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Purpose: To give an overview of the multicenter Prostate Cancer Outcomes (PCO) study, involving paper-based and web-based collection of patient-reported outcome measures (PROM) in patients undergoing local treatment for prostate cancer in certified centers in Germany. The PCO study is part of the larger Movember-funded TrueNTH Global Registry. The article reports on the study's design and provides a brief progress report after the first 2 years of data collection. Methods: Prostate cancer centers (PCCs) certified according to German Cancer Society requirements were invited to participate in collecting patient-reported information on symptoms and function before and at least once (at 12 months) after treatment. The data were matched with disease and treatment information. This report describes progress in patient inclusion, response rate, and variations between centers relative to online/paper use, and also data quality, including recruitment variations relative to treatment in the first participating PCCs. Results: PCC participation increased over time; 44 centers had transferred data for 3094 patients at the time of this report. Patient recruitment varied widely across centers. Recruitment was highest among patients undergoing radical prostatectomy. The completeness of the data was good, except for comorbidity information. Conclusions: The PCO study benefits from a quality improvement system first established over 10 years ago, requiring collection and harmonization of a predefined clinical dataset across centers. Nevertheless, establishing a PROM routine requires substantial effort on the part of providers and constant monitoring in order to achieve high-quality data. The findings reported here may be useful for guiding implementation in similar initiatives. [ABSTRACT FROM AUTHOR]

Background: Colorectal cancer (CRC) is prevalent in the developed world. Favourable survival rates highlight the need to better understand CRC survivors' experiences of long-term impacts of treatment, which can in turn inform decision making. This systematic review aimed to identify and synthesise CRC survivors' experiences of long-term impacts on health-related quality of life. Methods: We searched Medline, Embase and PsychINFO from inception to January 2019. Qualitative studies describing CRC survivors' experiences at least 1-year post-treatment were included. Study eligibility, quality assessment (COREQ guidelines), and data synthesis was performed independently by two reviewers and discussed with the study team. Results: Of 1363 papers retrieved, 20 reporting 15 studies met eligibility. Thematic synthesis produced 12 themes: symptoms, physical, social, psychological and sexual functioning, impact on relationships, informal care needs provided by family/friend, supportive care needs provided by healthcare professional, health care experiences, health behaviour, financial toxicity and occupational experiences. Stoma problems (e.g. leakage, skin irritation) were common in ostomates. Survivors with no/reversed stoma experienced unexpected, long-term altered and unpredictable bowel functioning. Survivors often regulated timing, amount and foods consumed to manage bowel functioning. Less common symptoms included fatigue, impaired sleep and anal pain. Stoma problems and altered bowel functioning impaired survivors' physical, social, sexual and psychological functioning. Cognitive functioning and heredity issues were not reported in any paper. Conclusion: CRC survivors experience ongoing symptoms and functioning impairments more than 1-year post-treatment completion. Many survivors find their own ways to manage symptoms rather than seek professional help. Follow-up care for CRC survivors should integrate screening for long-term effects and provide targeted supportive care. [ABSTRACT FROM AUTHOR]

The widespread adoption of science-based prevention requires local infrastructures for prevention service delivery. Communities That Care (CTC) is a tested prevention service delivery system that enables a local coalition of community stakeholders to use a science-based approach to prevention and improve the behavioral health of young people. This paper uses data from the Community Youth Development Study (CYDS), a community-randomized trial of CTC, to examine the extent to which better internal team functioning of CTC coalitions increases the community-wide adoption of science-based prevention within 12 communities, relative to 12 matched comparison communities. Specifically, this paper examines the potential of both a direct relationship between coalition functioning and the community-wide adoption of science-based prevention and a direct relationship between functioning and the coalition capacities that ultimately enable the adoption of science-based prevention. Findings indicate no evidence of a direct relationship between four dimensions of coalition functioning and the community-wide adoption of a science-based approach to prevention, but suggest a relationship between coalition functioning and coalition capacities (building new member skills and establishing external linkages with existing community organizations) that enable science-based prevention. [ABSTRACT FROM AUTHOR]

Purpose: Little is known about Latina breast cancer survivors' social networks or their perceived social support to achieve and maintain a healthy diet. This paper describes the social networks and perceived support for healthy eating in a sample of breast cancer survivors of predominantly Dominican descent living in New York City.Methods: Spanish-speaking Latina breast cancer survivors enrolled in a randomized controlled trial of a culturally tailored dietary intervention. Social networks were assessed using Cohen's Social Network Index and a modified General Social Survey Social Networks Module that included assessments of shared health promoting behaviors. Perceived social support from family and friends for healthy, food-related behaviors was assessed.Results: Participants' networks consisted predominantly of family and friends. Family members were more likely than other individuals to be identified as close network members. Participants were more likely to share food-related activities than exercise activities with close network members. Perceived social support for healthy eating was high, although perceived support from spouses and children was higher than support from friends. Despite high levels of perceived support, family was also identified as a barrier to eating healthy foods by nearly half of women.Conclusions: Although friends are part of Latina breast cancer survivors' social networks, spouses and children may provide greater support for healthy eating than friends.Implications For Cancer Survivors: Involving family members in dietary interventions for Latina breast cancer survivors may tap into positive sources of support for women, which could facilitate uptake and maintenance of healthy eating behaviors. [ABSTRACT FROM AUTHOR]

