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BackgroundSouth Asians, inclusive of individuals originating in India, Pakistan, Maldives, Bangladesh, Sri Lanka, Bhutan, and Nepal, comprise the largest diaspora in the world, with large South Asian communities residing in the Caribbean, Africa, Europe, and elsewhere. There is evidence that South Asian communities have disproportionately experienced COVID-19 infections and mortality. WhatsApp, a free messaging app, is widely used in transnational communication within the South Asian diaspora. Limited studies exist on COVID-19-related misinformation specific to the South Asian community on WhatsApp. Understanding communication on WhatsApp may improve public health messaging to address COVID-19 disparities among South Asian communities worldwide.ObjectiveWe developed the COVID-19-Associated misinfoRmation On Messaging apps (CAROM) study to identify messages containing misinformation about COVID-19 shared via WhatsApp.MethodsWe collected messages forwarded globally through WhatsApp from self-identified South Asian community members between March 23 and June 3, 2021. We excluded messages that were in languages other than English, did not contain misinformation, or were not relevant to COVID-19. We deidentified each message and coded them for one or more content categories, media types (eg, video, image, text, web link, or a combination of these elements), and tone (eg, fearful, well intentioned, or pleading). We then performed a qualitative content analysis to arrive at key themes of COVID-19 misinformation.ResultsWe received 108 messages; 55 messages met the inclusion criteria for the final analytic sample; 32 (58%) contained text, 15 (27%) contained images, and 13 (24%) contained video. Content analysis revealed the following themes: "community transmission" relating to misinformation on how COVID-19 spreads in the community; "prevention" and "treatment," including Ayurvedic and traditional remedies for how to prevent or treat COVID-19 infection; and messaging attemp

BackgroundThe COVID-19 pandemic prompted safety-net health care systems to rapidly implement telemedicine services with little prior experience, causing disparities in access to virtual visits. While much attention has been given to patient barriers, less is known regarding system-level factors influencing telephone versus video-visit adoption. As telemedicine remains a preferred service for patients and providers, and reimbursement parity will not continue for audio visits, health systems must evaluate how to support higher-quality video visit access.ObjectiveThis study aimed to assess health system-level factors and their impact on telephone and video visit adoption to inform sustainability of telemedicine for ambulatory safety-net sites.MethodsWe conducted a cross-sectional survey among ambulatory care clinicians at a hospital-linked ambulatory clinic network serving a diverse, publicly insured patient population between May 28 and July 14, 2020. We conducted bivariate analyses assessing health care system-level factors associated with (1) high telephone adoption (4 or more visits on average per session); and (2) video visit adoption (at least 1 video visit on average per session).ResultsWe collected 311 responses from 643 eligible clinicians, yielding a response rate of 48.4%. Clinician respondents (N=311) included 34.7% (n=108) primary or urgent care, 35.1% (n=109) medical, and 7.4% (n=23) surgical specialties. Our sample included 178 (57.2%) high telephone adopters and 81 (26.05%) video adopters. Among high telephone adopters, 72.2% utilized personal devices for telemedicine (vs 59.0% of low telephone adopters, P=.04). Video nonadopters requested more training in technical aspects than adopters (49.6% vs 27.2%, P<.001). Primary or urgent care had the highest proportion of high telephone adoption (84.3%, compared to 50.4% of medical and 37.5% of surgical specialties, P<.001). Medical specialties had the highest proportion of video adoption (39.1%, compare

BackgroundThe COVID-19 pandemic prompted safety-net health care systems to rapidly implement telemedicine services with little prior experience, causing disparities in access to virtual visits. While much attention has been given to patient barriers, less is known regarding system-level factors influencing telephone versus video-visit adoption. As telemedicine remains a preferred service for patients and providers, and reimbursement parity will not continue for audio visits, health systems must evaluate how to support higher-quality video visit access.ObjectiveThis study aimed to assess health system-level factors and their impact on telephone and video visit adoption to inform sustainability of telemedicine for ambulatory safety-net sites.MethodsWe conducted a cross-sectional survey among ambulatory care clinicians at a hospital-linked ambulatory clinic network serving a diverse, publicly insured patient population between May 28 and July 14, 2020. We conducted bivariate analyses assessing health care system-level factors associated with (1) high telephone adoption (4 or more visits on average per session); and (2) video visit adoption (at least 1 video visit on average per session).ResultsWe collected 311 responses from 643 eligible clinicians, yielding a response rate of 48.4%. Clinician respondents (N=311) included 34.7% (n=108) primary or urgent care, 35.1% (n=109) medical, and 7.4% (n=23) surgical specialties. Our sample included 178 (57.2%) high telephone adopters and 81 (26.05%) video adopters. Among high telephone adopters, 72.2% utilized personal devices for telemedicine (vs 59.0% of low telephone adopters, P=.04). Video nonadopters requested more training in technical aspects than adopters (49.6% vs 27.2%, P<.001). Primary or urgent care had the highest proportion of high telephone adoption (84.3%, compared to 50.4% of medical and 37.5% of surgical specialties, P<.001). Medical specialties had the highest proportion of video adoption (39.1%, compare

