Browsing by Author "Levoy, Kristin"
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Item Caregiver Engagement Enhances Outcomes among Randomized Control Trials of Transitional Care Interventions: A Systematic Review and Meta-Analysis(Wolters Kluwer, 2022) Levoy, Kristin; Rivera, Eleanor; McHugh, Molly; Hanlon, Alexandra; Hirschman, Karen B.; Naylor, Mary D.; School of NursingBackground: Fluctuations in health among chronically ill adults result in frequent health care transitions. Some interventions to improve patient outcomes after hospitalization include caregiver engagement as a core component, yet there is unclear evidence of the effects of this component on outcomes. Objective: The objective of this study was to synthesize evidence regarding the attention given to caregiver engagement in randomized control trials of transitional care interventions (TCIs), estimate the overall intervention effects, and assess caregiver engagement as a moderator of intervention effects. Methods: Three databases were systematically searched for randomized control trials of TCIs targeting adults living with physical or emotional chronic diseases. For the meta-analysis, overall effects were computed using the relative risk (RR) effect size and inverse variance weighting. Results: Fifty-four studies met criteria, representing 31,291 participants and 66 rehospitalizations effect sizes. Half (51%) the interventions lacked focus on caregiver engagement. The overall effect of TCIs on all-cause rehospitalizations was nonsignificant at 1 month (P=0.107, k=29), but significant at ≥2 months [RR=0.89; 95% confidence interval (CI): 0.82, 0.97; P=0.007, k=27]. Caregiver engagement moderated intervention effects (P=0.05), where interventions with caregiver engagement reduced rehospitalizations (RR=0.83; 95% CI: 0.75, 0.92; P=0.001), and those without, did not (RR=0.97; 95% CI: 0.87, 1.08; P=0.550). Interventions with and without caregiver engagement did not differ in the average number of components utilized, however, interventions with caregiver engagement more commonly employed baseline needs assessments (P=0.032), discharge planning (P=0.006), and service coordination (P=0.035). Discussion: Future TCIs must consistently incorporate the active participation of caregivers in design, delivery, and evaluation.Item Content Validity Assessment of the Revised Illness Perception Questionnaire in CKD Using Qualitative Methods(MDPI, 2022-07-16) Rivera, Eleanor; Levoy, Kristin; Clark-Cutai, Maya N.; Schrauben, Sarah; Townsend, Raymond R.; Rahman, Rahman; Lash, James; Saunders, Milda; Frazier, Rebecca; Rincon-Choles, Hernan; Hirschman, Karen B.; School of NursingBackground: The Revised Illness Perception Questionnaire (IPQ-R) measures individuals’ unique perceptions of their illness. While psychometric properties of the IPQ-R have been demonstrated in many disease populations, its content validity has not been extensively studied in non-dialysis chronic kidney disease (CKD). Unique features of CKD (e.g., few symptoms in early stages) may impact the measurement of illness perceptions. The purpose of this study was to explore the IPQ-R content validity in a sample of CKD patients. Methods: Thirty-one participants completed the IPQ-R and were interviewed regarding their subscale scores (timeline, consequences, personal control, treatment control, coherence, cyclical, and emotions). Participants’ agreement with their scores was tallied and assessed qualitatively for themes related to the content validity of the measure. Results: Individual participant agreement with their subscale scores averaged 79% (range: 29–100%). Subscale agreement varied: timeline (100%), consequences, coherence, and emotion (83% each), cyclical (75%), personal control (65%), and treatment control (64%). A qualitative exploration of disagreement responses revealed concerns with the relevance and comprehensibility of personal control and treatment control. Conclusions: Some IPQ-R subscales may pose content validity concerns in the non-dialysis CKD population. Item modification for comprehensibility (personal control) and relevance (treatment control) should be considered. Future studies should explore the impact of a patient’s symptom experience on IPQ-R validity, especially in populations like CKD with a higher proportion of asymptomatic patients.Item Don’t Throw the Baby Out with the Bathwater: Meta-Analysis of Advance Care Planning and End-of-life Cancer Care(Elsevier, 2023) Levoy, Kristin; Sullivan, Suzanne S.; Chittams, Jesse; Myers, Ruth L.; Hickman, Susan E.; Meghani, Salimah H.; School of NursingContext: There is ongoing discourse about the impact of advance care planning (ACP) on end-of-life (EOL) care. No meta-analysis exists to clarify ACP's impact on patients with cancer. Objective: To investigate the association between, and moderators of, ACP and aggressive vs. comfort-focused EOL care outcomes among patients with cancer. Methods: Five databases were searched for peer-reviewed observational/experimental ACP-specific studies that were published between 1990-2022 that focused on samples of patients with cancer. Odds ratios were pooled to estimate overall effects using inverse variance weighting. Results: Of 8,673 articles, 21 met criteria, representing 33,541 participants and 68 effect sizes (54 aggressive, 14 comfort-focused). ACP was associated with significantly lower odds of chemotherapy, intensive care, hospital admissions, hospice use fewer than seven days, hospital