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Background: Adolescent overweight and obesity are serious health risks, with prevalence varying by sociodemographic group. Studies link children's weight status and sex/race-ethnic differences with meeting recommendations for physical activity and diet. But, research examining the intersection of sociodemographic characteristics, behavior, and weight status is limited. This paper aims to identify sociodemographic differences in the association between adolescent weight status and meeting 6 national obesity-related recommendations., Methods: In 2011-2012, the Healthy Kids Colorado Survey was administered to all Denver high school students. Using descriptive and multivariate modeling, we examined subgroup associations between students' self-reported weight status and physical activity and diet., Results: Students (N = 6652) who met at least 1 recommendation were less likely to be at an unhealthy weight (OR = 0.87); also true for students who met at least 1 physical activity recommendation (OR = 0.80). However, the association varied across subgroups. The association between weight status and meeting at least 1 nutritional recommendation (OR = 0.91) was inconsistent across subgroups. Unexpected patterns also emerged in subgroup associations between meeting specific recommendations and weight status., Conclusions: Identifying subgroup differences in meeting recommendations and the association with weight status is important in identifying high risk groups and improving policy and programs that target childhood obesity prevention., (© 2017, American School Health Association.)

Background: Physicians' gender bias may contribute to gender disparities in cardiovascular testing. We used the Implicit Association Test to examine the association of implicit gender biases with decisions to use cardiovascular tests., Methods and Results: In 2014, cardiologists completed Implicit Association Tests and a clinical vignette with patient gender randomly assigned. The Implicit Association Tests measured implicit gender bias for the characteristics of strength and risk taking. The vignette represented an intermediate likelihood of coronary artery disease regardless of patient gender: chest pain (part 1) followed by an abnormal exercise treadmill test (part 2). Cardiologists rated the likelihood of coronary artery disease and the usefulness of stress testing and angiography for the assigned patient. Of the 503 respondents (9.3% of eligible; 87% male, median age of 45 years, 58% in private practice), the majority associated strength or risk taking implicitly with male more than female patients. The estimated likelihood of coronary artery disease for both parts of the vignette was similar by patient gender. The utility of secondary stress testing after an abnormal exercise treadmill test was rated as "high" more often for female than male patients (32.8% versus 24.3%, P =0.04); this difference did not vary with implicit bias. Angiography was more consistently rated as having "high" utility for male versus female patients (part 1: 19.7% versus 9.8%; part 2: 73.7% versus 64.3%; P <0.05 for both); this difference was larger for cardiologists with higher implicit gender bias on risk taking ( P =0.01)., Conclusions: Cardiologists have varying degrees of implicit gender bias. This bias explained some, but not all, of the gender variability in simulated clinical decision-making for suspected coronary artery disease., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Socially isolated aging adults are at risk of poor health and well-being. Occupational therapy can help address this issue; however, information is needed to guide such work. National surveys characterize social isolation in populations of aging adults but fail to provide meaningful information at a community level. The objective of this study is to describe multiple dimensions of social isolation and related factors among aging adults in diverse urban neighborhoods. Community-based participatory research involving a door-to-door survey of adults 50 years and older was used. Participants ( N = 161) reported social isolation in terms of small social networks (24%) and wanting more social engagement (43%). Participants aged 50 to 64 years reported the highest levels of isolation in most dimensions. Low income, poor health, lack of transportation, and infrequent information access appeared linked to social isolation. Occupational therapists can address social isolation in similar urban communities through policy and practice that facilitate social engagement and network building.

The growing prevalence of overweight and obesity among children is well documented, but prevalence estimates offer little insight into rates of transition to higher or lower body mass index (BMI; weight (kg)/height (m)(2)) categories. We estimated the expected numbers of years children would live as normal weight, overweight, and obese by race/ethnicity and sex, given rates of transition across BMI status levels. We used multistate life table methods and transition rates estimated from prospective cohort data (2007-2013) for Denver, Colorado, public schoolchildren aged 3-15 years. At age 3 years, normal-weight children could expect to live 11.1 of the following 13 years with normal weight status, and obese children could expect to live 9.8 years with obese status. At age 3 years, overweight children could expect to live 4.5 of the following 13 years with normal weight status, 5.1 years with overweight status, and 3.4 years with obese status. Whites and Asians lived more years at lower BMI status levels than did blacks or Hispanics; sex differences varied by race/ethnicity. Children who were normal weight or obese at age 3 years were relatively unlikely to move into a different BMI category by age 15 years. Overweight children are relatively likely to transition to normal weight or obese status., (© The Author 2016. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The Institute of Medicine recommends people with serious advanced illness have access to skilled palliative care. However, the predominant delivery model of nonhospice palliative care is inpatient, consultative care focused on the end of life, with a small specialist palliative care workforce., Objective: The study objective was to understand organizational factors that could influence the adoption and scale-up of outpatient palliative care in chronic advanced illness, using the example of heart failure., Methods: This was a cross-sectional qualitative study. Participants were 17 health care providers and local, regional, and national health system leaders from the Veterans Health Administration (VHA) who were considering whether and how to adopt and sustain outpatient palliative care. Individual interviews using semistructured questions assessed domains of the Consolidated Framework for Implementation Science., Results: Most providers and leaders perceived outpatient palliative care as high priority in the VHA given its patient-centeredness and potential to decrease health care use and costs associated with conditions like heart failure. They also supported a collaborative care team model of outpatient palliative care delivery where a palliative care specialist collaborates with medical nurses and social workers. They reported lack of performance measures/incentives for patient-centered care processes and outcomes as a potential barrier to implementation. Features of outpatient palliative care viewed as important for successful adoption and scale-up included coordination and communication with other providers, ease of integration into existing programs, and evidence of improving quality of care while not substantially increasing overall health care costs., Conclusion: Incentives such as performance measures and collaboration with local VHA providers and leaders could improve adoption and scale-up of outpatient palliative care.

