OBJECTIVES:To explore the experiences of socio-culturally diverse community members attempting to manage their chronic pain and enact evidence-based management plans following an index Emergency Department (ED) visit. METHODS:A convergent parallel mixed-methods design with qualitative interviews and descriptive analysis was undertaken in two public hospitals in a multicultural region in Sydney, Australia. Consecutive adults were recruited from culturally and linguistically diverse (CALD: n = 45) or Australian-born (n = 45) backgrounds, who presented to the ED for a chronic neuromusculoskeletal pain condition. Consenting participants were prescribed an individualised chronic pain management plan following examination by a physiotherapist, who collected standardised measures of pain and health literacy. Six months later, participants underwent a structured phone survey regarding their pain status and whether they had actioned management plans. Participants were invited to participate in a semi-structured interview. RESULTS:Six-month data were available for 82 of 90 participants who attended the ED and consented to the baseline assessment (40 CALD and 42 Australian-born). Participants were 52% females, predominately middle-aged (mean age 54.7 years), with an overall mean symptom duration of 10 years (SD 9.0). At 6 months, there were nine representations by six CALD participants and 23 by nine Australian-born participants. Overall, 52% reported unchanged pain, 24% were worse and 23% improved, with similar action plan progress for CALD (58%) and Australian-born (53%) participants. Pain features and health literacy were similar, irrespective of progress with pain management plans. From 41 participants who consented to phone interviews, three themes emerged to explain their progress with recommendations: 'illness model', 'urgency' and 'control orientation'. CONCLUSIONS:Patients presenting to the ED with chronic pain might be more likely to action discharge recommendations if primary care providers identify patient-specific and contextual barriers to implementation.

Innovative technology-based solutions in mental healthcare promise significant improvements in care quality and clinical outcomes. However, their successful implementation is profoundly influenced by the levels of trust patients hold toward their treatment providers, organizations, and the technology itself. This paper delves into the complexities of building and assessing patient trust within the intensive mental health care context, focusing on inpatient settings. We explore the multifaceted nature of trust, including interpersonal, institutional, and technological trust. We highlight the crucial role of therapeutic trust, which comprises both interpersonal trust between patients and providers, and institutional trust in treatment organizations. The manuscript identifies potential key barriers to trust, from sociocultural background to a patient's psychopathology. Furthermore, it examines the concept of technological trust, emphasizing the influence of digital literacy, socio-economic status, and user experience on patients' acceptance of digital health innovations. By emphasizing the importance of assessing and addressing the state of trust among patients, the overarching goal is to leverage digital innovations to enhance mental healthcare outcomes within intensive mental health settings.

Introduction First steps for knee osteoarthritis (OA) is a cluster randomised implementation trial examining the effect of an educational reminder message included in knee X-ray reports on the proportion of people subsequently referred to exercise professionals for their knee OA. Evaluating the processes supporting the completion of the study and the efficacy of the reminder message is essential to interpreting the outcomes of the study and aiding translation into practice.Methods and analysis We will conduct a concurrent process evaluation throughout the current study using a previously published framework for examining cluster randomised trials. This framework divides processes into those occurring at the cluster level and those at the target population level. For the current study, the cluster level is within radiology clinics. The target population is people with newly diagnosed radiologically evident, structural knee OA. A mixed methods design, incorporating survey data, administrative records, field notes and semi-structured interviews with representatives from radiology clinics and people with knee OA, will evaluate these processes. The focus of the evaluation will be recruitment and response processes of the radiology clinics and delivery and response processes for the people with knee OA. We will also describe the context and explore how the nudge theory of behavioural change influences the outcome of the study.Ethics and dissemination The study protocol, inclusive of the process evaluation, was approved by Macquarie University Human Research Ethics Committee (#520221190343842). Findings will be disseminated through national and international conferences, national industry stakeholders and patient advocacy groups to reach all levels of healthcare. Staff at radiology clinics and people with knee OA involved in interviews provide written, informed consent to participate in the process evaluation. Specific findings will be incorporated into training modules aimed at radiology clinics and will be developed by our industry partners.Trial registration Prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12622001414707p). Registration occurred in December 2022

