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Background: Payers are increasingly interested in quality improvement for opioid use disorder (OUD) treatment, including incorporating patient experiences. Medicaid is the largest payer for OUD treatment, yet we know little about the treatment benefits Medicaid members report, how these vary across members, or changed with the COVID-19 pandemic.Objective: To examine Medicaid members' report of outpatient treatment benefits, employment, and housing outcomes before and during the pandemic.Methods: A representative sample of 1,032 Virginia Medicaid members (52% women) receiving OUD treatment completed a survey of treatment benefits, health status and social needs. A reported treatment benefit index was created based on seven self-reported items. Multivariable linear regression models, pooled and stratified by time (pre-COVID-19/COVID-19), assessed member characteristics associated with reported treatment benefit, employment and housing outcomes.Results: Members reported strong treatment benefit (mean: 21.8 [SD: 5.9] out of 28 points) and improvements in employment (2.4 [1.3] out of 5) and housing (2.8 [1.2] out of 5). After adjustment, mental distress (regression coefficient: -3.00 [95% CI:-3.97;-2.03]), polysubstance use (-1.25 [-1.99;-0.51]), and food insecurity (-1.00 [-1.71;-0.29]), were associated with decreased benefits from treatment. During COVID-19, justice-involved individuals reported decreased benefits (-2.17 [-3.54; -0.80]) compared to before the pandemic (-0.09 [-1.4-;1.24] p < .05).Conclusions: Medicaid members receiving outpatient OUD treatment reported positive treatment benefits, and housing and employment outcomes. However, those with comorbid health and social conditions often benefited the least. As payers move toward quality improvement and value-based purchasing initiatives, collecting and integrating patient reported outcomes into quality metrics is critical.

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BACKGROUND: Healthcare delivery organizations are increasingly screening patients for social risks using tools that vary in content and length. OBJECTIVES: To compare two screening tools both containing questions related to financial hardship. DESIGN: Cross-sectional survey. PARTICIPANTS: Convenience sample of adult patients (n = 471) in three primary care clinics. MAIN MEASURES: Participants randomly assigned to self-complete either: (1) a screening tool developed by the Centers for Medicare & Medicaid Services (CMS) consisting of six questions on financial hardship (housing stability, housing quality, food security, transportation security, utilities security); or (2) social and behavioral risk measures recommended by the National Academy of Medicine (NAM), including one question on financial hardship (financial strain). We compared patient acceptability of screening, positive screening rates for financial hardship, patient interest in assistance, and self-rated health. RESULTS: Ninety-one percent of eligible/interested patients completed the relevant survey questions to be included in the study (N = 471/516). Patient acceptability was high for both tools, though more participants reported screening was appropriate when answering the CMS versus NAM questions (87% vs. 79%, p = 0.02). Of respondents completing the CMS tool, 57% (132/232) reported at least one type of financial hardship; on the NAM survey, 52% (125/239) reported financial hardship (p = 0.36). Nearly twice as many respondents indicated interest in assistance related to financial hardship after completing items on the CMS tool than on the NAM question (39% vs. 21%, p < 0.01). CONCLUSIONS: Patients reported high acceptability of both social risk assessment tools. While rates of positive screens for financial hardship were similar across the two measures, more patients indicated interest in assistance after answering questions about financial hardship on the CMS tool. This might be because the screening questions on the CMS tool help patients to appreciate the types of assistance related to financial hardship that may be available after screening. Future research should assess the validity and comparative validity of individual measures and measure sets. Tool selection should be based on setting and population served, screening goals, and resources available.

