Browsing by Subject "Mixed methods"

Now showing 1 - 10 of 15
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    A pragmatic, stepped-wedge, hybrid type II trial of interoperable clinical decision support to improve venous thromboembolism prophylaxis for patients with traumatic brain injury
    (Springer Nature, 2024-08-05) Tignanelli, Christopher J.; Shah, Surbhi; Vock, David; Siegel, Lianne; Serrano, Carlos; Haut, Elliott; Switzer, Sean; Martin, Christie L.; Rizvi, Rubina; Peta, Vincent; Jenkins, Peter C.; Lemke, Nicholas; Thyvalikakath, Thankam; Osheroff, Jerome A.; Torres, Denise; Vawdrey, David; Callcut, Rachael A.; Butler, Mary; Melton, Genevieve B.; Surgery, School of Medicine
    Background: Venous thromboembolism (VTE) is a preventable medical condition which has substantial impact on patient morbidity, mortality, and disability. Unfortunately, adherence to the published best practices for VTE prevention, based on patient centered outcomes research (PCOR), is highly variable across U.S. hospitals, which represents a gap between current evidence and clinical practice leading to adverse patient outcomes. This gap is especially large in the case of traumatic brain injury (TBI), where reluctance to initiate VTE prevention due to concerns for potentially increasing the rates of intracranial bleeding drives poor rates of VTE prophylaxis. This is despite research which has shown early initiation of VTE prophylaxis to be safe in TBI without increased risk of delayed neurosurgical intervention or death. Clinical decision support (CDS) is an indispensable solution to close this practice gap; however, design and implementation barriers hinder CDS adoption and successful scaling across health systems. Clinical practice guidelines (CPGs) informed by PCOR evidence can be deployed using CDS systems to improve the evidence to practice gap. In the Scaling AcceptabLE cDs (SCALED) study, we will implement a VTE prevention CPG within an interoperable CDS system and evaluate both CPG effectiveness (improved clinical outcomes) and CDS implementation. Methods: The SCALED trial is a hybrid type 2 randomized stepped wedge effectiveness-implementation trial to scale the CDS across 4 heterogeneous healthcare systems. Trial outcomes will be assessed using the RE2-AIM planning and evaluation framework. Efforts will be made to ensure implementation consistency. Nonetheless, it is expected that CDS adoption will vary across each site. To assess these differences, we will evaluate implementation processes across trial sites using the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework (a determinant framework) using mixed-methods. Finally, it is critical that PCOR CPGs are maintained as evidence evolves. To date, an accepted process for evidence maintenance does not exist. We will pilot a "Living Guideline" process model for the VTE prevention CDS system. Discussion: The stepped wedge hybrid type 2 trial will provide evidence regarding the effectiveness of CDS based on the Berne-Norwood criteria for VTE prevention in patients with TBI. Additionally, it will provide evidence regarding a successful strategy to scale interoperable CDS systems across U.S. healthcare systems, advancing both the fields of implementation science and health informatics.
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    Conceptualizing care partners' burden, stress, and support for reintegrating Veterans: a mixed methods study
    (Frontiers Media, 2024-02-19) Rattray, Nicholas A.; Flanagan, Mindy; Mann, Allison; Danson, Leah; Do, Ai-Nghia; Natividad, Diana; Spontak, Katrina; True, Gala; Medicine, School of Medicine
    Background: People who support Veterans as they transition from their military service into civilian life may be at an increased risk of psychological distress. Existing studies focus primarily on paid family caregivers, but few studies include spouses and informal non-family "care partners." We sought to identify key challenges faced by care partners of Veterans with invisible injuries. Methods: Semi-structured interviews were conducted with 36 individuals involved in supporting a recently separated US military Veteran enrolled in a 2-year longitudinal study. CPs completed validated measures on perceived stress, caregiving burden, quality of their relationship, life satisfaction, and flourishing. Independent t-tests were used to compare cases in these groups on caregiving burden, quality of their relationship, life satisfaction, and flourishing. Care partners were categorized as reporting high and low levels of stress. Exemplar cases were used to demonstrate divergences in the experiences of CPs with different levels of stress over time. Results: Care partners reported shifts in self-perception that occurred from supporting a Veteran, emphasizing how they helped Veterans navigate health systems and the processes of disclosing health and personal information in civilian contexts. Exemplar cases with high and low burdens demonstrated divergent experiences in self-perception, managing multi-faceted strain, and coping with stress over time. Case studies of specific care partners illustrate how multi-faceted strain shifted over time and is affected by additional burdens from childcare, financial responsibilities, or lack of education on mental health issues. Conclusions: Findings suggest the unique needs of individuals who support military Veterans with invisible injuries, highlighting variations and diachronic elements of caregiving. This sample is younger than the typical caregiver sample with implications for how best to support unpaid care partners caring for Veterans in the early to mid-period of their use of VA and civilian health services.
