Atrial fibrillation (AF) is the most common significant cardiac rhythm disorder and is a powerful... more Atrial fibrillation (AF) is the most common significant cardiac rhythm disorder and is a powerful common risk factor for stroke. Randomized trials have demonstrated that anticoagulation can reduce the risk of stroke in patients with AF. Yet, there continues to be widespread underutilization of this therapy. To address this practice gap locally and improve efforts to reduce the risk of stroke for patients with AF in our health system, we have designed a study to implement and evaluate the effectiveness of an Atrial Fibrillation Decision Support Tool (AFDST) embedded within our electronic health record (EHR). Our intervention is provider-facing and focused on decision support. The clinical setting is ambulatory patients being seen by primary care physicians. Patients include those with both incident and prevalent AF. This randomized, prospective trial will enroll 800 patients in our University of Cincinnati Health System who are currently receiving less than optimal anticoagulation therapy as determined by the AFDST. Patients will be randomized to one of two arms - 1) usual care, in which the AFDST is available for use; 2) addition of a best practice advisory (BPA) to the AFDST notifying the clinician that their patient stands to gain a significant benefit from a change in their current thromboprophylactic therapy. The primary outcome is effectiveness of the BPA measured by change to "appropriate thromboprophylaxis" based on the AFDST recommendation at 3 months post randomization. Secondary endpoints include Reach and Adoption, from the RE-AIM framework for implementation studies. Sample size is based upon an improvement from inappropriate to appropriate anticoagulation therapy estimated at 4% in the usual care arm and ≥10% in the experimental arm. Our goal is to examine whether addition of a BPA to an AFDST focused on primary care physicians in an ambulatory care setting will improve "appropriate thromboprophylaxis" compared with usual care. Results will be examined at 3 months post randomization and at the end of the study to evaluate durability of changes. We expect to complete patient enrollment by the end of June 2022.
Because billboards are predominantly visual and designed to convey succinct messages for passers-... more Because billboards are predominantly visual and designed to convey succinct messages for passers-by, they allow viewers to create a quick first impression. Even the most elaborate and thoughtful design choices can be immediately digested and evaluated, making the credibility (ethos) of the messenger and the message vulnerable to quick dismissal. This article analyzes an anti-drug design (see Figure 1) found on a billboard, from a multi-faceted rhetorical perspective
Scholars in the humanities, social sciences, and medicine are paying increasing attention to the ... more Scholars in the humanities, social sciences, and medicine are paying increasing attention to the genre of illness narratives. Little of this scholarship, however, focuses on online settings. To better understand these online stories and their structures, the author undertakes the analysis of a collection of patient diagnosis vlogs to argue that the characteristics of YouTube and the Internet more generally enable fluctuations or oscillations in these illness vlogs. These fluctuations foster genre emergence online and reflect the experiences of people living with these illnesses in a way discursive genres cannot. Paying attention to these fluctuations can add to our knowledge of the role of medium in genre emergence online and give us a potential mechanism to help explain the emergence, proliferation, and variability of online genres.
Proceedings of the 35th ACM International Conference on the Design of Communication, 2017
This panel consists of six case studies that investigate how emerging contexts for use created by... more This panel consists of six case studies that investigate how emerging contexts for use created by health wearables present UX designers with challenges related to agency, surveillance, and health outcomes, as wearables assess the body in new, potentially unforeseen ways.
In this webtext we borrow Kelli Cargile Cook's (2002) concept of layered literacies in techni... more In this webtext we borrow Kelli Cargile Cook's (2002) concept of layered literacies in technical communication to argue that health literacy is an embodied, multisensory experience that is invariably mediated by healthcare technologies. We illustrate this concept through three case studies that describe scenarios in which non-experts and lay experts engage in non-discursive literacy practices: parents caring for an infant in a neonatal intensive care unit (NICU), people with type 1 diabetes (T1D) self-managing their treatment, and public audiences reporting symptoms to a crowd-sourced flu-tracking program. We propose that the literacy practices we identify in each scenario--aural, tactile, and visual, respectively--are fundamentally shaped by the use of specific healthcare technologies unique to that scenario: physiological monitors, insulin pumps, and crowd-sourced flu maps. More specifically, we argue that these technologies enable, constrain, and integrate multisensorial lite...