Background: Patient complexity is often operationalized by counting multiple chronic conditions (MCC) without considering contextual factors that can affect patient risk for adverse outcomes.Objective: Our objective was to develop a conceptual model of complexity addressing gaps identified in a review of published conceptual models.Data Sources: We searched for English-language MEDLINE papers published between 1 January 2004 and 16 January 2014. Two reviewers independently evaluated abstracts and all authors contributed to the development of the conceptual model in an iterative process.Results: From 1606 identified abstracts, six conceptual models were selected. One additional model was identified through reference review. Each model had strengths, but several constructs were not fully considered: 1) contextual factors; 2) dynamics of complexity; 3) patients' preferences; 4) acute health shocks; and 5) resilience. Our Cycle of Complexity model illustrates relationships between acute shocks and medical events, healthcare access and utilization, workload and capacity, and patient preferences in the context of interpersonal, organizational, and community factors.Conclusions/implications: This model may inform studies on the etiology of and changes in complexity, the relationship between complexity and patient outcomes, and intervention development to improve modifiable elements of complex patients. [ABSTRACT FROM AUTHOR]

The use of embodied conversational agents in mental health has increased in the last years. Several studies exist describing the benefits and advantages of this technology as a complement to psychotherapeutic interventions for the prevention and treatment of depression, anxiety, or post-traumatic stress disorder, to name a few. A small number of these works implement capabilities in the virtual agent focused on the detection and prevention of suicidality risks. The work presented in this paper describes the development of an embodied conversational agent used as the main interface in HelPath, a mobile-based application addressed to individuals detected with any of the suicidal behaviours: ideation, planning or attempt. The main objective of HelPath is to continuously collect user's information that, complemented with data from the electronic health record, supports the identification of risks associated with suicidality. Through the virtual agent, the users also receive information and suggestions based on cognitive behaviour therapy that would help them to maintain a healthy condition. The paper also presents the execution of an exploratory pilot to assess the acceptability, perception and adherence of users towards the virtual agent. The obtained results are presented and discussed, and some actions for further improvement of the embodied conversational agent are also identified. [ABSTRACT FROM AUTHOR]

Background: The UK Medical Research Council approach to evaluating complex interventions moves through development, feasibility, piloting, evaluation and implementation in an iterative manner. This approach might be useful as a conceptual process underlying complex valuation tasks.Objective: The objective of the study was to explore the applicability of such a framework using a single case study (valuing the ICECAP-Supportive Care Measure) and considering three key uncertainties: the number of response categories for the measure; experimental design; and the potential for using slightly different variants of the measure with the same value set.Methods: Three on-line pilot studies (n = 204, n = 100, n = 102) were undertaken during 2012 and 2013 with adults from the UK general population. Each used variants of discrete choice and best-worst scaling tasks; respondents were randomly allocated to different groups to allow exploration of the number of levels for the instrument (four or five), optimal experimental design and the values for alternative wording around prognosis. Conditional logit regression models were used in the analysis and variance scale factors were explored.Results: The five-level version of the measure seemed to result in simplifying heuristics. Plotting the variance scale factors suggested that best-worst scaling answers were approximately four times more consistent than the discrete choice answers. The likelihood ratio test indicated there was virtually no difference in values between the differently worded versions.Conclusion: Rigorous piloting can improve the design of valuation studies. Thinking in terms of a 'complex valuation framework' may emphasise the importance of conducting and funding such rigorous pilots. [ABSTRACT FROM AUTHOR]

With increased patient access to data, healthcare services are experiencing change where patients are moving away from being mere passive actors towards becoming more active and involved participants. In this paper, we explore the role of patient accessible electronic health records (PAEHRs) with respect to this increase in patient involvement. The study was performed as a case study and included nine interviews with patients and a survey that was responded to by 56 patients. Our results show that PAEHRs have a role in the enhancement of patient involvement because PAEHRs (i) foster a more balanced relationship between patients and healthcare professionals and (ii) increase access to information. [ABSTRACT FROM AUTHOR]

The Indian Council of Medical Research-National Institute of Cancer Prevention and Research (ICMR-NICPR) has been conducting online cancer screening training certificate courses since 2017. Thereafter, multiple cohorts have been trained successfully in cancer screening using the Extensions for Community Healthcare Outcomes (ECHO) platform. A 14-week course was designed for various cadres of healthcare professionals (HCP), through which they were trained in cancer screening and their roles and responsibilities in implementing the population-based cancer screening, as per the operational framework released by the Ministry of Health and Family Welfare. Then, a contact program was held to upskill the participants in cancer screening techniques. Eight cohorts have been successfully trained using the hybrid model of online training and hands-on training. Cancer screening conducted utilizing the hybrid model, consisting of the online ECHO model, followed by hands-on training is a suitable training model to train large cohorts, such as the one in populous countries like India. [ABSTRACT FROM AUTHOR]

Background and Aims: A strong cardiorespiratory fitness is suggested to have beneficial effects on cardiovascular risk; the exact mechanisms underlying the cardioprotective effects of fitness remain uncertain. Our aim was to investigate associations between cardiorespiratory fitness and multiple plasma proteins, in order to obtain insights about physiological pathways associated with the effects of exercise on cardiovascular health. Methods: In the Prospective investigation of Obesity, Energy and Metabolism (POEM) study (n=444 adults aged 50 years, 50% women), cardiorespiratory fitness was measured by a maximal exercise test on bicycle ergometer with gas exchange (VO2peak) normalized for body lean mass (dual-energy X-ray absorptiometry (DXA)). We measured 82 cardiovascular proteins associated with cardiovascular pathology and inflammation in plasma samples with a proximity extension assay. Results: In sex-adjusted linear regression, VO2peak was associated with 18 proteins after Bonferroni correction for multiple testing (p<0.0006). Following additional adjustment for fat mass (DXA), fasting glucose (mmol/L), low-density lipoprotein (LDL, mmol/L), smoking status, waist/hip ratio, blood pressure (mmHg), education level, and lpnr (lab sequence number), higher VO2peak was significantly associated with lower levels of 6 proteins: fatty-acid binding protein-4 (FABP4), interleukin-6 (IL-6), leptin, cystatin-B (CSTB), interleukin-1 receptor antagonist (IL-1RA), and growth differentiation factor 15 (GDF-15), and higher levels of 3 proteins: galanin, kallikrein-6 (KLK6), and heparin-binding EGF-like growth factor (HB-EGF), at nominal p-values (p<0.05). Conclusions: We identified multiple novel associations between cardiorespiratory fitness and plasma proteins involved in several atherosclerotic processes and key cellular mechanisms such as inflammation, energy homeostasis, and protease activity, which shed new light on how exercise asserts its beneficial effects on cardiovascular health. Our findings encourage additional studies in order to understand the underlying causal mechanisms for these associations. [ABSTRACT FROM AUTHOR]