ObjectivesSafety-net health care systems, serving vulnerable populations, see longer delays to timely colonoscopy after a positive fecal occult blood test (FOBT), which may contribute to existing disparities. We sought to identify root causes of colonoscopy delay after positive FOBT result in the primary care safety net.MethodsWe conducted a multisite root cause analysis of cases of delayed colonoscopy, identifying cases where there was a delay of greater than 6 months in completing or scheduling a follow-up colonoscopy after a positive FOBT. We identified cases across 5 California health systems serving low-income, vulnerable populations. We developed a semistructured interview guide based on precedent work. We conducted telephone individual interviews with primary care providers (PCPs) and patients. We then performed qualitative content analysis of the interviews, using an integrated inductive-deductive analytic approach, to identify themes related to recurrent root causes of colonoscopy delay.ResultsWe identified 12 unique cases, comprising 5 patient and 11 PCP interviews. Eight patients completed colonoscopy; median time to colonoscopy was 11.0 months (interquartile range, 6.3 months). Three patients had advanced adenomatous findings. Primary care providers highlighted system-level root causes, including inability to track referrals between primary care and gastroenterology, lack of protocols to follow up with patients, lack of electronic medical record interoperability, and lack of time or staffing resources, compelling tremendous additional effort by staff. In contrast, patients' highlighted individual-level root causes included comorbidities, social needs, and misunderstanding the importance of the FOBT. There was a little overlap between PCP and patient-elicited root causes.ConclusionsCurrent protocols do not accommodate communication between primary care and gastroenterology. Interventions to address specific barriers identified include improved interoperab

Background: Bhagandara has been described as one of the eight grave diseases by Acharya Sushruta which is difficult to cure. ‘Fistula-in-ano is an abnormal hollow tract lined by unhealthy granulation tissue and that connects primary opening inside the anal canal to a secondary opening in the perianal skin. Methods: diagnosed cases of Bhagandara of age groups of 18-70 years of either sex are selected. Ksharasutra treatment is given for the period of 3 months and patients will be observed up to complete healing of fistula tract or 3 months whichever is earlier. Observations And Results: the results of Kutaja Ksharasutra on criteria like pain, discharge ,itching, burning sensation were foundstatistically highly significant after cutting through tract. Mean U.C.T was found 8.86 approx 9 days. Conclusion: Kutaja Ksharasutra can be considered best because of more acceptability, easily availability, reduction in U.C.T &better wound healing property.

Background: Bhagandara has been described as one of the eight grave  diseases by Acharya Sushruta which is difficult to cure. ‘Fistula-in-ano  is an abnormal hollow tract lined by unhealthy granulation tissue and  that connects primary opening inside the anal canal to a secondary  opening in the perianal skin.  Methods: diagnosed cases of Bhagandara of age groups of 18-70 years  of either sex are selected. Ksharasutra treatment is given for the period  of 3 months and patients will be observed up to complete healing of  fistula tract or 3 months whichever is earlier.  Observations And Results: the results of Kutaja Ksharasutra on  criteria like pain, discharge ,itching, burning sensation were found  statistically highly significant after cutting through tract. Mean U.C.T  was found 8.86 approx 9 days.  Conclusion: Kutaja Ksharasutra can be considered best because of  more acceptability, easily availability, reduction in U.C.T &better  wound healing property.

ObjectivesPatients and caregivers are the primary stakeholders in ambulatory safety, given they perform daily chronic disease self-management, medication administration and outpatient follow-up. However, little attention has been given to their role in adverse events. We identified themes related to patient and caregiver factors and challenges in ambulatory safety incident reports from a Patient Safety Organization.MethodsWe conducted a mixed-methods analysis of ambulatory incident reports submitted to the Collaborative Healthcare Patient Safety Organization, including 450 hospitals or clinic members in 13 US states. We included events that had patient and/or caregiver behavioural, socioeconomic and clinical factors that may have contributed to the event. Two members of the team independently coded patient/caregiver factors, with dual coding of 20% of events. We then conducted a 'frequent item set' analysis to identify which factors most frequently co-occurred. We applied inductive analysis to the most frequent sets to interpret themes. Our team included a diverse stakeholder advisory council of patients, caregivers and healthcare staff.ResultsWe analysed 522 incident reports and excluded 73 for a final sample of 449 events. Our co-occurrence analysis found the following three themes: (1) clinical advice may conflict with patient priorities; (2) breakdowns in communication and patient education cause medication adverse events and (3) patients with disabilities are vulnerable to the external environment.ConclusionsAmbulatory safety reports capture both structural and behavioural factors contributing to adverse events. Actionable takeaways include the following: improving clinician counselling of patients to convey medical advice to elicit priorities, enhanced education regarding medication adverse events and expanding safety precautions for patients with disabilities at home. Ambulatory safety reporting must include patients in reporting and event review for better m

ObjectivesPatients and caregivers are the primary stakeholders in ambulatory safety, given they perform daily chronic disease self-management, medication administration and outpatient follow-up. However, little attention has been given to their role in adverse events. We identified themes related to patient and caregiver factors and challenges in ambulatory safety incident reports from a Patient Safety Organization.MethodsWe conducted a mixed-methods analysis of ambulatory incident reports submitted to the Collaborative Healthcare Patient Safety Organization, including 450 hospitals or clinic members in 13 US states. We included events that had patient and/or caregiver behavioural, socioeconomic and clinical factors that may have contributed to the event. Two members of the team independently coded patient/caregiver factors, with dual coding of 20% of events. We then conducted a 'frequent item set' analysis to identify which factors most frequently co-occurred. We applied inductive analysis to the most frequent sets to interpret themes. Our team included a diverse stakeholder advisory council of patients, caregivers and healthcare staff.ResultsWe analysed 522 incident reports and excluded 73 for a final sample of 449 events. Our co-occurrence analysis found the following three themes: (1) clinical advice may conflict with patient priorities; (2) breakdowns in communication and patient education cause medication adverse events and (3) patients with disabilities are vulnerable to the external environment.ConclusionsAmbulatory safety reports capture both structural and behavioural factors contributing to adverse events. Actionable takeaways include the following: improving clinician counselling of patients to convey medical advice to elicit priorities, enhanced education regarding medication adverse events and expanding safety precautions for patients with disabilities at home. Ambulatory safety reporting must include patients in reporting and event review for better m