Supervised walking exercise is an effective treatment to improve walking ability of patients with peripheral artery disease (PAD), but few exercise programs in community settings have been effective. The aim of this study was to determine the efficacy of a community-based walking exercise program with training, monitoring and coaching (TMC) components to improve exercise performance and patient-reported outcomes in PAD patients. This was a randomized, controlled trial including PAD patients (n=25) who previously received peripheral endovascular therapy or presented with stable claudication. Patients randomized to the intervention group received a comprehensive community-based walking exercise program with elements of TMC over 14 weeks. Patients in the control group did not receive treatment beyond standard advice to walk. The primary outcome in the intent-to-treat (ITT) analyses was peak walking time (PWT) on a graded treadmill. Secondary outcomes included claudication onset time (COT) and patient-reported outcomes assessed via the Walking Impairment Questionnaire (WIQ). Intervention group patients (n=10) did not significantly improve PWT when compared with the control group patients (n=10) (mean ± standard error: +2.1 ± 0.7 versus 0.0 ± 0.7 min, p=0.052). Changes in COT and WIQ scores were greater for intervention patients compared with control patients (COT: +1.6 ± 0.8 versus -0.6 ± 0.7 min, p=0.045; WIQ: +18.3 ± 4.2 versus -4.6 ± 4.2%, p=0.001). This pilot using a walking program with TMC and an ITT analysis did not improve the primary outcome in PAD patients. Other walking performance and patient self-reported outcomes were improved following exercise in community settings. Further study is needed to determine whether this intervention improves outcomes in a trial employing a larger sample size., (© The Author(s) 2015.)

This paper examines predictors of cancer-specific distress among posttreatment adult leukemia and lymphoma survivors (LLS). Using a survey mailed to LLS in the Colorado Central Cancer Registry (N = 477), the authors developed a multivariable risk profile for distress. Thirty one percent of LLS reported indicators of distress. Significantly higher distress was associated with younger age (p < 0.001) in bivariate analyses. The risk profile included fear of recurrence, financial burden, and younger age. Distress did not attenuate based on time since treatment completion and may persist up to 4 years posttreatment, suggesting a need for intervention, particularly among high-risk LLS.

Using in-depth interviews, this paper explores the nature and sources of cancer-specific distress among 51 posttreatment adult leukemia and lymphoma survivors (LLS), focusing on the role of lifespan stage in shaping reported stressors. LLS (all ages) reported physical aftereffects of cancer treatment, with reported sources of emotional and financial distress varying by lifespan stage. Young adult survivors (18-39) reported a greater number of distress sources. Distress may persist up to 4 years posttreatment, particularly among younger LLS, who appear to be at greater risk of distress in multiple domains.

Background: Despite the availability of psychosocial evidence-based practices (EBPs), treatment and outcomes for persons with mental disorders remain suboptimal. Replicating Effective Programs (REP), an effective implementation strategy, still resulted in less than half of sites using an EBP. The primary aim of this cluster randomized trial is to determine, among sites not initially responding to REP, the effect of adaptive implementation strategies that begin with an External Facilitator (EF) or with an External Facilitator plus an Internal Facilitator (IF) on improved EBP use and patient outcomes in 12 months., Methods/design: This study employs a sequential multiple assignment randomized trial (SMART) design to build an adaptive implementation strategy. The EBP to be implemented is life goals (LG) for patients with mood disorders across 80 community-based outpatient clinics (N = 1,600 patients) from different U.S. regions. Sites not initially responding to REP (defined as < 50% patients receiving ≥ 3 EBP sessions) will be randomized to receive additional support from an EF or both EF/IF. Additionally, sites randomized to EF and still not responsive will be randomized to continue with EF alone or to receive EF/IF. The EF provides technical expertise in adapting LG in routine practice, whereas the on-site IF has direct reporting relationships to site leadership to support LG use in routine practice. The primary outcome is mental health-related quality of life; secondary outcomes include receipt of LG sessions, mood symptoms, implementation costs, and organizational change., Discussion: This study design will determine whether an off-site EF alone versus the addition of an on-site IF improves EBP uptake and patient outcomes among sites that do not respond initially to REP. It will also examine the value of delaying the provision of EF/IF for sites that continue to not respond despite EF., Trial Registration: ClinicalTrials.gov identifier: NCT02151331.

Background: People with chronic heart failure (HF) suffer from numerous symptoms that worsen quality of life. The CASA (Collaborative Care to Alleviate Symptoms and Adjust to Illness) intervention was designed to improve symptoms and quality of life by integrating palliative and psychosocial care into chronic care., Objective: Our aim was to determine the feasibility and acceptability of CASA and identify necessary improvements., Methods: We conducted a prospective mixed-methods pilot trial. The CASA intervention included (1) nurse phone visits involving structured symptom assessments and guidelines to alleviate breathlessness, fatigue, pain, or depression; (2) structured phone counseling targeting adjustment to illness and depression if present; and (3) weekly team meetings with a palliative care specialist, cardiologist, and primary care physician focused on medical recommendations to primary care providers (PCPs, physician or nurse practioners) to improve symptoms. Study subjects were outpatients with chronic HF from a Veteran's Affairs hospital (n=15) and a university hospital (n=2). Measurements included feasibility (cohort retention rate, medical recommendation implementation rate, missing data, quality of care) and acceptability (an end-of-study semi-structured participant interview)., Results: Participants were male with a median age of 63 years. One withdrew early and there were <5% missing data. Overall, 85% of 87 collaborative care team medical recommendations were implemented. All participants who screened positive for depression were either treated for depression or thought to not have a depressive disorder. In the qualitative interviews, patients reported a positive experience and provided several constructive critiques., Conclusions: The CASA intervention was feasible based on participant enrollment, cohort retention, implementation of medical recommendations, minimal missing data, and acceptability. Several intervention changes were made based on participant feedback.

Background: Although readmission after hospitalization for heart failure has received increasing attention, little is known about its root causes. Prior investigations have relied on administrative databases, chart review, and single-question surveys., Methods and Results: We performed semistructured 30- to 60-minute interviews of patients (n=28) readmitted within 6 months of index heart failure admission. Established qualitative approaches were used to analyze and to interpret data. Interview findings were the primary focus of the study, but patient information and provider comments from chart data were also consulted. Patient median age was 61 years; 29% were nonwhite; 50% were married; 32% had preserved ejection fraction; and median time from discharge to readmission was 31 days. Reasons for readmission were multifactorial and not easily categorized into mutually exclusive reasons. Five themes emerged as reasons cited for hospital readmission: distressing symptoms, unavoidable progression of illness, influence of psychosocial factors, good but imperfect self-care adherence, and health system failures., Conclusions: Our study provides the first systematic qualitative assessment of patient perspectives concerning heart failure readmission. Contrary to prior literature and distinct from what we found documented in the medical record, patient experiences were highly heterogeneous, not easily categorized as preventable or not preventable, and not easily attributed to a single cause. These findings suggest that future interventions designed to reduce heart failure readmissions should be multifaceted, should be systemic in nature, and should integrate patient input.