ObjectiveKnowledge-based preparedness for surgery is achieved through education. It is unclear which of brief or extended education programs prior to knee or hip arthroplasty provides better patient preparedness. Using the Patient Preparedness for Surgery survey, we investigated whether people awaiting arthroplasty attending a hospital that provided education over multiple visits via a pre-surgery management program ('Extended') report superior preparedness compared to those attending a hospital in the same health district that only provides education at the pre-admission clinic assessment ('Brief').ResultsA consecutive sample of 128 people (n = 101, 'Extended', n = 27 'Brief') completed the anonymized survey. COVID-19 related service disruptions undermined the sample size, reducing statistical power. The pre-specified superiority of the Extended program (a relative 20% more reporting 'agree'/'strongly agree') was not observed for 'Overall preparedness' [95% (Extended) vs. 89% (Brief), p = 0.36]. Between-group differences exceeding 20% relative superiority were observed for three preparedness sub-domains ['Alternatives explained' (52 vs. 33%, p = 0.09); 'Prepared for home' (85 vs. 57%, p < 0.01); 'Recall of complications' (42 vs 26%, p = 0.14)]. The preliminary findings suggest an extended education program potentially yields better patient-reported preparedness in some preparedness sub-domains, but not all.

Few studies have investigated the association between obesity, preoperative weight loss and postoperative outcomes beyond 30- and 90-days post-arthroplasty. This study investigated whether body mass index (BMI) and preoperative weight loss in people with obesity predict postoperative complications and patient-reported outcomes 6 months following total knee or hip arthroplasty. Two independent, prospectively collected datasets of people undergoing primary total knee or hip arthroplasty for osteoarthritis between January 2013 and June 2018 at two public hospitals were merged. First, the sample was grouped into BMI categories, < 35 kg/m2 and ≥ 35 kg/m2. Subgroup analysis was completed separately for hips and knees. Second, a sample of people with BMI ≥ 30 kg/m2 was stratified into participants who did or did not lose ≥ 5

Introduction Chronic disease is a leading cause of death and disability that disproportionately burdens culturally and linguistically diverse (CALD) communities. Self-management is a cornerstone of effective chronic disease management. However, research suggests that patients from CALD communities may be less likely to engage with self-management approaches. The Natural Helper Programme aims to facilitate patient engagement with self-management approaches (ie, ‘activation’) by embedding cultural mentors with lived experience of chronic disease into chronic disease clinics/programmes. The Natural Helper Trial will explore the effect of cultural mentors on patient activation, health self-efficacy, coping efforts and health-related quality of life (HRQoL) while also evaluating the implementation strategy.Methods and analysis A hybrid type-1 effectiveness-implementation cluster-randomised controlled trial (phase one) and a mixed-method controlled before-and-after cohort extension of the trial (phase 2). Hospital clinics in highly multicultural regions in Australia that provide healthcare for patients with chronic and/or complex conditions, will participate. A minimum of 16 chronic disease clinics (clusters) will be randomised to immediate (active arm) or delayed implementation (control arm). In phase 1, the active arm will receive a multifaceted strategy supporting them to embed cultural mentors in their services while the control arm continues with usual care. Each cluster will recruit an average of 15 patients, assessed at baseline and 6 months (n=240). In phase 2, clusters in the control arm will receive the implementation strategy and evaluate the intervention on an additional 15 patients per cluster, while sustainability in active arm clusters will be assessed qualitatively. Change in activation over 6 months, measured using the Patient Activation Measure will be the primary effectiveness outcome, while secondary effectiveness outcomes will explore changes in chronic disease self-efficacy, coping strategies and HRQoL. Secondary implementation outcomes will be collected from patient–participants, mentors and healthcare providers using validated questionnaires, customised surveys and interviews aligning with the Reach, Effectiveness, Adoption, Implementation, Maintenance framework to evaluate acceptability, reach, dose delivered, sustainability, cost-utility and healthcare provider determinants.Ethics and dissemination This trial has full ethical approval (2021/ETH12279). The results from this hybrid trial will be presented at scientific meetings and published in peer-reviewed journals.Trial registration number ACTRN12622000697785.