The exponential growth of telemedicine in ambulatory care triggered by the COVID-19 public health emergency has undoubtedly impacted the quality of care and patient safety. In particular, the increased adoption of remote care has impacted communication, care teams, and patient engagement, which are key factors that impact patient safety in ambulatory care. In this perspective, we draw on a scoping review of the literature, our own clinical experiences, and conversations with patient safety experts to describe how changes in communication, care teams, and patient engagement have impacted two high priority areas in ambulatory safety: diagnostic errors and medication safety. We then provide recommendations for research funders, researchers, healthcare systems, policy makers, and healthcare payors for how to improve patient safety in telemedicine based on what is currently known as well as next steps for how to advance understanding of the safety implications of telemedicine utilization.

The exponential growth of telemedicine in ambulatory care triggered by the COVID-19 public health emergency has undoubtedly impacted the quality of care and patient safety. In particular, the increased adoption of remote care has impacted communication, care teams, and patient engagement, which are key factors that impact patient safety in ambulatory care. In this perspective, we draw on a scoping review of the literature, our own clinical experiences, and conversations with patient safety experts to describe how changes in communication, care teams, and patient engagement have impacted two high priority areas in ambulatory safety: diagnostic errors and medication safety. We then provide recommendations for research funders, researchers, healthcare systems, policy makers, and healthcare payors for how to improve patient safety in telemedicine based on what is currently known as well as next steps for how to advance understanding of the safety implications of telemedicine utilization.

In the wake of the racial injustices laid bare in 2020, on top of centuries of systemic racism, it is clear we need actionable strategies to fundamentally restructure health care systems to achieve racial/ethnic health equity. This paper outlines the pillars of a health equity framework from the Institute for Healthcare Improvement, overlaying a concrete example of telemedicine equity. Telemedicine is a particularly relevant and important topic, given the growing evidence of disparities in uptake by racial/ethnic, linguistic, and socioeconomic groups in the United States during the COVID-19 pandemic, as well as the new standard of care that telemedicine represents post-pandemic. We present approaches for telemedicine equity across the domains of: (1) strategic priorities of a health care organization, (2) structures and processes to advance equity, (3) strategies to address multiple determinants of health, (4) elimination of institutional racism and oppression, and (5) meaningful partnerships with patients and communities.

BACKGROUND: Racial/ethnic disparities in anticoagulation management are well established. Differences in warfarin monitoring can contribute to these disparities and should be measured. OBJECTIVE: We assessed for differences in international normalized ratio (INR) monitoring by race/ethnicity and language preference across safety-net care systems serving predominantly low-income, ethnically diverse populations. DESIGN: Cross-sectional analysis of process and safety data shared from the Safety Promotion Action Research and Knowledge Network (SPARK-Net) initiative, a consortium of five California safety-net hospital systems. PARTICIPANTS: Eligible patients were at least 18 years old, received warfarin for at least 56 days during the measurement period from July 2015 to June 2017, and had INR testing in an ambulatory care setting at a participating healthcare system. MAIN MEASURES: We conducted a scaled Poisson regression for adjusted rate ratio of having at least one INR checked per 56-day time period for which a patient had a warfarin prescription. Adjusting for age, sex, healthcare system, and insurance status/type, we assessed for racial/ethnic and language disparities in INR monitoring. KEY RESULTS: Of 8129 patients, 3615 (44%) were female; 1470 (18%), Black/African American; 3354 (41%), Hispanic/Latinx; 1210 (15%), Asian; 1643 (20%), White; and 452 (6%), other. Three thousand five hundred forty-nine (45%) were non-English preferring. We did not observe statistically significant disparities in the rate of appropriate INR monitoring by race/ethnicity or language; the primary source of variation was by healthcare network. Older age, female gender, and uninsured patients had a slightly higher rate of appropriate INR monitoring, but differences were not clinically significant. CONCLUSIONS: We did not find a race/ethnicity nor language disparity in INR monitoring; safety-net site was the main source of variation.

ObjectiveThe aim of the study was to analyze diverse patients' experiences throughout the medication use process to inform the development of overarching interventions that support safe medication use in community settings.MethodsUsing a qualitative observational approach, we conducted approximately 18 hours of direct observation of the medication use process across multiple settings for a sample of vulnerable, high-risk patients. Observers recorded detailed field notes during the observations. To enrich the observational findings, we also conducted six semistructured interviews with medication safety experts representing a diversity of perspectives. Barriers and facilitators to safe medication use were identified based on inductive coding of the data.ResultsA variety of safety vulnerabilities plague all stages of the medication use process and many of the well-established evidence-based interventions aimed at improving the safety of medication use at key stages of the process have not been widely implemented in community settings observed in this study. Key safety vulnerabilities identified include: limited English proficiency, low health literacy, lack of clinician continuity, incomplete medication reconciliation and counseling, unsafe medication storage and disposal habits, and conflicting healthcare agendas with caregivers.ConclusionsOur findings underscore a need for overarching, comprehensive interventions that span the entire process of medication use, including integrated communication systems between clinicians, pharmacies, and patients, and a "patient navigator" program that assists patients in navigating the entire medication-taking process. Collective ownership of the medication management system and mutual motivation for devising collaborative solutions is needed among key sectors.

