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Introduction: People experiencing health-related social needs (HRSNs), such as transportation insecurity, are less likely to undergo preventive health screenings. They are more likely to have worse health outcomes overall, including a higher rate of late-stage cancer diagnoses. If primary care clinicians are aware of HRSNs, they can tailor preventive care, including cancer screening approaches. Accordingly, recent guidelines recommend that clinicians "adjust" care based on HRSNs. This study assessed the level of clinician awareness of patient-reported HRSNs and congruence between clinician perception and patient-reported HRSNs. Methods: We surveyed patients aged 50 to 85 years and their clinicians in 3 primary care clinics that routinely screen patients for HRSNs. Patients and clinicians reported the presence/absence of 6 HRSNs, including food, transportation, housing and financial insecurity for medications/healthcare, financial insecurity for utilities, and social isolation. Kappa statistics assessed the concordance of reported HRSNs between patients and clinicians. Results: Across 237 paired patient-clinician surveys, mean patient age was 65 years, and 62% and 13% of patients were female and Latinx/Hispanic, respectively. Concordance between clinician- and patient-reported HRSNs varied by HRSN, with the lowest agreement for food insecurity (kappa =.08; 95% CI: 0.00, 0.17; P =.01) and highest agreement for transportation insecurity (kappa =.39; 95% CI: 0.18, 0.59; P <.001). The other HRSNs assessed were housing insecurity (kappa =.30; 95% CI: 0.05, 0.55; P <.001), social isolation (kappa =.24; 95% CI: 0.03, 0.45; P <.001), financial insecurity for utilities (kappa =.21; 95% CI: −0.02, 0.45; P <.001), and financial insecurity for healthcare/medications (kappa =.12; 95% CI: −0.02, 0.27; P <.001). In particular, discrepancies were noted in food insecurity prevalence: patient-reported food insecurity was 29% whereas clinician-reported food insecurity was only 3%. Discussion: Clinician awareness of patients' social needs was only modest to fair, and varied by specific HRSN. In order to adjust care for HRSNs, clinics need processes for increased sharing of patient-reported HRSNs screening information with the entire clinical team. Future research should explore options for sharing HRSN data across teams and evaluate whether better HRSN data-sharing impacts outcomes. [ABSTRACT FROM AUTHOR]

Background: Despite lung cancer being a leading cause of death in the United States and lung cancer screening (LCS) being a recommended service, many patients eligible for screening do not receive it. Research is needed to understand the challenges with implementing LCS in different settings. This study investigated multiple practice members and patient perspectives impacting rural primary care practices related to LCS uptake by eligible patients. Methods: This qualitative study involved primary care practice members in multiple roles (clinicians n = 9, clinical staff n = 12 and administrators n = 5) and their patients (n = 19) from 9 practices including federally qualified and rural health centers (n = 3), health system owned (n = 4) and private practices (n = 2). Interviews were conducted regarding the importance of and ability to complete the steps that may result in a patient receiving LCS. Data were analyzed using a thematic analysis with immersion crystallization then organized using the RE-AIM implementation science framework to illuminate and organize implementation issues. Results: Although all groups endorsed the importance of LCS, all also struggled with implementation challenges. Since assessing smoking history is part of the process to identify eligibility for LCS, we asked about these processes. We found that smoking assessment and assistance (including referral to services) were routine in the practices, but other steps in the LCS portion of determining eligibility and offering LCS were not. Lack of knowledge about screening and coverage, patient stigma, and resistance and practical considerations such as distance to LCS testing facilities complicated completion of LCS compared to screening for other types of cancer. Conclusions: Limited uptake of LCS results from a range of multiple interacting factors that cumulatively affect consistency and quality of implementation at the practice level. Future research should consider team-based approaches to conduct of LCS eligibility and shared decision making. [ABSTRACT FROM AUTHOR]

