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AIM To examine the value of peer support in the self-management of diabetes among veterans in an integrated health care system. METHODS We conducted semi-structured in-depth interviews with veterans and clinicians 6 months after their participation in Empowering Patients in Chronic Care (EPIC), a group-based diabetes intervention with a peer-support component. Interviews elicited clinicians' narratives of how peer support unfolded in the groups and veterans' experiences of giving and receiving support from their peers. Data analysis was guided by principles of framework analysis using Heisler's peer-support model. RESULTS Findings support Heisler's peer-support model and provide evidence supporting professional-led group visits with peer exchange. Clinicians and veterans endorsed informational and emotional support received in EPIC groups. Clinicians often referred to EPIC as an open forum or a support group where veterans could both give and receive help. Veterans noted the benefits of shared problem-solving and the support they received. Clinicians and veterans perceived the peer-support component of EPIC as facilitating increased empowerment in terms of self-efficacy, increased perceived social support and increased understanding of self-care. Ultimately, many veterans acknowledged that their participation in EPIC facilitated improved health-related quality of life, improved health behaviours and improved chronic disease control. CONCLUSIONS Findings emphasize the value of peer support in managing chronic illness. Peer-support programmes may address veterans' unique challenges and have the potential to improve physical and mental health.

Despite the efficacy of evidence-based psychotherapies (EBP) for posttraumatic stress disorder (PTSD) and efforts to disseminate them, only 6–13% of veterans seeking care through the Veterans Affairs health care system receive these treatments. EBPs such as prolonged exposure (PE) and cognitive processing therapy (CPT) are exposure-based treatments. Provider and patient fears regarding the tolerability of exposure-based treatments likely impede their delivery and completion. The present study utilized qualitative interviews with 23 veterans who completed at least eight sessions of either PE or CPT to elicit firsthand accounts of veterans’ experiences in these EBPs. Results suggest that while a minority of veterans reported initial symptom worsening, the majority of veterans reported positive experiences and felt that, despite being stressful, these EBPs were “worth it.” Most veterans discussed thoughts of discontinuing treatment prematurely, but stated that adherence was encouraged by their commitment to finishing, desperation for relief, therapist/group support, and family support. Veterans believed exposure made an important contribution to symptom improvement, as did greater self-understanding and changing negative or unhelpful beliefs. These findings indicate veteran satisfaction with PE and CPT, and may assist providers to develop strategies to increase adherence and treatment completion.

BackgroundDelivery of preventive chemotherapy (PC) through mass drug administration (MDA) is used to control or eliminate five of the most common neglected tropical diseases (NTDs). The success of an MDA campaign relies on the ability of drug distributors and their supervisors-the NTD front-line workers-to reach populations at risk of NTDs. In the past, our understanding of the demographics of these workers has been limited, but with increased access to sex-disaggregated data, we begin to explore the implications of gender and sex for the success of NTD front-line workers.Methodology/principal findingsWe reviewed data collected by USAID-supported NTD projects from national NTD programs from fiscal years (FY) 2012-2017 to assess availability of sex-disaggregated data on the workforce. What we found was sex-disaggregated data on 2,984,908 trainees trained with financial support from the project. We then analyzed the percentage of males and females trained by job category, country, and fiscal year. During FY12, 59% of these data were disaggregated by sex, which increased to nearly 100% by FY15 and was sustained through FY17. In FY17, 43% of trainees were female, with just four countries reporting more females than males trained as drug distributors and three countries reporting more females than males trained as trainers/supervisors. Except for two countries, there were no clear trends over time in changes to the percent of females trained.Conclusions/significanceThere has been a rapid increase in availability of sex-disaggregated data, but little increase in recruitment of female workers in countries included in this study. Women continue to be under-represented in the NTD workforce, and while there are often valid reasons for this distribution, we need to test this norm and better understand gender dynamics within NTD programs to increase equity.

Advanced liver disease (AdvLD) is a high-risk common condition with a progressive, highly morbid, and often fatal course. Despite effective treatments, there are substantial shortfalls in access to and use of evidence-based supportive and palliative care for AdvLD. Although patient-centered, chronic illness models that integrate early supportive and palliative care with curative treatments hold promise, there are several knowledge gaps that hinder development of an integrated model for AdvLD. We review these evidence gaps. We also describe a conceptual framework for a patient-centered approach that explicates key elements needed to improve integrated care. An integrated model of AdvLD would allow clinicians, patients, and caregivers to work collaboratively to identify treatments and other healthcare that best align with patients' priorities.