Patient engagement in primary care leadership is an important means to involve community voices at community health centers. Federally qualified health centers (FQHCs) are mandated to have patient representation within their governing boards, while practices seeking patient-centered medical home certification receive credit for implementing patient advisory councils (PACs). Our objective was to compare and contrast how community health centers engage patients in clinic management, decision-making and planning within governing boards versus PACs. Qualitative study conducted from August 2016 to June 2017 at community health centers in California, Arizona and Hawaii. We interviewed practice leaders of patient engagement programs at their site. Eligible clinics had patient representatives within their governing board, PAC, or both. We assessed patient demographics, roles and responsibilities of patients participating, and extent of involvement in quality improvement among governing boards versus PACs. We interviewed 19 sites, of which 17 were FQHCs that had governing boards. Of the 17 FQHCs, 11 had also implemented PACs. Two non-FQHC safety-net sites had PACs but did not have governing boards. Governing board members had formal, structured membership responsibilities such as finances and hiring personnel. PAC roles were more flexible, focusing on day-to-day clinic operations. Clinics tended to recruit governing board patient members for their skill set and professional experience; PAC member recruitment focused more on demographic representation of the clinic's patient population. Both groups worked on quality improvement, but governing boards tended to review clinic performance metrics, while PAC members were involved in specific project planning and implementation to improve clinical outcomes and patient experience. Patient involvement in clinic improvement in CHCs includes higher-level decision-making and governance through mechanisms such as governing boards, as wel

IntroductionEmerging policy consensus advocates that patient-centered care should include an active, practice-level patient role, but it is unknown how commonly these roles are implemented. We sought to understand current prevalence and predictors of practice-level patient engagement in US primary care settings.MethodsWe assessed practice-level patient engagement by using 2016 American Board of Family Medicine Certification Examination registration data, restricted to ambulatory primary care site respondents randomly selected for a patient-centered medical home (PCMH) question module. Multivariate logistic regression models identified predictors of high-intensity patient engagement, defined as a patient advisory council or patient volunteers in quality improvement activities.ResultsA total of 6900 examinees reported practicing in primary care sites; 1368 randomly received PCMH questions. Practice-level patient engagement included patient surveys (76.5%; 95% CI, 74.3-78.8%), patient suggestion boxes (52.9%; 95% CI, 50.2-55.5%), patient board of director memberships (18.8%; 95% CI, 16.7-20.9%), patient advisory councils (23.8%; 95% CI, 21.5-26.0%), and patient participation in quality improvement (20.5%; 95% CI, 18.3-22.6%). High-intensity patient engagement was reported by 31.1% (95% CI, 28.7-33.6%); predictors included large practice size (OR, 3.30; 95% CI, 1.96-5.57), serving more vulnerable patient populations, (OR, 1.83; 95% CI, 1.18-2.84) and PCMH certification (OR, 2.19; 95% CI, 1.62-2.97).ConclusionsNearly one-third of physicians reported working in settings with high-intensity practice-level patient engagement. An implementation science approach should examine why high-intensity activities are more common in some practice settings and whether these activities add value through improved patient experience and health outcomes.

Following publication of the original article [1], the authors reported that reference no. 4 be changed. The details of the correction are as follows.

Patients and caregivers play a central role in health care safety in the hospital, ambulatory care setting, and community. Despite this, interventions to promote patient engagement in safety are still underexplored. We conducted an overview of review articles on patient engagement interventions in safety to examine the current state of the evidence. Of the 2,795 references we evaluated, 52 articles met our full-text inclusion criteria for synthesis in 2018. We identified robust evidence supporting patients' self-management of anticoagulation medications and mixed-quality evidence supporting patient engagement in medication and chronic disease self-management, adverse event reporting, and medical record accuracy. Promising modes of patient engagement in safety, such as anticoagulation management and patient portal access, are not widely implemented. We discuss major implementation priorities and propose directions for future research and policy to enhance patient partnership within safety efforts.

Patients and caregivers play a central role in health care safety in the hospital, ambulatory care setting, and community. Despite this, interventions to promote patient engagement in safety are still underexplored. We conducted an overview of review articles on patient engagement interventions in safety to examine the current state of the evidence. Of the 2,795 references we evaluated, 52 articles met our full-text inclusion criteria for synthesis in 2018. We identified robust evidence supporting patients' self-management of anticoagulation medications and mixed-quality evidence supporting patient engagement in medication and chronic disease self-management, adverse event reporting, and medical record accuracy. Promising modes of patient engagement in safety, such as anticoagulation management and patient portal access, are not widely implemented. We discuss major implementation priorities and propose directions for future research and policy to enhance patient partnership within safety efforts.

Following publication of the original article [1], the authors reported that reference no. 4 be changed. The details of the correction are as follows.

Patient engagement in primary care leadership is an important means to involve community voices at community health centers. Federally qualified health centers (FQHCs) are mandated to have patient representation within their governing boards, while practices seeking patient-centered medical home certification receive credit for implementing patient advisory councils (PACs). Our objective was to compare and contrast how community health centers engage patients in clinic management, decision-making and planning within governing boards versus PACs. Qualitative study conducted from August 2016 to June 2017 at community health centers in California, Arizona and Hawaii. We interviewed practice leaders of patient engagement programs at their site. Eligible clinics had patient representatives within their governing board, PAC, or both. We assessed patient demographics, roles and responsibilities of patients participating, and extent of involvement in quality improvement among governing boards versus PACs. We interviewed 19 sites, of which 17 were FQHCs that had governing boards. Of the 17 FQHCs, 11 had also implemented PACs. Two non-FQHC safety-net sites had PACs but did not have governing boards. Governing board members had formal, structured membership responsibilities such as finances and hiring personnel. PAC roles were more flexible, focusing on day-to-day clinic operations. Clinics tended to recruit governing board patient members for their skill set and professional experience; PAC member recruitment focused more on demographic representation of the clinic's patient population. Both groups worked on quality improvement, but governing boards tended to review clinic performance metrics, while PAC members were involved in specific project planning and implementation to improve clinical outcomes and patient experience. Patient involvement in clinic improvement in CHCs includes higher-level decision-making and governance through mechanisms such as governing boards, as wel