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BACKGROUND: Surveys of hospitalized patients are important for research and learning about unobservable medical issues (eg, mental health, quality of life, and symptoms), but there has been little work examining survey data quality in this population whose capacity to respond to survey items may differ from the general population. OBJECTIVE: The aim of this study is to determine what factors drive response rates, survey drop-offs, and missing data in surveys of hospitalized patients. METHODS: Cross-sectional surveys were distributed on an inpatient tablet to patients in a large, midwestern US hospital. Three versions were tested: 1 with 174 items and 2 with 111 items; one 111-item version had missing item reminders that prompted participants when they did not answer items. Response rate, drop-off rate (abandoning survey before completion), and item missingness (skipping items) were examined to investigate data quality. Chi-square tests, Kaplan-Meyer survival curves, and distribution charts were used to compare data quality among survey versions. Response duration was computed for each version. RESULTS: Overall, 2981 patients responded. Response rate did not differ between the 174- and 111-item versions (81.7% vs 83%, P=.53). Drop-off was significantly reduced when the survey was shortened (65.7% vs 20.2% of participants dropped off, P<.001). Approximately one-quarter of participants dropped off by item 120, with over half dropping off by item 158. The percentage of participants with missing data decreased substantially when missing item reminders were added (77.2% vs 31.7% of participants, P<.001). The mean percentage of items with missing data was reduced in the shorter survey (40.7% vs 20.3% of items missing); with missing item reminders, the percentage of items with missing data was further reduced (20.3% vs 11.7% of items missing). Across versions, for the median participant, each item added 24.6 seconds to a survey's duration. CONCLUSIONS: Hospitalized patients may have a higher tolerance for longer surveys than the general population, but surveys given to hospitalized patients should have a maximum of 120 items to ensure high rates of completion. Missing item prompts should be used to reduce missing data. Future research should examine generalizability to nonhospitalized individuals.

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BACKGROUND: The COVID-19 pandemic required that our research team change our mail-only (MO) strategy for a research survey to a strategy more manageable by staff working remotely. We used a modified web-push approach (MWP), in which patients were mailed a request to respond online and invited to call if they preferred the questionnaire by mail or phone. We also changed from a pre-completion gift to a post-completion gift card incentive. Our objective is to compare response patterns between modes for a survey that used an MO strategy pre-pandemic followed by an MWP strategy peri-pandemic for data collection. METHODS: Observational study using data from a national multi-scale survey about patients' experience of specialty care coordination administered via MO in 2019 and MWP from 2020 to 2021 to Veterans receiving primary care and specialty care within the Veterans Health Administration (VA). We compared response rates, respondent characteristics and responses about care coordination between MO and MWP, applying propensity weights to account for differences in the underlying samples. RESULTS: The response rate was lower for MWP vs. MO (13.4% vs. 36.6%), OR = 0.27, 95% CI = 0.25-0.30, P < .001). Respondent characteristics were similar across MO and MWP. Coordination scale scores tended to be slightly higher for MWP, but the effect sizes for these differences between modes were small for 9 out of 10 scales. CONCLUSIONS: While the logistics of MWP survey data collection are well-suited to the remote research work environment, response rates were lower than those for the MO method. Future studies should examine addition of multi-mode contacts and/or pre-completion incentives to increase response rates for MWP.

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BACKGROUND: Each year, roughly 20% of U.S. adults visit an emergency department (ED), but little is known about patients' choice of ED. OBJECTIVES: Examine the discretion patients have to choose among EDs, characteristics associated with ED choice, and relationship between ED choice and self-reported care experiences of ED patients. METHODS: We surveyed adult patients discharged to the community (DTC) in January-March 2018 from 16 geographically dispersed hospital-based EDs, geocoded patient and hospital-based ED addresses within 100 miles of patient addresses, and calculated travel distances. We examined the likelihood of visiting the closest ED based on patient and ED characteristics. Linear regression models examined the association of choosing the closest ED with seven measures of patient experience of care (scaled 0-100), adjusting for patient characteristics. RESULTS: 43.6% of 4647 responding patients visited the ED nearest their home (on average, 5.7 miles away). Patients who chose a farther ED had more urgent conditions, were more educated, and were less likely to be non-Hispanic White. They were significantly more likely to have visited an ED in a higher-rated, metropolitan, network hospital with major teaching status, a cardiac intensive care unit, and a certified trauma center. Patients who chose a farther ED were more likely to recommend that ED, with "medium-to-large" differences in scores (+4.3% more selected "definitely yes", p < 0.05). CONCLUSIONS: Fewer than half of patients visited the closest ED. Patients who chose a farther ED tended to seek higher-rated hospitals and report more favorable experiences.

