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Matthew P Genelin,1 Laura J Helmkamp,2 John F Steiner,1,3 Julie A Maertens,2 Rebecca Hanratty,1,4 Suma Vupputuri,5 Edward P Havranek,1,4,6 L Miriam Dickinson,1,2 Irene V Blair,7 Stacie L Daugherty1– 3,6 1University of Colorado School of Medicine, Aurora, CO, USA; 2Adult and Child Consortium for Outcomes Research and Delivery Sciences (ACCORDS), University of Colorado, Aurora, CO, USA; 3Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA; 4Department of Medicine, Denver Health and Hospital Authority, Denver, CO, USA; 5Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA; 6Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA; 7Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO, USACorrespondence: Matthew P Genelin, University of Colorado School of Medicine, 3500 Rockmont Drive, &num;15-209, Denver, CO, 80202, USA, Email matthew.genelin@cuanschutz.eduBackground: The strategies patients use to organize medications (eg, pill dispenser) may be reflected in adherence measured at follow-up. We studied whether medication organization strategies patients use at home are associated with adherence measured using pharmacy-fills, self-report, and pill counts.Design: Secondary analysis of data from a prospective randomized clinical trial.Setting: Eleven US safety-net and community primary care clinics.Patients: Of the 960 enrolled self-identified non-Hispanic Black and White patients prescribed antihypertensive medications, 731 patients reported pill organization strategies and were included.Variable: Patients were asked if they use any of the following medication organization strategies: finish previous refills first; use a pill dispenser; combine same prescriptions; or combine dissimilar prescriptions.Outcomes: Adherence to antihypertensive medications using pill counts (range, 0.0– 1.0% of the days covered), pharmacy-fill (proportion of days covered > 90%), and self-report (adherent/non-adherent).Results: Of the 731 participants, 38.3% were men, 51.7% were age ≥ 65, 52.9% self-identified as Black or African American. Of the strategies studied, 51.7% finished previous refills first, 46.5% used a pill dispenser, 38.2% combined same prescriptions and 6.0% combined dissimilar prescriptions. Median (IQR) pill count adherence was 0.65 (0.40– 0.87), pharmacy-fill adherence was 75.7%, and self-reported adherence was 63.2%. Those who combined same prescriptions had significantly lower measured pill count adherence than those who did not (0.56 (0.26– 0.82) vs 0.70 (0.46– 0.90), p< 0.01) with no significant difference in pharmacy-fill (78.1% vs 74%, p=0.22) or self-reported adherence (63.0% vs 63.3%, p=0.93).Conclusion: Self-reported medication organization strategies were common. Combining same prescriptions was associated with lower adherence as measured using pill counts but not pharmacy-fills or self-report. Clinicians and researchers should identify the pill organization strategies used by their patients to understand how these strategies may influence measures of patient adherence.Trial Registration: ClinicalTrials.gov NCT03028597; https://clinicaltrials.gov/ct2/show/NCT03028597 (Archived by WebCite at http://www.webcitation.org/72vcZMzAB).Keywords: hypertension, medication adherence, management strategies, organization strategies, medication management behaviors, chronic disease, pill count, pharmacy-fill, self-reported adherence

ObjectivesThis project seeks to improve providers’ practices and patient outcomes from prehospital (ie, ambulance-based) trauma care in a middle-income country using a novel implementation strategy to introduce a bundled clinical intervention.DesignWe conduct a two-arm, controlled, mixed-methods, hybrid type II study.SettingThis study was conducted in the Western Cape Government Emergency Medical Services (EMS) system of South Africa.InterventionsWe pragmatically implemented a simplified prehospital bundle of trauma care (with five core elements) using a novel workplace-based, peer-to-peer, rapid training format. We assigned the intervention and control sites.Outcome measuresWe assessed implementation effectiveness among EMS providers and stakeholders, using the RE-AIM framework. Clinical effectiveness was assessed at the patient level, using changes in Shock Index x Age (SIxAge). Indices and cut-offs were established a priori. We performed a difference-in-differences (D-I-D) analysis with a multivariable mixed effects model.Results198 of 240 (82.5%) EMS providers participated, 93 (47%) intervention and 105 (53%) control, with similar baseline characteristics. The overall implementation effectiveness was excellent (80.6%): reach was good (65%), effectiveness was excellent (87%), implementation fidelity was good (72%) and adoption was excellent (87%). Participants and stakeholders generally reported very high satisfaction with the implementation strategy citing that it was a strong operational fit and effective educational model for their organisation. A total of 770 patients were included: 329 (42.7%) interventions and 441 (57.3%) controls, with no baseline differences. Intervention arm patients had more improved SIxAge compared with control at 4 months, which was not statistically significant (−1.4 D-I-D; p=0.35). There was no significant difference in change of SIxAge over time between the groups for any of the other time intervals (p=0.99).ConclusionsIn this quasi-experimental trial of bundled care using the novel workplace rapid training approach, we found overall excellent implementation effectiveness but no overall statistically significant clinical effectiveness.

Background: Social vulnerability indicators are associated with health care inequities and may similarly impede ongoing participation in research studies. We evaluated the association of social vulnerability indicators and research participant attrition in a trial focused on reducing health disparities. Methods: Self-identified White or Black adults enrolled in the HYVALUE trial (Hypertension and VALUEs), a randomized trial testing a values-affirmation intervention on medication adherence, from February 2017 to September 2019 were included. The self-reported measures of social vulnerability indicators included: (1) Black race; (2) female gender; (3) no health insurance; (4) unemployment; (5) a high school diploma or less; and (6) financial-resource strain. Full attrition was defined as not completing at least one 3- or 6-month follow-up study visit. Log-binomial regression models adjusted for age, gender, race, medical comorbidities, and the other social vulnerability indicators to estimate the relative risk of each social vulnerability indicator with study attrition. Results: Among 825 participants, the mean age was 63.3 years (±11.7 years), 60% were women, 54% were Black, and 97% reported at least one social vulnerability. Overall, 21% participants had full attrition after study enrollment. After adjustment for all other social vulnerabilities, only financial-resource strain remained consistently associated with full attrition (relative risk, 1.71 [95% CI, 1.28–2.29]). In a secondary analysis of partial attrition (completed only one follow-up visit), financial-resource strain (relative risk, 1.40 [95% CI, 1.09–1.81]) and being uninsured (relative risk, 1.54 [95% CI, 1.01–2.34]) were associated with partial attrition. Conclusions: In a trial aimed at reducing disparities in medication adherence, participants who reported financial-resource strain had a higher risk of participant attrition independent of race or gender. Our findings suggest that efforts to retain diverse populations in clinical trials should extend beyond race and gender to consider other social vulnerability indicators. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03028597.

Objective To evaluate the feasibility, acceptability, and initial efficacy of a pilot texting intervention (“t4she”) in primary care designed to increase sexual health knowledge and promote dual protection strategies to reduce unintended pregnancies and sexually transmitted infections among adolescent females. Methods Participants were recruited from 2 federally qualified health centers. Eligibility included: being 13 to 18 years of age; assigned female at birth; English-speaking; not currently pregnant and/or intending to become pregnant; and having texting capabilities. A randomized controlled trial assessed between-group differences at 3 and 6 months on knowledge, Health Belief Model constructs, and sexual behaviors. Input on intervention acceptability was obtained at 3 months. Results Among 244 participants enrolled and randomized, the average age was 16 (±1.6), 80% were Hispanic/Latina, 53% had ever had vaginal sex, and 50% had used prescription birth control with 24% currently using a long-acting reversible method. Among those sexually active, 29% reported consistent condom use and 24% reported engaging in dual protection behaviors at last sex. Among participants with all follow-up data (N = 136), intervention participants had significant increases in sexual health knowledge and reported more prescription birth control use at follow-up than control participants. No significant outcome differences were found for condom use or dual protection behaviors. Intervention participants reported receiving messages, being introduced to new information, and reading and sharing the messages. Conclusions The pilot t4she sexual health intervention significantly improved knowledge and use of short-acting prescription birth control among young females in primary care and was acceptable by youth and feasible to implement.