Business and Professional Communication Quarterly, 2016
Business communication evolves and adapts to suit the times, and today’s workplace documents are ... more Business communication evolves and adapts to suit the times, and today’s workplace documents are increasingly multimodal. Therefore, business and professional communication specialists need to adapt to a new media workplace ecology—one that requires proficiencies with technologies such as video production, digital animation, and sound. Business and professional writing teachers, in turn, need to adopt teaching methods that include working with evolving technologies and be willing to teach multimodal skills to students. In this article I offer a case study of a flipped learning pedagogy to teach multimodal skills in the professional writing classroom.
Journal of the American Geriatrics Society, May 1, 2016
To assess the appropriateness of oral anticoagulant therapy (OAT) in women and elderly adults, lo... more To assess the appropriateness of oral anticoagulant therapy (OAT) in women and elderly adults, looking for patterns of undertreatment or unnecessary treatment. Retrospective cohort study. Primary care practices of an academic healthcare system. Adults (aged 28-93) with nonvalvular atrial fibrillation (AF) seen between March 2013 and February 2014 (N = 1,585). Treatment recommendations were made using an AF decision support tool (AFDST) based on projections of quality-adjusted life expectancy calculated using a decision analytical model that integrates individual-specific risk factors for stroke and hemorrhage. Treatment was discordant from AFDST-recommended treatment in 45% (326/725) of women and 39% (338/860) of men (P = .02). Although current treatment was discordant from recommended in 35% (89/258) of participants aged 85 and older and in 43% (575/1,328) of those younger than 85 (P = .01), many undertreated elderly adults were receiving aspirin as the sole antithrombotic agent. P...
Link to publication on Research at Birmingham portal General rights Unless a licence is specified... more Link to publication on Research at Birmingham portal General rights Unless a licence is specified above, all rights (including copyright and moral rights) in this document are retained by the authors and/or the copyright holders. The express permission of the copyright holder must be obtained for any use of this material other than for purposes permitted by law. • Users may freely distribute the URL that is used to identify this publication. • Users may download and/or print one copy of the publication from the University of Birmingham research portal for the purpose of private study or non-commercial research. • User may use extracts from the document in line with the concept of 'fair dealing' under the Copyright, Designs and Patents Act 1988 (?) • Users may not further distribute the material nor use it for the purposes of commercial gain. Where a licence is displayed above, please note the terms and conditions of the licence govern your use of this document. When citing, please reference the published version. Take down policy While the University of Birmingham exercises care and attention in making items available there are rare occasions when an item has been uploaded in error or has been deemed to be commercially or otherwise sensitive.
Objective-Patient values and preferences are an important component to decision making when trade... more Objective-Patient values and preferences are an important component to decision making when tradeoffs exist that impact quality of life, such as tradeoffs between stroke prevention and hemorrhage in patients with atrial fibrillation (AF) contemplating anticoagulant therapy. Our objective is to describe the development of an Atrial Fibrillation Guideline Support Tool (AFGuST) to assist the process of integrating patients' preferences into this decision. Materials and Methods-CHA 2 DS 2 VASc and HAS-BLED were used to calculate risks for stroke and hemorrhage. We developed a Markov decision analytic model as a computational "engine" to integrate patient-specific risk for stroke and hemorrhage and individual patient values for relevant outcomes in decisions about anticoagulant therapy. Results-Individual patient preferences for health-related outcomes may have greater or lesser impact on the choice of optimal antithrombotic therapy, depending upon the balance of patientspecific risks for ischemic stroke and major bleeding. These factors have been incorporated into patient-tailored booklets which, along with an informational video were developed through an iterative process with clinicians and patient focus groups. Key Limitations-Current risk prediction models for hemorrhage, such as the HAS-BLED, used in the AFGuST, do not incorporate all potentially significant risk factors. Novel oral anticoagulant agents recently approved for use in the United States, Canada, and Europe have not been included in the AFGuST. Rather, warfarin has been used as a conservative proxy for all oral anticoagulant therapy. Conclusions-We present a proof of concept that a patient-tailored decision-support tool could bridge the gap between guidelines and practice by incorporating individual patient's stroke and bleeding risks and their values for major bleeding events and stroke to facilitate a shared decision making process. If effective, the AFGuST could be used as an adjunct to published guidelines to enhance patient-centered conversations about the anticoagulation management.