death, and aggressive care composite measures. ACP was associated with 1.51 times greater odds of do-not-resuscitate orders. Other outcomes-cardiopulmonary resuscitation, emergency department admissions, mechanical ventilation, and hospice use-were not impacted. Tests of moderation revealed that the communication components of ACP produced greater reductions in the odds of hospital admissions compared to other components of ACP (e.g., documents); and, observational studies, not experimental, produced greater odds of hospice use. Conclusion: This meta-analysis demonstrated mixed evidence of the association between ACP and EOL cancer care, where tests of moderation suggested that the communication components of ACP carry more weight in influencing outcomes. Further disease-specific efforts to clarify models and components of ACP that work and matter to patients and caregivers will advance the field.Item Health Correlates of Abuse History and Moderating Effect of Parenting Stress for Mothers with Mental Disorders(Taylor & Francis, 2021) Williams, Jessica R.; McCabe, Brian E.; de Tantillo, Lila; Levoy, Kristin; Behar-Zusman, Victoria; School of NursingParenting stress is common and may lead to worsening health, particularly in the context of other risk factors such as mental disorders or a history of abuse. This study investigated how parenting-related stress impacts the effect of abuse experiences on health among mothers with mental health disorders. Survey data was analyzed from 172 predominantly Hispanic mothers receiving outpatient behavioral health services. Most (80.2%) mothers had experienced abuse. Those reporting childhood abuse had 3.82 greater odds of experiencing abuse in adulthood. Findings demonstrated worse health outcomes among those experiencing abuse in both childhood and adulthood and those with a greater number of abuse experiences. Caregiving load intensified the relationship between abuse and anxiety and sleep disturbance. Parenting self-agency intensified the relationship between abuse and cigarette use. These findings have important implications for mental health nursing practice by identifying parenting-stress as an important target for interventions to improve health among women with histories of abuse and mental health disorders.Item Impact of Cannabis Use on Least Pain Scores Among African American and White Patients with Cancer Pain: A Moderation Analysis(Dove Press, 2021-11-05) Meghani, Salimah H.; Quinn, Ryan; Ashare, Rebecca; Levoy, Kristin; Worster, Brooke; Naylor, Mary; Chittams, Jesse; Cheatle, Martin; School of NursingIntroduction: Based on many published reports, African American patients with cancer experience higher pain severity scores and lower pain relief than White patients. This disparity results from undertreatment of pain and is compounded by low adherence to prescribed non-opioid and opioid analgesics among African American patients with cancer. While nearly one in four patients use cannabis to manage cancer-related symptoms, less is known about how cannabis use influences pain relief in this patient population. Methods: This study is based on preliminary data from an ongoing study of longitudinal outcomes of opioid therapy among African American and White patients with cancer. Linear mixed-effects models were utilized to assess the interaction of race and cannabis use on pain relief using "least pain" item scores from the Brief Pain Inventory (BPI) averaged across three time points. Models were adjusted for sociodemographic and clinical variables. Results: This analysis included 136 patients (49 African American, 87 White). Overall, 30.1% of the sample reported cannabis use for cancer pain. The mean "least pain" score on BPI was 3.3 (SD=2.42) on a scale of 0-10. African American patients had a mean "least pain" score 1.32±0.48 units higher (indicating lower pain relief) than White patients (p=0.006). Cannabis use did not have a significant main effect (p=0.28). However, cannabis use was a significant moderator of the relationship between race and "least pain" (p=0.03). In the absence of cannabis use, African Americans reported higher "least pain" scores compared to Whites (mean difference=1.631±0.5, p=0.001). However, this disparity was no longer observed in African American patients reporting cannabis use (mean "least pain" difference=0.587±0.59, p=0.32). Conclusion: These findings point to the possible role of cannabis in cancer pain management and its potential to reduce racial disparities. These findings are preliminary and further research into the role of cannabis in cancer pain outcomes is needed.Item "It's Rougher on Me Than It Is on Him": Family Caregiver-Generated and Prioritized Illness Concerns While Patients Undergo Cancer Treatments(American Society of Clinical Oncology, 2022) Levoy, Kristin; Wool, Jesse; Ashare, Rebecca L.; Rosa, William E.; Barg, Frances K.; Meghani, Salimah H.; School of NursingPurpose: Research eliciting patients' illness concerns has typically focused later in the cancer continuum, rather than during cancer treatments. Family caregiver concerns are overlooked during this time. Less is known about how patients and caregivers prioritize concerns during cancer treatments, which holds potential for improving supportive oncology care (ie, primary palliative care). The purpose of this study was to elicit and compare which domains of supportive oncology are of highest importance to patients and caregivers during cancer treatments. Methods: Freelisting, a cognitive anthropology method, was used to elicit concerns in order of importance. Freelist data were analyzed using Smith's salience index. Qualitative interviews were conducted with a caregiver subsample to add explanatory insights. Results: In descending order, pain, death, fear, family, and awful were salient Freelist items for patients (n = 65), whereas sadness, time-consuming, support, anger, tired, death, and frustration were salient for caregivers (n = 24). When integrated with supportive oncology domains, patients' concerns reflected a prioritization of the physical (pain) and emotional (death, fear, and awful) domains, with less emphasis on social (family) aspects. Caregivers' prioritized the emotional (sadness, anger, death, and frustration) and social (time-consuming and support) domains, with less emphasis on the physical (tired) aspects. Conclusion: Our findings suggest that enhancing primary palliative care delivery by oncology teams requires systems thinking to support both the patient and caregiver as the primary unit of care. Primary palliative care may be improved by prioritizing interventions that address physical concerns among patients as well as key social concerns among caregivers to support the complex caregiving role while patients undergo cancer treatments.Item “I’m Dealing with That”: Illness Concerns of African American and White Cancer Patients while Undergoing Active Cancer Treatments(Sage, 2021) Meghani, Salimah H.; Levoy, Kristin; Magan, Kristin Corey; Starr, Lauren T.; Yocavitch, Liana; Barg, Frances K.; School of NursingBackground: National oncology guidelines recommend early integration of palliative care for patients with cancer. However, drivers for this integration remain understudied. Understanding illness concerns at the time of cancer treatment may help facilitate integration earlier in the cancer illness trajectory. Objective: To describe cancer patients' concerns while undergoing cancer treatment, and determine if concerns differ among African Americans and Whites. Methods: A 1-time, semi-structured qualitative interview was conducted with a purposive subsample of cancer patients participating in a larger study of illness concerns. Eligible patients were undergoing cancer treatments and had self-reported moderate-to-severe pain in the last week. Analysis encompassed a qualitative descriptive approach with inductive thematic analysis. Results: Participants (16 African American, 16 White) had a median age of 53 and were predominantly females (72%) with stage III/IV cancer (53%). Illness concerns were largely consistent across participants and converged on 3 themes: symptom experience (pain, options to manage pain), cancer care delivery (communication, care coordination and care transitions), and practical concerns (access to community and health system resources, financial toxicity). Conclusions: The findings extend the scope of factors that could be utilized to integrate palliative care earlier in the cancer illness trajectory, moving beyond the symptoms- and prognosis-based triggers that typify current referrals to also consider diverse logistical concerns. Using this larger set of concerns aids anticipatory risk mitigation and planning (e.g. care transitions, financial toxicity), helps patients receive a larger complement of support services, and builds cancer patients' capacity toward a more patient-centered treatment and care experience.Item Mindfulness to enhance quality of life and support advance care planning: a pilot randomized controlled trial for adults with advanced cancer and their family caregivers(Springer Nature, 2024-09-28) Mosher, Catherine E.; Beck-Coon, Kathleen A.; Wu, Wei; Lewson, Ashley B.; Stutz, Patrick V.; Brown, Linda F.; Tang, Qing; Helft, Paul R.; Levoy, Kristin; Hickman, Susan E.; Johns, Shelley A.; Psychology, School of ScienceBackground: Patients with advanced cancer and family caregivers often use avoidant coping strategies, such as delaying advance care planning discussions, which contribute to deterioration in their quality of life. Mindfulness-based interventions have shown promise in improving quality of life in this population but have rarely been applied to advance care planning. This pilot trial examined the preliminary efficacy of a group-based Mindfulness to Enhance Quality of Life and Support Advance Care Planning (MEANING) intervention for patient-caregiver dyads coping with advanced cancer. Primary outcomes were patient and caregiver quality of life or well-being, and secondary outcomes included patient advanced care planning engagement (self-efficacy and readiness) and other psychological and symptom outcomes. Methods: In this pilot trial, dyads coping with advanced cancer were recruited from five oncology clinics in the midwestern U.S. and randomized to six weekly group sessions of a mindfulness intervention (n = 33 dyads) or usual care (n = 22 dyads). Outcomes were assessed via surveys at baseline, post-intervention, and 1 month post-intervention. All available data were included in the multilevel models assessing intervention efficacy. Results: Patients in the MEANING condition experienced significant increases in existential well-being and self-efficacy for advance care planning across follow-ups, whereas usual care patients did not. Other group differences in outcomes were not statistically significant. These outcomes included other facets of patient well-being, caregiver quality of life, patient readiness for