Despite the many advantages of lung ultrasound (LUS) in the diagnosis and management of patients with dyspnea, its adoption among hospitalists has been slow. We performed semi-structured interviews of hospitals from four diverse health systems in the United States to understand determinants of adoption within a range of clinical settings. We used the diffusion of innovation theory to guide a framework analysis of the data. Of the 27 hospitalists invited, we performed 22 interviews from four hospitals of diverse types. Median years post-residency of interviewees was 10.5 [IQR:5-15]. Four main themes emerged: (1) There are important clinical advantages to LUS despite operator dependence, (2) LUS enhances patient and clinician experience, (3) Investment of clinician time to learn and perform LUS is a barrier to adoption but yields improved efficiency for the health system and (4) Mandated training and use may be necessary to achieve broad adoption as monetary incentives are less effective. Despite the perceived benefits of LUS for patients, clinicians and health systems, a significant barrier to broad LUS adoption is the experience of time scarcity by hospitalists. Future implementation strategies should focus on changes to the clinical environment that address clinician barriers to learning and adoption of new skills.

IMPORTANCE: Socioeconomic disadvantage is associated with poor health outcomes. However, whether socioeconomic factors are associated with post–myocardial infarction (MI) outcomes in younger patient populations is unknown. OBJECTIVE: To evaluate the association of neighborhood-level socioeconomic disadvantage with long-term outcomes among patients who experienced an MI at a young age. DESIGN, SETTING, AND PARTICIPANTS: This cohort study analyzed patients in the Mass General Brigham YOUNG-MI Registry (at Brigham and Women’s Hospital and Massachusetts General Hospital in Boston, Massachusetts) who experienced an MI at or before 50 years of age between January 1, 2000, and April 30, 2016. Each patient’s home address was mapped to the Area Deprivation Index (ADI) to capture higher rates of socioeconomic disadvantage. The median follow-up duration was 11.3 years. The dates of analysis were May 1, 2020, to June 30, 2020. EXPOSURES: Patients were assigned an ADI ranking according to their home address and then stratified into 3 groups (least disadvantaged group, middle group, and most disadvantaged group). MAIN OUTCOMES AND MEASURES: The outcomes of interest were all-cause and cardiovascular mortality. Cause of death was adjudicated from national registries and electronic medical records. Cox proportional hazards regression modeling was used to evaluate the association of ADI with all-cause and cardiovascular mortality. RESULTS: The cohort consisted of 2097 patients, of whom 2002 (95.5%) with an ADI ranking were included (median [interquartile range] age, 45 [42-48] years; 1607 male individuals [80.3%]). Patients in the most disadvantaged neighborhoods were more likely to be Black or Hispanic, have public insurance or no insurance, and have higher rates of traditional cardiovascular risk factors such as hypertension and diabetes. Among the 1964 patients who survived to hospital discharge, 74 (13.6%) in the most disadvantaged group compared with 88 (12.6%) in the middle group and 41 (5.7%) in the least disadvantaged group died. Even after adjusting for a comprehensive set of clinical covariates, higher neighborhood disadvantage was associated with a 32% higher all-cause mortality (hazard ratio, 1.32; 95% CI, 1.10-1.60; P = .004) and a 57% higher cardiovascular mortality (hazard ratio, 1.57; 95% CI, 1.17-2.10; P = .003). CONCLUSIONS AND RELEVANCE: This study found that, among patients who experienced an MI at or before age 50 years, socioeconomic disadvantage was associated with higher all-cause and cardiovascular mortality even after adjusting for clinical comorbidities. These findings suggest that neighborhood and socioeconomic factors have an important role in long-term post-MI survival.

PURPOSE: Women who experience out-of-hospital cardiac arrest have similar rates of survival to hospital admission as men; however, women are less likely to survive to hospital discharge. We hypothesized that women would have higher rates of “do not attempt resuscitation” (DNAR) orders and that this order would be associated with lower use of aggressive interventions. METHODS: We identified adult hospital admissions with a diagnosis of cardiac arrest (ICD-9 427.5) from the 2010 California State Inpatient Dataset. Multivariable logistic regression was used to test the association between patient sex and a DNAR order within the first 24 h of admission, adjusting for patient demographic characteristics and comorbid medical conditions. In secondary analysis, procedures performed after establishment of DNAR order and survival to hospital discharge were compared by sex. FINDINGS: We analyzed 6562 patients (44% women, 56% men) who experienced out-of-hospital cardiac arrest and survived to hospital admission. In unadjusted analysis, more women than men had establishment of a DNAR order during the first 24 h of admission (23.4% versus 19.3%; P < 0.01). After adjusting for age, race, and comorbid conditions, women remained significantly more likely to have a DNAR order established during the first 24 h of their hospital admission after cardiac arrest compared with men (odds ratio = 1.23; 95% CI,1.09–1.40). No sex difference was found in procedures used after DNAR order was established. IMPLICATIONS: Female survivors of cardiac arrest are significantly more likely than men to have a DNAR order established within the first 24 h of in-hospital treatment. The establishment of a DNAR order is associated with patients undergoing fewer procedures than individuals who do not have a DNAR order established. Given that patients who have a DNAR order receive less-aggressive intervention after arrest, it is possible that an early DNAR order may contribute to sex differences in survival to hospital discharge.

Author(s): Trent, Stacy A.; Morse, Erica A.; Ginde, Adit A.; Havranek, Edward P.; Haukoos, Jason S. | Abstract: Introduction: Despite significant morbidity and mortality from stroke, patient delays to emergency department (ED) presentation following the onset of stroke symptoms are one of the main contraindications to treatment for acute ischemic stroke (AIS). Our objective was to identify patient and environmental factors associated with delayed presentations to the ED after onset of stroke symptoms. Methods: This was a pre-planned secondary analysis of data from a multicenter, retrospective observational study at three hospitals in Colorado. We included consecutive adult patients if they were admitted to the hospital from the ED, and the ED diagnosed or initiated treatment for AIS. Patients were excluded if they were transferred from another hospital. Primary outcome was delayed presentation to the ED (g 3.5 hours) following onset stroke symptoms. Results: Among 351 patients, 63% presented to the ED more than 3.5 hours after onset of stroke symptoms. Adjusted results show that patients who presented in the evening hours (odds ratio [OR] [0.45], 95% confidence interval [CI] [0.3-0.8]), as compared to daytime, were significantly less likely to have a delayed presentation. Speaking a language other than English (Spanish [OR 3.3, 95% CI 1.2-8.9] and “other” [OR 9.1, 95% CI 1.2-71.0]), having known cerebrovascular risk factors (g2 risk factors [OR 2.4, 95% CI 1.05-5.4] and 1-2 risk factors [OR 2.3, 95% CI 1.03-5.1], compared to zero risk factors), and presenting to a rural hospital (OR 2.2, 95% CI 1.2-4.2), compared to urban, were significantly associated with delayed presentation. Conclusion: Important patient and environmental factors are significantly associated with delayed ED presentations following the onset of stroke symptoms. Identifying how best to educate patients on stroke risk and recognition remains critically important.

Background: Women who suffer an out-of-hospital cardiac arrest receive bystander cardiopulmonary resuscitation (CPR) less often than men. Understanding public perceptions of why this occurs is a necessary first step toward equitable application of this potentially life-saving intervention. Methods: We conducted a national survey of members of the public using Mechanical Turk, Amazon’s crowdsourcing platform, to determine reasons why women might receive bystander CPR less often than men. Eligible participants were adults (≥18 years) located in the United States. Responses were excluded if the participant was not able to define CPR correctly. Participants were asked to answer the following free-text question: “Do you have any ideas on why women may be less likely to receive CPR than men when they collapse in public?” Descriptive statistics were used to define the cohort. The free-text response was coded using open coding, and major themes were identified via classical content analysis. Results: In total, 548 subjects were surveyed. Mean age was 38.8 years, and 49.8% were female. Participants were geographically distributed as follows: 18.5% West, 9.2% Southwest, 22.0% Midwest, 27.5% Southeast, and 22.9% Northeast. After analysis, 3 major themes were detected for why the public perceives that women receive less bystander CPR. They include the following: (1) sexualization of women’s bodies; (2) women are weak and frail and therefore prone to injury; and (3) misperceptions about women in acute medical distress. Overall, 41.9% (227) were trained in CPR while 4.4% reported having provided CPR in a medical emergency. Conclusions: Members of the general public perceive fears about inappropriate touching, accusations of sexual assault, and fear of causing injury as inhibiting bystander CPR for women. Educational and policy efforts to address these perceptions may reduce the sex differences in the application of bystander CPR.