Background: National growth in translational research has increased the need for practical tools to improve how academic institutions engage communities in research., Methods: One used by the Colorado Clinical and Translational Sciences Institute (CCTSI) to target investments in community-based translational research on health disparities is a Community Engagement (CE) Pilot Grants program. Innovative in design, the program accepts proposals from either community or academic applicants, requires that at least half of requested grant funds go to the community partner, and offers two funding tracks: One to develop new community-academic partnerships (up to $10,000), the other to strengthen existing partnerships through community translational research projects (up to $30,000)., Results and Conclusion: We have seen early success in both traditional and capacity building metrics: the initial investment of $272,742 in our first cycle led to over $2.8 million dollars in additional grant funding, with grantees reporting strengthening capacity of their community- academic partnerships and the rigor and relevance of their research.

Background: Adult immunizations prevent morbidity and mortality yet coverage remains suboptimal, in part due to missed opportunities. Clinical decision support systems (CDSSs) can improve immunization rates when integrated into routine work flow, implemented wherever care is delivered, and used by staff who can act on the recommendation., Methods: An adult immunization improvement project was undertaken in a large integrated, safety-net health care system. A CDSS was developed to query patient records and identify patients eligible for pneumococcal, influenza, or tetanus immunization and then generate a statement that recommends immunization or indicates a previous refusal. A new agency policy authorized medical assistants and nurses in clinics, and nurses in the hospital, to use the CDSS as a standing order. Immunization delivery work flow was standardized, and staff received feedback on immunization rates., Results: The CDSS identified more patients than a typical paper standing order and can be easily modified to incorporate changes in vaccine indications. The intervention led to a 10% improvement in immunization rates in adults 65 years of age or older and in younger adults with diabetes or chronic obstructive pulmonary disease. Overall, the improvements were sustained beyond the project period. The CDSS was expanded to encompass additional vaccines., Conclusions: Interdepartmental collaboration was critical to identify needs, challenges, and solutions. Implementing the standing order policy in clinics and the hospital usually allowed immunizations to be taken out of the hands of clinicians. As an on-demand tool, CDSS must be used at each patient encounter to avoid missed opportunities. Staff retraining accompanied by ongoing assessment of immunization rates, work flow, and missed opportunities to immunize patients are critical to sustain and enhance improvements.

Background: Healthy People 2020 calls for increased monitoring of local health and health disparities, but successful models of designing and implementing data collection systems for this purpose are lacking., Community Context: We describe the process, methods, and outcomes of a community-based participatory research initiative, Taking Neighborhood Health to Heart, designed to collect and disseminate comprehensive health data from 5 diverse urban neighborhoods in Denver, Colorado., Methods: Since its beginning in 2006, this initiative has involved community members in collection of individual health surveys from 1,146 households; audits of sidewalks, buildings, and other built environment features in 412 neighborhood blocks; audits of availability, price, and quality of fresh produce in 69 local stores; and audits of conditions and amenities in 20 local parks. Community members and researchers share, interpret, and disseminate these data through a joint data review and dissemination committee., Outcome: Through our community-based data collection system, Taking Neighborhood Health to Heart has been able to collect, analyze, and disseminate locally relevant data on people and neighborhoods to monitor heath and health disparities., Interpretation: Since 2006, the initiative has sustained its focus on community-based participatory research that targets collection and dissemination of local health data. We have used this information to identify salient health issues and advocate for neighborhood programs, policies, and environmental changes to built and social features of neighborhoods that have historically led to unequal opportunities and social disadvantage.

Background: The American College of Cardiology Foundation/American Heart Association (ACC/AHA) Guidelines for the Management of Heart Failure recommend palliative care in the context of Stage D HF or at the end of life. Previous studies related to heart failure (HF) palliative care provide useful information about patients' experiences, but they do not provide concrete guidance for what palliative care needs are most important and how a palliative care program should be structured., Objectives: Describe HF patients' and their family caregivers' major concerns and needs. Explore whether, how, and when palliative care would be useful to them., Design and Participants: Qualitative study using in-depth interviews of 33 adult outpatients with symptomatic HF identified using purposive sampling and 20 of their family caregivers., Approach: Interviews were transcribed verbatim and analyzed using the constant comparative method., Key Results: Overall, patients and caregivers desired early support adjusting to the limitations and future course of illness, relief of a number of diverse symptoms, and the involvement of family caregivers using a team approach. A diverse group of participants desired these elements of palliative care early in illness, concurrent with their disease-specific care, coordinated by a provider who understood their heart condition and knew them well. Some diverging needs and preferences were found based on health status and age., Conclusions: HF patients and their family caregivers supported early integration of palliative care services, particularly psychosocial support and symptom control, using a collaborative team approach. Future research should test the feasibility and effectiveness of integrating such a program into routine HF care.

Background: As community-based participatory research (CBPR) gains national prominence, it is increasingly important to examine critically the meaning of community participation and the roles of research participants. Many CBPR projects rely heavily on key informants, but because of their social position, economic status, or professional role, they may not represent the views of community members., Objectives: This paper compares key informant and community member perspectives about neighborhood health to explore the types of knowledge produced by each group., Methods: The data used for this study are part of a larger CBPR project, Taking Neighborhood Health to Heart (TNH2H). We conducted five focus groups with community members and 16 interviews with key informants., Results: Reported knowledge and beliefs about the community generally came from three perspectives: Primary key informant (key informant reports about neighborhoods and community members), secondary key informant (key informant assessments of community member beliefs and motivations for their behaviors), and community members. A number of differences emerged between key informants and community members in the types of knowledge they shared, revealing important assumptions held by key informants about community members., Conclusions: As more funders call for health researchers to engage community members to improve the reach, impact, and translation of their research to improve population health, they must clarify what is meant by community engagement and recognize the roles that people's relative status and positions in society play in their knowledge about a given place.

