Romil Rakesh Parikh

BACKGROUND Effective postoperative pain management is critical to surgical recovery; however, patients frequently report feeling inadequately prepared before and after surgery, resulting in uncertainty regarding pain expectations and medication use. We developed the Managing Pain After Laparoscopic Surgery (M-PALS) website as an evidence-based digital resource to provide tailored information on pain expectations, medication options, and safe medication practices for patients, caregivers, and care team members. Evaluating digital health resources before routine integration into clinical practice is essential for identifying barriers, ensuring usability, and refining implementation strategies. OBJECTIVE This protocol outlines an iterative, formative pre-implementation evaluation designed to (1) assess website usability, acceptability, appropriateness, and feasibility among patient, caregiver, and care team member end users; (2) identify perceived facilitators and barriers to clinical workflow integration among care team members; (3) evaluate patient behavioral implications (e.g., pain expectations, medication decision-making, and patient-provider communication); and (4) guide multi-stage website refinements, both mid-evaluation and post-analysis, in advance of systemwide clinical implementation. METHODS We are conducting an iterative mixed-methods quality improvement evaluation that combines semi-structured interviews and validated survey scales with laparoscopic surgery patients and members of the multidisciplinary care team at a large academic health system. We interviewed an initial cohort of patients to evaluate the website’s usability, acceptability, appropriateness, and feasibility to guide initial website refinements. Following these updates, we continue to interview a follow-up cohort of patients to assess perceived behavioral impacts, including pain expectations, medication decision-making, and patient-provider communication. Concurrently, we are interviewing care team members to evaluate the website’s usability, acceptability, appropriateness, and feasibility, as well as its integration into clinical workflows prior to broader clinical implementation. We will measure quantitative outcomes using the System Usability Scale, Acceptability of Intervention Measure, Intervention Appropriateness Measure, and the Technology Acceptance Model-Perceived Ease of Use subscale. We will analyze quantitative data using descriptive statistics and qualitative data using a human-in-the-loop, generative artificial intelligence-assisted thematic analysis framework. RESULTS A total of 24 postoperative patients (n=13 pre-website refinement; n=11 post-website refinement) and 5 care team members completed evaluation activities. The first patient cohort feedback directly informed iterative website updates. All cohorts will inform website updates prior to broader implementation. Analyses are ongoing and expected to conclude by December 2026. CONCLUSIONS Conclusions: This evaluation provides actionable insights into user experience and clinical feasibility, guiding final refinements of the M-PALS website prior to broader implementation at the participating healthcare system. This evaluation offers a replicable model for pre-implementation evaluation of digital patient education tools in surgical care settings.

Purpose: Most older adults prefer aging in place, for which home‐ and community‐based services (HCBS) play an essential role. However, it is unknown whether rural‐urban differences in unmet HCBS needs differ by dementia status, which is an important evidence gap to develop targeted interventions to improve HCBS access. Therefore, we evaluated associations of rural‐urban continuum (RUCA classification) with consumer‐reported unmet HCBS needs by dementia status. Methods: We analyzed data from the National Core Indicators‐ Aging & Disability survey (2016‐2019; 14,645 community‐dwelling consumers; age, ≥65years; 23 states) using logistic regression, comparing adjusted odds ratios (OR) of consumer‐reported unmet HCBS needs across rural‐urban continuum, stratified by dementia. Findings: Among people living with dementia (PLWD, n = 2438), compared to metropolitan areas, prevalence of unmet HCBS needs was greater in micropolitan areas (35.4% versus 30.7% consumers; OR, 1.32, 95% CI, 0.98–1.77), small towns (36.3% consumers; OR, 1.44, 95% CI, 0.97–2.13), and rural areas (44.8% consumers; OR, 1.83, 95% CI, 1.11–3.04). These associations were reversed in those without dementia (n = 12,207). Compared with metropolitan areas, prevalence of unmet HCBS needs was lower among those in micropolitan areas (28.7% vs 31.4% consumers; OR, 0.82; 95% CI 0.72–0.93), small towns (29.3%; OR 0.85; 95% CI 0.73–1.00) and rural areas (25.4%; OR, 0.73, 95% CI, 0.58‐0.90). Conclusion: Among PLWD, unmet HCBS needs are significantly greater in rural areas. These findings highlight the critical need for dementia‐capable HCBS in rural areas to improve equitable access to these essential services among PLWD.

Background and Objectives: Consumer-reported measures are important quality indicators for ensuring person-centeredness in home and community-based services (HCBS). However, administrative data commonly used to assess HCBS quality often lacks consumer-reported measures. To address this gap, we developed and validated novel consumer-reported quality indicators using data from the National Core Indicators-Aging and Disability (NCI-AD) Adult Consumer Survey. Research Design and Methods: We conducted exploratory factor analyses using the 2018–2019 survey wave of NCI-AD (n = 5,572 community-dwellingolder consumers, age ≥65 years) and identified seven QIs. We then confirmed the validity of these seven new QIs in 2 ways: (a) qualitatively through a technical expert panel (for face validity and contextualization) and (b) quantitatively, using confirmatory factor analyses in the 2017–2018 survey wave (n = 9,145 community-dwelling consumers, age ≥65 years). Results: The seven validated QIs were service satisfaction, staff quality, environmental safety, service decision-making, daily life decision-making, community inclusion, and overall health and quality of life. Internal consistency was strong across domains (Cronbach's alpha = 0.63–0.89; McDonald's omega = 0.70–0.90). Exploratory analyses also identified differences in selected QI scores by dementia status and age. Discussion and Implications: These seven consumer-reported QIs provide a practical, validated framework for evaluating person-centered HCBS quality. They can support researchers, providers, and policymakers in monitoring service quality, identifying modifiable targets for improvement, and advancing quality measurement in publicly funded HCBS.