OBJECTIVES: Evidence-based clinical practice guidelines (CPGs) for the treatment of pneumonia and sepsis have existed for many years with multiple studies suggesting improved patient outcomes. Despite their importance, little is known about variation in emergency department (ED) adherence to these CPGs. Our objectives were to estimate variation in ED adherence across CPGs for pneumonia and sepsis and identify patient, provider, and environmental factors associated with adherence. METHODS: This was a multicenter retrospective study using standard medical record review methods. The population consisted of consecutive adults hospitalized for pneumonia or sepsis (identified by discharge ICD-9 codes) at five Colorado hospitals (two academic, three community) who were admitted to the hospital from the ED and for whom the ED diagnosed or initiated treatment. The outcome measured was ED adherence to the CPG (primary) and in-hospital mortality (secondary). Hierarchical generalized linear models were used for analysis. RESULTS: Among 827 patients, ED care was 57% adherence to CPGs with significant variation in adherence across CPGs (sepsis 50%, pneumonia 64%, p < 0.001). Patients were less likely to receive adherent care if they presented with chief complaints that were associated but not typical of the diagnosis (odds ratio [OR] = 0.6, 95% confidence interval [CI] = 0.4–0.8), received an ED diagnosis that was not specific to the CPG (associated diagnosis OR = 0.3 [95% CI = 0.2–0.5]; unrelated diagnosis OR = 0.4 [95% CI = 0.2–0.6]) or presented to a community hospital (OR = 0.6,95% CI = 0.4–0.9). ED CPG nonadherence was associated with higher in-hospital mortality (OR = 2.4, 95% CI = 1.2–4.8). CONCLUSION: Adherence to ED infectious CPGs for pneumonia and sepsis varies significantly across diseases and types of institutions with significant room for improvement, especially in light of a significant association with in-hospital mortality.

BACKGROUND Evidence-based guidelines are often cited as a means of ensuring high-quality care for all patients. Our objective was to assess whether emergency department (ED) adherence to core evidence-based guidelines differed by patient sex and race/ethnicity and to assess the effect of ED guideline adherence on patient outcomes by sex and race/ethnicity. METHODS We conducted a preplanned secondary analysis of data from a multicenter retrospective observational study evaluating variation in ED adherence to five core evidence-based treatment guidelines including aspirin for acute coronary syndrome, door-to-balloon time for acute ST-elevation myocardial infarction, systemic thrombolysis for acute ischemic stroke, antibiotic selection for inpatient pneumonia, and early management of severe sepsis/septic shock. This study was performed at six hospitals in Colorado with heterogeneous and diverse practice environments. Hierarchical generalized linear modeling was used to estimate adjusted associations between ED adherence and patient sex and race/ethnicity while controlling for other patient, physician, and environmental factors that could confound this association. RESULTS A total of 1,880 patients were included in the study with a median (IQR) age of 62 (51-74) years. Males and non-Hispanic whites comprised 59% and 71% of the cohort, respectively. While unadjusted differences were identified, our adjusted analyses found no significant association between ED guideline adherence and sex or race/ethnicity. Patients who did not receive guideline adherent care in the ED were significantly more likely to die while in the hospital (odds ratio = 2.0, 95% confidence interval = 1.3 to 3.2). CONCLUSIONS Longstanding, nationally reported evidence-based guidelines can help eliminate sex and race/ethnicity disparities in quality of care. When providers know their care is being monitored and reported, their implicit biases may be less likely to impact care.

Our goal was to develop a patient-centered text-message intervention for adolescent females in an urban safety-net health system. We conducted interviews with adolescent females to explore sexual health knowledge and inform the development of a text-messaging intervention. Focused group discussions (FGDs) verified or challenged interview themes and elicited preferences for intervention design. Forty-two females participated, including 15 interviewees and 27 FGD participants. Over half (67%) were Hispanic/Latina, 19% Black, 10% White and 5% Asian. The average age was 16 (±1.5) and 55% reported ever having sex. Participants felt susceptible to and were more concerned with preventing unintended pregnancies than sexually transmitted infections, and described more barriers to condom use than other contraceptive methods. Their input informed the development of a text-messaging intervention, which is described. This study supports the acceptability of a patient-centered texting intervention for promoting and normalizing healthy sexual behaviors among adolescent females in an urban safety-net setting.

Background: Prehospital emergency care is a vital component of healthcare access, and emergency medical services (EMS) plays an essential role in healthcare delivery. Understanding the distribution of medical and trauma EMS calls at the neighborhood level would be beneficial to identify at-risk communities and facilitate targeted interventions. Objectives: The primary objective was to evaluate and characterize 9-1-1 ambulance contacts for medical and trauma-related events in Denver. The secondary objective was to evaluate the co-existence of medical and trauma-related EMS calls to determine if these emergencies occur in the same neighborhoods. Methods: We conducted a secondary analysis of prospectively collected EMS calls in Denver between January 1, 2011, through August 8, 2017. The primary outcome was the incidence of trauma and medical EMS calls in each census tract. EMS events were aggregated to tracts and incidence rates were calculated based on the adult daytime and nighttime population. Three different spatial analysis methods (SaTScan's spatial scan statistic, Gini coefficient, and Local Moran's I) were utilized to identify clusters of medical and trauma EMS events at the tract level. Results: A total of 425,527 EMS calls in 142 census tracts occurred during the study period. The median age of study participants was 48 (IQR 33, 62), 56% were male, and the majority (74%) of EMS calls were for medical events. An emergent EMS return to the hospital occurred in 5% of all calls. We identified several high-risk census tracts with a coexistence of medical and trauma EMS events. When compared to the Denver County population, the tracts with high EMS call rates were diverse, with many tracts exhibiting a higher proportion of black, unemployment, below poverty, and lower median income while other tracts demonstrated a smaller proportion of black, unemployment, below poverty, and a higher median income. Conclusions: Disparities exist in the distribution of medical and trauma EMS calls in varied census tracts in Denver. Identifying neighborhoods in which there is an incidence of higher medical and trauma emergencies is important to guide EMS care delivery and may help facilitate targeted public health interventions for at-risk populations to improve health outcomes.

Introduction: Women who suffer an out of hospital cardiac arrest receive bystander cardiopulmonary resuscitation (bCPR) less often than men. We sought to determine if there were differences in potential deterrents to providing CPR if the rescuer was a man or a woman. Methods: We surveyed participants via Amazon’s Mechanical Turk, a national crowdsourcing platform, to query why women receive less bCPR than men based on the sex of the rescuer. We asked participants to rank five themes previously identified. Eligible participants were ≥18 years, US residents, and correctly defined CPR. Participants were asked to rank the 5 following themes if the sex of the rescuer was unidentified sex, male, and female: 1) Rescuers are afraid to injure or hurt women; 2) Rescuers might have a misconception that women don’t suffer cardiac arrest; 3) Rescuers are afraid to be accused of sexual assault or sexual harassment; 4) Rescuers have a fear of touching women or that the touch might be inappropriate; 5) Rescuers think that women are “faking it” or being “overdramatic.” Results: In total, 576 participants were surveyed, and 520 responses were formally analyzed. The respondents were 42.3% female, 74.2% Caucasian, 10.4% African American, and 6.7% Hispanic. To determine a “consensus” ranking, a statistical model that finds the mode of the rankings was used, generating separate results for each of the categories of rescuer. This method determined that the modal ranking for respondents asked about a female rescuer was Hurt/Injure, Touch, Overdramatic, Misconception, Sexual Assault/Harassment. By contrast, when respondents were asked about a male rescuer, the modal ranking was found to be Touch, Sexual Assault/Harassment, Hurt/Injure, Misconception, Overdramatic. When the sex of the rescuer was not identified, the modal ranking was identical to that for the male rescuer question. Conclusion: When querying the public as to why women receive less-bystander CPR than men, there were differences in response based on the sex of the rescuer. Participants reported that a male rescuer would potentially be hindered by fears of accusation of sexual assault/harassment or inappropriate touch, while female rescuers would be more deterred due to fears of causing physical injury or harm.