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    Data collection challenges in community settings: Insights from two field studies of patients with chronic disease
    (Springer, 2015-05) Holden, Richard J.; McDougald Scott, Amanda M.; Hoonakker, Peter L.T.; Hundt, Ann S.; Carayon, Pascale; Department of Biohealth Informatics, School of Informatics and Computing
    Purpose Collecting information about health and disease directly from patients can be fruitfully accomplished using contextual approaches, ones that combine more and less structured methods in home and community settings. This paper's purpose is to describe and illustrate a framework of the challenges of contextual data collection. Methods A framework is presented based on prior work in community-based participatory research and organizational science, comprised of ten types of challenges across four broader categories. Illustrations of challenges and suggestions for addressing them are drawn from two mixed-method, contextual studies of patients with chronic disease in two regions of the US. Results The first major category of challenges was concerned with the researcher-participant partnership, for example, the initial lack of mutual trust and understanding between researchers, patients, and family members. The second category concerned patient characteristics such as cognitive limitations and a busy personal schedule that created barriers to successful data collection. The third concerned research logistics and procedures such as recruitment, travel distances, and compensation. The fourth concerned scientific quality and interpretation, including issues of validity, reliability, and combining data from multiple sources. The two illustrative studies faced both common and diverse research challenges and used many different strategies to address them. Conclusion Collecting less structured data from patients and others in the community is potentially very productive but requires the anticipation, avoidance, or negotiation of various challenges. Future work is necessary to better understand these challenges across different methods and settings, as well as to test and identify strategies to address them.
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    Human Factors Affecting Logging Injury Incidents in Idaho and the Potential for Real-Time Location-Sharing Technology to Improve Safety
    (MDPI, 2018-10) Newman, Soren M.; Keefe, Robert F.; Brooks, Randall H.; Ahonen, Emily Q.; Wempe, Ann M.; Social and Behavioral Sciences, School of Public Health
    Human factors, including inadequate situational awareness, can contribute to fatal and near-fatal traumatic injuries in logging, which is among the most dangerous occupations in the United States. Real-time location-sharing technology may help improve situational awareness for loggers. We surveyed and interviewed professional logging contractors in Idaho to (1) characterize current perceptions of in-woods hazards and the human factors that lead to injuries; (2) understand their perspectives on using technology-based location-sharing solutions to improve safety in remote work environments; and (3) identify logging hazard scenarios that could be mitigated using location-sharing technology. We found production pressure, fatigue, and inexperience among the most-common factors contributing to logging injuries from the perspective of participants. Potential limitations of location-sharing technology identified included potential for distraction and cost. Contractors identified several situations where the technology may help improve safety, including (1) alerting workers of potential hand-faller injuries due to lack of movement; (2) helping rigging crews to maintain safe distances from yarded trees and logs during cable logging; and (3) providing a means for equipment operators to see approaching ground workers, especially in low-visibility situations.
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    Impact of a multimedia educational tool incorporating theoretical and mixed methods on the fruit and vegetable intakes of middle school children
    (2017-12-11) Whelan, JoAnne Louise; Arnold, Brent; Ernst, Judith; Staten, Lisa; Magee, Paula
    In the United States, over 30 percent of children are categorized as overweight or obese. Comorbid conditions, such as cardiovascular disease and other health complications related to obesity, are also on the rise. This public health issue is often related to disproportionate dietary intake and lack of physical activity. Efforts that promote fruits and vegetables (F/V) as preferred food choices over high fat and high sugar foods may help combat the increasing incidence of overweight and obesity. Other benefits from F/V include prebiotics or fiber that helps to create and maintain a healthy microbiota, which is now recognized as essential for long-term positive health outcomes. Many children, however, fall short in consuming the recommended daily amounts of F/V servings, and therefore, lack key nutrients such as vitamins, minerals, phytonutrients and fiber. This study is a pilot, quasi-experimental design that provides information related to the importance of eating F/V to children, ages 11-12 years, who attend a parochial school in Indianapolis, Indiana. The data from this study describe the amounts of F/V servings in home-prepared school lunches. The primary aim of this study is to determine if eight interactive multimedia lessons and activities delivered to one group of students (intervention) and a single lesson delivered to a different group of students in the same school and grade (control), affects the amount of lunch F/V servings, student knowledge, attitude, and self-efficacy/perception. This baseline data will contribute to the design and implementation of a health curriculum for middle school age students. Focus groups, adapted validated assessment tools as well as the on-site observation of F/V servings brought in lunches and consumed at lunch are compared between both groups to document any effects of the instruction. The results show that a statistically significant change in knowledge occurred within the intervention group following the implementation of this F/V education series. Favorable findings, with a positive upward trend in relative amounts of F/V, were identified and more research in this area is warranted.