Digital transformation is the adoption of digital technologies by an entity in an effort to increase operational efficiency. In mental health care, digital transformation entails technology implementation to improve the quality of care and mental health outcomes. Most psychiatric hospitals rely heavily on “high-touch” interventions or those that require in-person, face-to-face interaction with the patient. Those that are exploring digital mental health care interventions, particularly for outpatient care, often copiously commit to the “high-tech” model, losing the crucial human element. The process of digital transformation, especially within acute psychiatric treatment settings, is in its infancy. Existing implementation models outline the development of patient-facing treatment interventions within the primary care system; however, to our knowledge, there is no proposed or established model for implementing a new provider-facing ministration tool within an acute inpatient psychiatric setting. Solving the complex challenges within mental health care demands that new mental health technology is developed in concert with a use protocol by and for the inpatient mental health professional (IMHP; the end user), allowing the “high-touch” to inform the “high-tech” and vice versa. Therefore, in this viewpoint article, we propose the Technology Implementation for Mental-Health End-Users framework, which outlines the process for developing a prototype of an IMHP-facing digital intervention tool in parallel with a protocol for the IMHP end user to deliver the intervention. By balancing the design of the digital mental health care intervention tool with IMHP end user resource development, we can significantly improve mental health outcomes and pioneer digital transformation nationwide.

AIMS:To describe patient-reported physical activity and step count trajectory and explore perceived barriers and enablers to physical activity amongst people with obesity participating in a chronic care programme whilst awaiting arthroplasty.DESIGN:Convergent parallel mixed-method study.METHOD:A patient cohort derived from a longitudinal sample of adults with end-stage osteoarthritis and obesity from a chronic care programme whilst awaiting primary total knee or hip arthroplasty (n = 97) was studied. Physical activity was measured at baseline (entry to the wait list) and before surgery (9-12 months waiting time) using the Lower Extremity Activity Scale (LEAS) and activity monitors (activPAL™). A subset of participants completed in-depth semi-structured interviews 6 months after being waitlisted to explore perceived barriers and enablers to physical activity. Themes were inductively derived and then interpreted through the COM-B model.RESULTS:Baseline LEAS and activPAL™ data were available from 97 and 63 participants, respectively. The proportion of community ambulant individuals reduced from 43% (95% CI 33%-53%) at baseline to 17% (95% CI 9%-28%) pre-surgery. Paired activPAL™ data (n = 31) for step count, upright time, and stepping time remained unchanged. Twenty-five participants were interviewed. Five themes underpinning physical activity were mapped to the COM-B model components of capability (physical capability), opportunity (accessibility and social norms), and motivation (self-efficacy and beliefs and physical activity).CONCLUSIONS:Participation in a chronic care programme did not improve physical activity levels for people with obesity awaiting arthroplasty. Programs cognisant of the COM-B model components may be required to address the natural trajectory of declining physical activity levels while awaiting arthroplasty.

INTRODUCTION:This cluster randomised implementation trial will assess the effect of two behavioural change interventions on the proportion of people with structural knee osteoarthritis (OA) referred and attending exercise-based professionals (physiotherapists and exercise physiologists). The interventions are designed to increase awareness of guidelines, benefits and access pathways for exercise therapy. We hypothesise either strategy will result in more people with knee OA being referred and attending physiotherapy/exercise physiology than current standard of care.METHODS AND ANALYSIS:We will recruit 30 radiology clinics. 10 clinics will be randomly assigned to each trial arm with 1020 people with knee OA consecutively recruited (102 people per practice) into each arm. Intervention arm 1 is an educational reminder message targeted at primary care practitioners with a hyperlink to national guidelines regarding knee OA clinical management. It will be included in the reporting template of a plain knee X-ray. Intervention arm 2 is the reminder message and a patient-facing infographic explaining the benefits and access pathways for exercise. Both interventions will be delivered once, by the radiology clinics, when a person undergoes plain X-ray for non-traumatic knee pain/dysfunction. The primary outcome is referral to physiotherapist/exercise physiology. The secondary outcome is attendance to that appointment. Both outcomes are self-reported via an online survey administered 4 weeks after the X-ray. Additional survey questions explore facilitators and barriers to appointment attendance and acceptability of the interventions. A subsample of the intervention groups will be recruited for semistructured telephone-based interviews to further explore these latter outcomes.ETHICS AND DISSEMINATION:The study protocol was approved by Macquarie University Human Research Ethics Committee (#520221190343842) and prospectively registered with the Australian New Zealand Clinical Trials Registry. The findings of the trial will be disseminated through peer-reviewed scientific journals and conferences. We will engage with Australian physician colleges and main-stream media to distribute findings.TRIAL REGISTRATION NUMBER:ACTRN12622001414707p.