Objectives: It is important to understand the unique perspectives and values that motivate patients and clinicians in rural primary care settings to participate in clinical care activities. Our objective was to explore perspectives, preferences, and values related to primary care that could influence implementation of evidence-based programs. Methods: Qualitative study utilizing semi-structured interviews and using immersion/crystallization and thematic analysis. Participants were primary care practice members (clinicians, clinical staff, and administrators) and their patients in rural Colorado. Results: Twenty-six practice members and 23 patients across 9 practices participated. There were 4 emergent themes that were consistent across practice members and some patients. Patient perspectives are located in parenthesis. They included: (1) Focus on quality patient care, patient satisfaction, and continuity of care (patients appreciated quality and compassionate care), (2) Importance of prevention and wellness (patients appreciated help with preventing health problems), (3) Clinician willingness and ability to meet patient preferences for care (patients described comfort with local care), and (4) Passion for serving underserved, uninsured, or vulnerable populations (patients described their vulnerabilities). There were differences in how the perspectives were operationalized by practice member role, illustrating the importance of different ways of addressing these values. Conclusions: Successful implementation requires consideration of context, and much of context is understanding what is important to those involved in the primary care experience. This study sheds light on salient values of rural primary care practice members and their patients, which may inform interventions designed with and for this setting. [ABSTRACT FROM AUTHOR]

OBJECTIVE -- To evaluate associations between psychosocial and social-environmental variables and diabetes self-management, and diabetes control. RESEARCH DESIGN AND METHODS -- Baseline data from a type 2 diabetes self-management randomized trial with 463 adults having elevated BMI (M = 34.8 kg/m²) were used to investigate relations among demographic, psychosocial, and social-environmental variables; dietary, exercise, and medication-taking behaviors; and biologic outcomes. RESULTS -- Self-efficacy, problem solving, and social-environmental support were independently associated with diet and exercise, increasing the variance accounted for by 23 and 19%, respectively. Only diet contributed to explained variance in BMI (β = -0.17, P = 0.0003) and self-rated health status (β = 0.25, P < 0.0001); and only medication-taking behaviors contributed to lipid ratio (total-to-HDL) (β = -0.20, P = 0.0001) and A1C (β = -0.21, P < 0.0001). CONCLUSIONS -- Interventions should focus on enhancing self-efficacy, problem solving, and social-environmental support to improve self-management of diabetes. [ABSTRACT FROM AUTHOR]

Vaccine uptake during pregnancy remains low. Our objectives were to describe 1) development and adaptation of a clinician communication training intervention for maternal immunizations and 2) obstetrics and gynecology (ob-gyn) clinician and staff perspectives on the intervention and fit for the prenatal care context. Design of the Motivational Interviewing for Maternal Immunizations (MI4MI) intervention was based on similar communication training interventions for pediatric settings and included presumptive initiation of vaccine recommendations ("You're due for two vaccines today") combined with motivational interviewing (MI) for hesitant patients. Interviews and focus group discussions were conducted with ob-gyn clinicians and staff in five Colorado clinics including settings with obstetric physicians, certified nurse midwives (CNMs), and clinician-trainees. Participants were asked about adapting training to the ob-gyn setting and their implementation experiences. Feedback was incorporated through iterative changes to training components. Interview and focus group discussion results from participants before (n = 3), during (n = 11) and after (n = 25) implementation guided intervention development and adaptation. Three virtual, asynchronous training components were created: a video and two interactive modules. This virtual format was favored due to challenges attending group meetings; however, participants noted opportunities to practice skills through role-play were lacking. Training modules were adapted to include common challenging vaccine conversations and live-action videos. Participants liked interactive training components and use of adult learning strategies. Some participants initially resisted the presumptive approach but later found it useful after applying it in their practices. Overall, participants reported that MI4MI training fit well with the prenatal context and recommended more inclusion of non-clinician staff. MI4MI training was viewed as relevant and useful for ob-gyn clinicians and staff. Suggestions included making training more interactive, and including more complex scenarios and non-clinician staff. [ABSTRACT FROM AUTHOR]