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Background: High-quality cancer care should be effective, safe, accessible, efficient, equitable, and responsive to patients' needs. In Switzerland, information on the safety and effectiveness of cancer care is available, but not on responsiveness. Systematic and comprehensive reports from patients on cancer care are missing and needed to complete the assessment of the quality of cancer care. Evidence: Patient-reported experiences of cancer care are key to evaluate responsiveness of care and drive quality improvement initiatives in oncology practice. Studies have found that responsive care leads to more positive experiences of care, which can lead to more effective treatments and health benefits. Policy Options and Recommendations: Our first recommendation is to develop a position statement on the importance and value of patient-reported experiences of cancer care. Our second recommendation is to systematically collect patients' experiences of cancer care at the national level, through a dedicated national cancer-specific measurement program or through the integration of patient-reported experiences measures in cancer registries. Conclusion: The systematic collection of patient-reported experiences of cancer care provides essential information on what matters to patients in addition to traditional clinical information, including patients as partners of the overall assessment of healthcare performance.

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BACKGROUND. Patients are increasingly using online information regarding patient experiences to guide care decisions. OBJECTIVE. The purpose of our study was to compare patient experience scores between radiologists and nonradiologist physicians and to assess changes in scores after their public posting in an online physician directory. METHODS. This retrospective study included data collected from May 1, 2017, to November 30, 2018, at a single large academic medical center. After all institutional outpatient visits, patients were e-mailed the Press Ganey Medical Practice Survey, which included 10 questions (answered using a Likert scale and converted to 100-point range) relating to the patient's experience with the specific provider for the encounter. Surveys were distributed to patients after radiology encounters if involving an image-guided invasive procedure. Mean scores for each question and the mean weighted overall score were displayed on each physician's publicly available profile on the hospital's online physician directory and were updated monthly. Scores were compared between radiologists and nonradiologist physicians; temporal changes were assessed. RESULTS. The response rate was 18.0% (96,057/533,983). After exclusions (23,989 surveys completed without provider ratings; 183 surveys evaluating physician assistants), 71,885 physician surveys were evaluated: 2703 surveys for 65 radiologists, 49,403 surveys for 916 physicians in 17 nonsurgical specialties, and 19,779 surveys for 262 physicians in 13 surgical specialties. Over the study period, the mean overall score was 95.6 for radiologists and 95.9 for nonradiologists (94.6 for surgical specialties, 96.4 for nonsurgical specialties). For the 10 individual questions, scores ranged for radiologists from 94.6 (time spent with patient) to 96.8 (friendliness/courtesy) and for nonradiologists from 94.6 (time spent with patient) to 97.0 (friendliness/courtesy). The mean overall score increased from the first month to the final month for radiologists from 94.2 to 97.1 and for nonradiologists from 95.7 to 96.3. For radiologists, the largest improvement was for instructions regarding postprocedure follow-up care (increased from 91.4 to 97.4). CONCLUSION. Radiologists received high scores on patient experience surveys when evaluated on encounters involving invasive procedures, achieving scores similar to those for other physicians. Scores improved over time, possibly related to online posting of survey results. CLINICAL IMPACT. The findings support the utility of implementing patient experience surveys in radiology.