In a word, Risa Applegarth’s book is about power. Like many rhetorical genre scholars, Applegarth... more In a word, Risa Applegarth’s book is about power. Like many rhetorical genre scholars, Applegarth considers genres to reflect “the rhetorical experience of the people who create and interpret the discourse” (Miller 152). As such, they imply hierarchal social and ideological relationships. Applegarth adds to the conversation on genre, gender, and knowledge by tracing the “discursive practices embedded in institutional and historical disciplinary contexts” (Berkenkotter and Ravotas 256). In her case, these contexts are within the field of anthropology at a time when the discipline is undergoing the early process of professionalization as a science (1920–1945). Quoting Schryer, Applegarth reminds us that “every genre expresses space/time relations that reflect current social beliefs regarding the placement and actions of human individuals in space and time” (Schryer 459). Similar to how Mikhail Bakhtin used the chronotope to categorize genres, Applegarth engages with the metaphor of a rhetorical archaeology to examine the spatial–temporal dimensions of the anthropological texts she analyzes. Rhetorical archaeology, she explains, combines practices from genre scholars and historians to “reveal material traces of a community’s epistemic and discursive negotiations” (176). To begin digging through the textual strata of genres, Applegarth starts with the ethnographic monograph, characterizing it as the main genre through which the field made its knowledge claims. After establishing the monograph’s role as the most privileged genre of the time period, in chapter 1, Applegarth turns her attention to alternative genres written by women who did not have full access to all the resources for writing the traditional monograph. She focuses on the genre of field autobiographies in chapter 2, drawing on Ann Axtell Morris’ Digging in the Southwest and Gladys Reichard’s Spider Woman in particular. Applegarth argues that in contrast to the monograph, these biographies ground knowledge in lived experience. In chapter 3 Applegarth turns to folklore collections such as those created by Ella Cara Deloria and Zora Neale Hurston to contend that the genre establishes the writer’s identity as a legitimate researcher but at same time makes “disruptive use” of the genre. These writers, she tells us, “foreground relations folklore collections typically obscure, critique the ostensible objectivity of ethnographic work, and represent their home communities as vibrant and persistent” (98). In chapter 4 the author offers her final example: ethnographic
Iowa State University Summer Symposium on Science Communication
Scholars in scientific communication have shared a growing concern about the ethical implications... more Scholars in scientific communication have shared a growing concern about the ethical implications of approaches to direct-consumer genetic testing. To add to this evolving conversation, this paper addresses the debate about the ethics of communicating genetic testing results through a rhetorical inquiry of the 23andMe controversy.
This article offers an empirical study of literature in the rhetoric of health and medicine (RHM)... more This article offers an empirical study of literature in the rhetoric of health and medicine (RHM) and the medical humanities (MH). Article traces the topics, funding mechanisms, research methods, theoretical frameworks, evidence types, audience, discourse arrangement patterns, and action orientation that constitute the scholarship in the sample to offer a landscape of the current state of RHM and the MH. Findings can be leveraged to assess the potential for alignment between these fields for future research.
The Appalachian community in the Lower Price Hill (LPH) neighborhood of Cincinnati, Ohio, used co... more The Appalachian community in the Lower Price Hill (LPH) neighborhood of Cincinnati, Ohio, used community-based participatory principles and methods to develop, implement, and evaluate an on-going initiative to address the high prevalence of diabetes among its residents. Led by the Urban Appalachian Council in partnership with a number of academic and community organizations, the initiative conducted town-hall meetings of LPH residents to identify diabetes-related areas that needed to be addressed and to select an initial pilot intervention. The result was a Community Health Advocate (CHA) program which trained neighborhood residents to canvass households to conduct diabetes risk assessments and provide education on diabetes prevention, schedule follow-up diabetes screenings at a wellness site established by the community, and conduct follow-up telephone calls to ensure wellness site participation. The extensive case-finding effort by the CHAs led to the identification of a substanti...