Background: Despite improved survival and increasing hospital mandates, discordance with sepsis resuscitation guidelines is common. We sought to determine whether choice architecture can promote faster or slower decision-making among physicians and the associated risk of guideline-discordance in sepsis.Methods: We conducted an electronic, survey-based time-to-event analysis using a sepsis clinical vignette and multivariable Cox proportional hazards regression. Respondents included physicians from multiple specialties and levels of training at an academic tertiary-care hospital and academic safety-net hospital. Respondents were randomized to one of three distinct answer sets: control (6 options with no time limit), time constraint (10 seconds, intended to promote faster thinking) or choice overload (24 options, intended to promote slower thinking). The primary outcomes were response time and discordance with Surviving Sepsis Campaign 2016 fluid resuscitation guidelines, adjusting for physician characteristics. Physician risk tolerance and predisposition towards intuitive or analytical thinking were assessed for effect modification.Results: 189 of 624 (30.3%) physicians completed the survey. Total response time was lower in time constraint (45.8s, IQR 38.3s-56.6s, PConclusions: Choice architecture may impact clinical decisions and guideline discordance in sepsis, warranting further investigation in real-world contexts.

Background: Clinical research has long suffered from a lack of research participants of diverse backgrounds, such as racial-ethnic minorities and women. How social determinants of health (SDOH) influence retention of research participants in clinical trials has not been well studied. Among a population of patients from three diverse health systems who enrolled in a prospective trial testing a psychosocial intervention, values affirmation, on racial disparities in hypertension medication adherence, we assessed whether SDOH were associated with study retention over 6 months. Methods: Adults who self-identified as non-Hispanic White or Black/African American, had uncontrolled hypertension and enrolled in the Hypertension and Values (HYVALUE) trial from January 2016 through June 2019 were included. Measures of high SDOH burden included: 1) self-reported low-education attainment (high school diploma or equivalent or less than a high school education), 2) difficulty paying for basics (individuals that reported it was hard to pay for the basics like food, housing, medical care, and heating), OR 3) social isolation (unmarried or lived alone). Poor study retention was defined as not completing at least one of the 3- or 6-month follow-up visits. Log binomial regression models adjusting for age, gender, and race-ethnicity were used to estimate the probability of study retention associated with 1 or more SDOH factors. Results: Among 814 study participants, the mean age was 63 years (standard deviation, 11.7 years), 59.1% were women, 51.2% were African-American, and 68.6% had at least one SDOH factor. Overall, 78.1% of participants completed at least one follow-up study visit. African-American participants, women, and individuals with public insurance (i.e., Medicare and/or Medicaid) were more likely to have at least one SDOH factor (72.4% of AAs vs 64.5% of white, 71.1% of women vs 64.5% of men, and 75.2% of those with public insurance vs 53.9% with commercial, respectively). Participants with at least one SDOH factor were less likely to have to have completed a follow-up visit compared to those with no SDOH (75.1% vs 84.8%, p =0.002). When adjusted for age, gender and race-ethnicity, those with at least one SDOH remained significantly less likely to have completed a follow-up visit (adjusted RR 0.91, 95% CI 0.85-0.97). Conclusions: In an ongoing prospective trial evaluating the impact of a Values Affirmation intervention on hypertension medication adherence, we found that a higher burden of SDOH was associated with poorer study retention independent of age, gender or race. Our study suggests that trials with diverse populations should consider retention plans that are attentive to challenges of socially disadvantaged participants.

The objective was to estimate the effect of feedback with blinded peer comparison on emergency physician adherence to guidelines for appropriate antibiotic administration for inpatient pneumonia and completion of the 3-hour Surviving Sepsis Bundle for severe sepsis. The authors performed a quasi-experiment using a stepped wedge design at a single urban safety net hospital. Attending emergency physicians were randomized into 6 clusters. Once a cluster crossed into the intervention group, physicians in that cluster began receiving detailed feedback with blinded peer comparison on their adherence to guidelines for pneumonia and sepsis. Feedback with blinded peer comparison significantly improved guideline adherence from 52% without feedback to 65% with feedback (difference = 13%, 95% confidence interval = 4% to 22%). In adjusted analyses, the odds of providing guideline adherent care were 1.8 (95% confidence interval = 1.01-3.2) after the introduction of feedback with blinded peer comparison. Feedback with blinded peer comparison significantly improved emergency physician guideline adherence.

Background Prehospital (ambulance) care can reduce morbidity and mortality from trauma. Yet, there is a dearth of effective evidence-based interventions and implementation strategies. Emergency Medical Services Traumatic Shock Care (EMS-TruShoC) is a novel bundle of five core evidence-based trauma care interventions. High-Efficiency EMS Training (HEET) is an innovative training and sensitization program conducted during clinical shifts in ambulances. We assess the feasibility of implementing EMS-TruShoC using the HEET strategy, and feasibility of assessing implementation and clinical outcomes. Findings will inform a main trial. Methods We conducted a single-site, prospective cohort, multi-methods pilot implementation study in Western Cape EMS system of South Africa. Of the 120 providers at the study site, 12 were trainers and the remaining were eligible learners. Feasibility of implementation was guided by the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. Feasibility of assessing clinical outcomes was assessed using shock indices and clinical quality of care scores, collected via abstraction of patients’ prehospital trauma charts. Thresholds for progression to a main trial were developed a priori. Results The average of all implementation indices was 83% (standard deviation = 10.3). Reach of the HEET program was high, with 84% learners completing at least 75% of training modules. Comparing the proportion of learners attaining perfect scores in post- versus pre-implementation assessments, there was an 8-fold (52% vs. 6%) improvement in knowledge, 3-fold (39% vs. 12%) improvement in skills, and 2-fold (42% vs. 21%) increase in self-efficacy. Clinical outcomes data were successfully calculated—there were clinically significant improvements in shock indices and quality of prehospital trauma care in the post- versus pre-implementation phases. Adoption of HEET was good, evidenced by 83% of facilitator participation in trainings, and 100% of surveyed stakeholders indicating good programmatic fit for their organization. Stakeholders responded that HEET was a sustainable educational solution that aligned well with their organization. Implementation fidelity was very high; 90% of the HEET intervention and 77% of the implementation strategy were delivered as originally planned. Participants provided very positive feedback, and explained that on-the-job timing enhanced their participation. Maintenance was not relevant to assess in this pilot study. Conclusions We successfully implemented the EMS-TruShoC educational intervention using the HEET training strategy in a single-site pilot study conducted in a low-resource international setting. All clinical outcomes were successfully calculated. Overall, this pilot study suggests high feasibility of our future, planned experimental trial.

OBJECTIVES: Myocardial infarction and stroke are two of the leading causes of death in the U.S. Both diseases have clinical practice guidelines (CPGs) specific to the emergency department (ED) that improve patient outcomes. Our primary objectives were to estimate differences in ED adherence across CPGs for these diseases and identify patient, provider, and environmental factors associated with adherence. METHODS: Design: Retrospective study at 3 hospitals in Colorado using standard medical record review. Population: Consecutive adults (≥18) hospitalized for acute coronary syndrome (ACS), ST-elevation myocardial infarction (STEMI), or acute ischemic stroke (AIS), who were admitted to the hospital from the ED and for whom the ED diagnosed or initiated treatment. Outcome: ED adherence to the CPG (primary); in-hospital mortality and length-of-stay (secondary). Analysis: Multivariable logistic regression using generalized estimating equations was used. RESULTS: Among 1053 patients, ED care was adherent in 84% with significant differences in adherence between CPGs (p < 0.001) and across institutions (p = 0.04). When patients presented with atypical chief complaints, the odds of receiving adherent care was 0.6 (95% CI 0.4–0.9). When the primary ED diagnosis was associated but not specific to the CPG, the odds of receiving adherent care was 0.5 (95% CI 0.3–0.9) and 0.3 (95% CI 0.2–0.5) for unrelated primary diagnoses. CONCLUSIONS: Adherence to ED CPGs for ACS, STEMI and AIS differs significantly between cardiovascular and cerebrovascular diseases and is more likely to occur when the diagnosis is highly suggested by the patient's complaint and acknowledged as the primary diagnosis by the treating ED physician.