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Background: To compare serious illness programs (SIPs) using recently developed patient experience measures, adjustment must be made for patient characteristics not under control of the programs. Objectives: To develop a case-mix adjustment model to enable fair comparison of patient experience between SIPs by investigating the roles of patient characteristics, proxy response, and mode of survey administration (mail-only vs. mail with telephone follow-up) in survey responses. Methods: Using survey data from 2263 patients from 32 home-based SIPs across the United States, we fit regression models to assess the association between patient-level variables and scores for seven quality measures (Communication, Care Coordination, Help for Symptoms, Planning for Care, Support for Family and Friends, and two global assessments of care). Characteristics that are not consequences of the care the program delivered were considered as adjustors. Results: Final recommended case-mix adjustors are age, education, primary diagnosis, self-reported functional status, self-rated physical health, self-rated mental health, proxy respondent use, and response percentile (a measure of how soon a person responded compared with others in the same program and mode). Age, primary diagnosis, self-rated mental health, and proxy respondent use had the most impact on program-level scores. We also recommend adjusting for mode of survey administration. We find that up to 12 percent of pairs of programs would have their rankings reversed by adjustment. Conclusions: To ensure fair comparison of programs, scores should be case-mix adjusted for variables that influence patients' reports about care quality, but are not under the control of the program administering care.

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The routine use of patient reported outcome measurements (PROMs) can support the orientation of healthcare systems towards the value and usefulness for patients. The collation of patient reported experience measurements (PREMs) is suitable for bringing transparency to the patient orientation of healthcare processes and the experience gained. Both PREM and PROM will become an integral component of the assessment of medical quality in Germany when the guidelines for data-supported quality assurance across institutions (DeQS-RL) come into force. By means of newly developed patient surveys per medical service area, they will be used as additional sources for the legally binding quality assurance. Although this gives more weight to the evaluation of the quality of treatment by patients, special features must be taken into account in the development and implementation for orthopedics and trauma surgery in order to avoid misinterpretation of the results and subsequent misguidance in the healthcare system.

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BACKGROUND: Several factors besides appointment availability can influence access to care. Among these factors are the diverse challenges that patients may experience in navigating the healthcare system. However, the relationship between these challenges or "hassles" and delaying or forgoing care has not been assessed. METHODS: We examined the relationship between healthcare system hassles and delaying or forgoing needed care. We used data from a 2016 Veterans Affairs (VA) survey of women veterans (N = 821) who were active users of primary care (3+ primary care visits in the past year) at any of 12 VA medical centers. The main independent variable was a measure of 16 healthcare system hassles, encompassing a wide range of clinically-relevant aspects of patient experience, such as uncertainty about when/how to take a medication or difficulty getting questions answered between appointments. The outcome was a self-reported measure of delaying or forgoing needed care. We used logistic regression to estimate this outcome as a function of hassles, adjusting for age, comorbidities, and health care utilization. Survey weights accounted for within-site clustering, nonproportional sampling, and nonresponse. RESULTS: Overall, 26% of participants reported 0 hassles, and 39% reported 4 or more. Reporting 4 or more hassles (vs. 0) was associated with a roughly 5-fold increase in the predicted probability of delaying or forgoing care. CONCLUSION: Addressing healthcare system hassles could yield unexpected benefits to realized access.

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Introduction: Our purpose was to develop and test a brief, self-report, and scorable survey instrument for measuring population health profiles from the individual respondent's perspective. We defined population health as the state of physical, mental, and social well-being of a group of individuals, including determinants of their well-being. Materials and Methods: Respondents were adult patients in a community health center. Instrument items, an overall scale, and two subscales were developed and evaluated. Reliability was tested by Cronbach's alphas and test-retest correlations; construct validity was tested by correlations between scores and economic and clinical factors; criterion validity was tested by regression analyses for prediction of morbidity and health care utilization by baseline scores; and feasibility was tested by length of administration time. Results: This was a 2-years prospective study of 450 patients, mostly black non-Hispanics (54%) and Hispanics (29%), many with no health insurance (45%), and poor enough to meet the federal poverty level (73%). The Duke Population Health Profile (Duke-PH) was developed with a 14-item PH scale for overall population health profile and two 7-item subscales, one for social determinants and the other for health determinants. Validity of item selection was indicated by item convergent and item discriminant correlations. Scale and subscale reliability were supported for internal consistency by Cronbach's alphas of 0.63-0.73, and for temporal stability by test-retest correlations of 0.65-0.78. Support for construct validity was shown by the more favorable baseline subscale and scale mean scores for patients able to buy private insurance than for patients unable to afford it. Criterion validity was supported by regression analyses showing that baseline scale and subscale scores predicted both baseline morbidity and 6-months utilization. Feasibility was shown by the mean self-administration time of 3.9 min and mean interviewer-administration time of 5.8 min. Discussion: The strength of this study is support for Duke-PH reliability, validity, and feasibility in a community health center patient population. The new instrument is unique because it measures both social and health determinants of population health from the perspective of individuals in the population.