Background: Financial burden can affect healthcare utilization. Few studies have assessed the short-term associations between material (debt, trouble paying rent) and psychological (worry or distress about affording future healthcare) financial risks, and subsequent outpatient and emergency healthcare use. Worry was defined as concerns about affording future healthcare.Objective: Examine whether worry about affording healthcare is associated with healthcare utilization when controlling for material risk and general anxiety DESIGN: Longitudinal observational study PARTICIPANTS: Kaiser Permanente members with exchange-based federally subsidized health insurance (n = 450, 45% response rate) MAIN MEASURES: Survey measures of financial risks (material difficulty paying for medical care and worry about affording healthcare) and general anxiety. Healthcare use (primary care, urgent care, emergency department, and outpatient specialty visits) in the 6 months following survey completion.Key Results: Emergency department and primary care visits were not associated with material risk, worry about affording care, or general anxiety in individual and pooled analyses (all 95% confidence intervals (CI) for relative risk (RR) included 1). Although no individual predictor was associated with urgent care use (all 95% CIs for RR included 1), worry about affording prescriptions (relative risk (RR) = 2.01; 95% CI 1.14, 3.55) and general anxiety (RR = 0.38; 95% CI 0.15, 0.95) were significant when included in the same model, suggesting the two confounded each other. Worry about affording healthcare services was associated with fewer specialty care visits (RR = 0.40; 95% CI 0.25, 0.64) even when controlling for material risk and general anxiety, although general anxiety was also associated with more specialty care visits (RR = 1.98; 95% CI, 1.23, 3.18).Conclusions: Screening for both general anxiety and financial worry may assist with specialty care utilization. Identifying these concerns may provide more opportunities to assist patients. Future research should examine interventions to reduce worry about cost of care. [ABSTRACT FROM AUTHOR]

Purpose: For adult spinal deformity (ASD) patients receiving operative (op) and non-operative (non-op) treatment, the relationship between HRQoL measures, complications and self-reported satisfaction remains unclear. The objective of this analysis is to study nonlinear association dynamics between ASD patient satisfaction, HRQoL, and complications over a two-year follow-up period.Methods: From a prospective multicenter international adult spinal deformity database, all patients with 2-year follow-up data on satisfaction (21st question of SRS-22r) were identified and included. A total of 12 LOESS (local polynomial fit) regressions were performed between patient satisfaction (SRS22 item 21) and HRQoL measures (ODI, SF36PCS and SRS22 subtotal) interacting with surgery at baseline, 6 months and 1 and 2 years of follow-up.Results: A total of 856 patients (527 op and 329 non-op) were included. At baseline, satisfaction was lower for patients scheduled for surgery even when HRQL was similar to those elected for conservative treatment. The nonlinear correlations showed that for similar PROMs, op patients reached higher satisfaction levels during follow-up, especially at six months. In fact, at six months operated patients with a deterioration of their initial PROMs had some improvement in their satisfaction, which could not be further observed at the end of follow-up.Conclusions: Satisfaction does not correlate well with other PROMs, and it might be subject to other external factors not directly related to treatment. Even if patient satisfaction is important in evaluating well-being and patient's experience with medical care, it should not be considered as an isolated proxy to measure quality of treatment. [ABSTRACT FROM AUTHOR]

Background: Innovations and improvements in care delivery are often not spread across all settings that would benefit from their uptake. Scale-up and spread efforts are deliberate efforts to increase the impact of innovations successfully tested in pilot projects so as to benefit more people. The final stages of scale-up and spread initiatives must contend with reaching hard-to-engage sites.Objective: To describe the process of scale-up and spread initiatives, with a focus on hard-to-engage sites and strategies to approach them.Design: Qualitative content analysis of systematically identified literature and key informant interviews.Participants: Leads from large magnitude scale-up and spread projects.Approach: We conducted a systematic literature search on large magnitude scale-up and spread and interviews with eight project leads, who shared their perspectives on strategies to scale-up and spread clinical and administrative practices across healthcare systems, focusing on hard-to-engage sites. We synthesized these data using content analysis.Key Results: Searches identified 1919 titles, of which 52 articles were included. Thirty-four discussed general scale-up and spread strategies, 11 described hard-to-engage sites, and 7 discussed strategies for hard-to-engage sites. These included publications were combined with interview findings to describe a fourth phase of the national scale-up and spread process, common challenges for spreading to hard-to-engage sites, and potential benefits of working with hard-to-engage sites, as well as useful strategies for working with hard-to-engage sites.Conclusions: We identified scant published evidence that describes strategies for reaching hard-to-engage sites. The sparse data we identified aligned with key informant accounts. Future work could focus on better documentation of the later stages of spread efforts, including specific tailoring of approaches and strategies used with hard-to-engage sites. Spread efforts should include a "flexible, tailored approach" for this highly variable group, especially as implementation science is looking to expand its impact in routine care settings. [ABSTRACT FROM AUTHOR]

