Ashley M. Hughes

Background: Alert fatigue is defined as alert dismissals due to excessive or irrelevant alerts and is frequently cited as a barrier to clinical decision support system use and impact. However, the criteria for determining the presence or absence of alert fatigue are poorly defined. The objective of this systematic review of systematic reviews was to identify operationalized definitions and measures of alert fatigue or alert-related metrics. Methods: Systematic reviews reporting at least one alert-related metric or measure/operationalization of alert fatigue for physician-directed electronic alerts were included. The Cochrane Library, Embase, and PubMed were searched from database start to 2024. The Revised Assessment of Multiple Systematic Reviews was used to assess study quality and risk of bias. Data were synthesized narratively and with descriptive statistics. Results: A total of 22 studies were included in the review. Studies reported between 1 and 11 alert metrics. Studies were most often of medium quality. Reporting of primary study characteristics was frequently judged to be insufficient. Only one article reported an operational definition of alert fatigue. The most common alert metrics were quantity, override rate, and acceptance rate. Discussion: Alert fatigue measurement methods are not clearly or consistently defined in systematic reviews related to alert fatigue in clinical decision support. Reporting of other primary study characteristics is often limited. We recommend that future efforts use a significant, sustained decrease in appropriate alert response rates from an established baseline as a measure of alert fatigue.

Background: Children and young adults with special health care needs comprise a significant portion of the pediatric population in the United States, where 1 in every 5 children has a complex health care need. These patients are more likely to receive unsafe care and have their needs unmet in part due to lack of accessible information and limited training support. Barriers in communication may contribute to detrimental outcomes for this vulnerable, high-risk population. Objective: This project aims to identify barriers to communication in children and young adults with special health care needs in the health care setting. These barriers will inform prototype development using human-centered design approaches to create a web-based application. Feedback from patients, caregivers, and health care providers (HCPs) was obtained on the usability and usefulness of the tool within the health care setting. Methods: A needs assessment was conducted in which participants shared their experiences in providing or receiving health care services via a semistructured interview that was recorded and transcribed. Transcripts were analyzed inductively for themes, coded, and used to categorize the data. On the basis of these themes, iterative development of a web-based application for social stories took place. Focus groups were held to provide relevant feedback on the prototype. Results: There were 15 participants (n=10, 67% HCPs and n=5, 33% patients and caregivers) interviewed for the needs assessment that informed prototype development. A web-based application for social stories depicting different aspects of health care interactions was created. Focus group feedback from 19 participants (n=12, 63% HCPs and n=7, 37% patients and caregivers) on usability through the System Usability Scale, along with narrative feedback, was obtained. Overall, the usability of the application was supported by caregivers and HCPs. Conclusions: Children and young adults with special health care needs require medical services that their peers generally do not, thereby compounding potential barriers in communication surrounding health care delivery. Using social stories geared toward health care interactions may help reduce anxiety and difficulty.

BACKGROUND Children and young adults with special health care needs comprise a significant portion of the pediatric population in the United States, where 1 in every 5 children has a complex health care need. These patients are more likely to receive unsafe care and have their needs unmet in part due to lack of accessible information and limited training support. Barriers in communication may contribute to detrimental outcomes for this vulnerable, high-risk population. OBJECTIVE This project aims to identify barriers to communication in children and young adults with special health care needs in the health care setting. These barriers will inform prototype development using human-centered design approaches to create a web-based application. Feedback from patients, caregivers, and health care providers (HCPs) was obtained on the usability and usefulness of the tool within the health care setting. METHODS A needs assessment was conducted in which participants shared their experiences in providing or receiving health care services via a semistructured interview that was recorded and transcribed. Transcripts were analyzed inductively for themes, coded, and used to categorize the data. On the basis of these themes, iterative development of a web-based application for social stories took place. Focus groups were held to provide relevant feedback on the prototype. RESULTS There were 15 participants (n=10, 67% HCPs and n=5, 33% patients and caregivers) interviewed for the needs assessment that informed prototype development. A web-based application for social stories depicting different aspects of health care interactions was created. Focus group feedback from 19 participants (n=12, 63% HCPs and n=7, 37% patients and caregivers) on usability through the System Usability Scale, along with narrative feedback, was obtained. Overall, the usability of the application was supported by caregivers and HCPs. CONCLUSIONS Children and young adults with special health care needs require medical services that their peers generally do not, thereby compounding potential barriers in communication surrounding health care delivery. Using social stories geared toward health care interactions may help reduce anxiety and difficulty.