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OBJECTIVE: To assess documentation of urinary incontinence (UI) in prostatectomy patients using unstructured clinical notes from Electronic Health Records (EHRs). METHODS: We developed a weakly-supervised natural language processing tool to extract assessments, as recorded in unstructured text notes, of UI before and after radical prostatectomy in a single academic practice across multiple clinicians. Validation was carried out using a subset of patients who completed EPIC-26 surveys before and after surgery. The prevalence of UI as assessed by EHR and EPIC-26 was compared using repeated-measures ANOVA. The agreement of reported UI between EHR and EPIC-26 was evaluated using Cohen's Kappa coefficient. RESULTS: A total of 4870 patients and 716 surveys were included. Preoperative prevalence of UI was 12.7 percent. Postoperative prevalence was 71.8 percent at 3 months, 50.2 percent at 6 months and 34.4 and 41.8 at 12 and 24 months, respectively. Similar rates were recorded by physicians in the EHR, particularly for early follow-up. For all time points, the agreement between EPIC-26 and the EHR was moderate (all p < 0.001) and ranged from 86.7 percent agreement at baseline (Kappa = 0.48) to 76.4 percent agreement at 24 months postoperative (Kappa = 0.047). CONCLUSIONS: We have developed a tool to assess documentation of UI after prostatectomy using EHR clinical notes. Our results suggest such a tool can facilitate unbiased measurement of important PCOs using real-word data, which are routinely recorded in EHR unstructured clinician notes. Integrating PCO information into clinical decision support can help guide shared treatment decisions and promote patient-valued care.

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BACKGROUND: Health care organizations are increasingly using electronic health (eHealth) platforms to provide and exchange health information and advice (HIA). There is limited information about how factors beyond internet access affect use of eHealth resources by middle-aged and older adults. OBJECTIVE: We aimed to estimate prevalence of use of the internet, health plan patient portal, and Web-based HIA among middle-aged and older adults; investigate whether similar sociodemographic-related disparities in eHealth resource use are found among middle-aged and older adults; and examine how sociodemographic and internet access factors drive disparities in eHealth resource use among adults who use the internet. METHODS: We analyzed cross-sectional survey data for 10,920 Northern California health plan members aged 45 to 85 years who responded to a mailed and Web-based health survey (2014-2015). We used bivariate and multivariable analyses with weighted data to estimate prevalence of and identify factors associated with internet use and self-reported past year use of the health plan's patient portal and Web-based HIA resources by middle-aged adults (aged 45 to 65 years; n=5520), younger seniors (aged 65 to 75 years; n=3014), and older seniors (aged 76 to 85 years; n=2389). RESULTS: Although approximately 96% of middle-aged adults, 92% of younger seniors, and 76% of older seniors use the internet to obtain information, about 4%, 9%, and 16%, respectively, require someone's help to do so. The percentages who used the patient portal and Web-based HIA resources were similar for middle-aged adults and younger seniors but lower among older seniors (59.6%, 61.4%, and 45.0% and 47.9%, 48.4%, and 37.5%, respectively). Disparities in use of the internet, patient portal, and Web-based HIA across levels of education and between low and higher income were observed in all age groups, with wider disparities between low and high levels of education and income among seniors. Multivariable analyses showed that for all 3 age groups, educational attainment, ability to use the internet without help, and having 1 or more chronic condition were significant predictors of patient portal and Web-based HIA use after controlling for gender, race/ethnicity, and internet use. CONCLUSIONS: Internet use, and especially use without help, significantly declines with age, even within a middle-aged group. Educational attainment is significantly associated with internet use, ability to use the internet without help, and use of patient portal and Web-based HIA resources by middle-aged and older adults. Even among middle-aged and older adult internet users, higher educational attainment and ability to use the internet without help are positively associated with patient portal and Web-based HIA use. Organizations serving middle-aged and older adults should take into account target population characteristics when developing and evaluating uptake of eHealth resources and should consider offering instruction and support services to boost patient engagement.