Introduction: Vaccination against influenza and pertussis in pregnancy offers a 'two-for-one' opportunity to protect mother and child. Pregnant patients have increased risk of severe disease from influenza and newborns have increased risk of severe disease from both influenza and pertussis. Obstetricians need communication tools to support their self-efficacy and effectiveness in communicating the importance of immunisation during pregnancy and ultimately improving maternal vaccination rates., Methods and Analysis: We describe the protocol for a pragmatic study testing the feasibility and potential impact of a clinician communication strategy on maternal vaccination uptake. This study will be conducted in five prenatal care settings in Colorado, USA. The Motivational Interviewing for Maternal Immunisation strategy involves training prenatal care providers to use motivational interviewing in the vaccine conversation with pregnant patients. Our primary outcomes will be the adoption and implementation of the intervention measured using the Enhanced RE-AIM/Practical Robust Implementation and Sustainability Model for dissemination and implementation. Secondary outcomes will include provider time spent, fidelity to Motivational Interviewing and self-efficacy measured through audio recorded visits and provider surveys, patients' visit experience based on audio recorded visits and follow-up interviews, and maternal vaccine uptake as measured through chart reviews., Ethics and Dissemination: This study is approved by the following institutional review boards: Colorado Multiple Institutional Review Board. Results will be disseminated through peer-reviewed manuscripts and conference presentations., Trial Registration Number: NCT04302675., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background. Despite demonstrated efficacy, patient decision aids (DAs) are rarely used in clinical practice in the absence of coverage mandates. Deciding whether to pursue a left ventricular assist device (LVAD) is a major, preference-sensitive decision-ideal for exploring implementation of a DA. Methods. We conducted a type II effectiveness-implementation hybrid trial at 6 LVAD programs using a stepped-wedge cluster-randomized design. Using the RE-AIM framework, we collected both quantitative and qualitative outcomes, including a checklist collected by study staff for each enrolled patient regarding DA use and interviews with LVAD program clinicians preintervention, 6 months postintervention, and at the conclusion of the study. Results. From June 2015 to January 2017, 248 patients and their caregivers were enrolled. A total of 69 interviews were conducted with 48 clinicians at 3 time points. The DA reached 95% of eligible patients. Adoption was 100%, as all sites approached agreed to participate in the trial. Interviews revealed several themes related to the implementation of the DA: clinicians had a strong desire to ensure patients were informed and embraced the DA. Despite this, they reported communication challenges among their team that impeded implementation. Five of the 6 sites have maintained use of the DA following the trial; 1 site reported concerns about decreased procedural volume with use of the DA as a reason for discontinuation. Conclusions. In this hybrid trial, a DA for patients considering LVADs and their caregivers demonstrated high reach. Adoption and implementation were facilitated by a strong desire to ensure that patients were well informed. Future dissemination research and practice should attend to concerns about procedure volume and coverage mandates and facilitate ongoing communication at sites using the DA.

Background: Shared medical appointments (SMAs) have been shown to be an efficient and effective strategy for providing diabetes self-management education and self-management support. SMA features vary and it is not known which features are most effective for different patients and practice settings. The Invested in Diabetes study tests the comparative effectiveness of SMAs with and without multidisciplinary care teams and patient topic choice for improving patient-centered and clinical outcomes related to diabetes., Methods: This study compares the effectiveness of two SMA approaches using the Targeted Training for Illness Management (TTIM) curriculum. Standardized SMAs are led by a health educator with a set order of TTIM topics. Patient-driven SMAs are delivered collaboratively by a multidisciplinary care team (health educator, medical provider, behavioral health provider, and a peer mentor); patients select the order and emphasis on TTIM topics. Invested in Diabetes is a cluster randomized pragmatic trial involving approximately 1440 adult patients with type 2 diabetes. Twenty primary care practices will be randomly assigned to either standardized or patient-driven SMAs. A mixed-methods evaluation will include quantitative (practice- and patient-level data) and qualitative (practice and patient interviews, observation) components. The primary patient-centered outcome is diabetes distress. Secondary outcomes include autonomy support, self-management behaviors, clinical outcomes, patient reach, and practice-level value and sustainability., Discussion: Practice and patient stakeholder input guided protocol development for this pragmatic trial comparing SMA approaches. Implementation strategies from the enhanced Replicating Effective Programs framework will help ensure practices maintain fidelity to intervention protocols while tailoring workflows to their settings. Invested in Diabetes will contribute to the literature on chronic illness management and implementation science using the RE-AIM model., Trial Registration: ClinicalTrials.gov, NCT03590041. Registered on 5 July 2018.