AIM:To explore perceived barriers and enablers to weight management among people with obesity awaiting total knee or hip arthroplasty.DESIGN:A nested qualitative study within a multi-centre, quasi-experimental pilot study comparing usual care weight management to a dietitian-led weight-loss diet.METHODS:Semi-structured individual interviews were conducted with adults with end-stage osteoarthritis and a body mass index ≥30 kg/m2 waitlisted for primary total knee or hip arthroplasty. Participants with diverse sociodemographic characteristics and varied success with weight management in the pilot study were purposively sampled. Interviews were analysed using inductive thematic analysis, underpinned by constructivist-interpretivist epistemology. The Patient Activation Measure and Health Literacy Questionnaire were used for context when interpreting the findings.RESULTS:Twenty-five participant interviews were conducted with a sociodemographically varied sample (aged 44-80 years, 9 born in Australia, 6 in paid employment and 11 lost ≥5% of their baseline weight). Four identified themes underpinned successful weight management: beliefs, adaptability, navigating healthcare and sociocultural context. Beliefs about whether weight was perceived as a problem, the expectation of weight loss and treatment-related beliefs influenced participants' perspectives towards weight loss. Adaptability, the ability to overcome barriers to weight loss, comprised three subthemes; readiness to act, degree of independence and problem-solving skills. Approaches towards navigating healthcare influenced uptake and adherence to weight management recommendations. Importantly, these themes were dependent on social and environmental circumstances, which influenced the type of barriers experienced and resources available to the individual.CONCLUSION:Differences in a person's beliefs, their ability to adapt and navigate healthcare and sociocultural context appear to explain successful weight management among people with end-stage arthritis.IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE:Clinicians should allow for individualisation cognisant of the identified themes when providing advice and treatment to promote adherence to weight management interventions.IMPACT:This study explored perceived barriers and enablers to weight management among people with obesity awaiting total knee or hip arthroplasty. Four identified themes underpinned successful weight management: beliefs, adaptability, navigating healthcare and sociocultural context. Beliefs about whether weight was perceived as a problem, the expectation of weight loss and treatment-related beliefs influenced participants' perspectives towards weight loss. Understanding and assessing the contribution of each factor may guide weight management from clinicians treating patients with obesity and osteoarthritis.REPORTING METHOD:The data are reported using the COREQ guidelines.PATIENT OR PUBLIC CONTRIBUTION:Patients contributed to the data collected.

Over the last several decades, inpatient psychiatric length of stay (LOS) has been greatly reduced to the detriment of patients. Latent variable mixture modeling, can be used to improve the quality of care for patients by identifying unobserved subgroups and optimize treatment variables, including LOS. This study had three objectives (1) to replicate the findings made by Oh et al. in a distinct sample, (2) to examine demographic differences related to inpatient treatment trajectories, and (3) to relate additional variables to each trajectory. We collected data on six key mental illness factors and information on felonies, misdemeanors, history of stopping psychiatric medication and psychotherapy, length of time in psychotherapy, and the number of therapists and psychiatrists from 489 patients at an inpatient psychiatric hospital. We derived latent mental illness scores after applying growth mixture modeling to these data. We identified three distinct trajectories of mental illness change: High-Risk, Rapid Improvement (HR-RI), Low-Risk, Partial Response (LR-PR), and High-Risk, Gradual Improvement (HR-GI). The HR-GI group was more likely to have patients who were female, Asian, younger, Yearly Income (YI) <$20,000, that spent more time in psychotherapy throughout their life, and had the longest LOS while inpatient. The LR-PR group had was more likely to be male, Hispanic/Latino and multiracial, older, YI >$500,000, have a history of misdemeanors, and this group had the shortest LOS (p < .05). These findings replicate and extend our previous findings in Oh et al. (2020a) and highlight the clinical utility of agnostically determining the treatment trajectories.