To help primary care teams improve patient-centered care, we elicited health and life goals of immigrants with a chronic disease. We conducted an exploratory study of the (1) acceptability of home visits by volunteers to collect health information and (2) content of health and life goals within a primary care program for immigrants with chronic disease. Pairs of trained community volunteers visited 23 patients in their homes and asked them to identify three life goals and three health goals. We conducted content analyses of written notes. Health goals were related to disease prevention and symptom control, family well-being, own quality of life, own or family members' work and/or financial situation. Life goals concerned family well-being, their own quality of life, work/financial situation and health. Given the limited time health professionals have with their patients, trained community volunteers could be important members of primary care teams caring for immigrants. [ABSTRACT FROM AUTHOR]

Purpose: People affected by chronic diseases such as cancer report high levels of distress and a need for psychosocial support. It is unclear whether telephone-based services for people affected by chronic disease are a practical setting for implementing distress screening, referral protocols and rescreening to direct supportive care where it is needed. This systematic review aimed to describe the published literature regarding distress screening and supportive care referral practices in telephone-based services for people affected by chronic diseases such as cancer.Methods: A systematic literature search of MEDLINE, Embase, PsycInfo, CINAHL, Cochrane and Scopus was conducted in February 2018. Included quantitative studies involved: patients or caregivers affected by chronic diseases including cancer and describe a health service assessing psychosocial needs or distress via telephone. Extracted data included the type of cancer or other chronic disease, sample size, screening tool, referral or rescreening protocols, and type of health service.Results: The search identified 3989 potential articles with additional searches returning 30 studies (n = 4019); fourteen were eligible for full-text review. Of the 14 studies, 13 included cancer patients. Studies were across multiple settings and identified nine distress screening tools in use.Conclusion: The reviewed studies indicate that validated distress-screening tools are being used via telephone to identify distress, particularly in relation to cancer. Screening-driven supportive care referrals are also taking place in telephone-based services. However, not all services use an established referral protocol. Ongoing rescreening of callers' distress is also limited despite it being an important recommendation from psycho-oncology guidelines. [ABSTRACT FROM AUTHOR]

Background: Practice facilitation is an implementation strategy used to build practice capacity and support practice changes to improve health care outcomes. Yet, few studies have investigated how practice facilitation strategies are tailored to different primary care contexts.Objective: To identify contextual factors that drive facilitators' strategies to meet practice improvement goals, and how these strategies are tailored to practice context.Design: Semi-structured, qualitative interviews analyzed using inductive (open coding) and deductive (thematic) approaches. This study was conducted as part of a larger study, HealthyHearts New York City, which evaluated the impact of practice facilitation on adoption of cardiovascular disease prevention and treatment guidelines.Participants: 15 facilitators working in two practice contexts: small independent practices (SIPs) and Federally Qualified Health Centers (FQHCs).Main Measures: Strategies facilitators use to support and promote practice changes and contextual factors that impact this approach.Key Results: Contextual factors were described similarly across settings and included the policy environment, patient needs, site characteristics, leadership engagement, and competing priorities. We identified four facilitation strategies used to tailor to contextual factors and support practice change: (a) remain flexible to align with practice and organizational priorities; (b) build relationships; (c) provide value through information technology expertise; and (d) build capacity and create efficiencies. Facilitators in SIPs and FQHCs described using the same strategies, often in combination, but tailored to their specific contexts.Conclusions: Despite significant infrastructure and resource differences between SIPs and FQHCs, the contextual factors that influenced the facilitator's change process and the strategies used to address those factors were remarkably similar. The findings emphasize that facilitators require multidisciplinary skills to support sustainable practice improvement in the context of varying complex health care delivery settings. [ABSTRACT FROM AUTHOR]

Background: Targeted neutrophil inhibitory-hirulog (TNHH) is a novel hybrid glycoprotein that may be a potential drug candidate for acute ischaemic stroke.Objective: The aim of this study was to evaluate the safety, tolerability, pharmacokinetics and pharmacodynamics of TNHH in healthy volunteers and thereby determine the dose range for future clinical studies.Methods: This randomized, placebo-controlled study was a single ascending dose design with dose levels of 0.05-1.8 mg/kg (n = 4-6 active, 2 placebos per cohort) in 68 participants. In the TNHH 0.2-1.8 mg/kg and control cohorts, pharmacokinetic and pharmacodynamic blood samples were collected over 168 h after intravenous (IV) administration. TNHH occupancy in peripheral blood neutrophils and blood coagulation were evaluated as the markers of target engagement.Results: Two subjects withdrew from the trial before administration of the study treatment, 66 subjects are included in the data analysis. TNHH was well tolerated in all dose regimens. In total, five mild, self-limiting adverse events (AEs) were observed in 4 of the 66 study subjects. Dose-proportional increases in maximum plasma concentration (Cmax) and area under the curve (AUC0-t) of TNHH were observed. Traces of TNHH were excreted in urine. The elimination half-life (t½) ranged from 0.6 to 1.3 h in the eight groups with ascending dose levels. TNHH combined with CD11b/CD18 quickly achieved > 90% receptor occupancy in groups with doses above 0.2 mg/kg. The Cmax and AUC of binding TNHH with CD11b/CD18 increased with the dose. A significant prolongation with dose was observed on thrombin time (TT), and weak influences were observed on prothrombin time (PT) and activated partial thromboplastin time (APTT).Conclusion: TNHH was well-tolerated following IV infusion. The pharmacokinetic and pharmacodynamic characteristics of TNHH indicate that it merits clinical trials. It is recommended that the single dose of TNHH should be 1.0 mg/kg in future studies, and the expected effect may be achieved after 5-7 days of continuous administration.Trial Registration: The study is registered at http://www.chictr.org.cn as ChiCTR-TQR-14004752. [ABSTRACT FROM AUTHOR]