Background: Although implantable cardioverter-defibrillators (ICDs) reduce mortality in selected patients, they are also associated with potential risks. Periprocedural decision making requires understanding both benefits and risks., Methods: This qualitative study aims to understand cardiologists' and patients' perspectives about decision making surrounding ICD implantation using semi-structured, in-depth interviews. We interviewed 11 cardiologists (including four electrophysiologists) and 20 patients (14 with ICDs; six who declined ICDs). The data were analyzed through the theoretical lens of patient-centered care using the constant comparative method., Results: Cardiologists emphasized the benefits of ICD therapy but varied substantially in the extent to which they emphasized the various risks associated with ICD implantation with patients. Cardiologists indicated that they were influenced by the benefits of therapy as presented in published guidelines. Many patients who chose to receive an ICD indicated that they followed the advice of their physician without questioning the risks and benefits of the device. Some ICD recipients described not learning many of the risks until after device implantation or when they experienced these side effects. Patients who declined ICD implantation were concerned that the ICD was unnecessary or believed that the risks related to sudden death without an ICD did not apply to them. Only one patient considered the trade-off between dying quickly versus living longer with progressive heart failure., Conclusions: In our sample, cardiologists' desire to adhere to published guidelines appears to inhibit shared decision making. The marked variability in the discussions surrounding ICD decisions highlights a need for an improved process of ICD decision making., (©2011, The Authors. Journal compilation ©2011 Wiley Periodicals, Inc.)

Objective: The aim of this program was to (1) increase awareness of individual cardiovascular disease (CVD) risk in underserved communities, (2) educate participants about lifestyle modifications to reduce CVD risk, and (3) link individuals at moderate to high risk with healthcare. Community health workers (CHWs) delivered the program in 14 urban, rural and frontier Colorado communities., Method: We analyzed data from CVD screenings of 17,995 individuals throughout Colorado between 2006 and 2009 in order to understand the reach and impact of the program on reaching target populations, identifying at-risk individuals and improving awareness of CVD risk., Results: In 3 years, 15 CHWs screened 17,995 clients for CVD risk, of which, almost 60% were racial and ethnic minorities and 42% were uninsured. Twenty-nine percent of participants had medium or high Framingham Risk Scores. Over three-quarters were overweight or obese, over one-fifth had mildly to severely high blood pressure, and 42% had borderline high or high cholesterol. Significantly, 82% had no knowledge of their CVD risk prior to screening., Conclusion: This program is a replicable model for reaching minority and medically underserved populations who are at risk for CVD in urban, rural and frontier communities., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Objective: To document the perceived frequency, type, and impact of unavailable ("missing") clinical information during pediatric emergency and general ambulatory encounters., Methods: This prospective cohort set in the Emergency Department and General Ambulatory Pediatric Clinic at The Children's Hospital, Aurora, CO, assessed pediatric attending physician perceptions regarding missing information at emergency and general ambulatory encounters. The main outcome measures were the frequency of perceived missing information; its presumed location; time spent seeking; and the perceived effects on resource utilization and overall quality of care., Results: Pediatric physicians reported missing information for 2% of emergency and 22% of general ambulatory encounters. Types of missing information at general ambulatory visits included immunization (34% of types), general past medical (29%), and disease or visit specific histories (13%). Missing information at ambulatory visits was sought 20% of the time, obtained 4% of the time, and rated "somewhat or very important for today's care" (73% of the time) and "somewhat or very important for future care" (84% of the time). For encounters with unattained missing information, physicians reported adverse affects on the efficiency of the visit (64%), physician's confidence in care (33%), patient/family satisfaction (17%), disposition decisions (8%), and recommended additional treatment (38%), laboratory studies (16%), and imaging (12%). For 57% of encounters with missing information, physicians perceived an adverse effect on overall quality of care. Missing information was associated with not having a primary care visit at TCH within 12 months of the encounter, (OR 2.8; 95% CI, 1.7, 4.5)., Conclusion: Pediatric physicians more commonly experience missing information at general ambulatory visits than emergency visits and report that missing information adversely impacts quality, efficiency, their confidence in care, patient and family satisfaction, and leads to potentially redundant resource utilization.

Background: Making the kind of improvement changes necessary to move toward a patient-centered medical home will continue to challenge small, independent primary care practices. Here we describe further analysis of a successful program to understand the roles of coleaders of a change management process., Methods: Through an improvement collaborative we trained 2 coleaders (a physician and a non-physician) from 16 small primary care practices to institute depression care improvements. These coleaders participated in 3 learning sessions that provided depression care content as well as skills to implement a change management strategy. Qualitative data were collected by observation during the learning sessions and through in-depth interviews conducted at baseline, between each learning session, at the end of the project, 6 months after the project ended, and, finally, 26 months after the project's end., Results: Interview results with the coleaders affirmed that a team approach is a viable strategy for practice improvement. The 2 coleaders used their complementary skills, relationships, and credibility among the practice staff to implement and sustain practice improvements. In their differing roles, they varied in how they perceived barriers to change and how they assessed their team's progress., Conclusions: Involving both a physician and a non-physician as coleaders enables improvement teams in small primary care practices to make progress both in the clinical content of their work and in the critical change management activities involved with creating a team, managing meetings, and coordinating work between meetings. Using a coleader structure enriches the improvement process, broadens participation in the change process, and helps to sustain these efforts over time.

Objective: A combination of quantitative data and illustrative narratives may allow cancer survivorship researchers to disseminate their research findings more broadly. We identified recent, methodologically rigorous quantitative studies on return to work after cancer, summarized the themes from these studies, and illustrated those themes with narratives of individual cancer survivors., Methods: We reviewed English-language studies of return to work for adult cancer survivors through June 2008, and identified 13 general themes from papers that met methodological criteria (population-based sampling, prospective and longitudinal assessment, detailed assessment of work, evaluation of economic impact, assessment of moderators of work return, and large sample size). We drew survivorship narratives from a prior qualitative research study to illustrate these themes., Results: Nine quantitative studies met four or more of our six methodological criteria. These studies suggested that most cancer survivors could return to work without residual disabilities. Cancer site, clinical prognosis, treatment modalities, socioeconomic status, and attributes of the job itself influenced the likelihood of work return. Three narratives-a typical survivor who returned to work after treatment, an individual unable to return to work, and an inspiring survivor who returned to work despite substantial barriers-illustrated many of the themes from the quantitative literature while providing additional contextual details., Conclusion: Illustrative narratives can complement the findings of cancer survivorship research if researchers are rigorous and transparent in the selection, analysis, and retelling of those stories.