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OBJECTIVES: 1) Refine pilot scale measuring patients' experiences of outpatient nurses' and providers' care; 2) Determine variance explained by (a) pilot scale items and (b) "Survey of Health Experiences of Patients" (SHEP)/"Consumer Assessment of Health Care Providers and Systems" (CAHPS) scale items. METHODS: Randomly selected Veteran patients with recent visits with primary care outpatient nurses and providers (n = 1192) completed scales: pilot "PCC in Primary Care: Nurses and Providers Scale" and SHEP/CAHPS scale items. Factor analyses conducted using structural equation modeling (SEM), variance measurement using regression strategies. RESULTS: SEM generated scale comprised 17 items in 3 factors; 2 operationalized nurses' care; 1 providers' care. Fit statistics were acceptable. Variance explained for total PCC: nurses = 42%, providers = 56%. Combined pilot and SHEP/CAHPS item analyses yielded similarly structured scale. 70% of provider care variance explained by single item. CONCLUSION: Appraisal of team, value-based care requires accrediting care to the appropriate clinician. The "PCC in Primary Care: Nurses and Providers Scale (PC2:NaPS)" provides a psychometrically sound measure for this purpose. PRACTICE IMPLICATIONS: PC2:NaPS use would improve primary care leaders' and clinicians' analyses of patient centered care and associated outcomes in their settings, and thus enhance success of quality improvement and organizational projects.

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BACKGROUND: Research underpinning the patient experience of people with chronic conditions in Australian general practice is not well developed. We aimed to ascertain the perspectives of key stakeholders on aspects of patient experience, more specifically with regards to accessing general practice in Australia. METHODS: Using a qualitative design, semi-structured interviews were conducted by telephone and face-to-face with people living with one or more chronic conditions, informal carers, and primary care providers between October 2016 and October 2017. Participants were recruited and selected from three demographically representative primary health networks across Sydney, Australia. Interview transcripts and researcher's reflective fieldnotes were coded and analyzed for key themes of access. Analysis and interpretation of data were guided by Levesque's model of access, a conceptual framework to evaluate access broadly and from corresponding patient- and provider-side dimensions. RESULTS: A total of 40 interviews were included in the analysis. Most participants had attended their general practices for 10 years or more and had regular primary care providers. People with chronic conditions reported access barriers predominantly in their ability to reach services, which were related to illness-related disabilities (limited mobility, chronic pain, fatigue, frailty) and limitations in the availability and accommodation of health services to address patient preferences (unavailability of after-hours services, lack of alternative modes of service delivery). While cost was not a major barrier, we found a lack of clarity in the factors that determined providers' decisions to waive or reduce costs for some patients and not others. CONCLUSIONS: People managing chronic conditions with a long-term primary care provider experienced access barriers in general practice, particularly in their ability to physically reach care and to do so on a timely basis. This study has important policy and practice implications, as it highlights patients' experiences of accessing care and possible areas for improvement to appropriately respond to these experiences. Themes identified may be useful in the design of a patient experience survey tool specific to this population. While it incorporates perspectives from patients, carers and providers, this study could be further strengthened by including perspectives from culturally and linguistically underrepresented patient groups and more carers.