Background: Efforts to predict success in chronic disease management programs have been generally unsuccessful., Objective: To identify patient subgroups associated with success at each of 6 steps in a diabetes self-management (DSM) program., Design: Using data from a randomized trial, recursive partitioning with signal detection analysis was used to identify subgroups associated with 6 sequential steps of program success: agreement to participate, completion of baseline, initial website engagement, 4-month behavior change, later engagement, and longer-term maintenance., Setting: The study was conducted in 5 primary care clinics within Kaiser Permanente Colorado., Patients: Different numbers of patients participated in each step, including 2076, 544, 270, 219, 127, and 89. All measures available were used to address success at each step. Intervention. Participants were randomized to receive either enhanced usual care or 1 of 2 Internet-based DSM programs: 1) self-administered, computer-assisted self-management and 2) the self-administered program with the addition of enhanced social support., Measurements: Two sets of potential predictor variables and 6 dichotomous outcomes were created., Results: Signal detection analysis differentiated successful and unsuccessful subgroups at all but the final step. Different patient subgroups were associated with success at these different steps. Demographic factors (education, ethnicity, income) were associated with initial participation but not with later steps, and the converse was true of health behavior variables., Limitations: Analyses were limited to one setting, and the sample sizes for some of the steps were modest., Conclusions: Signal detection and recursive partitioning methods may be useful for identifying subgroups that are more or less successful at different steps of intervention and may aid in understanding variability in outcomes.

Objective: Internet-based programs offer potential for practical, cost-effective chronic illness self-management programs., Methods: We report 12-month results of an Internet-based diabetes self-management program, with and without additional support, compared to enhanced usual care in a 3-arm practical randomized trial. Patients (n=463) were randomized: 77.3% completed 12-month follow-up. Primary outcomes were changes in health behaviors of healthy eating, physical activity, and medication taking. Secondary outcomes were hemoglobin A1c, body mass index, lipids, blood pressure, and psychosocial factors., Results: Internet conditions improved health behaviors significantly vs. usual care over the 12-month period (d for effect size=.09-.16). All conditions improved moderately on biological and psychosocial outcomes. Latinos, lower literacy, and higher cardiovascular disease risk patients improved as much as other participants., Conclusions: The Internet intervention meets the reach and feasibility criteria for a potentially broad public health impact. However, 12-month magnitude of effects was small, suggesting that different or more intensive approaches are necessary to support long-term outcomes. Research is needed to understand the linkages between intervention and maintenance processes and downstream outcomes., Practice Implications: Automated self-management interventions should be tailored and integrated into primary care; maintenance of patient self-management can be enhanced through links to community resources., (Published by Elsevier Ireland Ltd.)

Introduction: There have been few comprehensive evaluations of smoking reduction, especially in health care delivery systems, and little is known about its cost, maintenance of reduced smoking, or robustness across patient subgroups., Methods: A generally representative sample of 320 adult smokers from an HMO scheduled for outpatient surgery or a diagnostic procedure was randomized to enhanced usual care or a theory-based smoking reduction intervention that combined telephone counseling and tailored newsletters. Outcomes included cigarettes smoked, carbon monoxide levels, and costs., Results: Both intervention and control conditions continued to improve from 3- to 12-month assessments. Between-condition differences using intent-to-treat analyses on both self-report and carbon monoxide measures were nonsignificant by the 12-month follow-up (25% vs. 19% achieved 50% or greater reductions in cigarettes smoked). The intervention was implemented consistently despite logistical constraints and was generally robust across patient characteristics (eg, education, ethnicity, health literacy, dependence)., Conclusions: In the absence of nicotine replacement therapy, the long-term effects of this smoking reduction intervention seem modest and nonsignificant. Future research is indicated to enhance intervention effects and conduct more comprehensive economic analyses of program variations.