Background: People living in rural areas may be less likely to be up to date (UTD) with screening guidelines for colorectal cancer (CRC)., Objectives: To determine (1) rates of being UTD with screening or ever having had a test for CRC and (2) correlates for testing among patients living in a rural area who visit a provider., Design: Cross-sectional survey., Participants: Five hundred seventy patients aged 50 years and older who visited their health-care provider in High Plains Research Network (HPRN) practices., Measurements: (1) Ever having had a CRC screening test, (2) being UTD with CRC screening, and (3) intention to get tested., Results: The survey completion rate was 65%; 71% of patients had ever had any CRC screening test, while 52% of patients were UTD. Correlates of intending to get tested included having a family history of CRC, having a doctor recommend a test, knowing somebody who got tested, and believing that testing for CRC gives one a feeling of being in control of their health. Of those who had never had a CRC screening test, 12% planned on getting tested in the future, while 55% of those who were already up to date intended to be tested again (p < 0.001)., Conclusions: Prevalence of being UTD with CRC testing in the HPRN was on par with statewide CRC testing rates, but over three quarters of patients who had not yet been screened had no intention of getting tested for CRC, despite having a medical home.

Background: Primary care practices would benefit from improved understanding of how to make and sustain fundamental changes in their delivery systems. An improvement collaborative project was conducted in 2005 to not only improve the quality of depression care but help participating practices adopt and adapt more effective change processes to implement improved depression care. In a follow-up to an article on the project's impact in terms of measurable, sustained improvements in depression care, an exploratory qualitative study was conducted to examine primary care practices' adoption of effective change processes., Methods: Qualitative data were collected from 16 primary care practices participating in the National Depression Management Leadership Initiative's Improving Depression Care project. A multistep process of qualitative analysis was used to identify exemplar practices, and a constant comparative method was applied to identify salient features that influenced adoption of change processes associated with improvements in depression care during the course of the 18-month project., Results: The participating practices showed considerable variability in terms of the improvements they made in depression care and corresponding adoption of change processes to help make these and other improvements. Nearly all practices that showed the greatest improvements in depression care also adopted more effective processes for change, with several features associated with exemplar practices able to improve depression care and change processes., Discussion: These findings support the thesis that successful quality improvement efforts should address both clinical content and change processes. They also add to the literature on the impact of improvement collaborative projects, which to date have demonstrated mixed effects in a variety of chronic diseases, including depression.

The chasm between knowledge and practice decried by the Institute of Medicine (IOM) is the result of other chasms that have not been addressed. They include the chasm between what we know and what we need to know to improve care; the chasm between those who provide primary care and those who do not fund, study, support, or publish practical primary care studies; and the chasm between research and quality improvement (QI). These chasms are a result of problematic concepts, attitudes, traditions, time frames, and financing approaches among the various participants. If we are to facilitate the production and use of the knowledge needed for primary care to cross IOM's chasm, major changes are needed. These changes include the following: (1) admission by all primary care professions that we have quality problems that require our unified attention and action; (2) conversion of the paradigm from "translate research into practice" to "optimizing health and health care through research and QI"; (3) development and facilitation of more partnerships among clinicians, researchers, and care delivery leaders for engaged scholarship in both research and QI; (4) modification of the agendas and methods of funders and researchers so they emphasize the problems of patients and patient care and support practical time frames and research designs; and (5) facilitation by funders and journals of the dissemination and implementation of lessons from QI and practical research.

Introduction: There is much in the literature regarding the potential for commercial bias in clinical research and in continuing medical education (CME), but no studies were found regarding the potential for bias in reporting original research in CME venues. This pilot study investigated the presence of perceived bias in oral and print content of research findings presented in certified CME activities., Methods: Research presentations at two national primary care CME activities, where authors had self-reported potential conflicts of interest, were peer reviewed and monitored for perceived commercial bias. Blinded and unblinded peer reviewers' and monitors' analyses of bias were compared to assess whether knowledge of potential conflicts of interest affected perceptions of bias., Results: Knowledge of potential conflicts of interest appeared to increase awareness of potential commercial bias with regard to use of a single product in care and assurance that there was reasonable evidence to support the practice recommendation. A perception of the presenter's strong opinion regarding care did not appear to be influenced by knowledge of a potential conflict of interest., Discussion: While limited, by study design, this research detected subjectivity and variability in perceiving commercial bias within research findings presented in CME venues. Further study of these questions is required to guide the resolution of conflicts of interest in research and CME.

Background: Most recommended care for chronic diseases is based on the research of single conditions. There is limited information on 'best' processes of care for persons with multiple morbidities. Our objective was to explore processes of care desired by elderly patients who have multimorbidities that may present competing demands for patients and providers., Methods: Qualitative investigation using one-on-one interviews of 26 community-dwelling HMO members aged 65-84 (50% male) who had, at a minimum, the combined conditions of diabetes, depression and osteoarthritis. Participants were chosen from a stratified random sample to have a range of 4-16 chronic medical conditions., Results: Participants' desired processes of care included: the need for convenient access to providers (telephone, internet or in person), clear communication of individualized care plans, support from a single coordinator of care who could help prioritize their competing demands and continuity of relationships. They also desired providers who would listen to and acknowledge their needs, appreciate that these' needs were unique and fluctuating and have a caring attitude., Conclusions: These respondents describe an ideal process of care that is patient centered and individualized and that supports their unique constellations of problems, shifting priorities and multidimensional decision making. Individual and ongoing care coordination managed by a primary contact person may meet some of these needs. Achieving these goals will require developing efficient methods of assessing patient care needs and flexible care management support systems that can respond to patients' needs for different levels of support at different times.