Background: For at least the past two decades, medical educators have worked to improve patient communication and health care delivery to diverse patient populations; despite efforts, patients continue to report prejudice and bias during their clinical encounters. Targeted instruction in implicit bias recognition and management may promote the delivery of equitable care, but students at times resist this instruction. Little guidance exists to overcome this resistance and to engage students in implicit bias instruction; instruction over time could lead to eventual skill development that is necessary to mitigate the influence of implicit bias on clinical practice behaviors.Objective: To explore student perceptions of challenges and opportunities when participating in implicit bias instruction.Approach: We conducted a qualitative study that involved 11 focus groups with medical students across each of the four class years to explore their perceptions of challenges and opportunities related to participating in such instruction. We analyzed transcripts for themes.Key Results: Our analysis suggests a range of attitudes toward implicit bias instruction and identifies contextual factors that may influence these attitudes. The themes were (1) resistance; (2) shame; (3) the negative role of the hidden curriculum; and (4) structural barriers to student engagement. Students expressed resistance to implicit bias instruction; some of these attitudes are fueled from concerns of anticipated shame within the learning environment. Participants also indicated that student engagement in implicit bias instruction was influenced by the hidden curriculum and structural barriers.Conclusions: These insights can inform future curriculum development efforts. Considerations related to instructional design and programmatic decision-making are highlighted. These considerations for implicit bias instruction may provide useful frameworks for educators looking for opportunities to minimize student resistance and maximize engagement in multi-session instruction in implicit bias recognition and management. [ABSTRACT FROM AUTHOR]

Background: Spending on new healthcare technologies increases net population health when the benefits of a new technology are greater than their opportunity costs-the benefits of the best alternative use of the additional resources required to fund a new technology.Objective: The objective of this study was to estimate the expected incremental cost per quality-adjusted life-year (QALY) gained of increased government health expenditure as an empirical estimate of the average opportunity costs of decisions to fund new health technologies. The estimated incremental cost-effectiveness ratio (ICER) is proposed as a reference ICER to inform value-based decision making in Australia.Methods: Empirical top-down approaches were used to estimate the QALY effects of government health expenditure with respect to reduced mortality and morbidity. Instrumental variable two-stage least-squares regression was used to estimate the elasticity of mortality-related QALY losses to a marginal change in government health expenditure. Regression analysis of longitudinal survey data representative of the general population was used to isolate the effects of increased government health expenditure on morbidity-related, QALY gains. Clinical judgement informed the duration of health-related quality-of-life improvement from the annual increase in government health expenditure.Results: The base-case reference ICER was estimated at AUD28,033 per QALY gained. Parametric uncertainty associated with the estimation of mortality- and morbidity-related QALYs generated a 95% confidence interval AUD20,758-37,667.Conclusion: Recent public summary documents suggest new technologies with ICERs above AUD40,000 per QALY gained are recommended for public funding. The empirical reference ICER reported in this article suggests more QALYs could be gained if resources were allocated to other forms of health spending. [ABSTRACT FROM AUTHOR]

Background: Decision makers are increasingly tasked with reducing health care costs, but the public may be mistrustful of these efforts. Public deliberation helps gather input on these types of issues by convening a group of diverse individuals to learn about and discuss values-based dilemmas.Objective: To explore public perceptions of health care costs and how they intersect with medical mistrust.Design and Participants: This mixed-methods study analyzed data from a randomized controlled trial including four public deliberation groups (n = 96) and a control group (n = 348) comprising English-speaking adults aged 18 years and older. Data were collected in 2012 in four U.S. regions.Approach: We used data from four survey items to compare attitude shifts about costs among participants in deliberation groups to participants in the control group. We qualitatively analyzed deliberation transcripts to identify themes related to attitude shifts and to provide context for quantitative results about attitude shifts.Key Results: Deliberation participants were significantly more likely than control group participants to agree that doctors and patients should consider cost when making treatment decisions (β = 0.59; p < 0.01) and that people should consider the effect on group premiums when making treatment decisions (β = 0.48; p < 0.01). Qualitatively, participants mistrusted the health care system's profit motives (e.g., that systems prioritize making money over patient needs); however, after grappling with patient/doctor autonomy and learning about and examining their own views related to costs during the process of deliberation, they largely concluded that payers have the right to set some boundaries to curb costs.Conclusions: Individuals who are informed about costs may be receptive to boundaries that reduce societal health care costs, despite their mistrust of the health care system's profit motives, especially if decision makers communicate their rationale in a transparent manner. Future work should aim to develop transparent policies and practices that earn public trust. [ABSTRACT FROM AUTHOR]

Background: With emerging global payment structures, medical systems need to understand longer-term impacts of care transition strategies.Objective: To determine the effect of a care transition program using patient navigators (PNs) on health service utilization among high-risk safety-net patients over a 180-day period.Design: Randomized controlled trial conducted October 2011 through April 2013.Participants: Patients admitted to the general medicine service with ≥1 readmission risk factor: (1) age ≥ 60; (2) in-network inpatient admission within prior 6 months; (3) index length of stay ≥ 3 days; or (4) admission diagnosis of heart failure or (5) chronic obstructive pulmonary disease. The analytic sample included 739 intervention patients, 1182 controls.Interventions: Through hospital visits and 30 days of post-discharge telephone outreach, PNs provided coaching and assistance with medications, appointments, transportation, communication with primary care, and self-care.Main Measures: Primary outcomes: (1) hospital-based utilization, a composite of ED visits and hospital admissions; (2) hospital admissions; (3) ED visits; and (4) outpatient visits. We evaluated outcomes following an index discharge, stratified by patient age (≥ 60 and < 60 years), using a 180-day time frame divided into six 30-day periods.Key Results: The PN program produced starkly different outcomes by patient age. Among older PN patients, hospital-based utilization was consistently lower than controls, producing an 18.7% cumulative decrease at 180 days (p = 0.038); outpatient visits increased in the critical first 30-day period (p = 0.006). Among younger PN patients, hospital-based utilization was 31.7% (p = 0.038) higher at 180 days, largely reflecting sharply higher utilization in the initial 30 days (p = 0.002), with non-significant changes thereafter; outpatient visits experienced no significant changes.Conclusions: A PN program serving high-risk safety-net patients differentially impacted patients based on age, and among younger patients, outcomes varied over time. Our findings highlight the importance for future research to evaluate care transition programs among different subpopulations and over longer time periods. [ABSTRACT FROM AUTHOR]

