across the Grade 1–12 curriculum. The paper traces a cycle of expansive learning actions, revealing how committed, activist research methods promoted teacher professional learning and agency in challenging contexts of the Global South, shifting from what is towards what ought to be.

Intervention to Promote Communication About Goals of Care for Hospitalized Patients With Serious Illness

Discussions about goals of care are important for high-quality palliative care yet are often lacking for hospitalized older patients with serious illness. To evaluate a communication-priming intervention to promote goals-of-care discussions between clinicians and hospitalized older patients with serious illness. A pragmatic, randomized clinical trial of a clinician-facing communication-priming intervention vs usual care was conducted at 3 US hospitals within 1 health care system, including a university, county, and community hospital. Eligible hospitalized patients were aged 55 years or older with any of the chronic illnesses used by the Dartmouth Atlas project to study end-of-life care or were aged 80 years or older. Patients with documented goals-of-care discussions or a palliative care consultation between hospital admission and eligibility screening were excluded. Randomization occurred between April 2020 and March 2021 and was stratified by study site and history of dementia. Physicians and advance practice clinicians who were treating the patients randomized to the intervention received a 1-page, patient-specific intervention (Jumpstart Guide) to prompt and guide goals-of-care discussions. The primary outcome was the proportion of patients with electronic health record-documented goals-of-care discussions within 30 days. There was also an evaluation of whether the effect of the intervention varied by age, sex, history of dementia, minoritized race or ethnicity, or study site. Of 3918 patients screened, 2512 were enrolled (mean age, 71.7 [SD, 10.8] years and 42% were women) and randomized (1255 to the intervention group and 1257 to the usual care group). The patients were American Indian or Alaska Native (1.8%), Asian (12%), Black (13%), Hispanic (6%), Native Hawaiian or Pacific Islander (0.5%), non-Hispanic (93%), and White (70%). The proportion of patients with electronic health record-documented goals-of-care discussions within 30 days was 34.5% (433 of 1255 patients) in the intervention group vs 30.4% (382 of 1257 patients) in the usual care group (hospital- and dementia-adjusted difference, 4.1% [95% CI, 0.4% to 7.8%]). The analyses of the treatment effect modifiers suggested that the intervention had a larger effect size among patients with minoritized race or ethnicity. Among 803 patients with minoritized race or ethnicity, the hospital- and dementia-adjusted proportion with goals-of-care discussions was 10.2% (95% CI, 4.0% to 16.5%) higher in the intervention group than in the usual care group. Among 1641 non-Hispanic White patients, the adjusted proportion with goals-of-care discussions was 1.6% (95% CI, -3.0% to 6.2%) higher in the intervention group than in the usual care group. There was no evidence of differential treatment effects of the intervention on the primary outcome by age, sex, history of dementia, or study site. Among hospitalized older adults with serious illness, a pragmatic clinician-facing communication-priming intervention significantly improved documentation of goals-of-care discussions in the electronic health record, with a greater effect size in racially or ethnically minoritized patients. ClinicalTrials.gov Identifier: NCT04281784.