Background: Improving primary care depression care is costly and challenging to sustain. The feasibility and potential success ofa modified improvement collaborative model to create sustained improvements in depression care was assessed., Methods: Sixteen practices from the American Academy of Family Physicians National Research Network and the American College of Physicians Practice-based Research Network completed a nine-month program. Two practice champions (PCs) from each practice attended three two-day learning sessions, where practice change strategies and key depression care elements were discussed. The nine-item Patient Health Questionnaire (PHQ-9) was used for screening, diagnosis, surveillance, tracking and care management, and self-management support. Pre- and postintervention depression care survey data were gathered from all practice clinicians, and qualitative data were collected via interviews with PCs and field notes from learning sessions., Results: On the basis of PC reports at nine months, 16 practices had implemented the PHQ-9 for depression case-finding and 13 for monitoring severity; 5 practices had implemented tracking and care management and 1, self-management support. At the 15-month follow-up, nearly all changes had been sustained, and additional practices had implemented tracking/care management and self-management support. Significant pre-post improvements were reported on several subscales of the clinician survey, demonstrating substantial diffusion from the PC to other clinicians in the practice., Discussion: The program led to measurable improvements in implementation of office procedures and systems known to improve depression care. The improvements were both sustained beyond the end of the program and substantially diffused to the other clinicians in the practice.

Most previously employed cancer survivors continue to work after treatment, but the impact of cancer symptoms or psychosocial concerns on their work has seldom been assessed. We conducted a community-based survey of cancer survivors from the Colorado Central Cancer Registry to assess the changes in their work and the demographic, clinical, and psychosocial characteristics associated with work changes over the 2 years following diagnosis. Of 100 survivors, 92 returned to work, but 57% of those reduced their work by more than 4 h/week, and 56% noted a change in some aspect of their occupational role. Physical symptoms, particularly lack of energy or nausea/vomiting, and psychological symptoms, particularly feeling bored or useless or feeling depressed, were significantly associated with a reduction in work hours or a change in occupational role. Since changes in work are common and are associated with both physical and psychosocial symptoms, strategies are needed to reduce symptom burden and barriers to work and to improve work capacity for working-age cancer survivors.

Diabetes-STAR is a disease management program integrated with an online patient portal. Of 331 patients enrolled in a randomized trial, we interviewed 37 users about benefits, barriers and recommendations for program improvements. User preferences included 1) addressing differences in types of users, 2) sending out alerts when new information is available, and 3) providing more oversight of user diary data.

Background: With increased focus on improving surgical care quality, understanding structures and processes that influence surgical care is timely and important, as is more precise specification of these through improved measurement., Study Design: We conducted a qualitative study to help design a quantitative survey of structures and processes of surgical care. We audiotaped 44 face-to-face interviews with surgical care leaders and other diverse members of the surgical care team from 6 hospitals (two Veterans Affairs, four private sector). Qualitative interviews were transcribed and analyzed to identify common structures and processes mentioned by interviewees to include on a quantitative survey and to develop a rich description of salient themes on indicators of effective surgical care services and surgical care teams., Results: Qualitative analyses of transcripts resulted in detailed descriptions of structures and processes of surgical care services that affected surgical care team performance--and how particular structures led to effective and ineffective processes that impacted quality and outcomes of surgical care. Communication and care coordination were most frequently mentioned as essential to effective surgical care services and teams. Informants also described other influences on surgical quality and outcomes, such as staffing, the role of residents, and team composition and continuity., Conclusions: Surgical care team members reinforced the importance of understanding surgical care processes and structures to improve both quality and outcomes of surgical care. The analysis of interviews helped the study team identify potential measures of structures and processes to include in our quantitative survey.

Background: The systematic collection of quantitative data on structures and processes from surgical services participating in the National Surgical Quality Improvement Program (NSQIP) has not been a focus to date. Efficient collection of useful measures of structures and processes may improve understanding of surgical outcomes and strategies for improving the quality of surgical care, as NSQIP continues to expand. The purpose of this article was to describe results of a quantitative survey designed to measure surgical care structures and processes within NSQIP sites., Study Design: A cross-sectional survey was mailed to 123 Department of Veteran Affairs (VA) and 14 private sector sites participating in the Agency for Healthcare Research and Quality (AHRQ)-funded Patient Safety in Surgery (PSS) Study. The survey included questions about organizational structures and processes of preoperative, intraoperative, and postoperative general surgical care services. For this study, we included only data from 90 VA sites that returned a survey (73% response rate). We used descriptive statistics and examined the bivariate association of structures and processes items or scales with risk-adjusted observed-to-expected (O/E) ratios of surgical morbidity and mortality., Results: Examination of frequency or means and standard deviations of items and scales revealed substantial variation in the structures and processes of surgical care services in participating VA sites, with correlation analyses demonstrating that, of 35 process and structure variables, there was a statistically significant relationship with the hospital's observed-to-expected ratio for 14 variables for morbidity, but only 4 variables for mortality., Conclusions: This descriptive analysis provides support for the potential importance of measuring organizational structures and processes of care in addition to risk-adjusted morbidity and mortality.

Purpose: We wanted to describe community-based participatory research in practice-based research networks in the United States., Methods: We surveyed all identified practice-based research networks (PBRNs) in the United States to find out whether they had a mechanism for obtaining feedback or involvement from the community of patients served by PBRN physicians. We asked open-ended questions on how they involve community members and whether they had plans for future involvement of community members and/or patients., Results: We received 46 completed questionnaires (71% response rate). Twenty-four reported that they have some mechanism to involve community members and/or patients in their research. No PBRN reported full participatory methods; however, several PBRNs reported active involvement by community members to generate research ideas, review research protocols, interpret results, and disseminate findings., Conclusion: While perhaps not meeting the classical definition of CBPR, some PBRNs are involving community members and patients in their research. There is a wide spectrum of involvement by community members in PBRN research. Many PBRNs reported plans to involve community members in their research. We believe that community involvement will enhance PBRN research.

Online patient portals, which provide patients with personal information and facilitate electronic doctor-patient communication, can help patients manage chronic diseases. These systems will be most beneficial if they have broad and durable appeal. In a randomized trial, we compared a portal providing generic diabetes self-management information to one providing personalized information (Diabetes-STAR). We assessed (1) the characteristics of patient-users and (2) whether including personalized content promotes sustained use.