Atrial fibrillation (AF) is the most common significant cardiac rhythm disorder and is a powerful... more Atrial fibrillation (AF) is the most common significant cardiac rhythm disorder and is a powerful common risk factor for stroke. Randomized trials have demonstrated that anticoagulation can reduce the risk of stroke in patients with AF. Yet, there continues to be widespread underutilization of this therapy. To address this practice gap locally and improve efforts to reduce the risk of stroke for patients with AF in our health system, we have designed a study to implement and evaluate the effectiveness of an Atrial Fibrillation Decision Support Tool (AFDST) embedded within our electronic health record (EHR). Our intervention is provider-facing and focused on decision support. The clinical setting is ambulatory patients being seen by primary care physicians. Patients include those with both incident and prevalent AF. This randomized, prospective trial will enroll 800 patients in our University of Cincinnati Health System who are currently receiving less than optimal anticoagulation therapy as determined by the AFDST. Patients will be randomized to one of two arms - 1) usual care, in which the AFDST is available for use; 2) addition of a best practice advisory (BPA) to the AFDST notifying the clinician that their patient stands to gain a significant benefit from a change in their current thromboprophylactic therapy. The primary outcome is effectiveness of the BPA measured by change to "appropriate thromboprophylaxis" based on the AFDST recommendation at 3 months post randomization. Secondary endpoints include Reach and Adoption, from the RE-AIM framework for implementation studies. Sample size is based upon an improvement from inappropriate to appropriate anticoagulation therapy estimated at 4% in the usual care arm and ≥10% in the experimental arm. Our goal is to examine whether addition of a BPA to an AFDST focused on primary care physicians in an ambulatory care setting will improve "appropriate thromboprophylaxis" compared with usual care. Results will be examined at 3 months post randomization and at the end of the study to evaluate durability of changes. We expect to complete patient enrollment by the end of June 2022.
Because billboards are predominantly visual and designed to convey succinct messages for passers-... more Because billboards are predominantly visual and designed to convey succinct messages for passers-by, they allow viewers to create a quick first impression. Even the most elaborate and thoughtful design choices can be immediately digested and evaluated, making the credibility (ethos) of the messenger and the message vulnerable to quick dismissal. This article analyzes an anti-drug design (see Figure 1) found on a billboard, from a multi-faceted rhetorical perspective
Scholars in the humanities, social sciences, and medicine are paying increasing attention to the ... more Scholars in the humanities, social sciences, and medicine are paying increasing attention to the genre of illness narratives. Little of this scholarship, however, focuses on online settings. To better understand these online stories and their structures, the author undertakes the analysis of a collection of patient diagnosis vlogs to argue that the characteristics of YouTube and the Internet more generally enable fluctuations or oscillations in these illness vlogs. These fluctuations foster genre emergence online and reflect the experiences of people living with these illnesses in a way discursive genres cannot. Paying attention to these fluctuations can add to our knowledge of the role of medium in genre emergence online and give us a potential mechanism to help explain the emergence, proliferation, and variability of online genres.
Proceedings of the 35th ACM International Conference on the Design of Communication, 2017
This panel consists of six case studies that investigate how emerging contexts for use created by... more This panel consists of six case studies that investigate how emerging contexts for use created by health wearables present UX designers with challenges related to agency, surveillance, and health outcomes, as wearables assess the body in new, potentially unforeseen ways.
In this webtext we borrow Kelli Cargile Cook's (2002) concept of layered literacies in techni... more In this webtext we borrow Kelli Cargile Cook's (2002) concept of layered literacies in technical communication to argue that health literacy is an embodied, multisensory experience that is invariably mediated by healthcare technologies. We illustrate this concept through three case studies that describe scenarios in which non-experts and lay experts engage in non-discursive literacy practices: parents caring for an infant in a neonatal intensive care unit (NICU), people with type 1 diabetes (T1D) self-managing their treatment, and public audiences reporting symptoms to a crowd-sourced flu-tracking program. We propose that the literacy practices we identify in each scenario--aural, tactile, and visual, respectively--are fundamentally shaped by the use of specific healthcare technologies unique to that scenario: physiological monitors, insulin pumps, and crowd-sourced flu maps. More specifically, we argue that these technologies enable, constrain, and integrate multisensorial lite...