advance care planning, caregiver burden, and patient and caregiver depressive symptoms, anxiety, sleep disturbance, cognitive avoidance, and peaceful acceptance of cancer. However, only MEANING patients showed moderate increases in psychological well-being across follow-ups, and MEANING caregivers showed moderate increases in quality of life at 1-month follow-up. Certain psychological outcomes, such as caregiver burden at 1-month follow-up, also showed moderate improvement in the MEANING condition. Patients in both conditions reported small to moderate increases in readiness to engage in advance care planning. Conclusions: A mindfulness-based intervention showed promise in improving quality-of-life and advance care planning outcomes in patients and caregivers coping with advanced cancer and warrants further testing.Item The Moderating Effect of Caregiver Engagement in Transitional Care Intervention Outcomes: A Meta-Analysis(Oxford University Press, 2021-12-17) Levoy, Kristin; Rivera, Eleanor; McHugh, Molly; Hanlon, Alexandra; Hirschman, Karen; Naylor, Mary; School of NursingAs chronically ill adults age, increased fluctuations in health status result in frequent care transitions. Caregiver engagement is often a core component of evidence-based transitional care interventions, yet little is known about the relative contribution of this element to observed outcomes. This meta-analysis aimed to synthesize evidence of caregiver engagement in randomized control trials (RCT’s) of transitional care interventions, estimate the overall intervention effects on all-cause hospital readmissions, and test caregiver engagement as a moderator of interventions’ effects. Relative risk was the effect size, and the overall effect was estimated using inverse variance weighting. Fifty-four studies met criteria, representing 31,399 participants and 65 effect sizes. The weighted sample mean age was 64 years. The majority (64%) of interventions targeted participants with specific diagnoses, such as heart disease, but more than half (54%) lacked caregiver engagement components. Among all reviewed studies of transitional care interventions, the overall effect on all-cause readmissions at 1 month was non-significant (p=.123, k=28). However, intervention effects at 2 or more months were significant (RR=0.89, 95% CI: 0.82, 0.97, p=.007, k=26), indicating a 12% reduction in the relative risk of all-cause readmissions among intervention participants compared to controls. Caregiver engagement was found to moderate intervention effects (p=.05). Specifically, interventions that included caregiver engagement produced more robust effects (RR=0.83, 95% CI: 0.75, 0.92, p=.001), than those without such engagement (RR=0.97, 95% CI: 0.87, 1.08, p=.550). Findings suggest that transitional care interventions need to more explicitly engage caregivers as active partners in order to optimize patient outcomes.Item Nurse to Family Communication in Intensive Care Units(2024-05) Dees, Mandy Lynn; Carpenter, Janet; Levoy, Kristin; Longtin, Krista; Reising, Deanna; Wocial, LuciaNurse to family communication is a crucial aspect of high-quality care delivery in adult intensive care units (ICU). Adult ICU nurses hold a unique position to engage in meaningful communication with families, often being the most accessible healthcare team members to family. However, these nurses frequently express a sense of ineptitude in their nurse to family communication skills. Simultaneously, families often find themselves unprepared for these adult ICU interactions yet are regularly tasked with the responsibility of surrogate decision-making when patients are incapacitated. Despite the successful utilization of the COMFORT (Connect, Options, Making meaning, Family caregivers, Openings, Relating, and Team) communication intervention in other settings, its implementation in the adult ICU has not been realized. Exploring the perspectives of adult nurses and nurse leaders on the COMFORT intervention topics could enhance the success of its implementation and sustainability in clinical practice. The overall goal of this three-paper dissertation was to advance scientific knowledge about nurse to family communication in the adult ICU setting. An integrative review was conducted to systematically assess available research evidence on enhancing communication between adult ICU patients/families and nurses. Using qualitative focus group approach, the aims of the next two studies were to gather participants’ perspectives of the practicability, appeal, and relevance of each COMFORT communication intervention topics and strategies for its implementation among adult ICU nurse leaders (second paper) and ICU nurses (third paper). Results of these studies indicate the importance of nurse to family communication in adult ICU environments and nurse leaders’ and nurses’ enthusiasm for the implementation of the COMFORT intervention in the ICU setting. Recommendations emerging from the focus group interviews include providing adult ICU nurses dedicated time to complete training during work hours, allowing early adopters to use the COMFORT app before expanding it to the entire unit staff nurse population, making the app accessible on unit computers, providing training suitable for nurses at all experience levels (from early career to seasoned staff), adopting a phased approach to implementation, and offering education on the COMFORT topics in quick, digestible learning tools suitable for a fast-paced nursing unit.