Federally qualified health centers (FQHC) aim to improve cancer prevention by providing screening options and efforts to prevent harmful behavior. Patient portals are increasingly being used to deliver health promotion initiatives. However, little is known about patient portal activation rates in FQHC settings and the factors associated with activation. This study examined patient portal activation among FQHC patients and assessed correlations with demographic, clinical, and health service use variables. We analyzed electronic health record data from adults >18 years old with at least one appointment. Data were accessed from the electronic health records for patients seen between 1 September 2018 and 31 August 2022 (n = 40,852 patients). We used multivariate logistic regression models to examine the correlates of having an activated EPIC-supported MyChart patient portal account. One-third of patients had an activated MyChart portal account. Overall, 35% of patients with an activated account had read at least one portal message, 69% used the portal to schedule an appointment, and 90% viewed lab results. Demographic and clinical factors associated with activation included younger age, female sex, white race, English language, being partnered, privately insured, non-smoking, and diagnosed with a chronic disease. More frequent healthcare visits were also associated with an activated account. Whether or not a patient had an email address in the EHR yielded the strongest association with patient portal activation. Overall, 39% of patients did not have an email address; only 2% of those patients had activated their accounts, compared to 54% of those with an email address. Patient portal activation rates were modest and associated with demographic, clinical, and healthcare utilization factors. Patient portal usage to manage one’s healthcare needs is increasing nationally. As such, FQHC clinics should enhance efforts to improve the uptake and usage of patient portals, including educational campaigns and eliminating email requirements for portal activation, to reinforce cancer prevention efforts.

Introduction: The COVID-19 pandemic continues to place an unprecedented strain on the US healthcare system, and primary care is no exception. Primary care services have shifted toward a team-based approach for delivering care in the last decade. COVID-19 placed extraordinary stress on primary care teams at the forefront of the pandemic response efforts. The current work applies the science of effective teams to examine the impact of COVID-19—a crisis or adverse event—on primary care team resilience.Methods: Little empirical research has been done testing the theory of team resilience during an extremely adverse crisis event in an applied team setting. Therefore, we conducted an archival study by using large-scale national data from the Veterans Health Administration to understand the characteristics and performance of 7,023 Patient Aligned Care Teams (PACTs) during COVID-19.Results: Our study found that primary care teams maintained performance in the presence of adversity, indicating possible team resilience. Further, team coordination positively predicted team performance (B = 0.53) regardless of the level of adversity a team was experiencing.Discussion: These findings in turn attest to the need to preserve team coordination in the presence of adversity. Results carry implications for creating opportunities for teams to learn and adjust to an adverse event to maintain performance and optimize team-member well-being. Teamwork can act as a protective factor against high levels of workload, burnout, and turnover, and should be studied further for its role in promoting team resilience.