Business and Professional Communication Quarterly, 2016
Business communication evolves and adapts to suit the times, and today’s workplace documents are ... more Business communication evolves and adapts to suit the times, and today’s workplace documents are increasingly multimodal. Therefore, business and professional communication specialists need to adapt to a new media workplace ecology—one that requires proficiencies with technologies such as video production, digital animation, and sound. Business and professional writing teachers, in turn, need to adopt teaching methods that include working with evolving technologies and be willing to teach multimodal skills to students. In this article I offer a case study of a flipped learning pedagogy to teach multimodal skills in the professional writing classroom.
Journal of the American Geriatrics Society, May 1, 2016
To assess the appropriateness of oral anticoagulant therapy (OAT) in women and elderly adults, lo... more To assess the appropriateness of oral anticoagulant therapy (OAT) in women and elderly adults, looking for patterns of undertreatment or unnecessary treatment. Retrospective cohort study. Primary care practices of an academic healthcare system. Adults (aged 28-93) with nonvalvular atrial fibrillation (AF) seen between March 2013 and February 2014 (N = 1,585). Treatment recommendations were made using an AF decision support tool (AFDST) based on projections of quality-adjusted life expectancy calculated using a decision analytical model that integrates individual-specific risk factors for stroke and hemorrhage. Treatment was discordant from AFDST-recommended treatment in 45% (326/725) of women and 39% (338/860) of men (P = .02). Although current treatment was discordant from recommended in 35% (89/258) of participants aged 85 and older and in 43% (575/1,328) of those younger than 85 (P = .01), many undertreated elderly adults were receiving aspirin as the sole antithrombotic agent. P...
Link to publication on Research at Birmingham portal General rights Unless a licence is specified... more Link to publication on Research at Birmingham portal General rights Unless a licence is specified above, all rights (including copyright and moral rights) in this document are retained by the authors and/or the copyright holders. The express permission of the copyright holder must be obtained for any use of this material other than for purposes permitted by law. • Users may freely distribute the URL that is used to identify this publication. • Users may download and/or print one copy of the publication from the University of Birmingham research portal for the purpose of private study or non-commercial research. • User may use extracts from the document in line with the concept of 'fair dealing' under the Copyright, Designs and Patents Act 1988 (?) • Users may not further distribute the material nor use it for the purposes of commercial gain. Where a licence is displayed above, please note the terms and conditions of the licence govern your use of this document. When citing, please reference the published version. Take down policy While the University of Birmingham exercises care and attention in making items available there are rare occasions when an item has been uploaded in error or has been deemed to be commercially or otherwise sensitive.
Objective-Patient values and preferences are an important component to decision making when trade... more Objective-Patient values and preferences are an important component to decision making when tradeoffs exist that impact quality of life, such as tradeoffs between stroke prevention and hemorrhage in patients with atrial fibrillation (AF) contemplating anticoagulant therapy. Our objective is to describe the development of an Atrial Fibrillation Guideline Support Tool (AFGuST) to assist the process of integrating patients' preferences into this decision. Materials and Methods-CHA 2 DS 2 VASc and HAS-BLED were used to calculate risks for stroke and hemorrhage. We developed a Markov decision analytic model as a computational "engine" to integrate patient-specific risk for stroke and hemorrhage and individual patient values for relevant outcomes in decisions about anticoagulant therapy. Results-Individual patient preferences for health-related outcomes may have greater or lesser impact on the choice of optimal antithrombotic therapy, depending upon the balance of patientspecific risks for ischemic stroke and major bleeding. These factors have been incorporated into patient-tailored booklets which, along with an informational video were developed through an iterative process with clinicians and patient focus groups. Key Limitations-Current risk prediction models for hemorrhage, such as the HAS-BLED, used in the AFGuST, do not incorporate all potentially significant risk factors. Novel oral anticoagulant agents recently approved for use in the United States, Canada, and Europe have not been included in the AFGuST. Rather, warfarin has been used as a conservative proxy for all oral anticoagulant therapy. Conclusions-We present a proof of concept that a patient-tailored decision-support tool could bridge the gap between guidelines and practice by incorporating individual patient's stroke and bleeding risks and their values for major bleeding events and stroke to facilitate a shared decision making process. If effective, the AFGuST could be used as an adjunct to published guidelines to enhance patient-centered conversations about the anticoagulation management.