Background and Objectives: Family members play an essential role in monitoring and advocating for quality of care in assisted living (AL) communities. Despite their importance, few population-based studies have examined how family and facility characteristics influence family satisfaction in AL. We evaluated family and facility characteristics associated with family satisfaction in AL. Research Design and Methods: Using cross-sectional survey data from the Minnesota Assisted Living Report Card project (2024), we identified resident- and facility-level predictors of AL resident-reported quality of life in eight domains, including experience, choice, needs, housekeeping, food, environment, staff, and overall satisfaction, using multivariable linear mixed regression with facility-level random intercept to account for facility-level clustering. Results: Among 15,320 family member respondents in licensed AL facilities with >5 beds (51.1% of age <65 years, 65.4% female, 92.3% White), mean domain scores ranged from 67.2 (food) to 82.1 (overall), indicating generally positive perceptions. Across all domains, lower satisfaction was observed among respondents who are younger, people of color, and female, and among spouses or siblings of residents. Families visiting or communicating less frequently tended to report lower satisfaction with choice and overall satisfaction. Smaller and non-profit facilities received higher ratings across most domains, while facilities in the Twin Cities metropolitan area scored higher than those in the rest of the state. Discussion and Implications: Family satisfaction in AL reflects both family composition and facility context. Policymakers and providers can leverage family satisfaction metrics to inform targeted quality improvement and promote equitable, family-centered care across the AL sector.

Background: Long‐term services and supports (LTSS) serve > 9 million adults in the United States. We examined prevalence and quality of life (QoL)‐related outcomes of consumer‐reported unmet LTSS needs in publicly‐funded LTSS. Methods: We pooled cross‐sectional data from the 2016–2017, 2017–2018, 2018–2019, 2021–2022, and 2022–2023 National Core Indicators–Aging and Disability Adult Consumer Surveys. We included 61,829 adults (34% with age < 65 years; 66% female; 27 states). Survey weights generated population‐representative estimates. We ascertained unmet LTSS needs by response to: “Do the long‐term care services you receive meet your current needs and goals?” (dichotomized‐ yes vs. no). We estimated weighted prevalence of unmet LTSS needs overall and across subpopulations, and examined associations with two self‐reported QoL‐related outcomes (dichotomized‐ yes/no): (1) being active in community; (2) satisfied with how one spends one's day. Prevalence ratios (PRs) were estimated using weighted Poisson regression with robust variance estimators, adjusting for demographics, health and functional status, multimorbidity, funding program, residence setting, state, and survey year. Results: Among respondents, 18,004 (weighted‐estimate, 29%) reported unmet LTSS needs. Prevalence of unmet needs varied across sociodemographic strata, care settings (higher in community‐based than in residential‐care settings), and funding programs (lower in PACE than in Medicaid programs). Individuals with unmet needs were significantly less likely to report being active in the community (PR, 0.65; 95% CI, 0.62–0.68) and satisfied with how they spend their day (PR, 0.62; 95% CI, 0.60–0.64). Post hoc analyses revealed potential dose–response associations between increasing degree of unmet LTSS needs and outcomes. Conclusions: Consumer‐reported unmet LTSS needs are frequent, vary greatly across care settings and funding programs, and are associated with poorer QoL‐related outcomes; highlighting substantial system‐level gaps in the fragmented LTSS landscape and the need for coordinated investments and structural reforms to better meet the needs of individuals relying on these services.

Background: Malnutrition is an independent risk factor for postoperative complications—particularly surgical site infections—and recovery delays following colorectal surgery. While some evidence suggests perioperative nutritional interventions have the potential to decrease complication rates, this literature is heterogeneous with difficult to control implementation barriers. We conducted a systematic review and meta‐analysis to appraise available evidence regarding perioperative nutritional interventions. Methods: We searched Medline, Embase, CAB Abstracts, and CINAHL between 2000 and 2023 for studies assessing perioperative protein supplementation, immunonutrition, carbohydrate loading, and postoperative diet progression in colorectal surgery patients. Individual study risk of bias and overall strength of evidence (SOE) were evaluated using standardized methods. We used random‐effects modeling for meta‐analyses of study‐level data when ≥3 studies were available. Results: Twenty‐seven eligible studies underwent data extraction. Ten were low/moderate risk of bias. Compared to dietary advice alone, protein supplementation and immunonutrition may show a benefit in lower surgical site infection rates, and carbohydrate loading may result in no difference (all low SOE). Both immunonutrition and carbohydrate loading probably do not impact anastomotic leak rates (moderate SOE). Immunonutrition and carbohydrate loading may result in no length of stay differences (low SOE). Evidence was insufficient assessing the optimal diet immediately following surgery. Conclusions: Perioperative colorectal surgery nutrition interventions are heterogeneous with current evidence suggesting small to negligible benefits regarding postoperative complications. No studies comparing low‐fiber diet to regular diet met inclusion criteria. The majority of evidence is insufficient, highlighting research opportunities to further enhance nutritional optimization and limit complications.