Objective: To explore patient perceptions of patient-provider communication after an actual adverse medical event because prior patient error studies are rarely based on real situations., Design: We conducted four patient focus groups using a semi-structured guide. We analyzed transcripts using an editing approach to identify themes., Setting: Three sites in Colorado., Study Participants: participants were recruited from statewide post-injury program. Purposeful sampling began with patients in a geographic location; we contacted every other patient (up to 50). Twenty-two patients initially agreed to participate; 16 adults participated, representing 13 cases., Results: Complex issues and processes were involved in resolution attempts. Effective communication was an important factor in whether professional relationships continued after an adverse event. The communication nature and quality influenced whether patients defined event as 'honest mistake' or 'error'. Two types of trauma (physical and emotional) were expected and found. A third (financial) uncovered and proved in some cases the most salient factor influencing patients' subsequent actions. Caring, honest, quick, personal, and repeated provider responses were linked to patient satisfaction., Conclusions: Provider communication timeliness and quality were important influences on patients' responses to adverse events. Confronting an adverse medical event collaboratively helped both patients and providers with patients' emotional, physical, and financial trauma and minimized the anger and frustration commonly experienced. Health organizations, providers, investigators, and policymakers should consider the patient experience when developing provider training or evaluating processes in patient resolution.

Few studies have examined the impact of cancer on the survivor's quality of work life. The purpose of this qualitative study is to describe the work experiences among a diverse group of cancer survivors and to explore factors influencing decisions about work after cancer diagnosis and treatment. We interviewed 28 participants with a broad range of socioeconomic backgrounds and primary cancer sites. Qualitative results indicate that after learning about their cancer diagnosis, participants had diverse and complex patterns of work return and work change, and experienced a variety of factors that influenced post-cancer decisions. Experiences at work after cancer also varied in relation to how others responded, changes in productivity, effects of cancer and treatment on work, and feelings about work. Most respondents received little guidance from their physicians about work, and many participants described their cancer as impacting their priority of work relative to other aspects of their lives. Our findings reinforce the complexity of measuring employment outcomes and the range of adaptations made to improve the quality of work life. Additional research is needed to identify prognostic factors that can guide clinical or workplace efforts to restore cancer survivors to their desired level of work function and economic productivity., (Copyright 2005 John Wiley & Sons, Ltd)

Exploring selected working conditions and performance in nursing homes suggests that high and low performers can be determined based on both quantitative and qualitative findings.

Purpose: We wanted to study patient receptivity to using pen-tablet computers for collecting data in a practice-based research network., Methods: We analyzed exit interviews and field notes collected by trained research assistants as part of a larger Colorado Research Network (CaReNet) study comparing pen-tablet and paper-pencil methods to collect data for the Primary Care Network Survey (PRINS)., Results: A total of 168 patients completed a patient exit interview after completion of the pen-tablet-based survey instrument. Analyses of these brief interviews and field notes indicated that patients had favorable reactions to using pen-tablet computers. The most common barriers were related to glitches in the technology; the voice recognition software was the most problematic, with patients (as well as clinicians) finding this feature to be frustrating., Conclusions: Patients were able and willing to use pen-tablet computers for completing forms within busy primary care offices. Increasing patient involvement in practice-based research may be even more practicable through the use of this novel technology, which can allow patient-directed data collection at a single point in time as well as longitudinally.

Purpose: To assess the association between mentorship and both subsequent research productivity and career development among primary care research fellows., Method: In 1998, using a self-administered questionnaire, the authors surveyed 215 fellows who graduated from 25 National Research Service Award (NRSA) primary care research programs between 1988-1997 to assess quantitative aspects and qualitative domains of their mentorship experience during fellowship training., Results: A total of 139 fellows (65%) responded to mentorship questions a median of four years after their fellowship. Thirty-seven fellows (26.6%) did not have an influential mentor, 42 (30.2%) reported influential but not sustained mentorship, and 60 (43.2%) had influential and sustained mentorship. Individuals with influential mentorship spent more time conducting research (p =.007), published more papers (p =.003), were more likely to be the principal investigator on a grant (p =.008), and more often provided research mentorship to others (72.5% versus 66.7% of those with unsustained mentorship, and 36.4% of those with no influential mentor, p =.008). After controlling for other predictors, influential and sustained mentorship remained an important determinant of career development in research. On qualitative analysis, fellows identified three important domains of mentorship: the relationship between mentor and fellow (such as guidance and support), professional attributes of the mentor (such as reputation), and personal attributes of the mentor (such as availability and caring)., Conclusions: Influential and sustained mentorship enhances the research activity of primary care fellows. Research training programs should develop and support their mentors to ensure that they assume this critical role.

Background: We examined reports to a primary care, ambulatory, patient safety reporting system to describe types of errors reported and differences between anonymous and confidential reports., Methods: Applied Strategies for Improving Patient Safety (ASIPS) is a demonstration project designed to collect and analyze medical error reports from clinicians and staff in 2 practice-based research networks: the Colorado Research Network (CaReNet) and the High Plains Research Network (HPRN). A major component of ASIPS is a voluntary patient safety reporting system that accepts reports of errors anonymously or confidentially. Reports are coded using a multiaxial taxonomy., Results: Two years into this project, 33 practices with a total of 475 clinicians and staff have participated in ASIPS. Participants submitted 708 reports during this time (66% using the confidential reporting form). We successfully followed up on 84% of the confidential reports of interest within the allotted 10-day time frame. We ended up with 608 relevant, codable reports. Communication problems (70.8%), diagnostic tests (47%), medication problems (35.4%), and both diagnostic tests and medications (13.6%) were the most frequently reported errors. Confidential reports were significantly more likely than anonymous reports to contain codable data., Conclusion: A safe and secure reporting system that relies on voluntary reporting from clinicians and staff can be successfully implemented in primary care settings. Information from confidential reports appears to be superior to that from anonymous reports and may be more useful in understanding errors and designing interventions to improve patient safety.