Introduction: In Argentina, the national guidelines for lipid control emphasize the use of relatively inexpensive low- or moderate-potency statins by patients at high risk (>20 %) of a cardiovascular event. The objective of this study was to compare the impact and costs of the current national CVD prevention guidelines with regard to morbidity and mortality in Argentina with the impact and costs of three strategies that incorporate high-potency statins.Methods: We used the CVD Policy Model-Argentina to model the proposed interventions. This model is a national-scale, state-transition (Markov) computer simulation model of the CVD incidence, prevalence, mortality, and costs in adults 35-84 years of age. We modeled three scenarios: scenario 1 lowers the risk threshold for treatment to >10 % according the Framingham Risk Score (FRS); scenario 2 intensifies statin potency under current treatment thresholds; and scenario 3 combines both scenarios by lowering the treatment threshold to ≥10 % FRS and intensifying statin potency.Results: Scenario 1 would translate into 1400 fewer MIs and 500 fewer CHD deaths every year, a 3 % and 2 % reduction, respectively. Scenario 2 would lead to 2000 fewer MIs and 1000 fewer CHD deaths every year. Scenario 3 would result in the greatest reduction in MIs and CHD deaths, with 3400 fewer MIs and 1400 fewer CHD deaths every year, which translates to a 7 % and 6 % reduction, respectively. All scenarios were cost-effective if the cost of a high-potency statin pill was under US$0.25.Conclusion: Incorporating those individuals with greater than 10 % cardiovascular risk and the use of high-potency statins into Argentina's national lipid guidelines could result in fewer CHD deaths and events at a reasonable cost. [ABSTRACT FROM AUTHOR]

Background: Workforce projections indicate a potential shortage of up to 31,000 adult primary care providers by the year 2025. Approximately 80 % of internal medicine residents and nearly two-thirds of primary care internal medicine residents do not plan to have a career in primary care or general internal medicine.Objective: We aimed to explore contextual and programmatic factors within primary care residency training environments that may influence career choices.Design: This was a qualitative study based on semi-structured, in-person interviews.Participants: Three primary care internal medicine residency programs were purposefully selected to represent a diversity of training environments. Second and third year residents were interviewed.Approach: We used a survey guide developed from pilot interviews and existing literature. Three members of the research team independently coded the transcripts and developed the code structure based on the constant comparative method. The research team identified emerging themes and refined codes. ATLAS.ti was used for the analysis.Key Results: We completed 24 interviews (12 second-year residents, and 12 third-year residents). The age range was 27-39 years. Four recurrent themes characterized contextual and programmatic factors contributing to residents' decision-making: resident expectations of a career in primary care, navigation of the boundary between social needs and medical needs, mentorship and perceptions of primary care, and structural features of the training program.Conclusions: Addressing aspects of training that may discourage residents from careers in primary care such as lack of diversity in outpatient experiences and resident frustration with their inability to address social needs of patients, and strengthening aspects of training that may encourage interests in careers in primary care such as mentorship and protected time away from inpatient responsibilities during primary care rotations, may increase the proportion of residents enrolled in primary care training programs who pursue a career in primary care. [ABSTRACT FROM AUTHOR]

Background: The healthcare system is ill-equipped to meet the needs of adults on the autism spectrum.Objective: Our goal was to use a community-based participatory research (CBPR) approach to develop and evaluate tools to facilitate the primary healthcare of autistic adults.Design: Toolkit development included cognitive interviewing and test-retest reliability studies. Evaluation consisted of a mixed-methods, single-arm pre/post-intervention comparison.Participants: A total of 259 autistic adults and 51 primary care providers (PCPs) residing in the United States.Interventions: The AASPIRE Healthcare toolkit includes the Autism Healthcare Accommodations Tool (AHAT)-a tool that allows patients to create a personalized accommodations report for their PCP-and general healthcare- and autism-related information, worksheets, checklists, and resources for patients and healthcare providers.Main Measures: Satisfaction with patient-provider communication, healthcare self-efficacy, barriers to healthcare, and satisfaction with the toolkit's usability and utility; responses to open-ended questions.Key Results: Preliminary testing of the AHAT demonstrated strong content validity and adequate test-retest stability. Almost all patient participants (>94 %) felt that the AHAT and the toolkit were easy to use, important, and useful. In pre/post-intervention comparisons, the mean number of barriers decreased (from 4.07 to 2.82, p < 0.0001), healthcare self-efficacy increased (from 37.9 to 39.4, p = 0.02), and satisfaction with PCP communication improved (from 30.9 to 32.6, p = 0.03). Patients stated that the toolkit helped clarify their needs, enabled them to self-advocate and prepare for visits more effectively, and positively influenced provider behavior. Most of the PCPs surveyed read the AHAT (97 %), rated it as moderately or very useful (82 %), and would recommend it to other patients (87 %).Conclusions: The CBPR process resulted in a reliable healthcare accommodation tool and a highly accessible healthcare toolkit. Patients and providers indicated that the tools positively impacted healthcare interactions. The toolkit has the potential to reduce barriers to healthcare and improve healthcare self-efficacy and patient-provider communication. [ABSTRACT FROM AUTHOR]