Background: Telehealth was essential for maintaining care continuity during the COVID-19 pandemic, leading to its rapid adoption across the United States. Telehealth has been heralded as a strategy for improving health care access and reducing health disparities, especially for community-dwelling older adults who face significant barriers to in-person care. However, data on telehealth use among socially and financially vulnerable older adults are limited, and little is known about characteristics associated with telehealth use in this population. Objective: Guided by the Systems Engineering Initiative for Patient Safety (SEIPS) 3.0 framework, this study examined factors associated with postpandemic telehealth use among older adults living at home and receiving publicly funded home- and community-based services (HCBS), considering HCBS receipt as an indicator of social and financial vulnerability. Methods: This cross-sectional study included older adults aged 65 years or older living at home with available telehealth use data who participated in the 2021‐2022 survey wave of the National Core Indicators-Aging and Disabilities Adult Consumer Survey. We used complete-case multivariable logistic regression, adjusting for sociodemographic and health-related factors with state-level random intercepts, to examine associations between telehealth use and covariates of interest (age, sex, race/ethnicity, zip code, rural-urban commuting area code, internet access, self-perceived overall health, medical transportation access, living alone, number of known non–Alzheimer disease and related dementias [ADRD] diagnoses, known ADRD diagnosis, and HCBS program/payer type). Based on the regression results, we estimated bivariate associations between internet access and key sociodemographic variables (age, sex, race/ethnicity, and zip code rural-urban commuting area) using the Pearson chi-square test. Findings were organized and interpreted through the SEIPS 3.0 framework. Results: Of the 3680 participants, 1467 (40%) were telehealth users and 2213 (60%) were nonusers. Significantly lower odds of telehealth were observed for older adults in older age groups, males, Black individuals, those living in nonmetropolitan areas, and recipients of Older Americans Act services (odds ratios [OR] between 0.66 and 0.80). Individuals with more than one known non-ADRD diagnosis (OR 1.49, 95% CI 1.02‐2.17) and those with an ADRD diagnosis (OR 1.33, 95% CI 1.07‐1.66) had higher odds of telehealth use. Internet access was strongly associated with telehealth use (OR 2.51, 95% CI 2.15‐2.92). Follow-up bivariate analyses between internet access and sociodemographic characteristics revealed that those of younger age, females, and White individuals had higher levels of internet access. Conclusions: Differences in telehealth use among older HCBS recipients are associated with multiple individual, technological, and organizational factors. Interpreted through the SEIPS 3.0 framework, these findings underscore the importance of viewing telehealth use as the outcome of multiple features of the health care system. Future research should clarify the mechanisms driving variation in telehealth use to identify and address barriers to telehealth adoption among vulnerable older adults.

Background: Effectively managing acute postoperative pain after laparoscopic surgery (M-PALS) is essential to optimize outcomes, enhance recovery, and mitigate opioid-related risks. We aimed to systematically map evidence on effectiveness and harms of pharmacologic and non-pharmacologic interventions for M-PALS. Methods: We searched three databases (2012–2025) for randomized clinical trials (RCTs) that reported postoperative opioid use and pain-related outcomes. We assessed study quality using the Cochrane Risk of Bias (ROB)-2 tool. Results: From 7638 citations, we included 101 RCTs. Postoperative opioid use was reported variably (e.g., total use over 24 or 48 h postoperatively, frequency of rescue-opioid use, and time to first rescue-opioid use). One out of 101 RCTs evaluated opioid prescription at discharge. No RCT reported opioid use at ≥3 months postoperatively. Eleven strategies were evaluated in ≥2 RCTs, with usual care/ sham as comparators. None of the 101 RCTs favored usual care over any intervention for pain or opioid use outcomes. For regional anesthesia (21 RCTs total; 12 with low ROB), intraperitoneal/preperitoneal local anesthetic instillation (10 RCTs; 4 with low ROB), intravenous dexamethasone (3 RCTs; 1 with low ROB), and the Enhanced Recovery After Surgery (ERAS) protocol (3 RCTs; 0 with low ROB), compared to usual care, >50% of RCTs favored the intervention for reducing pain and opioid use. For adverse events, only 3 out of 101 RCTs favored comparators. Inconsistent outcome reporting across all RCTs and, for multimodal strategies, the uniqueness of intervention–comparator combinations hindered comparisons. Conclusions: Interventions for M-PALS appear safe, with no RCT indicating worse efficacy of intervention than usual care; but evidence regarding superiority is conflicting. Future research should establish standardized and longer-term core outcome sets and make head-to-head comparisons between optimal strategies.