Background Culturally diverse communities face barriers managing chronic musculoskeletal pain conditions including navigation challenges, sub-optimal healthcare provider engagement and difficulty adopting self-management behaviours. Objectives To explore the feasibility and trends of effectiveness of implementing a cultural mentoring program alongside clinical service delivery. Methods This quasi-experimental controlled before-and-after multiple case study was conducted in three hospital-based services that provide treatment for patients with musculoskeletal pain. Two prospective cohorts, a pre-implementation and a post-implementation cohort, of adults with chronic musculoskeletal pain who attended during the 6-month recruitment phase, were eligible if they self-identified with one of the cultures prioritised for mentoring by the clinic. The pre-implementation cohort received routine care for up to 3-months, while the post-implementation cohort received up to 3-months of cultural mentoring integrated into routine care (3 to 10 sessions), provided by a consumer ( n = 6) with lived experience. Feasibility measures (recruitment and completion rates, attendance, satisfaction), and trends of effectiveness (Patient Activation Measure and Health Literacy Questionnaire items one and six) were collated over 3-months for both cohorts. Outcomes were presented descriptively and analysed using Mann-Whitney U-tests for between-group comparisons. Translation and transcription of post-treatment semi-structured interviews allowed both cohorts’ perspectives of treatment to be analysed using a Rapid Assessment Process. Results The cultural mentor program was feasible to implement in clinical services with comparable recruitment rates (66% pre-implementation; 61% post-implementation), adequate treatment attendance (75% pre-implementation; 89% post-implementation), high treatment satisfaction (97% pre-implementation; 96% post-implementation), and minimal participant drop-out (< 5%). Compared to routine care ( n = 71), patients receiving mentoring ( n = 55) achieved significantly higher Patient Activation Measure scores (median change 0 vs 10.3 points, p < 0.01 ) at 3-months, while Health Literacy Questionnaire items did not change for either cohort over time. Three themes underpinned participant experiences and acceptability of the mentoring intervention: ‘expectational priming’, ‘lived expertise’ and ‘collectivist orientation’ to understand shared participant experiences and explore the potential differential effect of the mentoring intervention. Conclusion Participant experiences and observations of improved patient activation provide support for the acceptability of the mentoring intervention integrated into routine care. These results support the feasibility of conducting a definitive trial, while also exploring issues of scalability and sustainability.

