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Item Applying human factors principles to alert design increases efficiency and reduces prescribing errors in a scenario-based simulation(Oxford University Press, 2014-10) Russ, Alissa L.; Zillich, Alan J.; Melton, Brittany L.; Russell, Scott A.; Chen, Siying; Spina, Jeffrey R.; Weiner, Michael; Johnson, Elizabette G.; Daggy, Joanne K.; McAnas, M. Sue; Hawsey, Jason M.; Puleo, Anthony G.; Doebbeling, Bradley N.; Saleem, Jason J.; Medicine Faculty Volunteers, IU School of MedicineOBJECTIVE: To apply human factors engineering principles to improve alert interface design. We hypothesized that incorporating human factors principles into alerts would improve usability, reduce workload for prescribers, and reduce prescribing errors. MATERIALS AND METHODS: We performed a scenario-based simulation study using a counterbalanced, crossover design with 20 Veterans Affairs prescribers to compare original versus redesigned alerts. We redesigned drug-allergy, drug-drug interaction, and drug-disease alerts based upon human factors principles. We assessed usability (learnability of redesign, efficiency, satisfaction, and usability errors), perceived workload, and prescribing errors. RESULTS: Although prescribers received no training on the design changes, prescribers were able to resolve redesigned alerts more efficiently (median (IQR): 56 (47) s) compared to the original alerts (85 (71) s; p=0.015). In addition, prescribers rated redesigned alerts significantly higher than original alerts across several dimensions of satisfaction. Redesigned alerts led to a modest but significant reduction in workload (p=0.042) and significantly reduced the number of prescribing errors per prescriber (median (range): 2 (1-5) compared to original alerts: 4 (1-7); p=0.024). DISCUSSION: Aspects of the redesigned alerts that likely contributed to better prescribing include design modifications that reduced usability-related errors, providing clinical data closer to the point of decision, and displaying alert text in a tabular format. Displaying alert text in a tabular format may help prescribers extract information quickly and thereby increase responsiveness to alerts. CONCLUSIONS: This simulation study provides evidence that applying human factors design principles to medication alerts can improve usability and prescribing outcomes.Item Are Newborn Outcomes Different for Term Babies Who Were Exposed to Antenatal Corticosteroids?(Elsevier, 2021) McKinzie, Alexandra H.; Yang, Ziyi; Teal, Evgenia; Daggy, Joanne K.; Tepper, Robert S.; Quinney, Sarah K.; Rhoads, Eli; Haneline, Laura S.; Haas, David M.; Obstetrics and Gynecology, School of MedicineBackground: Antenatal corticosteroids improve newborn outcomes for preterm infants. However, predicting which women presenting for threatened preterm labor will have preterm infants is inaccurate, and many women receive antenatal corticosteroids but then go on to deliver at term. Objective: This study aimed to compare the short-term outcomes of infants born at term to women who received betamethasone for threatened preterm labor with infants who were not exposed to betamethasone in utero. Study design: We performed a retrospective cohort study of infants born at or after 37 weeks' gestational age to mothers diagnosed as having threatened preterm labor during pregnancy. The primary neonatal outcomes of interest included transient tachypnea of the newborn, neonatal intensive care unit admission, and small for gestational age and were evaluated for their association with betamethasone exposure while adjusting for covariates using multiple logistic regression. Results: Of 5330 women, 1459 women (27.5%) received betamethasone at a mean gestational age of 32.2±3.3 weeks. The mean age of women was 27±5.9 years and the mean gestational age at delivery was 38.9±1.1 weeks. Women receiving betamethasone had higher rates of maternal comorbidities (P<.001 for diabetes mellitus, asthma, and hypertensive disorder) and were more likely to self-identify as White (P=.022). Betamethasone-exposed neonates had increased rates of transient tachypnea of the newborn, neonatal intensive care unit admission, small for gestational age, hyperbilirubinemia, and hypoglycemia (all, P<.05). Controlling for maternal characteristics and gestational age at delivery, betamethasone exposure was