Peer support has been increasingly utilized within the Department of Veterans Affairs and offers an opportunity to augment existing care for posttraumatic stress disorder (PTSD). The current study sought to examine Veterans' perspectives on the potential benefits and drawbacks of peer support for PTSD. A sample of 23 Veterans with substantial treatment experience completed one-time qualitative interviews that were transcribed and coded for thematic content using grounded theory methodology. Results indicated that Veterans identified numerous potential benefits to a peer support program, including social support, purpose and meaning, normalization of symptoms and hope, and therapeutic benefits. Veterans also identified ways that peer support could complement psychotherapy for PTSD by increasing initiation and adherence to treatment and supporting continued use of skills after termination. Results also indicated that Veterans may prefer peer support groups that are separated according to trauma type, gender, and era of service. Other findings highlighted the importance of the leadership and interpersonal skills of a peer support group leader. Overall, Veterans found peer support to be a highly acceptable complement to existing PTSD treatments with few drawbacks.

This study looked at the effects of select behavior change interventions on the purchase and the correct and consistent use of a locally fabricated top-lit updraft (TLUD) stove in Uganda. Behavior change interventions included training of community sales agents and village health team volunteers on household air pollution and correct use, referral of interested community members to sales agents, community cooking demonstrations, information flyers, and direct sales of TLUDs and processed wood. Qualitative and quantitative research methods shaped interventions and were used to understand attitudes and practices related to TLUD stove acquisition and use. Results showed that TLUDs were appreciated because they use wood efficiently, cook quickly, reduce smoke, and produce charcoal. However, the substantial purchase price barrier, combined with the cost of processed wood, effectively eliminated the cost savings from its significant fuel efficiency. This made it difficult for the TLUD to be a meaningful part of most households' cooking practices.

Objective Conduct a formative evaluation to inform the implementation of ‘Empowering Patients in Chronic Care’ (EPIC), an evidence-based interdisciplinary group medical appointment intervention to improve collaborative goal-setting in patients with treated but uncontrolled diabetes. Design The formative evaluation involved qualitative, in-depth interviews with clinicians, structured according to the Promoting Action on Research in Health Services framework. Interviews elicited (1) participants’ knowledge regarding interdisciplinary group self-management and goal-setting programmes and how well clinicians embrace these interventions (evidence), (2) physical and social climate at each target facility and how the intervention can best be embedded into routine primary care (context) and (3) site-specific needs to be addressed by our implementation team and clinicians’ preparedness and intentions to participate in the intervention (facilitation). Setting Clinicians were part of a primary care setting at one of five participating medical facilities within one Veterans Health Administration Veterans Affairs regional network. Participants We interviewed a snowball sample of 35 interdisciplinary clinicians engaged in diabetes management, practising leadership and administrators at target sites. Results Most participants had previous experience with diabetes group self-management programmes and viewed group appointments as an effective approach to enhancing care. Discussions about existing group appointments provided a context for evaluating potential barriers and facilitators to implementing EPIC into target sites. Interviews revealed clinicians’ expectations about the roles they would play in the intervention, their assessments of the roles and strategies to facilitate their performance in those roles. Conclusions Successful implementation of evidence-based practices into routine care requires a partnered approach with engaged local staff. The intervention should address local goals and research objectives to encourage bidirectional engagement. Robust partnerships are nurtured further by sustained, open communication and must consider the context, target population and local experience to address barriers and facilitators to implementation.