IntroductionEmerging policy consensus advocates that patient-centered care should include an active, practice-level patient role, but it is unknown how commonly these roles are implemented. We sought to understand current prevalence and predictors of practice-level patient engagement in US primary care settings.MethodsWe assessed practice-level patient engagement by using 2016 American Board of Family Medicine Certification Examination registration data, restricted to ambulatory primary care site respondents randomly selected for a patient-centered medical home (PCMH) question module. Multivariate logistic regression models identified predictors of high-intensity patient engagement, defined as a patient advisory council or patient volunteers in quality improvement activities.ResultsA total of 6900 examinees reported practicing in primary care sites; 1368 randomly received PCMH questions. Practice-level patient engagement included patient surveys (76.5%; 95% CI, 74.3-78.8%), patient suggestion boxes (52.9%; 95% CI, 50.2-55.5%), patient board of director memberships (18.8%; 95% CI, 16.7-20.9%), patient advisory councils (23.8%; 95% CI, 21.5-26.0%), and patient participation in quality improvement (20.5%; 95% CI, 18.3-22.6%). High-intensity patient engagement was reported by 31.1% (95% CI, 28.7-33.6%); predictors included large practice size (OR, 3.30; 95% CI, 1.96-5.57), serving more vulnerable patient populations, (OR, 1.83; 95% CI, 1.18-2.84) and PCMH certification (OR, 2.19; 95% CI, 1.62-2.97).ConclusionsNearly one-third of physicians reported working in settings with high-intensity practice-level patient engagement. An implementation science approach should examine why high-intensity activities are more common in some practice settings and whether these activities add value through improved patient experience and health outcomes.

ContextCommunity education and engagement are important for informing family planning projects. The objective of this study was to update two prior systematic reviews assessing the impact of community education and engagement interventions on family planning outcomes.Evidence acquisitionSixteen electronic databases were searched for studies relevant to a priori determined inclusion/exclusion criteria in high development settings, published from March 2011 through April 2016, updating two reviews that included studies from 1985 through February 2011.Evidence synthesisNine relevant studies were included in this updated review related to community education, in addition to 17 from the prior review. No new community engagement studies met inclusion criteria, as occurred in the prior review. Of new studies, community education modalities included mass media, print/mail, web-based, text messaging, and interpersonal interventions. One study on mass media intervention demonstrated a positive impact on reducing teen and unintended pregnancies. Three of four studies on interpersonal interventions demonstrated positive impacts on medium-term family planning outcomes, such as contraception and condom use. Three new studies demonstrated mostly positive, but inconsistent, results on short-term family planning outcomes.ConclusionsFindings from this systematic review update are in line with a previous review showing the positive impact of community education using traditional modalities on short-term family planning outcomes, identifying additional impacts on long-term outcomes, and highlighting new evidence for education using modern modalities, such as text messaging and web-based education. More research is necessary to provide a stronger evidence base for directing community education and engagement efforts in family planning contexts.Theme informationThis article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Prov

ObjectiveWe sought to test whether participation in an online group including IUD users influenced IUD-related knowledge, attitudes, and behavior among IUD non-users, as a proof-of-concept evaluation of information dissemination for less commonly used or novel contraceptives.Study designWe conducted a blinded, randomized controlled trial on the effect of online communication with IUD users within an online program called Birth Control Connect. Participants were women age 18-45 living in the United States who had never used an IUD. We invited participants randomized to the intervention to join two-week, nine-member discussion groups including four satisfied IUD users and five IUD non-users; we invited control participants to groups including nine IUD non-users. We performed chi-squared tests on IUD knowledge, information-seeking, informational support and use in immediate post-surveys, and t-tests comparing change in IUD attitudes and frequency of logins to discussion groups.ResultsWe invited 488 IUD non-users and enrolled them into 70 groups between October 2015 and April 2016. We found increased positive attitudes towards the IUD in the intervention arm (0.65-point increase between pre- and post-surveys, versus 0.05 mean change for control arm, p = 0.03 for hormonal IUD, with a trend in the same direction for the non-hormonal IUD). Informational support also increased, with 70.3% of intervention arm participants self-reporting that they gained a better idea of what the IUD would be like, compared to 51.3% in control arm (p < 0.01). Of intervention participants, 63.3% versus 51.3% of control participants reported gaining new information from their group (p = 0.03). There were no differences in correct responses to knowledge items or information-seeking between groups.ConclusionsOnline exposure to IUD users increased positive attitudes toward the IUD and informational support for decision-making about the IUD among non-users.Implications statementOnline spaces pro

Patient engagement is a fundamental strategy for achieving patient centred care and is receiving increasing attention in primary care reform efforts such as the patient-centred medical home and related care models. Much of the prior published theory and evidence supporting patient engagement has focused on improving engagement in individual care. Much less is understood about engaging patients as partners in practice improvement at the primary care clinic or practice level. We review the historical and policy context for the growing interest in the USA and UK in patient engagement at the primary care practice level, highlight findings from systematic reviews of the research evidence on practice-level patient engagement and discuss practical considerations for implementing patient engagement. We conclude that while there are persuasive ethical and social justice reasons for empowering patient involvement in practice improvement at the clinic level, research conducted to date in primary care provides suggestive but not yet resounding evidence in support of the instrumental triple aim benefit of practice-level patient engagement. We propose a research agenda to better understand the process and outcomes of practice-level patient engagement and its potential advantages to both the practice and the patients and communities served. Better evidence as well as resources to support and incentivize effective and feasible engagement methods are needed to catalyse greater diffusion of practice-level patient engagement in primary care practices.