not associated with a diagnosis of transient tachypnea of the newborn (adjusted odds ratio, 1.10; 95% confidence interval, 0.80-1.51), although it was associated with more neonatal intensive care unit admissions (adjusted odds ratio, 1.49; 95% confidence interval, 1.19-1.86) and higher odds of the baby being small for gestational age (adjusted odds ratio, 1.78; 95% confidence interval, 1.48-2.14). Conclusion: Compared with women evaluated for preterm labor who did not receive betamethasone, women receiving betamethasone had infants with higher rates of neonatal intensive care unit admission and small for gestational age. Although the benefits of betamethasone to infants born preterm are clear, there may be negative impacts for infants delivered at term.Item Are Newborn Outcomes Different for Term Babies Who Were Exposed to Antenatal Corticosteroids?(American Journal of Obstetrics and Gynecology, 2021-05-03) McKinzie, Alexandra; Yang, Ziyi; Teal, Evgenia; Daggy, Joanne K.; Tepper, Robert S.; Quinney, Sarah K.; Rhoads, Eli; Haneline, Laura S.; Haas, David M.; Obstetrics and Gynecology, School of MedicineBackground Antenatal corticosteroids improve newborn outcomes for preterm infants. However, predicting which women presenting for threatened preterm labor will have preterm infants is inaccurate and many women receive antenatal corticosteroids but then go on to deliver at term. Objective The purpose of this study was to compare the short-term outcomes of infants born at term to women who received betamethasone (BMZ) for threatened preterm labor to infants who were not exposed to BMZ in utero. Study Design We performed a retrospective cohort study of infants born at or after 37 weeks’ gestational age (GA) to mothers diagnosed with threatened preterm labor during pregnancy. The primary neonatal outcomes of interest included transient tachypnea of the newborn (TTN), neonatal intensive care unit (NICU) admission, and small for gestational age (SGA), and were evaluated for their association with BMZ exposure while adjusting for covariates using multiple logistic regression. Results Of 5330 women, 1459 (27.5%) women received BMZ at a mean GA of 32.2±3.3 weeks. The mean age of women was 27±5.9 years-old and the mean GA at delivery was 38.9±1.1 weeks. Women receiving BMZ had higher rates of maternal comorbidities (P<0.001 for diabetes, asthma, and hypertensive disorder) and were more likely to self-identify as white (P=0.022). BMZ-exposed neonates had increased rates of TTN, NICU admission, SGA, hyperbilirubinemia, and hypoglycemia (all P-values <0.05). Controlling for maternal characteristics and GA at delivery, BMZ exposure was not significantly associated with diagnosis of TTN (aOR 1.10, 95% CI 0.80-1.51), though it was associated with more NICU admissions (aOR 1.49, 95% CI 1.19-1.86) and higher odds of the baby being small for gestational age (SGA, aOR 1.78, 95%CI 1.48 to 2.14). Conclusions Compared to women evaluated for preterm labor that did not receive BMZ, women receiving BMZ had infants with higher rates of NICU admission and SGA. While the benefits of BMZ to infants born preterm are clear, there may be negative impacts for infants delivered at term.Item Care Trajectories of Veterans in the Twelve Months following Hospitalization for Acute Ischemic Stroke(AHA, 2015-10) Arling, Greg; Ofner, Susan; Reeves, Mathew J.; Myers, Laura J.; Williams, Linda S.; Daggy, Joanne K.; Phipps, Michael S.; Chumbler, Neale R.; Bravata, Dawn M.; Department of Neurology, IU School of MedicineBackground—Recovery after a stroke varies greatly between individuals and is reflected by wide variation in the use of institutional and home care services. This study sought to classify veterans according to their care trajectories in the 12 months after hospitalization for ischemic stroke. Methods and Results—The sample consisted of 3811 veterans hospitalized for ischemic stroke in Veterans Health Administration facilities in 2007. Three outcomes—nursing home care, home care, and mortality—were modeled jointly >12 months using latent class growth analysis. Data on Veterans’ care use and cost came from the Veterans Administration and Medicare. Covariates included stroke severity (National Institutes of Health Stroke Scale), functional status (functional independence measure score), age, marital status, chronic conditions, and prestroke ambulation. Five