Current national guidelines recommend genomic testing on all stage 4 non-small cell lung cancers (NSCLC) of adenocarcinoma histology. Mutations are most often found among young, Asian, females without a history of smoking. As these characteristics are uncommon in the Veterans Health Administration (VHA) patient population, we sought to understand oncologists’ decision-making processes regarding utilization of genomic testing in the VHA. We conducted in-depth qualitative interviews with 30 VHA-based medical oncologists. Interviews aimed to elicit oncologists’ experiences and decision-making processes regarding genomic testing in patients with stage 4 non-small cell lung cancer with adenocarcinoma histology. Analysis was guided by principles of framework analysis. Sample size was determined by thematic saturation. We identified a wide variation in medical oncologists’ genomic testing practices. Consistent with guidelines, advanced stage and adenocarcinoma histology most often influenced practice patterns among our participants. However, patient characteristics like gender, age, smoking status, and performance status were also taken in to account by some oncologists when making testing decisions. This does not reflect a widespread adoption of national guidelines for genomic testing in the VHA. Qualitative interviews with VHA-based oncologists demonstrated that genomic testing decisions are not always consistent with current national guidelines. Efforts should be made to address modifiable barriers to genomic testing in the VHA setting.

Prior studies examining patterns of esophagogastroduodenoscopy (EGD) surveillance in patients with Barrett's esophagus (BE) demonstrate variable adherence to practice guidelines. In prior studies, memories of endoscopic experiences shaped overall perceptions and subsequent adherence behaviors, but the specific elements of that experience are unclear. We sought to identify specific elements of the EGD experience that frame overall perceptions of surveillance.We conducted structured in-depth, qualitative interviews with BE patients with a range of severity (non-dysplastic, low-grade and high-grade dysplasia) who recently completed an EGD. Data collection continued until we reached thematic saturation (n = 20). We applied principles of framework analysis to identify emerging themes regarding patients' salient EGD experiences. We validated our coding scheme through multidisciplinary consensus meetings comprised of clinician (gastroenterologist and internist) and non-clinician investigators (sociologist and public health expert).Patient experiences can be conceptualized within a temporal model: prior to, during, and after endoscopy. The most memorable aspects of the EGD experience include physician-patient communication prior to EGD, wait time at the endoscopy center, interpersonal interactions at the time of the EGD, level of pain or discomfort with the procedure, level of trust in the physician following EGD, and gaining a sense of control over BE.We identified six salient memories before, during, and after the procedure that shape patients' perceptions of the EGD experience. We offer recommendations for measuring patient experiences using a composite of validated survey items. Future studies should test the relation of patient experience measures and adherence to surveillance EGD.

Household air pollution from cooking with biomass fuels negatively impacts maternal and child health and the environment, and contributes to the global burden of disease. In Uganda, nearly 20,000 young children die of household air pollution-related pneumonia every year. Qualitative research was used to identify behavioral determinants related to the acquisition and use of improved cookstoves in peri-urban Uganda. Results were used to design a behavior change strategy for the introduction of a locally-fabricated top-lit updraft gasifier (TLUD) stove in Wakiso district. A theoretical framework—opportunity, ability, and motivation—was used to guide the research and behavior change strategy development. Participants consistently cited financial considerations as the most influential factor related to improved cookstove acquisition and use. In contrast, participants did not prioritize the potential health benefits of improved cookstoves. The theoretical framework, research methodology, and behavior change strategy design process can be useful for program planners and researchers interested in identifying behavioral determinants and designing and evaluating improved cookstove interventions.

BACKGROUND: In the Democratic Republic of Congo (DRC) men who have sex with men (MSM) and female sex workers (FSW) have the highest HIV prevalence but have the least access to services due to their marginalization within Congolese society. METHODS: The Projet Integre de VIH/SIDA au Congo (ProVIC) aims to reduce the risk and impact of HIV in the DRC through community- and facility-based prevention counseling and testing and treatment strategies aimed at high-risk populations including MSM and FSW. To more effectively meet the needs of key populations ProVIC tailored the existing interventions to better suit MSM and FSW by offering mobile counseling and rapid HIV testing services at night in MSM and FSW "hotspots" targeting outreach to and mobilizing key populations through social networks of MSM and FSW peer educators and recruiters and referring MSM and FSW who test HIV positive to "friendly" clinics. RESULTS: Through these approaches ProVIC was able to reach 2621 MSM and 12746 FSW with targeted prevention messaging in 2013 and provide testing and counseling services to 4366 MSM and 21033 FSW from October 2012 to June 2014. CONCLUSIONS: By applying innovative adaptations geared toward key populations ProVIC has been able to better reach MSM and FSW in the DRC. ProVICs targeted interventions for MSM and FSW provide promising examples of programming that can be used to meet the HIV prevention and testing needs of key populations and improve referrals for care and treatment particularly in complex and unstable settings similar to the DRC.