Background: Previous studies have shown that comatose survivors of cardiac arrest awaken approximately 3 days after return of spontaneous circulation (ROSC) however, variability in time to awakening is frequently observed. Recent data has shown that women metabolize drugs (sedatives and paralytics) differently than men. It is unknown if there are sex based differences in time to awakening for comatose survivors of cardiac arrest, and if this phenomenon might be affected by differences in withdrawal of life sustaining therapy (WLST). Objective: To determine if comatose women have different times to awakening after resuscitation from cardiac arrest. Methods: We analyzed 327 consecutive charts from a single center registry of all out of hospital cardiac arrest patients who had return of spontaneous circulation but remained comatose, cared for at an urban academic tertiary care hospital. Patient demographic and arrest characteristics were abstracted. We identified day of awakening for comatose survivors by abstracting day when Glasgow coma motor score was 6 as documented in nursing flowsheets. Time to withdrawal of life sustaining therapy was also abstracted for the cohort that did not awaken. Patients were excluded from analysis if they did not awaken or if they died for reasons other than WLST. Results: Twenty-eight percent of patients woke prior to hospital discharge and 43.4% underwent withdrawal of life sustaining therapy. Women made up 39.5% of the total cohort, 40% of the awakened cohort and 41% of the WLST cohort. Women had earlier day of awakening in comparison to men (day 2 (2, 4) vs. day 4 (2,5), p=0.0036), and also earlier time to WLST after ROSC than men (59 hours (26, 131) vs. 64 hours (22, 135), p=NS). Conclusion: In this single center cohort, there was a difference in time to awakening between men and women. How time to awakening might differ between the sexes with guideline concordant time to WLST is unknown. Further research is necessary to explore the role of therapeutic interventions and differing physiology between men and women as it applies to time to awakening.

Introduction: Post cardiac arrest patients frequently rely on surrogate decision makers (SDM) for critical decisions during their hospitalization. Our prior research has shown that bedside nurses are key resources for SDMs. Nurses’ understanding of post-arrest guidelines is therefore crucial if post-arrest care is to be concordant with guidelines. Objective: To explore critical care nurses familiarity with neuroprognostic guidelines and learn how they support families with decision making in the ICU. Methods: This inductive qualitative study consists of interviews with critical care nurses at an urban academic hospital. Subjects were identified by reviewing the care team of recent cardiac arrest patients. Nurses were invited by email to participate. Using a standardized interview guide, one on one interviews were conducted, audio recorded, and transcribed. Transcripts were read in entirety and thematically coded by two investigators. Results: Seven critical care nurses participated in this study. The participants were predominately female (6/7), mean age 32.4 years and had worked in critical care nursing from 1 year to 16 years. The nurses interviewed were based in the medical (3), cardiac (2) and neuro (2) ICUs. Major themes identified were: 1) discussion regarding prognosis is a team approach; 2) interpretation of neuroprognostic guidelines by nurses is variable; 3) communicating uncertainty to families and setting expectations is challenging. Excerpts to support these themes are identified in the table. Conclusion: Nurses are critical stakeholders in supporting surrogate decision makers in their decision-making. Ensuring that they are supported in relaying similar messages as the physician team, provided with more information regarding neurologic prognostication and supported in how to communicate uncertainty/set expectations will assist nurses in the integral and unique roll they play at the bedside of the post-cardiac arrest patient.

Introduction. This study investigated participants' acceptance of a short messaging service (SMS) intervention designed to support asthma management, including suggestions regarding program delivery and message content. Methods. Individual and group interviews were conducted with patients from a safety-net health care system in Denver, Colorado. Eligible participants were English or Spanish speakers between the ages of 13 and 40 years, with diagnosed persistent asthma. All individual and group interviews were digitally recorded, transcribed, translated from Spanish to English (where applicable), and analyzed for thematic content by experienced analysts using established qualitative content techniques. The qualitative software package ATLAS.ti was used for data analysis and management. Results. This study included a total of 43 participants. In general, participants were receptive toward the SMS program and supported the use of tailored and interactive messages. Adolescents supported the idea of enhancing care by sending messages to a support person, such as a parent or guardian. However, adults were less receptive toward this idea. Participants also preferred directive educational messages and cues to action, while general messages reminding them of their asthma diagnosis were viewed less favorably. Implications. The results from this study will inform a randomized control trial evaluating the efficacy of the SMS intervention.

Key Points Question Does a writing intervention focused on affirming one’s personal values improve adherence to hypertension medication? Findings In this randomized clinical trial including 960 adults with hypertension, patients who received a values affirmation intervention prior to a primary care visit had no significant change in 3-month or 6-month medication adherence or blood pressure compared with controls. Intervention response was comparable in self-identified Black and White patients. Meaning A brief writing exercise that affirms individual values did not significantly improve adherence to medication or blood pressure for Black or White patients with hypertension., Importance Stereotype threat, or the fear of confirming a negative stereotype about one’s social group, may contribute to racial differences in adherence to medications by decreasing patient activation to manage chronic conditions. Objective To examine whether a values affirmation writing exercise improves medication adherence and whether the effect differs by patient race. Design, Setting, and Participants The Hypertension and Values trial, a patient-level, blinded randomized clinical trial, compared an intervention and a control writing exercise delivered immediately prior to a clinic appointment. Of 20 777 eligible, self-identified non-Hispanic Black and White patients with uncontrolled hypertension who were taking blood pressure (BP) medications, 3891 were approached and 960 enrolled. Block randomization by self-identified race ensured balanced randomization. Patients enrolled between February 1, 2017, and December 31, 2019, at 11 US safety-net and community primary care clinics, with outcomes assessed at 3 and 6 months. Analysis was performed on an intention-to-treat basis. Interventions From a list of 11 values, intervention patients wrote about their most important values and control patients wrote about their least important values. Main Outcomes and Measures The primary outcome of adherence to BP medications was measured using pharmacy fill data (proportion of days covered >90%) at baseline, 3 months, and 6 months. The secondary outcome was systolic and diastolic BP. Patient activation to manage their health was also measured. Results Of 960 patients, 474 (286 women [60.3%]; 256 Black patients [54.0%]; mean [SD] age, 63.4 [11.9] years) were randomly assigned to the intervention group and 486 (288 women [59.3%]; 272 Black patients [56.0%]; mean [SD] age, 62.8 [12.0] years) to the control group. Baseline medication adherence was lower (318 of 482 [66.0%] vs 331 of 412 [80.3%]) and mean (SE) BP higher among Black patients compared with White patients (systolic BP, 140.6 [18.5] vs 137.3 [17.8] mm Hg; diastolic BP, 83.9 [12.6] vs 79.7 [11.3] mm Hg). Compared with baseline, pharmacy fill adherence did not differ between intervention and control groups at 3 months (odds ratio [OR], 0.91 [95% CI, 0.57-1.43]) or at 6 months (OR, 0.86 [95% CI, 0.53-1.38]). There were also no treatment effect differences in pharmacy fill adherence by patient race (Black patients at 3 months: OR, 1.08 [95% CI, 0.61-1.92]; at 6 months: OR, 1.04 [95% CI, 0.58-1.87]; White patients at 3 months: OR, 0.68 [95% CI, 0.33-1.44]; at 6 months: OR, 0.55 [95% CI, 0.24-1.27]). Immediately after the intervention, the median patient activation was higher in intervention patients than in control patients, but this difference was not statistically significant in an unadjusted comparison (75.0 [IQR, 65.5-84.8] vs 72.5 [IQR, 63.1-80.9]; P = .06). In adjusted models, the Patient Activation Measure score immediately after the intervention was significantly higher in the intervention patients than in control patients (mean difference, 2.3 [95% CI, 0.1-4.5]). Conclusions and Relevance A values affirmation intervention was associated with higher patient activation overall but did not improve adherence or blood pressure among Black and White patients with hypertension. Trial Registration ClinicalTrials.gov Identifier: NCT03028597, This randomized clinical trial examines whether a values affirmation writing exercise improves medication adherence and whether the effect differs by patient race and ethnicity.