care trajectories were identified: 49% of Veterans had Rapid Recovery with little or no use of care; 15% had a Steady Recovery with initially high nursing home or home care that tapered off; 9% had Long-Term Home Care; 13% had Long-Term Nursing Home Care; and 14% had an Unstable trajectory with multiple transitions between long-term and acute care settings. Care use was greatest for individuals with more severe strokes, lower functioning at hospital discharge, and older age. Average annual costs were highest for individuals with the Long-Term Nursing Home trajectory ($63 082), closely followed by individuals with the Unstable trajectory ($58 720). Individual with the Rapid Recovery trajectory had the lowest costs ($9271). Conclusions—Care trajectories after stroke were associated with stroke severity and functional dependency and they had a dramatic impact on subsequent costs.Item A cognitive systems engineering design approach to improve the usability of electronic order forms for medical consultation(Elsevier, 2018-09) Savoy, April; Militello, Laura G.; Patel, Himalaya; Flanagan, Mindy E.; Russ, Alissa L.; Daggy, Joanne K.; Weiner, Michael; Saleem, Jason J.; Biostatistics, School of Public HealthBackground During medical referrals, communication barriers between referring and consulting outpatient clinics delay patients’ access to health care. One notable opportunity for reducing these barriers is improved usefulness and usability of electronic medical consultation order forms. The cognitive systems engineering (CSE) design approach focuses on supporting humans in managing cognitive complexity in sociotechnical systems. Cognitive complexity includes communication, decision-making, problem solving, and planning. Objective The objective of this research was to implement a CSE design approach to develop a template that supports the cognitive needs of referring clinicians and improves referral communication. Methods We conducted interviews and observations with primary care providers and specialists at two major tertiary, urban medical facilities. Using qualitative analysis, we identified cognitive requirements and design guidelines. Next, we designed user interface (UI) prototypes and compared their usability with that of a currently implemented UI at a major Midwestern medical facility. Results Physicians’ cognitive challenges were summarized in four cognitive requirements and 13 design guidelines. As a result, two UI prototypes were developed to support order template search and completion. To compare UIs, 30 clinicians (referrers) participated in a consultation ordering simulation complemented with the think-aloud elicitation method. Oral comments about the UIs were coded for both content and valence (i.e., positive, neutral, or negative). Across 619 comments, the odds ratio for the UI prototype to elicit higher-valenced comments than the implemented UI was 13.5 (95% CI = [9.2, 19.8]), p < .001. Conclusion This study reinforced the significance of applying a CSE design approach to inform the design of health information technology. In addition, knowledge elicitation methods enabled identification of physicians’ cognitive requirements and challenges when completing electronic medical consultation orders. The resultant knowledge was used to derive design guidelines and UI prototypes that were more useful and usable for referring physicians. Our results support the implementation of a CSE design approach for electronic medical consultation orders.Item Evaluation of a Participant Co-designed Lifestyle Change Program for Youth(2022-05) Alharbi, Basmah Saleh; Perkins, Susan M.; Hannon, Tamara S.; Daggy, Joanne K.Introduction: Increasing obesity in children leads to an increase in the risk of Type 2 diabetes (T2D). Therefore, it is important to promote healthier lifestyles in youths and encourage their caregivers(s) to provide a healthy lifestyle environment. The PowerHouse program focuses on improving food choices, increasing physical activity, and adopting behavior changes for the reduction of obesity and the prevention of T2D. Method: The aim of this study was to assess the effects of implementing the PowerHouse program on both clinical and quality of life outcomes in high-risk, low-income youth and their caregivers. Primary outcomes were BMI standard deviation and BMI percentile in youths. Secondary outcomes