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    Implementation Evaluation of a Complex Intervention to Improve Timeliness of Care for Veterans with Transient Ischemic Attack
    (SpringerLink, 2021-02) Damush, T.M.; Miech, E.J.; Rattray, N.A.; Homoya, B.; Penney, Lauren S.; Cheatham, A.; Baird, S.; Myers, J.; Austin, C.; Meyers, L.J.; Perkins, A.J.; Zhang, Y.; Giacherio, B.; Kumar, M.; Murphy, L.D.; Sico, J.J.; Bravata, D.M.; Medicine, School of Medicine
    Background: The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was designed to address systemic barriers to providing timely guideline-concordant care for patients with transient ischemic attack (TIA). Objective: We evaluated an implementation bundle used to promote local adaptation and adoption of a multi-component, complex quality improvement (QI) intervention to improve the quality of TIA care Bravata et al. (BMC Neurology 19:294, 2019). Design: A stepped-wedge implementation trial with six geographically diverse sites. Participants: The six facility QI teams were multi-disciplinary, clinical staff. Interventions: PREVENT employed a bundle of key implementation strategies: team activation; external facilitation; and a community of practice. This strategy bundle had direct ties to four constructs from the Consolidated Framework for Implementation Research (CFIR): Champions, Reflecting & Evaluating, Planning, and Goals & Feedback. Main measures: Using a mixed-methods approach guided by the CFIR and data matrix analyses, we evaluated the degree to which implementation success and clinical improvement were associated with implementation strategies. The primary outcomes were the number of completed implementation activities, the level of team organization and > 15 points improvement in the Without Fail Rate (WFR) over 1 year. Key results: Facility QI teams actively engaged in the implementation strategies with high utilization. Facilities with the greatest implementation success were those with central champions whose teams engaged in planning and goal setting, and regularly reflected upon their quality data and evaluated their progress against their QI plan. The strong presence of effective champions acted as a pre-condition for the strong presence of Reflecting & Evaluating, Goals & Feedback, and Planning (rather than the other way around), helping to explain how champions at the +2 level influenced ongoing implementation. Conclusions: The CFIR-guided bundle of implementation strategies facilitated the local implementation of the PREVENT QI program and was associated with clinical improvement in the national VA healthcare system.
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    Improving Smoking and Blood Pressure Outcomes: The Interplay Between Operational Changes and Local Context
    (Annals of Family Medicine, 2021) Cohen, Deborah J.; Sweeney, Shannon M.; Miller, William L.; Hall, Jennifer D.; Miech, Edward J.; Springer, Rachel J.; Balasubramanian, Bijal A.; Damschroder, Laura; Marino, Miguel; Emergency Medicine, School of Medicine
    Purpose: We undertook a study to identify conditions and operational changes linked to improvements in smoking and blood pressure (BP) outcomes in primary care. Methods: We purposively sampled and interviewed practice staff (eg, office managers, clinicians) from a subset of 104 practices participating in EvidenceNOW-a multisite cardiovascular disease prevention initiative. We calculated Clinical Quality Measure improvements, with targets of 10-point or greater absolute improvements in the proportion of patients with smoking screening and, if relevant, counseling and in the proportion of hypertensive patients with adequately controlled BP. We analyzed interview data to identify operational changes, transforming these into numeric data. We used Configurational Comparative Methods to assess the joint effects of multiple factors on outcomes. Results: In clinician-owned practices, implementing a workflow to routinely screen, counsel, and connect patients to smoking cessation resources, or implementing a documentation change or a referral to a resource alone led to an improvement of at least 10 points in the smoking outcome with a moderate level of facilitation support. These patterns did not manifest in health- or hospital system-owned practices or in Federally Qualified Health Centers, however. The BP outcome improved by at least 10 points among solo practices after medical assistants were trained to take an accurate BP. Among larger, clinician-owned practices, BP outcomes improved when practices implemented a second BP measurement when the first was elevated, and when staff learned where to document this information in the electronic health record. With 50 hours or more of facilitation, BP outcomes improved among larger and health- and hospital system-owned practices that implemented these operational changes. Conclusions: There was no magic bullet for improving smoking or BP outcomes. Multiple combinations of operational changes led to improvements, but only in specific contexts of practice size and ownership, or dose of external facilitation.