BACKGROUND:Patient advisory councils are a way for healthcare organizations to promote patient engagement. Despite mandates to implement patient advisory councils through programs like the Patient-Centered Medical Home (PCMH), there is a paucity of data measuring the impact of patients functioning in advisory roles. Our objective is to investigate whether patient engagement in patient advisory councils is linked to improvements in clinical quality, patient safety or patient satisfaction. METHODS:We searched PubMed, SCOPUS, CINAHL and Google Scholar for English language publications between November 2002 to August 2015, using a combination of "patient advisor" and "care outcomes" search terms. Article selection utilized dual screening facilitated by DistillerSR software, with group discussion to resolve discordance. Observational studies, randomized controlled trials, and case studies were included that described patients serving in an advisory role where primary outcomes were mentioned. Reference lists of included studies and grey literature searches were conducted. Qualitative thematic analysis was performed to synthesize results. RESULTS:Database searching yielded 639 articles total after removing duplicates, with 129 articles meeting full text inclusion criteria. 32 articles were identified for final review, 16 of which were case studies. Advisory roles included patient advisory councils, ad-hoc patient committees, community advisory councils, experience-based co-design, and other. Four practice-based studies from one research group, involving community advisors in the design of public health interventions, found improved clinical outcomes. No prospective experimental studies assessed the impact of patient advisors on patient safety or patient satisfaction. One cluster-randomized RCT showed that patient advisors helped health care planning efforts identify priorities more aligned with the PCMH. Ten case studies reported anecdotal benefit to individual patient adv

Patient engagement is a fundamental strategy for achieving patient centred care and is receiving increasing attention in primary care reform efforts such as the patient-centred medical home and related care models. Much of the prior published theory and evidence supporting patient engagement has focused on improving engagement in individual care. Much less is understood about engaging patients as partners in practice improvement at the primary care clinic or practice level. We review the historical and policy context for the growing interest in the USA and UK in patient engagement at the primary care practice level, highlight findings from systematic reviews of the research evidence on practice-level patient engagement and discuss practical considerations for implementing patient engagement. We conclude that while there are persuasive ethical and social justice reasons for empowering patient involvement in practice improvement at the clinic level, research conducted to date in primary care provides suggestive but not yet resounding evidence in support of the instrumental triple aim benefit of practice-level patient engagement. We propose a research agenda to better understand the process and outcomes of practice-level patient engagement and its potential advantages to both the practice and the patients and communities served. Better evidence as well as resources to support and incentivize effective and feasible engagement methods are needed to catalyse greater diffusion of practice-level patient engagement in primary care practices.

BACKGROUND:Patient advisory councils are a way for healthcare organizations to promote patient engagement. Despite mandates to implement patient advisory councils through programs like the Patient-Centered Medical Home (PCMH), there is a paucity of data measuring the impact of patients functioning in advisory roles. Our objective is to investigate whether patient engagement in patient advisory councils is linked to improvements in clinical quality, patient safety or patient satisfaction. METHODS:We searched PubMed, SCOPUS, CINAHL and Google Scholar for English language publications between November 2002 to August 2015, using a combination of "patient advisor" and "care outcomes" search terms. Article selection utilized dual screening facilitated by DistillerSR software, with group discussion to resolve discordance. Observational studies, randomized controlled trials, and case studies were included that described patients serving in an advisory role where primary outcomes were mentioned. Reference lists of included studies and grey literature searches were conducted. Qualitative thematic analysis was performed to synthesize results. RESULTS:Database searching yielded 639 articles total after removing duplicates, with 129 articles meeting full text inclusion criteria. 32 articles were identified for final review, 16 of which were case studies. Advisory roles included patient advisory councils, ad-hoc patient committees, community advisory councils, experience-based co-design, and other. Four practice-based studies from one research group, involving community advisors in the design of public health interventions, found improved clinical outcomes. No prospective experimental studies assessed the impact of patient advisors on patient safety or patient satisfaction. One cluster-randomized RCT showed that patient advisors helped health care planning efforts identify priorities more aligned with the PCMH. Ten case studies reported anecdotal benefit to individual patient adv

The legume field pea can be a valuable component of crop rotations to reduce cereal disease carryover and increase soil nitrogen. However, it is frequently affected by Ascochyta blight which reduces yield. Fungicides are used to control the impact of the disease with mixed success, but effective management relies on a combination of strategies. To determine the efficacy of management strategies for disease suppression, field trials were run investigating;  The interaction between time-of-sowing and fungicide treatment at three locations in Western Australia in 2016, with four fungicide treatments applied either once or twice after sowing.  The impact of using wheat stubble from the preceding crop to trellis the field peas, reducing crop lodging, and potentially disease spread. Results showed that time of sowing had a greater impact on yield than repeated application of fungicide. Stubble-trellising using the previous year’s cereal stubble significantly reduced disease in the crop and increased yield.