In a word, Risa Applegarth’s book is about power. Like many rhetorical genre scholars, Applegarth... more In a word, Risa Applegarth’s book is about power. Like many rhetorical genre scholars, Applegarth considers genres to reflect “the rhetorical experience of the people who create and interpret the discourse” (Miller 152). As such, they imply hierarchal social and ideological relationships. Applegarth adds to the conversation on genre, gender, and knowledge by tracing the “discursive practices embedded in institutional and historical disciplinary contexts” (Berkenkotter and Ravotas 256). In her case, these contexts are within the field of anthropology at a time when the discipline is undergoing the early process of professionalization as a science (1920–1945). Quoting Schryer, Applegarth reminds us that “every genre expresses space/time relations that reflect current social beliefs regarding the placement and actions of human individuals in space and time” (Schryer 459). Similar to how Mikhail Bakhtin used the chronotope to categorize genres, Applegarth engages with the metaphor of a rhetorical archaeology to examine the spatial–temporal dimensions of the anthropological texts she analyzes. Rhetorical archaeology, she explains, combines practices from genre scholars and historians to “reveal material traces of a community’s epistemic and discursive negotiations” (176). To begin digging through the textual strata of genres, Applegarth starts with the ethnographic monograph, characterizing it as the main genre through which the field made its knowledge claims. After establishing the monograph’s role as the most privileged genre of the time period, in chapter 1, Applegarth turns her attention to alternative genres written by women who did not have full access to all the resources for writing the traditional monograph. She focuses on the genre of field autobiographies in chapter 2, drawing on Ann Axtell Morris’ Digging in the Southwest and Gladys Reichard’s Spider Woman in particular. Applegarth argues that in contrast to the monograph, these biographies ground knowledge in lived experience. In chapter 3 Applegarth turns to folklore collections such as those created by Ella Cara Deloria and Zora Neale Hurston to contend that the genre establishes the writer’s identity as a legitimate researcher but at same time makes “disruptive use” of the genre. These writers, she tells us, “foreground relations folklore collections typically obscure, critique the ostensible objectivity of ethnographic work, and represent their home communities as vibrant and persistent” (98). In chapter 4 the author offers her final example: ethnographic
Iowa State University Summer Symposium on Science Communication
Scholars in scientific communication have shared a growing concern about the ethical implications... more Scholars in scientific communication have shared a growing concern about the ethical implications of approaches to direct-consumer genetic testing. To add to this evolving conversation, this paper addresses the debate about the ethics of communicating genetic testing results through a rhetorical inquiry of the 23andMe controversy.
This article offers an empirical study of literature in the rhetoric of health and medicine (RHM)... more This article offers an empirical study of literature in the rhetoric of health and medicine (RHM) and the medical humanities (MH). Article traces the topics, funding mechanisms, research methods, theoretical frameworks, evidence types, audience, discourse arrangement patterns, and action orientation that constitute the scholarship in the sample to offer a landscape of the current state of RHM and the MH. Findings can be leveraged to assess the potential for alignment between these fields for future research.
The Appalachian community in the Lower Price Hill (LPH) neighborhood of Cincinnati, Ohio, used co... more The Appalachian community in the Lower Price Hill (LPH) neighborhood of Cincinnati, Ohio, used community-based participatory principles and methods to develop, implement, and evaluate an on-going initiative to address the high prevalence of diabetes among its residents. Led by the Urban Appalachian Council in partnership with a number of academic and community organizations, the initiative conducted town-hall meetings of LPH residents to identify diabetes-related areas that needed to be addressed and to select an initial pilot intervention. The result was a Community Health Advocate (CHA) program which trained neighborhood residents to canvass households to conduct diabetes risk assessments and provide education on diabetes prevention, schedule follow-up diabetes screenings at a wellness site established by the community, and conduct follow-up telephone calls to ensure wellness site participation. The extensive case-finding effort by the CHAs led to the identification of a substanti...
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