Depression prevalence is known to vary by individual factors (gender, age, race, medical comorbidities) and by neighborhood factors (neighborhood deprivation). However, the combination of individual- and neighborhood-level data is rarely available to assess their relative contribution to variation in depression across neighborhoods. We geocoded depression diagnosis and demographic data from electronic health records for 165,600 patients seen in two large health systems serving the Denver population (Kaiser Permanente and Denver Health) to Denver's 144 census tracts, and combined these data with indices of neighborhood deprivation obtained from the American Community Survey. Non-linear mixed models examined the relationships between depression rates and individual and census tract variables, stratified by health system. We found higher depression rates associated with greater age, female gender, white race, medical comorbidities, and with lower rates of home owner occupancy, residential stability, and higher educational attainment, but not with economic disadvantage. Among the Denver Health cohort, higher depression rates were associated with higher crime rates and a lower percent of foreign born residents and single mother households. Our findings suggest that individual factors had the strongest associations with depression. Neighborhood risk factors associated with depression point to low community cohesion, while the role of education is more complex. Among the Denver Health cohort, language and cultural barriers and competing priorities may attenuate the recognition and treatment of depression.

Purpose: To study the effect of the National Diabetes Prevention Program (NDPP) on weight loss in Latinos. Design: No-control, cohort study comparing Latino and non-Hispanic white (NHW) participants. Setting: A health-care system. Participants: Five hundred sixty-seven Latino and 175 NHW patients who enrolled in the NDPP. A total of 45.2% of Latinos selected the Spanish-language NDPP. Intervention: The NDPP is a nationwide translation of a clinical trial and seeks to prevent diabetes through weight loss in a yearlong group program. Measures: Independent variables included ethnicity, class language, and number of sessions attended. Main outcomes were initial attendance, number of sessions attended, and weight loss. Analysis: Multivariate logistic regression and analysis of covariance were used to determine differences in NDPP outcomes by ethnicity, language, and number of sessions attended. Results: Mean attendance was 8.60 of 22 sessions. Each session was associated with 0.30% (±0.02; P < .001) body weight loss. Latinos were half as likely to attend as NHWs, odds ratio 0.52 ( P < .001). Latino attendees came to 2.67 ± 0.63 ( P < .001) fewer sessions than NHWs. There were no weight loss differences by ethnicity after controlling for attendance. Outcomes did not differ among Latinos in the English- and Spanish-language NDPP. Conclusion: Latinos appeared to benefit less from the NDPP compared to NHWs, likely due to lower attendance rates. Further efforts are needed to support their participation.

While contemporary heart failure management has led to some improvements in morbidity and mortality, patients continue to report poor health status (i.e., burdensome symptoms, impaired function, and poor quality of life). The Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) trial is a NIH-funded, three-site, randomized clinical trial that examines the effect of the CASA intervention compared to usual care on the primary outcome of patient-reported health status at 6 months in patients with heart failure and poor health status. The CASA intervention involves a nurse who works with patients to treat symptoms (e.g., shortness of breath, fatigue, pain) using disease-specific and palliative approaches, and a social worker who provides psychosocial care targeting depression and adjustment to illness. The intervention uses a collaborative care team model of health care delivery and is structured and primarily phone-based to enhance reproducibility and scalability. This article describes the rationale and design of the CASA trial, including several decision points: (1) how to design a patient-centered intervention to improve health status; (2) how to structure the intervention so that it is reproducible and scalable; and (3) how to systematically identify outpatients with heart failure most likely to need and benefit from the intervention. The results should provide valuable information to providers and health systems about the use of team care to manage symptoms and provide psychosocial care in chronic illness.

Rationale There remains significant controversy regarding the optimal approach to fluid resuscitation for patients in shock. The magnitude of care variability in shock resuscitation, the confounding effects of disease severity and comorbidity, and the relative impact on sepsis survival are poorly understood. Objective To evaluate usual care variability and determine the differential effect of observed and predicted fluid resuscitation volumes on risk-adjusted hospital mortality for mechanically ventilated patients in shock. Methods We performed a retrospective outcome analysis of mechanically ventilated patients admitted to intensive care units using the 2013 Premier Hospital Database (Premier, Inc.). Observed and predicted hospital mortality were evaluated by observed and predicted day 1 fluid administration, using the difference in predicted and observed outcomes to adjust for disease severity between groups. Both predictive models were validated using a second large administrative database (Truven Health Analytics Inc.). Secondary outcomes included duration of mechanical ventilation, hospital and ICU length of stay, and cost. Results Among 33,831 patients, observed hospital mortality was incrementally higher than predicted for each additional liter of day 1 fluid beginning at 7 L (40.9% vs. 37.2%, p = 0.008). Compared to patients that received expected (± 1.5 L predicted) day 1 fluid volumes, greater-than-expected fluid resuscitation was associated with increased risk-adjusted hospital mortality (52.3% vs. 45.0%, p p p p = 0.037) day 1 fluid resuscitation were associated with increased risk-adjusted hospital mortality. Conclusions Highly variable day 1 fluid resuscitation was associated with a non-uniform impact on risk-adjusted hospital mortality among distinct subgroups of mechanically ventilated patients with shock. These findings support closer evaluation of fluid resuscitation strategies that include broadly applied fluid volume targets in the early phase of shock resuscitation.

Background: Latinos with end-stage renal disease (ESRD) have worse mental and kidney composite health-related quality of life (HRQOL) scores compared to non-Latino ESRD patients. Latino ESRD patients uniquely report that social factors (e.g., lack of care coordination, food insecurity, and low health literacy) and mental health influence their HRQOL. We developed a culturally tailored peer navigator (PN) intervention to improve the HRQOL of Latinos on hemodialysis. Objective: To determine the feasibility of the PN intervention. Design: Single-arm prospective study. The PN provided individualized support with advance care planning, care coordination, and counseling about the importance of diet and mental health. Setting and Participants: Latino with ESRD receiving scheduled outpatient thrice-weekly hemodialysis or reliant on emergency-only hemodialysis in Denver. Main measures: Recruitment, retention rates, data completeness, intervention dose, patient- and staff-reported satisfaction with the intervention. Results: Of 49 eligible patients, 40 (82%) agreed to participate. The majority of participants received scheduled outpatient hemodialysis (75%), 20 were women (50%), with a mean (standard deviation [SD]) age of 56 (13) years. No participants withdrew from the intervention. One participant died. The mean (SD) number of PN visits per participant was 7 (2) and the mean (SD) length of the visits was 97 minutes (49). The majority of visits took place at the hemodialysis facility (59%) and home (27%). The vast majority of participants reported that the PN improved their quality of life as a patient on hemodialysis (95%). Conclusions: The PN intervention achieved feasibility goals and was well received by participants.

BACKGROUND: To enhance the acute care delivery system, a comprehensive understanding of the patient’s perspectives for seeking care in the emergency department (ED) versus primary care (PC) is necessary. METHODS: We conducted a qualitative metasynthesis on reasons patients seek care in the ED instead of PC. A comprehensive literature search in PubMed, CINAHL, Psych Info, and Web of Science was completed to identify qualitative studies relevant to the research question. Articles were critically appraised using the McMaster University Critical Review Form for Qualitative Studies. We excluded pediatric articles and nonqualitative and mixed-methods studies. The metasynthesis was completed with an interpretive approach using reciprocal translation analyses. RESULTS: Nine articles met criteria for inclusion. Eleven themes under four domains were identified. The first domain was acuity of condition that led to the ED visit. In this domain, themes included pain: “it’s urgent because it hurts,” and concern for severe illness. The second domain was barriers associated with PC, which included difficulty accessing PC when ill: “my doctor said he was booked up and he instructed me to go to the ED.” The third domain was related to multiple advantages associated with ED care: “my doctor cannot do X-rays and laboratory tests, while the ED has all the technical support.” In this domain, patients also identified 24/7 accessibility of the ED and no need for an immediate copay at the ED as advantageous. The fourth domain included fulfillment of medical needs. Themes in this domain included the alleviation of pain and the perceived expertise of the ED healthcare providers. CONCLUSIONS: In this qualitative metasynthesis, reasons patients visit the ED over primary care included (1) urgency of the medical condition, (2) barriers to accessing primary care, (3) advantages of the ED, and (4) fulfillment of medical needs and quality of care in the ED.