Context and objectivePatient advisory councils (PACs) are a strategy for primary care clinics to engage patients in practice improvement. However, there is scant research on how PACs function. This study aimed to understand how PACs are organized and identify common challenges and perceived benefits of high-functioning PACs.Setting and populationKey informants identified 8 primary care clinics in California with high-functioning PACs. Leaders from each of the 8 clinics nominated 1 clinic staff member and 1 PAC patient member to be interviewed.Study designSemistructured, one-on-one interviews were conducted at each clinic site or by phone. Interviews were dual-coded using modified grounded theory. Common themes were identified that would be pertinent to the development of future best practices for running PACs.ResultsCommon characteristics of high-functioning PACs included careful attention to participant recruitment, facilitation strategies guiding diverse personalities toward a common purpose, and assigning accountability for practice improvement projects. Interviewees identified a variety of positive outcomes that ranged from tangible improvements to the waiting area to a more patient-centered staff culture.ConclusionsPACs show potential for promoting patient-centered practice improvements in primary care. Lessons learned from high-functioning PACs can inform a common set of strategies to assist practices in creating and sustaining effective advisory councils.

PurposeHealth coaching is effective for chronic disease self-management in the primary care safety-net setting, but little is known about the persistence of its benefits. We conducted an observational study evaluating the maintenance of improved cardiovascular risk factors following a health coaching intervention.MethodsWe performed a naturalistic follow-up to the Health Coaching in Primary Care Study, a 12-month randomized controlled trial (RCT) comparing health coaching to usual care for patients with uncontrolled diabetes, hypertension, or hyperlipidemia. Participants were followed up 24 months from RCT baseline. The primary outcome was the proportion at goal for at least 1 measure (hemoglobin A1c, systolic blood pressure, or LDL cholesterol) that had been above goal at enrollment; secondary outcomes included each individual clinical goal. Chi-square tests and paired t-tests compared dichotomous and continuous measures.Results290 of 441 participants (65.8%) participated at both 12 and 24 months. The proportion of patients in the coaching arm of the RCT who achieved the primary outcome dropped only slightly from 47.1% at 12 to 45.9% at 24 months (P = .80). The proportion at goal for hemoglobin A1c dropped from 53.4% to 36.2% (P = .03). All other clinical metrics had small, nonsignificant changes between 12 and 24 months.ConclusionsResults support the conclusion that most improved clinical outcomes persisted 1 year after the completion of the health coaching intervention.

Context and objectivePatient advisory councils (PACs) are a strategy for primary care clinics to engage patients in practice improvement. However, there is scant research on how PACs function. This study aimed to understand how PACs are organized and identify common challenges and perceived benefits of high-functioning PACs.Setting and populationKey informants identified 8 primary care clinics in California with high-functioning PACs. Leaders from each of the 8 clinics nominated 1 clinic staff member and 1 PAC patient member to be interviewed.Study designSemistructured, one-on-one interviews were conducted at each clinic site or by phone. Interviews were dual-coded using modified grounded theory. Common themes were identified that would be pertinent to the development of future best practices for running PACs.ResultsCommon characteristics of high-functioning PACs included careful attention to participant recruitment, facilitation strategies guiding diverse personalities toward a common purpose, and assigning accountability for practice improvement projects. Interviewees identified a variety of positive outcomes that ranged from tangible improvements to the waiting area to a more patient-centered staff culture.ConclusionsPACs show potential for promoting patient-centered practice improvements in primary care. Lessons learned from high-functioning PACs can inform a common set of strategies to assist practices in creating and sustaining effective advisory councils.

PurposeHealth coaching is effective for chronic disease self-management in the primary care safety-net setting, but little is known about the persistence of its benefits. We conducted an observational study evaluating the maintenance of improved cardiovascular risk factors following a health coaching intervention.MethodsWe performed a naturalistic follow-up to the Health Coaching in Primary Care Study, a 12-month randomized controlled trial (RCT) comparing health coaching to usual care for patients with uncontrolled diabetes, hypertension, or hyperlipidemia. Participants were followed up 24 months from RCT baseline. The primary outcome was the proportion at goal for at least 1 measure (hemoglobin A1c, systolic blood pressure, or LDL cholesterol) that had been above goal at enrollment; secondary outcomes included each individual clinical goal. Chi-square tests and paired t-tests compared dichotomous and continuous measures.Results290 of 441 participants (65.8%) participated at both 12 and 24 months. The proportion of patients in the coaching arm of the RCT who achieved the primary outcome dropped only slightly from 47.1% at 12 to 45.9% at 24 months (P = .80). The proportion at goal for hemoglobin A1c dropped from 53.4% to 36.2% (P = .03). All other clinical metrics had small, nonsignificant changes between 12 and 24 months.ConclusionsResults support the conclusion that most improved clinical outcomes persisted 1 year after the completion of the health coaching intervention.

Introduction: Pancytopenia is a challenging clinical entity for both clinicians and hematologists. The severity of pancytopenia and the underlying pathology determine the management and prognosis of these patients. Laboratory plays central role in determining the etiology of pancytopenia and thereby guiding the clinician in proper management of patient. The objective of the present study was to study the etiological factor, clinical features, peripheral blood picture, hematological parameters and bone marrow findings in different causes of pancytopenia in this region. Materials and Methods: In the prospective study carried out, a total of 132 patients of pancytopenia were evaluated for clinical features, hematological parameters, peripheral smear and bone marrow findings in Department of Pathology, Jawaharlal Nehru Hospital and Research Center, Bhilai, C .G. during a two years study period from March 2009 to April 2011. Results: Among the 132 cases studied, the age of patients studied ranged from 2.5 to 76 years with a mean age of 38.10 years. The maximum number of patients (53.7%) were noted in 2nd to 4th decade of age. Slight male preponderance was observed with male: female ratio 1.5:1. On analyzing for the specific causes of pancytopenia, majority of cases were found to be due to megaloblastic anemia (50 .7%), followed by hypersplenism (10.6.%), malaria (9.8%), leukemia (9.0%) and aplastic anemia (7.5%) cases. Other rare causes includes Wilson disease, Kala azar, HIV, alcoholism etc. Clinical presentation of the patients with pancytopenia varied but pallor was the most common clinical finding (96.9%) followed by fever (59.8%). Dimorphic with macrocytic anemia was the predominant peripheral blood picture. Bone marrow aspiration was done in 101 cases and biopsy in 10 cases. The commonest finding was hypercellularity in marrow with megaloblastic erythropoiesis. Conclusion: The present study concludes that detailed clinical examination along with readily available d