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    Integration Through Connecting in Explanatory Sequential Mixed Method Studies
    (Sage, 2020-12) Burke Draucker, Claire; Rawl, Susan M.; Vode, Emilee; Carter-Harris, Lisa; School of Nursing
    The purposes of this methods article are to (a) discuss how integration can occur through a connecting approach in explanatory sequential mixed methods studies, (b) describe a connecting strategy developed for a study testing a conceptual model to predict lung cancer screening, and (c) describe three analytic products developed by subsequent integration procedures enabled by the connecting strategy. Connecting occurs when numeric data from a quantitative strand of a study are used to select a sample to be interviewed for a subsequent qualitative strand. Because researchers often do not fully exploit numeric data for this purpose, we developed a multi-step systematic sampling strategy that produced an interview sample of eight subgroups of five persons (n = 40) whose profiles converged with or diverged from the conceptual model in specified ways. The subgroups facilitated the development of tailored interview guides, in-depth narrative summaries, and exemplar case studies to expand the quantitative findings.
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    Investigating Health Related Quality of Life in People with Schizophrenia
    (2019-02) Janela, Carlos M.; Draucker, Claire Burke; Carpenter, Janet S.; Oruche, Ukamaka M.; Minor, Kyle S.
    Schizophrenia is a serious mental illness that significantly lessens health-related quality of life (HRQoL). A better understanding of HRQoL is needed to inform holistic and patient-centered treatments for schizophrenia. The purpose of this dissertation is to conduct an in-depth exploration of HRQoL in people with schizophrenia. The dissertation includes three components. The first component is an integrative literature review aimed at identifying factors associated with physical quality of life (QoL) in people with schizophrenia. The review reveals that symptoms of schizophrenia, depression, obesity or body mass index, and physical activity are associated with physical QoL in this population. The second and third components are based on illness narratives of 20 people with schizophrenia who had participated in a larger study of individuals diagnosed with serious mental illness. The second component of the dissertation is a qualitative descriptive study conducted to describe common HRQoL concerns in people with schizophrenia. The results indicate that these concerns were related to social relationships, psychiatric symptoms, psychiatric care, and employment. The third component of the dissertation is a parallel convergent mixed-methods study conducted to explore whether computerized lexical analysis (CLA) of illness narratives of people with schizophrenia can reveal their HRQoL concerns. CLA is an automatized process that counts words in text data and sorts them into pre-defined word categories. The results provide preliminary support for the potential use of CLA to efficiently assess HRQoL in people with schizophrenia as the CLA identified some of the HRQoL concerns that had been identified in the prior qualitative descriptive study. The results of the three studies reveal the complexity of the phenomenon of HRQoL in people with schizophrenia and can inform the development of strategies to identify and promote HRQoL in this population.
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    A Mixed-method Analysis of Community-Engaged Theatre Illuminates Black Women’s Experiences of Racism and Addresses Healthcare Inequities by Targeting Provider Bias
    (Sage, 2020) Wasmuth, Sally; Pritchard, Kevin; Milton, Cierra; Smith, Emily; Occupational Therapy, School of Health and Human Sciences
    Theatre has been a powerful means of eliciting social change. This paper describes methods and outcomes of a theatre project to reduce healthcare inequities experienced by Black women. We conducted narrative interviews with a convenience sample of Black women and conducted thematic analysis of interview transcripts to learn about their experiences of healthcare and to inform development of a professional theatrical production. To assess the impact of the performance on the audience, we used a single post-test concurrent mixed-methods design using a self-created Likert-type survey that included space for open-ended responses. Ten Black women completed narrative interviews. Thematic analysis revealed 5 main themes: being ignored, being accused, being talked-down to, fearing harm, and being hurt. Narratives were used to create a script that centered on these themes, and that was professionally produced and performed. Audience members (n = 113, 25% healthcare providers) produced a mean total post-test score of 19.28 (agree/strongly agree) on a 25-point survey with 2 items scoring in the 2 to 3 range (disagree/not sure). Thematic analysis data revealed the extent to which Black women experienced discrimination in multiple settings. Quantitative survey data suggested audience members conceptually understood and were aware of inequity, but open-ended responses revealed this information was new for some, and prior knowledge for others. The audience reported planning to change personal behaviors that may contribute to inequity. Participants were unsure if they had contributed to inequity in the past. The performance stimulated conversation about implicit bias and discrimination and encouraged audience members to examine their contributions to the problem. Future pre-post studies are needed to better assess the impact of the performance. Theatre has the potential to illuminate the extent and nature of discrimination in healthcare and society, and to foster conversations that allow audience members to consider their own potential contributions to discrimination.