Background: Pilot data revealed gaps in knowledge and utilization of genomic-based targeted therapy among oncologists. We report these findings, and offer a protocol for a qualitative research project aimed to elicit oncologists’ perceptions regarding use of genomic-based targeted therapy for Veterans with lung cancer at the VHA. Using the Cabana et al. theoretical framework, a model of behavior change among providers, the study will identify how oncologists’ perceptions and facility characteristics potentially affect implementation of genomic-based targeted therapy in routine care. Methods and results: We will conduct a minimum of 40 and up to 60 semi-structured interviews with oncologists to elicit perceptions of genomic-based targeted therapy in four domains: 1) knowledge; 2) attitudes; 3) intent; and 4) barriers and facilitators for practicing genomic-based targeted therapy. Conclusion: This study is the first to examine decision-making surrounding the use of genomic based targeted therapy in lung cancer management. Findings will lay the foundation to design and implement effective strategies centering on integrating genomic medicine with routine practice, and will shed light on the decision-making processes of oncologists regarding selection of genomic-based and non-genomic-based treatment plans in managing lung cancer in veterans. This research is part of a larger study that will examine the utilization, clinical effectiveness, and cost effectiveness of genomic-based therapies in the treatment of advanced lung cancer.

Choosing Wisely is a campaign led by the American Board of Internal Medicine (ABIM) Foundation in collaboration with specialty medical societies including the American Gastroenterological Association (AGA)1. Choosing Wisely seeks to reduce several categories of overutilization of health care services (e.g., overtreatment, and failures in care coordination and execution of care processes)2. Choosing Wisely is based on principles of Parsimonious Medicine: an appeal to professionalism and physicians’ “good, sound judgment” to identify and apply clinical evidence 3. Parsimonious medicine suggests that appropriate utilization occurs when physician judgment and best evidence are applied within the context of individual patient’s needs3. Choosing Wisely addresses both physicians and patients through the publication of lists of “Five Things Physicians and Patients Should Question” for each specialty. The Choosing Wisely items identified by the AGA highlight potential overutilization of 1) pharmacologic treatments for gastroesophageal reflux disease, 2) screening colonoscopy in average risk individuals, 3) surveillance colonoscopy in individuals with low-risk polyps, 4) surveillance esophagogastroduodenoscopy (EGD) in individuals with Barrett’s Esophagus (BE), and 5) computed tomography (CT) in individuals with functional abdominal pain.1 The success of Choosing Wisely will depend on how patients and physicians weight the importance of best evidence against other factors that shape decisions at the clinical encounter. As part of a patient-centered, comparative effectiveness study of screening and surveillance esophagogastroduodenoscopy (EGD), we conducted qualitative interviews to explore patient and physician perceptions of one of the AGA Choosing Wisely items.4 Analysis of these interviews identified factors perceived to influence under and over utilization of surveillance EGD for Barrett’s Esophagus in the context of AGA clinical practice guidelines. We conducted in-depth qualitative interviews with 20 patients with BE who use the Veterans Administration (VA) system and 14 gastroenterologists from three practice settings: tax-supported public, private academic, and VA settings. We concluded sampling for each subgroup at the point of thematic saturation5. Interview content was informed by models of decision-making6. Interviews with patients elicited information about their experiences, perceptions, and attitudes regarding BE and surveillance EGD. Interviews with physicians elicited perceptions of practice guidelines and decision making regarding surveillance EGD in patients with BE. All interviews were recorded, transcribed, and analyzed for content.5 Of our sample of 20 patients with BE, the mean age of participants was 62.9±7.3 years; all male; and 10 had BE without dysplasia and 9 had BE with low-grade dysplasia. All of the 14 gastroenterologists interviewed were experienced endoscopists, 36% were female, 50% practiced in private settings full or part time; and had a median of 14 (range 1–36) years post-fellowship experience. Table 1 describes quotes from patients and gastroenterologists that frame the drivers of utilization of EGD for patients with BE as part of guideline-based cancer surveillance. Figure 1 depicts these 9 themes as drivers of utilization for surveillance EGD. Figure 1 Table 1 Drivers of Utilization Among Patients and Gastroenterologists Our interviews identified drivers of over and under utilization of EGD within the context of BE surveillance. Patients and physicians endorsed many factors (Figure 1) that drive utilization of EGD, other than the quality of evidence, that may not be influenced by appeals for professionalism or quality of evidence. These factors include, access and payments for healthcare (for patients), financial incentives and medical-legal considerations (for physicians). The results of our study specifically explore one of the Choosing Wisely items co-sponsored by AGA: follow-up surveillance examination should not be performed in less than three years as per published guidelines for BE patients without dysplasia1. However, current practice is not indicative of adherence to this item; for example, a recent three-site study (including one VA facility) found EGD overutilization was common among BE patients and insurance-related incentives were the primary driver of utilization6. The emphasis that Choosing Wisely places on Parsimonious Medicine is unlikely to mitigate the many drivers of overtreatment given some of the current evidence and structural issues related to heathcare delivery in a largely fee-for-service system. High quality evidence is critical because it anchors definitions of appropriate utilization (as illustrated in Figure 1). However, three of the five Choosing Wisely items from the AGA directly address overutilization of endoscopy (colonoscopy and EGD) where evidence guiding the optimal time interval between repeat studies is modest at best, yet there are multiple perceived factors driving overutilization. Moreover, systematic changes affecting incentive structures and medico-legal concerns are needed to encourage and enable the types of shared decisions that are consistent with best evidence. Without incentives to counteract the factors favoring overutilization, Choosing Wisely will struggle to meaningfully impact clinical decision making.