Introduction: Pancytopenia is a challenging clinical entity for both clinicians and hematologists. The severity of pancytopenia and the underlying pathology determine the management and prognosis of these patients. Laboratory plays central role in determining the etiology of pancytopenia and thereby guiding the clinician in proper management of patient. The objective of the present study was to study the etiological factor, clinical features, peripheral blood picture, hematological parameters and bone marrow findings in different causes of pancytopenia in this region. Materials and Methods: In the prospective study carried out, a total of 132 patients of pancytopenia were evaluated for clinical features, hematological parameters, peripheral smear and bone marrow findings in Department of Pathology, Jawaharlal Nehru Hospital and Research Center, Bhilai, C .G. during a two years study period from March 2009 to April 2011. Results: Among the 132 cases studied, the age of patients studied ranged from 2.5 to 76 years with a mean age of 38.10 years. The maximum number of patients (53.7%) were noted in 2nd to 4th decade of age. Slight male preponderance was observed with male: female ratio 1.5:1. On analyzing for the specific causes of pancytopenia, majority of cases were found to be due to megaloblastic anemia (50 .7%), followed by hypersplenism (10.6.%), malaria (9.8%), leukemia (9.0%) and aplastic anemia (7.5%) cases. Other rare causes includes Wilson disease, Kala azar, HIV, alcoholism etc. Clinical presentation of the patients with pancytopenia varied but pallor was the most common clinical finding (96.9%) followed by fever (59.8%). Dimorphic with macrocytic anemia was the predominant peripheral blood picture. Bone marrow aspiration was done in 101 cases and biopsy in 10 cases. The commonest finding was hypercellularity in marrow with megaloblastic erythropoiesis. Conclusion: The present study concludes that detailed clinical examination along with readily available d

Lentil is a leading pulse crop of Nepal. It is also a high value crop, having an immense potentiality of export to other countries. Although Nepal Agricultural Research Council (NARC) has recommended ten varieties and improved production technologies of lentil, the adoption at farmer’s field has been low due to which the average yield is far below its attainable yield. Poor access to improved seeds, technical knowledge and services among farmers, and lack of appropriate market intervention are major shortcomings to develop this sector commercially. So, to enhance the productivity and production of lentil and to improve linkages among the value chain actors, FORWARD Nepal implemented the project on commercial farming of lentil in 11 terai districts of Nepal in 2011/12 and 2012/13. The project introduced a technology package consisting of improved varieties, rhizobium inoculation, seed priming and basal application of fertilizer diammonium phosphate (DAP) on a cost share basis with farmer groups. Value chain improvement activities including collective marketing were intervened to help growers realize competitive price of the produce. The project used HH surveys and group discussions with concerned stakeholders for the study. The effectiveness of project interventions were assessed through baseline and endline surveys of the randomly selected sample households from the project districts. Data were analyzed using descriptive statistics and ANOVA techniques. The findings reveal the effectiveness of project interventions in increasing the production, productivity and household (HH) income of lentil growers. As a result of technology adoption, average lentil productivity increased by 18%, total HH production by 44%, area under lentil by 25%, HH sale by 29% and HH income by 115% over the baseline figure. It is concluded that in addition to delivery of technology packages to farmers, improvements in value chains and marketing play crucial roles in enhancing farm level profit, This article is an outcome of the project NEAT-GRA-STN-001 "Commercial promotion of lentil subsector in eleven terai districts of Nepal" with financial supports from the people of United States of America.

This article is an outcome of the project NEAT-GRA-STN-001 "Commercial promotion of lentil subsector in eleven terai districts of Nepal" with financial supports from the people of United States of America., Lentil is a leading pulse crop of Nepal. It is also a high value crop, having an immense potentiality of export to other countries. Although Nepal Agricultural Research Council (NARC) has recommended ten varieties and improved production technologies of lentil, the adoption at farmer's field has been low due to which the average yield is far below its attainable yield. Poor access to improved seeds, technical knowledge and services among farmers, and lack of appropriate market intervention are major shortcomings to develop this sector commercially. So, to enhance the productivity and production of lentil and to improve linkages among the value chain actors, FORWARD Nepal implemented the project on commercial farming of lentil in 11 Terai districts of Nepal in 2011/12 and 2012/13. The project introduced a technology package consisting of improved varieties, rhizobium inoculation, seed priming and basal application of fertilizer diammonium phosphate (DAP) on a cost share basis with farmer groups. Value chain improvement activities including collective marketing were intervened to help growers realize competitive price of the produce. The project used HH surveys and group discussions with concerned stakeholders for the study. The effectiveness of project interventions were assessed through baseline and end line surveys of the randomly selected sample households from the project districts. Data were analyzed using descriptive statistics and ANOVA techniques. The findings reveal the effectiveness of project interventions in increasing the production, productivity and household (HH) income of lentil growers. As a result of technology adoption, average lentil productivity increased by 18%, total HH production by 44%, area under lentil by 25%, HH sale by 29% and HH income by 115% over the baseline figure. It is concluded that in addition to delivery of technology packages to farmers, improvements in value chains and marketing play crucial roles in enhancing farm level profi