Objective: To describe decisions made by primary care providers on elevated HbA(1c) results and their reasons for not intensifying therapy., Research Design and Methods: In this cross-sectional study, a provider survey was administered in two practice-based research networks when HbA(1c) results were reviewed on all nonpregnant patients >18 years old with type 2 diabetes. Univariate and Mantel-Hantel analyses assessed associations between patient characteristics and clinical decisions., Results: A total of 483 surveys were completed by at least 88 providers at 19 clinics. Most patients were female (62.5%), mean age was 60 years, and 28.6% were Hispanic. The overall action rate on HbA(1c) results >/=7% (n = 294) was 70.7%. Patients who were black or had Medicare without medication insurance had lower rates of action on HbA(1c) >/=7 and >/=8%, respectively (P < 0.05). The most common reasons providers reported for inaction were "patient improving/doing well," "competing demands," and "hypoglycemic risk.", Conclusions: Primary care providers generally adhere to national glycemic control guidelines, although there may be disparities in black patients and patients without medication insurance coverage. A variety of reasons were given when control was not intensified.

Purpose: This paper describes the impact of a care recommendation (CR) letter intervention on patients with multisomatoform disorder (MSD) and analysis of patient factors that affect the response to the intervention., Methods: One hundred eighty-eight patients from 3 family practices, identified through screening of 2,902 consecutive patients, were classified using somatization diagnoses based on the number of unexplained physical symptoms from a standardized mental health interview. In a controlled, single-crossover trial, patients were randomized to have their primary care physician receive the CR letter either immediately following enrollment or 12 months after enrollment. The CR letter notified the physician of the patient's somatization status and provided recommendations for the patient's care. Patients were followed for 24 months with assessments of functional status at baseline, 12, and 24 months., Results: Longitudinal analysis revealed a 12-month intervention effect for patients with multisomatoform disorder (MSD) of 5.5 points (P < .001) on the physical functioning (PCS) scale of the SF-36. Analysis of scores on the MCS scale of the SF-36 found no significant effect on mental functioning. The intervention was more effective for patients with 1 or more comorbid chronic physical diseases (P = .01)., Conclusions: The CR letter has a favorable impact on physical impairment of primary care patients with MSD, especially for patients with comorbid chronic physical disease. Multisomatoform disorder appears to be a useful diagnostic classification for managing and studying somatization in primary care patients.

Medical error reporting systems are important information sources for designing strategies to improve the safety of health care. Applied Strategies for Improving Patient Safety (ASIPS) is a multi-institutional, practice-based research project that collects and analyzes data on primary care medical errors and develops interventions to reduce error. The voluntary ASIPS Patient Safety Reporting System captures anonymous and confidential reports of medical errors. Confidential reports, which are quickly de-identified, provide better detail than do anonymous reports; however, concerns exist about the confidentiality of those reports should the database be subject to legal discovery or other security breaches. Standard database elements, for example, serial ID numbers, date/time stamps, and backups, could enable an outsider to link an ASIPS report to a specific medical error. The authors present the design and implementation of a database and administrative system that reduce this risk, facilitate research, and maintain near anonymity of the events, practices, and clinicians.

Objective: The purpose of this study was to describe quality of life (QOL) and psychosocial and spiritual issues among patients receiving hospice care., Methods: A questionnaire addressing QOL, spirituality, optimism, loss, fears about the terminal process and death anxiety was administered to 66 adults receiving care from 14 hospices. The physical components of QOL (physical symptoms and physical well-being) were rated lower than the psychosocial and spiritual aspects (support, existential well-being, psychological symptoms)., Results: Respondents had a strong spiritual connection and a strong sense of hope. Although these individuals did not express anxiety or fear about death, there were concerns about the dying process itself. Also, although most felt at ease with their current situation, respondents were concerned about how their illness was affecting their family. Financial and legal issues did not concern most of these individuals., Significance of Results: There were few significant associations between patient characteristics and the QOL or other psychosocial or spiritual issues addressed. Among this older terminally ill population receiving hospice care, whose functional status was fair and for whom physical symptoms were troublesome, QOL persisted and a positive outlook prevailed.

Background: Chronic medical conditions often occur in combination, as comorbidities, rather than as isolated conditions. Successful management of chronic conditions depends on adequate self-care. However, little is known about the self-care strategies of patients with comorbid chronic conditions., Objective: Our objective was to identify perceived barriers to self-care among patients with comorbid chronic diseases., Methods: We conducted semistructured personal interviews with 16 adults from 4 urban family practices in the CaReNet practice-based research network who self-reported the presence of 2 or more common chronic medical conditions. Using a free-listing technique, participants were asked, "Please list everything you can think of that affects your ability to care for your medical conditions." Responses were analyzed for potential barriers to self-care., Results: Participants' responses revealed barriers to self-care, including physical limitations, lack of knowledge, financial constraints, logistics of obtaining care, a need for social and emotional support, aggravation of one condition by symptoms of or treatment of another, multiple problems with medications, and overwhelming effects of dominant individual conditions. Many of these barriers were directly related to having comorbidities., Conclusions: Persons with comorbid chronic diseases experience a wide range of barriers to self-care, including several that are specifically related to having multiple medical conditions. Self-management interventions may need to address interactions between chronic conditions as well as skills necessary to care for individual diseases.

Somatization is a common phenomenon that has been defined in many ways. The two most widely used diagnoses, Somatization Disorder (SD) and Abridged Somatization Disorder (ASD), are based on lifetime unexplained symptoms. However, reports indicate instability in lifetime symptom recall among somatizing patients. Multisomatoform disorder (MSD) is a new diagnosis based on current unexplained symptoms. To understand how knowledge about SD and ASD translates to MSD, we examined the diagnostic concordance, impairment and health care utilization of these groups in a sample from the Somatization in Primary Care Study. The diagnostic concordance was high between MSD and SD, but lower between MSD and ASD. All three groups reported considerable physical impairment (measured using the PCS subscale of the SF-36). The mental health (MCS) scores for the three groups were only slightly lower than those of the general population. Over the course of one year, physical functioning fell significantly for all three groups. Mental functioning did not change significantly for any of the three groups over this period. Utilization patterns were very similar for the three groups. The high prevalence, serious impairment, and worsening physical functioning over the course of one year suggest the importance of developing interventions in primary care to alleviate the impaired physical functioning and reduce utilization in somatizing patients. MSD should be a useful diagnosis for targeting these interventions because it identifies a sizable cohort of somatizing patients reporting impairment of comparable severity to full SD, using a more efficient diagnostic algorithm based on current symptoms.