included physical activity of youths and quality of life for both youths and their caregivers. Attendance rates were also calculated. Linear effect mixed models were used to test for time effects for all outcomes. Results: Clinical outcomes did not improve over time, except for youth HbA1c (p-value = 0.0447). Some improvements in youth quality-of-life outcomes were noted: specifically, the Sports Index score of the Fels Physical Activity Questionnaire for Children (adjusted p-value = 0.0213) and the Physical Summary (p-value = 0.0407), Psychosocial Summary (p-value = 0.0167), and Total score (p-value = 0.0094) for the youth-reported Pediatric Quality of Life Inventory. Quality of life did not change over time for caregivers. For attendance, there was an improvement after the intervention was modified to improve access to fresh produce (p-value = 0.0002). Conclusion: HbA1c and quality of life improved over time for youth; however, there was not an improvement in caregiver outcomes over time. The data suggest that more time may be needed to see the full effects of the intervention, and/or that a booster intervention may be needed.Item Impact of the coronavirus disease-2019 pandemic on Veterans Health Administration Sleep Services(Sage, 2023-05-03) Sico, Jason J.; Koo, Brian B.; Perkins, Anthony J.; Burrone, Laura; Sexson, Ali; Myers, Laura J.; Taylor, Stanley; Yarbrough, W. Claibe; Daggy, Joanne K.; Miech, Edward J.; Bravata, Dawn M.; Medicine, School of MedicineObjectives: To understand the impact of the coronavirus disease-2019 pandemic on sleep services within the United States Department of Veterans Affairs using separate surveys from "pre-COVID" and pandemic periods. Methods: Data from a pre-pandemic survey (September to November 2019) were combined with data from a pandemic-period survey (August to November 2020) to Veterans Affairs sleep medicine providers about their local sleep services within 140 Veterans Affairs facilities). Results: A total of 67 (47.9%) facilities responded to the pandemic online survey. In-lab diagnostic and titration sleep studies were stopped at 91.1% of facilities during the pandemic; 76.5% of facilities resumed diagnostic studies and 60.8% resumed titration studies by the time of the second survey. Half of the facilities suspended home sleep testing; all facilities resumed these services. In-person positive airway pressure clinics were stopped at 76.3% of facilities; 46.7% resumed these clinics. Video telehealth was either available or in development at 86.6% of facilities and was considered a lasting addition to sleep services. Coronavirus disease-2019 transmission precautions occurred at high rates. Sleep personnel experienced high levels of stress, anxiety, fear, and burnout because of the pandemic and in response to unexpected changes in sleep medicine care delivery. Conclusions: Sleep medicine services within the Veterans Affairs evolved during the pandemic with many key services being interrupted, including in-lab studies and in-person positive airway pressure clinics. Expansion and initiation of telehealth sleep services occurred commonly. The pandemic adversely affected sleep medicine personnel as they sought to maintain access to care.Item Informing Policy Change: A Study of Rapid Repeat Pregnancy in Adolescents to Increase Access to Immediate Postpartum Contraception(Mary Ann Liebert, Inc., 2020-06) Qasba, Neena T.; Stutsma, John W.; Weaver, Greta E.; Jones, Kathleen E.; Daggy, Joanne K.; Wilkinson, Tracey A.; Obstetrics and Gynecology, School of MedicineBackground: Rapid repeat pregnancy (RRP) is common among adolescents and is associated with adverse maternal and infant outcomes. Despite evidence that use of long-acting forms of contraception before hospital discharge can help minimize RRP rates, barriers to placement existed within the state of Indiana. We sought to determine state-specific RRP and induced abortion rates for adolescents based on chosen postpartum contraception to inform policy change. Methods: We examined a retrospective cohort of 227 adolescents (ages 12-18 years) who gave birth in Indiana between 2010 and 2012. Demographics, postpartum contraception, and subsequent pregnancies or abortions after the sentinel delivery were obtained. Rates of RRP based on type of immediate postpartum contraception, etonogestrel (ENG) contraceptive implant, depo-medroxyprogesterone