Purpose: Osteoarthritis (OA) has been shown to be associated with decreased physical function, which may impact upon a person's self-rated health (SRH). Only a few studies have examined the association between OA and SRH in the general population, but to date none have used a clinical definition of OA. The objectives are: (1) To examine the cross-sectional association between clinical OA and fair-to-poor SRH in the general population; (2) To examine whether this association differs between countries; (3) To examine whether physical function is a mediator in the association between clinical OA and SRH.Methods: Baseline data of the European Project on OSteoArthritis (EPOSA) were used, which includes pre-harmonized data from six European cohort studies (n = 2709). Clinical OA was defined according to the American College of Rheumatology criteria. SRH was assessed using one question: How is your health in general? Physical function was assessed using the Western Ontario and McMaster Universities OA Index and Australian/Canadian OA Hand Index.Results: The prevalence of fair-to-poor SRH ranged from 19.8 % in the United Kingdom to 63.5 % in Italy. Although country differences in the strength of the associations were observed, clinical OA of the hip, knee and hand were significantly associated with fair-to-poor SRH in five out of six European countries. In most countries and at most sites, the association between clinical OA and fair-to-poor SRH was partly or fully mediated by physical function.Conclusions: Clinical OA at different sites was related to fair-to-poor SRH in the general population. Most associations were (partly) mediated by physical functioning, indicating that deteriorating physical function in patients with OA should be a point of attention in patient care. [ABSTRACT FROM AUTHOR]

Background: Many Veterans treated within the VA Healthcare System (VA) are also enrolled in fee-for-service (FFS) Medicare and receive treatment outside the VA. Prior research has not accounted for the multiple ways that Veterans receive services across healthcare systems.Objective: We aimed to establish a typology of VA and Medicare utilization among dually enrolled Veterans with type 2 diabetes.Design: This was a retrospective cohort.Participants: 316,775 community-dwelling Veterans age ≥ 65 years with type 2 diabetes who were dually enrolled in the VA and FFS Medicare in 2008-2009.Methods: Using latent class analysis, we identified classes of Veterans based upon their probability of using VA and Medicare diabetes care services, including patient visits, laboratory tests, glucose test strips, and medications. We compared the amount of healthcare use between classes and identified factors associated with class membership using multinomial regression.Key Results: We identified four distinct latent classes: class 1 (53.9%) had high probabilities of VA use and low probabilities of Medicare use; classes 2 (17.2%), 3 (21.8%), and 4 (7.0%) had high probabilities of VA and Medicare use, but differed in their Medicare services used. For example, Veterans in class 3 received test strips exclusively through Medicare, while Veterans in class 4 were reliant on Medicare for medications. Living ≥ 40 miles from a VA predicted membership in classes 3 (OR 1.1, CI 1.06-1.15) and 4 (OR 1.11, CI 1.04-1.18), while Medicaid eligibility predicted membership in class 4 (OR 4.30, CI 4.10-4.51).Conclusions: Veterans with diabetes can be grouped into four distinct classes of dual health system use, representing a novel way to characterize how patients use multiple services across healthcare systems. This classification has applications for identifying patients facing differential risk from care fragmentation. [ABSTRACT FROM AUTHOR]

Trial-based economic evaluations are an important aspect of health technology assessment. The availability of patient-level data coupled with unbiased estimates of clinical outcomes means that randomised controlled trials are effective vehicles for the generation of economic data. However there are methodological challenges to trial-based evaluations, including the collection of reliable data on resource use and cost, choice of health outcome measure, calculating minimally important differences, dealing with missing data, extrapolating outcomes and costs over time and the analysis of multinational trials. This review focuses on the state of the art of selective elements regarding the design, conduct, analysis and reporting of trial-based economic evaluations. The limitations of existing approaches are detailed and novel methods introduced. The review is internationally relevant but with a focus towards practice in the UK. [ABSTRACT FROM AUTHOR]

Background: Over the last decade, various pay-for-performance (P4P) programs have been implemented to improve quality in health systems, including the VHA. P4P programs are complex, and their effects may vary by design, context, and other implementation processes. We conducted a systematic review and key informant (KI) interviews to better understand the implementation factors that modify the effectiveness of P4P.Methods: We searched PubMed, PsycINFO, and CINAHL through April 2014, and reviewed reference lists. We included trials and observational studies of P4P implementation. Two investigators abstracted data and assessed study quality. We interviewed P4P researchers to gain further insight.Results: Among 1363 titles and abstracts, we selected 509 for full-text review, and included 41 primary studies. Of these 41 studies, 33 examined P4P programs in ambulatory settings, 7 targeted hospitals, and 1 study applied to nursing homes. Related to implementation, 13 studies examined program design, 8 examined implementation processes, 6 the outer setting, 18 the inner setting, and 5 provider characteristics. Results suggest the importance of considering underlying payment models and using statistically stringent methods of composite measure development, and ensuring that high-quality care will be maintained after incentive removal. We found no conclusive evidence that provider or practice characteristics relate to P4P effectiveness. Interviews with 14 KIs supported limited evidence that effective P4P program measures should be aligned with organizational goals, that incentive structures should be carefully considered, and that factors such as a strong infrastructure and public reporting may have a large influence.Discussion: There is limited evidence from which to draw firm conclusions related to P4P implementation. Findings from studies and KI interviews suggest that P4P programs should undergo regular evaluation and should target areas of poor performance. Additionally, measures and incentives should align with organizational priorities, and programs should allow for changes over time in response to data and provider input. [ABSTRACT FROM AUTHOR]