OBJECTIVE:Postdischarge from inpatient psychiatry is the highest risk period for suicide, thus better understanding the predictors of death by suicide during this time is critical for improving mortality rates after inpatient psychiatric treatment. As such, we sought to determine whether there were predictable patterns in suicide ideation in hospitalized psychiatric patients.METHOD:We examined a sample of 2,970 adult's ages 18-87 admitted to an extended length of stay (LOS) inpatient psychiatric hospital. We used group-based trajectory modeling via the SAS macro PROC TRAJ to quantitatively determine four suicide ideation groups: nonresponders (i.e., high suicide ideation throughout treatment), responders (i.e., steady improvement in suicide ideation across treatment), resolvers (i.e., rapid improvement in suicide ideation across treatment), and no-suicide ideation (i.e., never significant suicide ideation in treatment). Next, we compared groups to clinical and suicide-specific outcomes, including death by suicide.RESULTS:Resolvers were the most likely to die by suicide postdischarge relative to all other suicide ideation groups. Resolvers also demonstrated significant improvement in all clinical outcomes from admission to discharge.CONCLUSION:There are essential inpatient psychiatry clinical implications from this work, including that clinical providers should not be lulled into a false sense of security when hospitalized adults rapidly improve in terms of suicide ideation. Instead, inpatient psychiatric treatment teams should increase caution regarding the patient's risk level and postdischarge treatment planning. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Objective The introduction of the Milestone Project underscored the need for objective assessments of resident progress across the competencies. Therefore, the authors examined the Psychiatry Resident-In-Training Examination (PRITE) utility for measuring improvements in medical knowledge (MK). Methods The authors compared the mean performance for each MK subcompetency by resident year for all residents taking the PRITE from 2015 to 2017 (18,175 examination administrations). In addition, they surveyed psychiatry residency program directors regarding how well they thought they teach these subcompetencies. Results Increases in MK subcompetencies by resident year were significant for Psychopathology (p < 0.003), Psychotherapy (p < 0.002), and Somatic Therapies (p < 0.000). Development, Clinical Neuroscience, and Practice of Psychiatry did not show statistically significant differences between postgraduate years. Eighty psychiatry program directors responded to the survey and felt optimistic about their ability to teach the Psychopathology, Psychotherapy, Somatic Therapies, and Practice of Psychiatry subcompetencies. Conclusions The PRITE measured significant improvements in medical knowledge for several of the core subcompetencies. The program director's responses would suggest that the lack of statistically significant differences found for Development and Clinical Neuroscience reflects areas in need of curricular development. The disparity between PRITE performance and program director perception of the Practice of Psychiatry subcompetency may reflect difficulties in defining the scope of this subcompetency. Overall, this suggests that structured examinations help measure improvements in certain subcompetencies and may also help identify curricular needs. However, there may be potential problems with the definition of some subcompetencies.

Objective This study explored factors that underpin decisions to seek emergency department (ED) care for chronic noncancer pain in patients identifying as culturally and linguistically diverse (CALD) or Australian born. Design and Methods This mixed-methods study was underpinned by the Behavioral Model of Health Services Use conceptual framework. Consenting consecutive patients attending the ED for a chronic pain condition were recruited to a CALD (n = 45) or Australian-born (n = 45) cohort. Statistical comparisons compared the demographic, pain, health literacy, and episode of care profiles of both cohorts. Twenty-three CALD and 16 Australian-born participants consented to an audio-recorded semi-structured interview (n = 24) or focus group (n = 5 focus groups) conducted in their preferred language. Interviews were translated and transcribed into English for analysis using applied thematic analysis, guided by the conceptual framework. Data were triangulated to investigate the patterns of ED utilization and contributing factors for both cohorts. Results ED attendance was a product of escalating distress, influenced by the degree to which participants’ perceived needs outweighed their capacity to manage their pain. This interaction was amplified by the presence of predisposing factors, including constrained social positions, trauma exposure, and biomedical health beliefs. Importantly, experiences varied between the two cohorts with higher degrees of pain catastrophizing, lower health literacy, and greater social challenges present for the CALD cohort. Conclusion This study highlights the role contextual factors play in amplifying pain-related distress for CALD and Australian-born patients with chronic pain. The findings support a need for health care providers to recognize features of higher vulnerability and consider streamlining access to available support services.

Familial susceptibility to alcoholism is likely to be linked to the externalizing diathesis seen in high-risk offspring from high-density alcohol use disorder (AUD) families. The present study aimed at comparing resting brain functional connectivity and their association with externalizing symptoms and alcoholism familial density in 40 substance-naive high-risk (HR) male offspring from high-density AUD families and 30 matched healthy low-risk (LR) males without a family history of substance dependence using graph theory-based network analysis. The HR subjects from high-density AUD families compared with LR, showed significantly reduced clustering, small-worldness, and local network efficiency. The frontoparietal, cingulo-opercular, sensorimotor and cerebellar networks exhibited significantly reduced functional segregation. These disruptions exhibited independent incremental value in predicting the externalizing symptoms over and above the demographic variables. The reduction of functional segregation in HR subjects was significant across both the younger and older age groups and was proportional to the family loading of AUDs. Detection and estimation of these developmentally relevant disruptions in small-world architecture at critical brain regions sub-serving cognitive, affective, and sensorimotor processes are vital for understanding the familial risk for early onset alcoholism as well as for understanding the pathophysiological mechanism of externalizing behaviors.