The recent trend toward health care consumerism is largely the product of market practices, which have instilled the notion of health care as a product to be purchased by informed, empowered consumers, rather than a service bestowed upon a patient by a paternalistic provider. In recent years, health care consumerism has been facilitated by direct-to-consumer advertising (DTCA) of pharmaceutical products. In this paper, we use the case of DTCA for antidepressant medications to examine medicalization techniques used to promote consumerism and establish and expand the antidepressant market. We used content analysis of DTCA from the 1997–2006 issues of a broad sample of women’s, men’s, and common readership magazines to identify techniques of medicalization, and we analyzed in-depth interviews with magazine readers and antidepressant users to examine how such messages are received. Findings are presented within a framework of economic sociology, which allowed us to unveil the links between emotions and social action that undergird responses to medicalization techniques and consumption of advertised products.

The rise of direct-to-consumer advertising (DTCA) has mirrored, if not facilitated, the shift toward more active health care consumers. We used content analysis to identify models of physician–patient interaction in DTCA from the 1997 to 2006 issues of a broad sample of women’s, men’s, and common readership magazines. We also conducted 36 in-depth interviews to examine the ways consumers receive and regard advertising messages, and to explore their preferences for clinical communication and decision making. We identified four models of physician–patient relationships that vary in their locus of control (physician, patient, or shared) and the form of support sought or obtained in the relationship (emotional or instrumental). Whereas consumer interviews reflected references to all four models of interaction, only two appeared in DTCA. The limited range of interactions seen in these advertisements creates a lack of congruity between interaction styles found in advertisements vs. styles reported by actual consumers.

Summary Adherence to practice guidelines for endoscopic surveillance of Barrett's esophagus is equivocal with evidence of underutilization and overutilization. While physicians report strong agreement with and adherence to recommended surveillance endoscopy (esophagogastroduodenoscopy [EGD]) guidelines, less is known about modifiable barriers and facilitators shaping patients' adherence behaviors. The aim of this study is to conduct a structured literature review of studies exploring patients' perspectives regarding surveillance EGD and to place these results within a conceptual framework. A structured literature review of PubMed, Cochrane, and Google Scholar databases with qualitative thematic analysis was performed. Six studies met eligibility criteria. Analysis of results identified five distinct themes. First, patients' objective cancer risk estimates are consistent with subjective risk perceptions, but neither is associated with EGD surveillance. Second, patients have strong beliefs in the benefits of cancer screening and surveillance and trust in their doctors. Third, anxiety and depression symptoms are related to risk perceptions and outcome expectancies of surveillance. Fourth, endoscopic surveillance itself has affective and physical consequences. Finally, health services and system variables are related to risk perception and EGD surveillance. These themes coherently fit within an integrated model of intuitive decision-making and health behaviors. Studies meeting eligibility criteria were heterogeneous in terms of their study objectives and findings. Quantitative meta-analyses of study findings could not be performed. To improve adherence, endoscopic surveillance programs should consider how patients intuitively frame risks and benefits and patients' emotional reactions to the endoscopy procedure, and focus on how physicians communicate recommendations.