Introduction: Women who suffer an out of hospital cardiac arrest have been observed to receive less bystander cardiopulmonary resuscitation (CPR) than men. Potential reasons for why women receive less bystander CPR than men are largely unknown. Methods: Mechanical Turk (MTurk), Amazon’s crowdsourcing platform, was used to pilot a national survey asking participants why they believe women receive less bystander CPR than men. Eligible participants were adults (18 years or over) located in the US. Participants were reimbursed $1 for their participation. To ensure adequate knowledge on the subject, survey responses were excluded if they incorrectly defined CPR. Participant demographics as well as familiarity with CPR were queried. Participants were asked to answer the following free-text question “Do you have any ideas on why women may be less likely to receive CPR than men when they collapse in public?” Descriptive statistics were used to define the cohort. The free text response was coded using thematic analysis and major themes were identified via classical content analysis. Results: Within 55 minutes of deploying the pilot survey, 54 individuals responded. All respondents answered the knowledge question correctly, and none were excluded. Mean age was 36.9 ±9.6 years and 38.9% were female. Participants were geographically distributed as follows: 13% West, 13% Southwest, 16.7% Midwest, 27.8% Southeast, 29.6% Northeast. Predominant themes identified for why women might receive less bystander CPR than men are identified in Table 1. Within this cohort, 27.8% were trained in CPR, and only 5.6% of respondents had actually performed CPR on a person. Conclusions: In this pilot survey, public perceptions identified social norms regarding fear of inappropriate touching and hurting women as significant contributors to reasons for why women receive less bystander CPR than men. Additional work using a larger national sample to confirm and expand on these findings is ongoing.

Introduction: Out-of-hospital cardiac arrest (OHCA) is an unexpected event that can render patients incapable of decision-making, requiring a surrogate decision maker (SDM), most often a family member, to be engaged. Yet how SDMs understand the information provided, and how they view their experience of making decisions for cardiac arrest patients is not well understood. Methods: This inductive qualitative study utilized data from semi-structured open-ended interviews with SDMs for OHCA patients. SDMs were approached: 1) at the bedside for consent to contact; and 2) 30 days after discharge/death to consent to interview. Interviews were conducted using a semi-structured interview guide, recorded, and transcribed for analysis. Transcripts were read in entirety and thematically coded by two investigators. Results: Over a 5-month period (1/18-5/18), 7 SDMs consented; however, 11 individuals were interviewed, as 3 SDMs invited family members to join the interviews. SDMs were living spouses (2), adult children (2), a parent (1) and siblings (2). Within this sample, 71.4% (5/7) of SDMs decided to withdraw life sustaining therapy or discontinue resuscitative efforts for their family member. Overall, experiences varied dramatically, with some families reporting a positive experience and others clearly reporting concerns about how the decision making process occurred. Major themes identified that affected the experience of decision-making include how SDMs perceived provider communication style, how they processed medical uncertainty from the providers, confidence in their decisions, and finally, conflict/discordance between the medical team and family. Families identified the following factors that might improve the decision making process for future SDMs; 1) updated “goals for the day”; 2) access to medical records; 3) Access to protocols for post-arrest patients; 4) a consistent liaison to the medical team; 5) consistent messaging amongst the care team. Conclusions: In this sample of SDMs, experiences with decision-making were variable. Notably, communication factors predominated in SDMs experience with decision-making. Finally, multiple important factors were identified to assist future SDMs in decision making for post-OHCA patients.

Vascular markers such as pulse-wave velocity and carotid intima-media thickness (CIMT) might improve the prediction of incident cardiovascular disease beyond traditional risk factors. These vascular markers have not been well characterized in minority populations and might be more useful than inflammatory biomarkers. We conducted a prospective, longitudinal cohort study among hypertensive patients in an urban safety-net hospital. We evaluated inflammatory biomarkers, arterial pulse-wave velocity, and carotid intima-media thickness at baseline, 1 year, and 2 years. The primary outcome variable was CIMT. Generalized linear mixed-effects models were used to evaluate associations between CIMT and predictive variables accounting for the correlation of multiple measurements within subjects over time. For our secondary outcome, we used administrative and National Death Index data to determine all-cause death, and univariate relationships were evaluated. Among 175 subjects, 117 were Latino (67%) and 117 were female (67%). Pulse-wave velocity and CIMT regressed over time (both P

Objective To summarize research relating to health services research translation in the safety net through analysis of the literature and case study of a safety net system. Data Sources/Study Setting Literature review and key informant interviews at an integrated safety net hospital. Study Design This paper describes the results of a comprehensive literature review of translational science literature as applied to health care paired with qualitative analysis of five key informant interviews conducted with senior-level management at Denver Health and Hospital Authority. Principal Findings Results from the literature suggest that implementing innovation may be more difficult in the safety net due to multiple factors, including financial and organizational constraints. Results from key informant interviews confirmed the reality of financial barriers to innovation implementation but also implied that factors, including institutional respect for data, organizational attitudes, and leadership support, could compensate for disadvantages. Conclusions Translating research into practice is of critical importance to safety net providers, which are under increased pressure to improve patient care and satisfaction. Results suggest that translational research done in the safety net can better illuminate the special challenges of this setting; more such research is needed.

BACKGROUND Medication nonadherence is a significant, modifiable contributor to uncontrolled hypertension. Stereotype threat may contribute to racial disparities in adherence by hindering a patient’s ability to actively engage during a clinical encounter, resulting in reduced activation to adhere to prescribed therapies. OBJECTIVE The Hypertension and Values (HYVALUE) trial aims to examine whether a values-affirmation intervention improves medication adherence (primary outcome) by targeting racial stereotype threat. METHODS The HYVALUE trial is a patient-level, blinded randomized controlled trial comparing a brief values-affirmation writing exercise with a control writing exercise among black and white patients with uncontrolled hypertension. We are recruiting patients from 3 large health systems in the United States. The primary outcome is patients’ adherence to antihypertensive medications, with secondary outcomes of systolic and diastolic blood pressure over time, time for which blood pressure is under control, and treatment intensification. We are comparing the effects of the intervention among blacks and whites, exploring possible moderators (ie, patients’ prior experiences of discrimination and clinician racial bias) and mediators (ie, patient activation) of intervention effects on outcomes. RESULTS This study was funded by the National Heart, Lung, and Blood Institute. Enrollment and follow-up are ongoing and data analysis is expected to begin in late 2020. Planned enrollment is 1130 patients. On the basis of evidence supporting the effectiveness of values affirmation in educational settings and our pilot work demonstrating improved patient-clinician communication, we hypothesize that values affirmation disrupts the negative effects of stereotype threat on the clinical interaction and can reduce racial disparities in medication adherence and subsequent health outcomes. CONCLUSIONS The HYVALUE study moves beyond documentation of race-based health disparities toward testing an intervention. We focus on a medical condition—hypertension, which is arguably the greatest contributor to mortality disparities for black patients. If successful, this study will be the first to provide evidence for a low-resource intervention that has the potential to substantially reduce health care disparities across a wide range of health care conditions and populations. CLINICALTRIAL ClinicalTrials.gov NCT03028597; https://clinicaltrials.gov/ct2/show/NCT03028597 (Archived by WebCite at http://www.webcitation.org/72vcZMzAB). INTERNATIONAL REGISTERED REPOR DERR1-10.2196/12498