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Policy Points Narratives about patients' experiences with outpatient care are essential for quality improvement because they convey ample actionable information that both elaborates on existing domains within patient experience surveys and describes multiple additional domains that are important to patients. The content of narrative feedback from patients can potentially be translated to improved quality in multiple ways: clinicians can learn from their own patients, groups of clinicians can learn from the experience of their peers' patients, and health system administrators can identify and respond to patterns in patients' accounts that reflect systemic challenges to quality. Consistent investment by payers and providers is required to ensure that patient narratives are rigorously collected, analyzed fully, and effectively used for quality improvement. CONTEXT: For the past 25 years, health care providers and health system administrators have sought to improve care by surveying patients about their experiences. More recently, policymakers have acted to promote this learning by deploying financial incentives tied to survey scores. This article explores the potential of systematically elicited narratives about experiences with outpatient care to enrich quality improvement. METHODS: Narratives were collected from 348 patients recruited from a nationally representative Internet panel. Drawing from the literature on health services innovation, we developed a two-part coding schema that categorized narrative content in terms of (a) the aspects of care being described, and (b) the actionability of this information for clinicians, quality improvement staff, and health system administrators. Narratives were coded using this schema, with high levels of reliability among the coders. FINDINGS: The scope of outpatient narratives divides evenly among aspects of care currently measured by patient experience surveys (35% of content), aspects related to measured domains but not captured by existing survey questions (31%), and aspects of care that are omitted from surveys entirely (34%). Overall, the narrative data focused heavily on relational aspects of care (43%), elaborating on this aspect of experience well beyond what is captured with communication-related questions on existing surveys. Three-quarters of elicited narratives had some actionable content, and almost a third contained three or more separate actionable elements. CONCLUSIONS: In a health policy environment that incentivizes attention to patient experience, rigorously elicited narratives hold substantial promise for improving quality in general and patients' experiences with care in particular. They do so in two ways: by making concrete what went wrong or right in domains covered by existing surveys, and by expanding our view of what aspects of care matter to patients as articulated in their own words and thus how care can be made more patient-centered. Most narratives convey experiences that are potentially actionable by those committed to improving health care quality in outpatient settings.

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It is difficult to apply U.S. Federal Code of Regulation's criterion for "minimal risk," because benchmarks of minimal risk have not been quantified. Our goal was to examine the psychological risks of several day-to-day activities. Using the Self-Assessment Manikin (SAM), we assessed the state valence and arousal of 432 patients and employees at a large Midwestern Department of Veterans Affairs medical facility before and after they had their blood drawn, saw their primary care physician or mental health provider, or took part in an exercise class. Exercise was associated with near-large to large salutary effects (Cohen's d = 0.76-1.17); other effects were small or moderate in positive directions (Cohen's d = 0.02-0.51). Our findings are a promising start toward establishing benchmarks and quantifying the psychological harms of minimal risk activities. Estimates such as these may help researchers determine whether their own research exceeds minimal risk.

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Background: The choice of vascular access for systemic therapy administration in breast cancer remains an area of clinical equipoise, and patient preference is not consistently acknowledged. Using a patient survey, we evaluated the patient experience with vascular access during treatment for early-stage breast cancer and explored perceived risk factors for lymphedema. Methods: Patients who had received systemic therapy for early-stage breast cancer were surveyed at 2 Canadian cancer centres. Results: Responses were received from 187 patients (94%). The route of vascular access was peripheral intravenous line (IV) in 24%, a peripherally inserted central catheter (picc) in 42%, and a surgically inserted central catheter (port) in 34%. Anthracycline-based regimens were associated with a greater use of central vascular access devices (cvads- that is, a picc or port; 86/97, 89%). Trastuzumab use was associated with greater use of ports (49/64, 77%). Although few patients (7%) reported being involved in the decisions about vascular access, most were satisfied or very satisfied (88%) with their access type. Patient preference centred mainly on avoiding delays in the initiation of chemotherapy. Self-reported rates of complications (183 evaluable responses) were infiltration with peripheral IVs (9/44, 20%), local skin infections with piccs (7/77, 9%), and thrombosis with ports (4/62, 6%). Perceived risk factors for lymphedema included use of the surgical arm for blood draws (117/156, 75%) and blood pressure measurement (115/156, 74%). Conclusions: Most patients reported being satisfied with the vascular access used for their treatment. Improved education and understanding about the evidence-based requirements for vascular access are needed. Perceived risk factors for lymphedema remain variable and are not evidence-based.