Purpose: People with severe mental illnesses (SMI) experience a 17- to 20-year reduction in life expectancy. One-third of deaths are due to cardiovascular disease. This study will establish the relationship of SMI with cardiovascular disease in ethnic minority groups (Indian, Pakistani, Bangladeshi, black Caribbean, black African and Irish), in the UK.Methods: E-CHASM is a mixed methods study utilising data from 1.25 million electronic patient records. Secondary analysis of routine patient records will establish if differences in cause-specific mortality, cardiovascular disease prevalence and disparities in accessing healthcare for ethnic minority people living with SMI exist. A nested qualitative study will be used to assess barriers to accessing healthcare, both from the perspectives of service users and providers.Results: In primary care, 993,116 individuals, aged 18+, provided data from 186/189 (98 %) practices in four inner-city boroughs (local government areas) in London. Prevalence of SMI according to primary care records, ranged from 1.3-1.7 %, across boroughs. The primary care sample included Bangladeshi [n = 94,643 (10 %)], Indian [n = 6086 (6 %)], Pakistani [n = 35,596 (4 %)], black Caribbean [n = 45,013 (5 %)], black African [n = 75,454 (8 %)] and Irish people [n = 13,745 (1 %)]. In the secondary care database, 12,432 individuals with SMI over 2007-2013 contributed information; prevalent diagnoses were schizophrenia [n = 6805 (55 %)], schizoaffective disorders [n = 1438 (12 %)] and bipolar affective disorder [n = 4112 (33 %)]. Largest ethnic minority groups in this sample were black Caribbean [1432 (12 %)] and black African (1393 (11 %)).Conclusions: There is a dearth of research examining cardiovascular disease in minority ethnic groups with severe mental illnesses. The E-CHASM study will address this knowledge gap. [ABSTRACT FROM AUTHOR]

The article discusses a project undertaken at Brigham and Womens Hospital (BWH) that focused on electronic referral order systems established in the U.S. and internationally with broad uptake by primary care physicians (PCPs) and improved physician satisfaction. It aims to add to the existing literature on eReferral systems by tracking physician satisfaction across an entire health system and using administrative claims to look at the impact of eReferral on total specialist utlization.

Introduction: Health economic models are increasingly important in funding decisions but most are based on data, which may therefore not represent the general population. We sought to establish the potential of real-world data available within the Clinical Practice Research Datalink (CPRD) and linked Hospital Episode Statistics (HES) to determine comprehensive healthcare utilisation and costs as input variables for economic modelling.Methods: A cohort of patients with irritable bowel syndrome (IBS) who first saw a gastroenterologist in 2008 or 2009, and with 3 years of data before and after their appointment, was created in the CPRD. Primary care, outpatient, inpatient, prescription and colonoscopy data were extracted from the linked CPRD and HES. The appropriate cost to the NHS was attached to each event. Total and stratified annual healthcare utilisation rates and costs were calculated before and after the gastroenterology appointment with distribution parameters. Absolute differences were calculated with 95% confidence intervals.Results: Total annual healthcare costs over 3 years increase by £935 (95% CI £928-941) following a gastroenterology appointment for IBS. We derived utilisation and cost data with parameter distributions stratified by demographics and time. Women, older patients, smokers and patients with greater comorbidity utilised more healthcare resources, which generated higher costs.Conclusions: These linked datasets provide comprehensive primary and secondary care data for large numbers of patients, which allows stratification of outcomes. It is possible to derive input parameters appropriate for economic models and their distributions directly from the population of interest. [ABSTRACT FROM AUTHOR]

In the era of the Information Age and personalized medicine, healthcare delivery systems need to be efficient and patient-centred. The health system must be responsive to individual patient choices and preferences about their care, while considering the system consequences. While dynamic simulation modelling (DSM) and big data share characteristics, they present distinct and complementary value in healthcare. Big data and DSM are synergistic-big data offer support to enhance the application of dynamic models, but DSM also can greatly enhance the value conferred by big data. Big data can inform patient-centred care with its high velocity, volume, and variety (the three Vs) over traditional data analytics; however, big data are not sufficient to extract meaningful insights to inform approaches to improve healthcare delivery. DSM can serve as a natural bridge between the wealth of evidence offered by big data and informed decision making as a means of faster, deeper, more consistent learning from that evidence. We discuss the synergies between big data and DSM, practical considerations and challenges, and how integrating big data and DSM can be useful to decision makers to address complex, systemic health economics and outcomes questions and to transform healthcare delivery. [ABSTRACT FROM AUTHOR]

Background: This study aimed to develop and provide a psychometric and feasibility pilot evaluation of the Heart Failure (HF) Symptom Tracker (HFaST), a new patient-reported tool designed to facilitate communication between patients and health care providers (HCPs) in routine clinical care. The HFaST enables patients to identify worsening HF symptoms, with a long-term goal of preventing hospitalizations or emergency room visits. Methods: The HFaST was developed drawing on evidence from the literature, qualitatively with cognitive interviews (12 patient/caregiver and 8 HCPs), and evaluated quantitatively (psychometric, feasibility assessment). The HFaST was administered for 7 consecutive days to 100 individuals diagnosed with HF during a multisite, non-interventional US pilot study. Health care providers then completed a survey assessing the feasibility and importance of the HFaST in clinical practice. Qualitative development included a literature review and cognitive interviews with patients, caregivers, and HCPs. The psychometric properties of the HFaST were evaluated using classical test theory methods. Descriptive statistics provided insight into HCPs' perceptions of the feasibility of using the HFaST in clinical practice. Results: A preliminary set of 40 items was developed for the symptom tracker and iteratively reduced to 10 items based on the qualitative phase. Test-retest reliability (weighted kappa 0.71–0.97), discriminating validity, and construct validity of the HFaST were acceptable. HCPs rated the HFaST as a good (70%) or excellent (30%) means of tracking HF symptoms. Six HFaST items were ultimately retained, covering concepts of fatigue, shortness of breath (3 items), swelling, and rapid weight gain. Conclusions: The 6-item HFaST is an easy-to-use tool designed to raise patients' awareness of HF symptoms and facilitate communication with HCPs. Future research should evaluate HFaST implementation in clinical practice and effectiveness as an intervention to potentially prevent hospitalizations and emergency room visits. [ABSTRACT FROM AUTHOR]