acetate (DMPA) injection, and short-acting methods were compared. Bivariate and logistic regression analyses were conducted. Results: RRP rates were 3.7% for those with ENG contraceptive implant, 22.6% for those with DMPA, and 39.1% for those who choose short-acting methods (p = 0.01). Adolescents who did not choose an ENG contraceptive implant were significantly more likely to have an RRP (adjusted odds ratio [aOR] = 11.8, 95% confidence interval: 2.74-110.3), compared with other contraceptive methods, even after adjusting for covariates such as age, prior pregnancies, and postpartum visit attendance. Conclusions: Immediate postpartum receipt of ENG implant was significantly associated with a lower likelihood of RRP in adolescents in Indiana. These data facilitated state policy change regarding insurance reimbursement to improve statewide access for all women, regardless of age, showing how local data can inform policy change.Item Mediators of improved PTSD symptoms in veterans and civilians following a yoga program(Cambridge University Press, 2023-08) Davis, Louanne W.; Schmid, Arlene A.; Daggy, Joanne K.; Yang, Ziyi; Biostatistics and Health Data Science, School of MedicineObjective: Although yoga shows some promise as an intervention for post-traumatic stress disorder (PTSD), little is known about how yoga reduces PTSD symptoms. The current study hypothesised that aspects of interoceptive awareness would mediate the effect of a yoga intervention on PTSD symptoms. Methods: We used data from our recently completed randomised controlled trial of a 16-week holistic yoga programme for veterans and civilians diagnosed with PTSD (n = 141) that offered weekly 90-minute sessions. We conducted a mediation analysis using interoceptive awareness and other variables that were associated with PTSD symptom reduction at mid-treatment and treatment end. Results: Although measures of anxiety, interoceptive awareness, and spirituality were identified in individual mediator models, they were no longer found to be significant mediators when examined jointly in multiple mediator models. When examining the multiple mediator models, the strongest mediator of the yoga intervention on PTSD symptoms was mental well-being at mid-treatment and stigma at the treatment end. The total effect of yoga on CAPS and PCL at the treatment end mediated by stigma was 37.1% (–1.81/–4.88) and 33.6% (–1.91/–5.68), respectively. Conclusion: Investigation of mental well-being and mental illness stigma as potential mediators is warranted in future studies of yoga as a treatment for PTSD as they may prove to be important foci for yoga interventions.Item Patient knowledge and attitudes toward cervical cancer screening after the 2012 screening guidelines(Elsevier, 2018) Clay, Jayanti M.; Daggy, Joanne K.; Fluellen, Sunetris; Edmonds, Brownsyne Tucker; Obstetrics and Gynecology, School of MedicineObjective To assess women’s attitudes and preferences related to recent changes in cervical cancer screening guidelines. Methods We distributed 380 surveys in three University based and Community clinics. Study participants anonymously completed surveys, which included questions related to demographics, cervical cancer, screening practices, risk perception and attitudes towards changing practices. Results 315 women agreed to participate (83%). 60% (185/310) of participants had some college education or higher and 12% (36/305) worked in the medical field. On average, participants answered 4.1 (SD = 1.3) of the 8 knowledge questions correctly. Knowledge scores significantly increased with education level (Kruskal-Wallis test p-value < 0.001). The majority (72%, n = 228) reported that they should be screened annually, and that screening should be initiated with the onset of sexual activity (63%, n = 197). Participants that were more knowledgeable of current screening practices were more comfortable extending screening intervals (Kruskal-Wallis test p < 0.001). Conclusion Even among a relatively highly educated population of women, participants had limited knowledge of cervical cancer and current screening guidelines. Many participants reported discomfort with less frequent screening intervals. Practice implications This study supports the need for improvement in cervical cancer prevention education especially with regards to the new screening guidelines.