ContextAntimicrobial Stewardship Programs (ASPs) are crucial to optimizing antibiotic use. ASPs are implemented in the Veterans Health Administration (VAs), but they do not target the needs of populations at high risk for resistant infections, such as spinal cord injury and disorder (SCI/D).ObjectiveThe goal of this study was to assess key ASP leader and SCI/D clinicians' perceived level of implementation and impact of 33 Antimicrobial Stewardship (AS) strategies.MethodSCI/D clinicians and ASP leaders across 24 VA facilities with SCI/D units were surveyed. Participants rated their perceived level of impact ("high", "mild", "low") and perceived level of implementation ("not", "partially", "fully") for 33 AS strategies in SCI/D units in VAs. Strategies were grouped into core elements which they support. We conducted a Fisher's exact test to assess differences between respondent perceptions based on role (SCI/D clinicians versus ASP leaders).ResultsAS strategy implementation varied across VA facilities. Of the AS strategies, pre-authorization was perceived to be highly impactful (78%) and fully implemented (82%). SCI/D clinicians and ASP leaders rated AS strategies differently such that SCI/D clinicians were less aware of implementation of AS strategies related to reporting requirements; further, SCI/D clinicians rated strategies which guide treatment duration and which limit C. difficile antibiotic exposure as more impactful than ASP leaders. Ratings for facility-wide and SCI/D unit ratings did not significantly differ for impact or implementation.ConclusionImplementation practices varied across VA facilities. Future work should implement highly impactful AS strategies according to facility and unit needs.

Multiple evidence-based interventions (EBIs) have been developed to improve the completion of colorectal cancer (CRC) screening within Federally Qualified Health Centers (FQHCs) and other safety net settings in marginalized communities. Little effort has been made, however, to evaluate their relative effectiveness across different clinical contexts and populations. To this end, we tested the relative effectiveness of three EBIs (mailed birthday cards, lay navigation, and provider-delivered education) among a convenience sample of 1252 patients (aged 50–75 years old, who were due for CRC screening and scheduled for a visit at one of three clinics within a network of Federally Qualified Health Centers (FQHCs) in the United States. To be eligible for the study, patients had to identify as African American (AA) or Latino American (LA). We compared the effects of the three EBIs on CRC screening completion using logistic regression. Overall, 20% of the study population, an increase from a baseline of 13%, completed CRC screening. Clinical demographics appeared to influence the effectiveness of the EBIs. Mailed birthday reminders appeared to be the most effective within the multi-ethnic clinic (p = 0.03), provider-delivered education within the predominantly LA clinic (p = 0.02), and lay navigation within the predominantly AA clinic (p = 0.03). These findings highlight the importance of understanding clinical context when selecting which evidence-based interventions to deploy.

The EZH2 methyltransferase silences gene expression through methylation of histone H3 on lysine 27 (H3K27). Recently, EZH2 mutations have been reported at Y641, A677, and A687 in non-Hodgkin lymphoma. Although the Y641F/N/S/H/C and A677G mutations exhibit clearly increased activity with substrates dimethylated at lysine 27 (H3K27me2), the A687V mutant has been shown to prefer a monomethylated lysine 27 (H3K27me1) with little gain of activity toward H3K27me2. Herein, we demonstrate that despite this unique substrate preference, A687V EZH2 still drives increased H3K27me3 when transiently expressed in cells. However, unlike the previously described mutants that dramatically deplete global H3K27me2 levels, A687V EZH2 retains normal levels of H3K27me2. Sequencing of B-cell–derived cancer cell lines identified an acute lymphoblastic leukemia cell line harboring this mutation. Similar to exogenous expression of A687V EZH2, this cell line exhibited elevated H3K27me3 while possessing H3K27me2 levels higher than Y641- or A677-mutant lines. Treatment of A687V EZH2-mutant cells with GSK126, a selective EZH2 inhibitor, was associated with a global decrease in H3K27me3, robust gene activation, caspase activation, and decreased proliferation. Structural modeling of the A687V EZH2 active site suggests that the increased catalytic activity with H3K27me1 may be due to a weakened interaction with an active site water molecule that must be displaced for dimethylation to occur. These findings suggest that A687V EZH2 likely increases global H3K27me3 indirectly through increased catalytic activity with H3K27me1 and cells harboring this mutation are highly dependent on EZH2 activity for their survival. Mol Cancer Ther; 13(12); 3062–73. ©2014 AACR.