Background: Medication nonadherence is a significant, modifiable contributor to uncontrolled hypertension. Stereotype threat may contribute to racial disparities in adherence by hindering a patient’s ability to actively engage during a clinical encounter, resulting in reduced activation to adhere to prescribed therapies. Objective: The Hypertension and Values (HYVALUE) trial aims to examine whether a values-affirmation intervention improves medication adherence (primary outcome) by targeting racial stereotype threat. Methods: The HYVALUE trial is a patient-level, blinded randomized controlled trial comparing a brief values-affirmation writing exercise with a control writing exercise among black and white patients with uncontrolled hypertension. We are recruiting patients from 3 large health systems in the United States. The primary outcome is patients’ adherence to antihypertensive medications, with secondary outcomes of systolic and diastolic blood pressure over time, time for which blood pressure is under control, and treatment intensification. We are comparing the effects of the intervention among blacks and whites, exploring possible moderators (ie, patients’ prior experiences of discrimination and clinician racial bias) and mediators (ie, patient activation) of intervention effects on outcomes. Results: This study was funded by the National Heart, Lung, and Blood Institute. Enrollment and follow-up are ongoing and data analysis is expected to begin in late 2020. Planned enrollment is 1130 patients. On the basis of evidence supporting the effectiveness of values affirmation in educational settings and our pilot work demonstrating improved patient-clinician communication, we hypothesize that values affirmation disrupts the negative effects of stereotype threat on the clinical interaction and can reduce racial disparities in medication adherence and subsequent health outcomes. Conclusions: The HYVALUE study moves beyond documentation of race-based health disparities toward testing an intervention. We focus on a medical condition—hypertension, which is arguably the greatest contributor to mortality disparities for black patients. If successful, this study will be the first to provide evidence for a low-resource intervention that has the potential to substantially reduce health care disparities across a wide range of health care conditions and populations. Trial Registration: ClinicalTrials.gov NCT03028597; https://clinicaltrials.gov/ct2/show/NCT03028597 (Archived by WebCite at http://www.webcitation.org/72vcZMzAB). International Registered Report Identifier (IRRID): DERR1-10.2196/12498

Health literacy is the degree to which individuals are able to access and process basic health information and services and thereby participate in health-related decisions. Limited health literacy is highly prevalent in the United States and is strongly associated with patient morbidity, mortality, healthcare use, and costs. The objectives of this American Heart Association scientific statement are (1) to summarize the relevance of health literacy to cardiovascular health; (2) to present the adverse associations of health literacy with cardiovascular risk factors, conditions, and treatments; (3) to suggest strategies that address barriers imposed by limited health literacy on the management and prevention of cardiovascular disease; (4) to demonstrate the contributions of health literacy to health disparities, given its association with social determinants of health; and (5) to propose future directions for how health literacy can be integrated into the American Heart Association’s mandate to advance cardiovascular treatment and research, thereby improving patient care and public health. Inadequate health literacy is a barrier to the American Heart Association meeting its 2020 Impact Goals, and this statement articulates the rationale to anticipate and address the adverse cardiovascular effects associated with health literacy.

The National Diabetes Prevention Program (NDPP) is the most widely available behavioral intervention to prevent diabetes, but attrition is a concern and strategies are needed to make the program more engaging. Previous evidence suggests that the 150-min weekly physical activity goal in NDPP is hard for many to achieve. Further study of the impact of this protocol recommendation may improve understanding for NDPP reach and effectiveness in reducing diabetes risk. We conducted an observational study of relationships between physical activity goal attainment and retention and weight loss among 391 NDPP participants between March 2013 and May 2016. Average percent of self-reported weekly physical activity goal attainment was 52.7% (SD = 35.1). Goal attainment was related to percent of sessions attended, β = 0.21 (p < .01) and program completion (OR 0.47; p < .05; 95% CI 0.24-0.90). Each occurrence of goal failure was associated with a 25% lower likelihood of attending the next session (OR 0.75; p < .001; 95% CI 0.64-0.87). Goal attainment was also related to total percent weight loss, β = -0.14 (p < .05) and achieving ≥5% weight loss (OR 0.39; p < .01; 95% CI 0.19-0.76), but there was no effect of goal attainment on weight change per session attended. Failing to attain physical activity goals may deter retention in the NDPP. Yet, goal attainment did not affect the rate of weight loss per session attended. It may be important to encourage continued engagement among individuals who struggle to achieve physical activity goals. Moreover, it may be necessary to modify physical activity recommendations to meet individual needs.

Importance Many patients with chronic heart failure experience reduced health status despite receiving conventional therapy. Objective To determine whether a symptom and psychosocial collaborative care intervention improves heart failure–specific health status, depression, and symptom burden in patients with heart failure. Design, Setting, and Participants A single-blind, 2-arm, multisite randomized clinical trial was conducted at Veterans Affairs, academic, and safety-net health systems in Colorado among outpatients with symptomatic heart failure and reduced health status recruited between August 2012 and April 2015. Data from all participants were included regardless of level of participation, using an intent-to-treat approach. Interventions Patients were randomized 1:1 to receive the Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) intervention or usual care. The CASA intervention included collaborative symptom care provided by a nurse and psychosocial care provided by a social worker, both of whom worked with the patients’ primary care clinicians and were supervised by a study primary care clinician, cardiologist, and palliative care physician. Main Outcomes and Measures The primary outcome was patient-reported heart failure–specific health status, measured by difference in change scores on the Kansas City Cardiomyopathy Questionnaire (range, 0-100) at 6 months. Secondary outcomes included depression (measured by the 9-item Patient Health Questionnaire), anxiety (measured by the 7-item Generalized Anxiety Disorder Questionnaire), overall symptom distress (measured by the General Symptom Distress Scale), specific symptoms (pain, fatigue, and shortness of breath), number of hospitalizations, and mortality. Results Of 314 patients randomized (157 to intervention arm and 157 to control arm), there were 67 women and 247 men, mean (SD) age was 65.5 (11.4) years, and 178 (56.7%) had reduced ejection fraction. At 6 months, the mean Kansas City Cardiomyopathy Questionnaire score improved 5.5 points in the intervention arm and 2.9 points in the control arm (difference, 2.6; 95% CI, –1.3 to 6.6;P = .19). Among secondary outcomes, depressive symptoms and fatigue improved at 6 months with CASA (effect size of –0.29 [95% CI, –0.53 to –0.04] for depressive symptoms and –0.30 [95% CI, –0.55 to –0.06] for fatigue;P = .02 for both). There were no significant changes in overall symptom distress, pain, shortness of breath, or number of hospitalizations. Mortality at 12 months was similar in both arms (10 patients died receiving CASA, and 13 patients died receiving usual care;P = .52). Conclusions and Relevance This multisite randomized clinical trial of the CASA intervention did not demonstrate improved heart failure–specific health status. Secondary outcomes of depression and fatigue, both difficult symptoms to treat in heart failure, improved. Trial Registration clinicaltrials.gov Identifier:NCT01739686

Objectives Depression is the most common mental health disorder and mediates outcomes for many chronic diseases. Ability to accurately identify and monitor this condition, at the local level, is often limited to estimates from national surveys. This study sought to compare and validate electronic health record (EHR)-based depression surveillance with multiple data sources for more granular demographic subgroup and subcounty measurements. Design/setting A survey compared data sources for the ability to provide subcounty (eg, census tract [CT]) depression prevalence estimates. Using 2011-2012 EHR data from 2 large health care providers, and American Community Survey data, depression rates were estimated by CT for Denver County, Colorado. Sociodemographic and geographic (residence) attributes were analyzed and described. Spatial analysis assessed for clusters of higher or lower depression prevalence. Main outcome measure(s) Depression prevalence estimates by CT. Results National and local survey-based depression prevalence estimates ranged from 7% to 17% but were limited to county level. Electronic health record data provided subcounty depression prevalence estimates by sociodemographic and geographic groups (CT range: 5%-20%). Overall depression prevalence was 13%; rates were higher for women (16% vs men 9%), whites (16%), and increased with age and homeless patients (18%). Areas of higher and lower EHR-based, depression prevalence were identified. Conclusions Electronic health record-based depression prevalence varied by CT, gender, race/ethnicity, age, and living status. Electronic health record-based surveillance complements traditional methods with greater timeliness and granularity. Validation through subcounty-level qualitative or survey approaches should assess accuracy and address concerns about EHR selection bias. Public health agencies should consider the opportunity and evaluate EHR system data as a surveillance tool to estimate subcounty chronic disease prevalence.