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BACKGROUND: Improving childhood vaccine coverage is a priority for global health, but challenging in low and middle-income countries. Although previous research has sought to measure determinants of vaccination, most has limitations. We measure determinants using a clearly-defined hypothetical model, multi-faceted data, and modeling strategy that makes full use of the hypothesis and data. METHODS: We use linked, cross-sectional survey data from households, health facilities, patients and health offices in Uganda and Zambia, and Bayesian Structural Equation Modeling to quantify the proportion of variance in childhood vaccination that is explained by key determinants, controlling for known confounding. RESULTS: We find evidence that the leading determinant of vaccination is different for different outcomes. For three doses of pentavalent vaccine, intent to vaccinate (on the part of the mother) is the leading driver, but for one dose of the vaccine, community access is a larger factor. For pneumococcal conjugate vaccine, health facility readiness is the leading driver. Considering specifically-modifiable determinants, improvements in cost, facility catchment populations and staffing would be expected to lead to the largest increase in coverage according to the model. CONCLUSIONS: This analysis measures vaccination determinants using improved methods over most existing research. It provides evidence that determinants should be approached in the context of relevant outcomes, and evidence of specific determinants that could have the greatest impact in these two countries, if targeted. Future studies should seek to improve our analytic framework, apply it in different settings, and utilize stronger study designs. Programs that focus on a particular determinant should use these results to select an outcome that is appropriate to measure their effectiveness. Vaccination programs in these countries should use our findings to better target interventions and continue progress against vaccine preventable diseases.

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BACKGROUND: One potential concern with using mailed surveys containing trauma-related content is the possibility of re-traumatizing survivors without a trained mental health professional present. Prior research provides insufficient guidance regarding the prevalence and magnitude of this risk because the psychological harms of trauma-related surveys have typically been estimated using single post-test observations. Post-test observations cannot quantify magnitude of change in participants' emotional states and may over or under estimate associations between participants' characteristics (risk factors) and post-survey upset. METHODS: We conducted two pre- and post-test studies in samples of former applicants for posttraumatic stress disorder disability benefits: 191 males who served during Gulf War I plus 639 male and 921 female Veterans who served sometime between 1955 and 1998. We used two 9-point items from the Self-Assessment Manikins to measure participants' valence (sadness/happiness) and arousal (tenseness/calmness) before and after they completed mailed surveys asking about trauma-related symptoms or experiences. We examined the following potential predictors for post-survey sadness and tenseness: screening positive for posttraumatic stress disorder, having a serious mental illness, and history of military sexual assault or combat. RESULTS: After the survey, across the groups, 29.3-41.8% were sadder, 45.3-52.2% had no change in valence, and 12.9-22.5% were happier; 31.7-40.2% were tenser, 40.6-48.2% had no change in arousal, and 17.3-24.0% were calmer. The mean increase in sadness or tenseness post-survey was less than one point in all groups (SD's < 1.7). Cohen's d ranged from 0.07 to 0.30. Most hypothesized predictors were associated with greater baseline sadness or tenseness, but not necessarily with larger post-survey changes. Women with a history of military sexual assault had the largest net post-survey changes in sadness (mean = 0.7, SD = 1.4) and tenseness (mean = 0.6, SD = 1.6). CONCLUSION: While a substantial minority of Veterans reported more sadness or tenseness post-survey, the net change in affect was small. Most hypothesized risk factors were actually associated with higher baseline sadness or tenseness scores. When receiving unsolicited, trauma-related surveys by mail, separate protections for Veterans with the risk factors studied here do not seem necessary.

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