e21577Background: With almost 12 million cancer survivors in the U.S., the Institute of Medicine (IOM) recommends provision of a treatment summary and survivorship care plan (TSSCP) to all cancer s...

e20573Background: Genomic-based targeted therapy (GBTT) has emerged as a treatment option for patients with advanced lung cancer. Clinical practice guidelines of the National Comprehensive Cancer N...

Medical decisions, including physicians’ prescribing behaviors, are shaped by a complex interplay of clinical and nonclinical factors. We aim to determine how physician, patient, and relationship characteristics influence physicians’ decisions to accommodate brand-name prescription drug requests. We applied multivariate logistic regression to data from the Attitudinal and Behavioral Effects of Direct-to-Consumer Promotion of Prescription Drugs physician survey. We used a national probability sample of 500 primary care and specialty physicians reporting on a clinical encounter that involved a prescription drug request. Independent variables include physician’s assessment of the patient’s understanding of risks and benefits of a requested medication, whether the patient had the condition the drug treats, duration of the clinical relationship, and physician’s age, area of practice, years of experience, and gender. These variables were used to predict whether the physician prescribed the requested drug. Physicians were more willing to accommodate requests when they believed that patients had a clear understanding of the drug’s risks and when patients had the condition the drug treats. Primary care practitioners, compared to specialists, had higher odds of prescribing a requested drug. We conclude that clinical and communicative factors shape physicians’ decisions to prescribe requested brand-name drugs. Findings offer insight into the influence that direct-to-consumer advertising can have in medical encounters, and may guide efforts to enhance physician–patient communication and shared decision making.

e17560 Background: Little is known about oncologists’ knowledge, perception, and utilization of genomic-based targeted therapy (GBTT) in routine practice. The objective of this pilot study was to e...

Jennifer Arney,1–3 Richard L Street Jr,2–4 Aanand D Naik2,31Department of Sociology, University of Houston – Clear Lake, 2Houston VA Health Services Research and Development Center of Excellence, Michael E DeBakey Department of Veterans Affairs Medical Center, 3Section on Health Services Research, Baylor College of Medicine, Houston, 4Department of Communication, Texas A&M University, College Station, TX, USAAbstract: Direct-to-consumer advertising (DTCA) is ubiquitous in media outlets, but little is known about the ways in which consumers' values, needs, beliefs, and biases influence the perceived meaning and value of DTCA. This article aims to identify the taxonomy of readership categories that reflect the complexity of how health care consumers interact with DTCA, with particular focus on individuals' perceptions of print DTCA in popular magazines. Respondent-driven sampling was used to recruit 18 male and female magazine readers and 18 male and female prescription medication users aged 18–71 years. Semi-structured, in-depth interviews with consumers about their attentiveness, motivations, perceived value, and behavioral responses to DTCA were conducted. The analyses were guided by principles of grounded theory analysis; four categories that vary in consumers' attentiveness, motivations, perceived value, and behavioral responses to DTCA were identified. Two categories – the lay physician and the informed shopper – see value in information from DTCA and are likely to seek medical care based on the information. One category – the voyeur – reads DTCA, but is not likely to approach a clinician regarding advertised information. The fourth category – the evader – ignores DTCA and is not likely to approach a clinician with DTCA information. Responses to DTCA vary considerably among consumers, and physicians should view patients' understanding and response to DTCA within the context of their health-related needs. Patients' comments related to DTCA may be used as an opportunity to engage and understand patients' perspectives about illness and medication use. Clinicians may use information about these categories to facilitate shared understanding and improve communication within the doctor–patient relationship.Keywords: communication, decision making, doctor–patient relationships, qualitative research