Exposure to secondhand smoke (SHS) harms all children's health, especially children with asthma. Yet, children with asthma are as likely to live with smokers as healthy children. Household smoking bans are being advocated to reduce children's harm from SHS. To measure the effect of household smoking bans on child SHS exposure and to examine correlates of strict smoking bans in a low-income, diverse sample, 91 children with asthma were matched to 91 healthy children. All had at least one smoker living in their homes. Nicotine dosimeters, child cotinine assays, and maternal reports quantified child SHS exposures. Maternal reports of household smoking rules, behaviors, and beliefs, and other family characteristics were also gathered. The presence of a strict household smoking ban vastly reduced children's SHS exposures and was associated with fewer cigarettes smoked by the mother and by other family members, the belief that SHS was a personal health risk, having children with asthma, and living in a single-family home. Many children are exposed to high levels of SHS at home. Strict household smoking bans greatly decrease, but do not eliminate children's SHS exposure. Even in disadvantaged families, mutable factors were associated with strict smoking bans. Increased dissemination and use of established public health strategies are needed to reduce children's SHS exposures.

Objective: To determine if a patient-centered, computer-assisted diabetes care intervention increased perceived autonomy support, perceived competence (from self-determination theory), and if these constructs mediated the effect of the intervention on ADA/NCQA recommended diabetes care outcomes., Design: A randomized controlled trial of 866 adult type 2 diabetes patients in heterogeneous primary care settings in Colorado., Main Outcome Measures: Perceived autonomy support, perceived competence, patient satisfaction, glycemic control (HbA1c), ratio of total to HDL cholesterol, diabetes distress, and depressive symptoms., Results: The computer-assisted intervention increased patient perception of autonomy support relative to a computer-based control condition ( p = .05). Change in perceived competence partially mediated the effects of increased autonomy support on the change in lipids, diabetes distress, and depressive symptoms. The construct of autonomy support was found to be separate from that of patient satisfaction., Conclusions: A patient-centered, computer-assisted intervention was effective in improving diabetes self-management outcomes, in part, because it increased patients' perception that their autonomy was supported which changed perceived competence. These findings support the self-determination model for health behavior change and the chronic care model and support the further study of the use of these technologies to motivate patients to improve their health outcomes., ((PsycINFO Database Record (c) 2007 APA, all rights reserved).)

Purpose: The purpose of this study was to evaluate costs associated with the primary intervention of the Mediterranean Lifestyle Program (MLP), which targeted postmenopausal women with type 2 diabetes at risk for coronary heart disease., Methods: Using retrospective data collected during MLP development and implementation, the authors estimated costs for the first 6 months relative to the usual care condition and incremental costs per behavioral, biologic, and quality-of-life change. Sensitivity analyses were conducted using variations in inflation rates, implementation settings, labor and nonlabor inputs, and market wage rates., Results: Of the sample of 279 study participants, 163 were randomized into the MLP condition. Total intervention costs were estimated at $211 061 ($148 022 direct costs) or $1295 per MLP participant relative to usual care ($908 direct costs). This translates to $3808 per average change in coronary heart disease risk as measured by an average 1-point reduction in hemoglobin A1C. Relative to other measured improvements, this corresponds to $2345 per unit reduction in body mass index and $644 per unit improvement in Problem Areas in Diabetes Quality-of-Life Self-care Summary score, and a $196 per-gram reduction in intake of saturated fatty acids as noted by the Food Frequency Questionnaire. A significant portion of the direct costs were related to the resources used during the recruitment phase., Conclusions: Providing a relatively intensive lifestyle self-management program for this high-risk group is associated with modest incremental costs compared with usual care, making the program potentially appealing to policy makers.

Background: Physical activity (PA) is important for management of diabetes, yet practical interventions that achieve sustained behavior change are rare., Purpose: The goals of this research were to evaluate the effectiveness of a multifaceted PA intervention for people with type 2 diabetes that emphasized participant choice in activity selection. Baseline activity patterns were examined to determine whether they predicted changes in PA at 2 months., Methods: Three hundred thirty-five participants were recruited from 42 primary care physicians and then randomized to either a computer-assisted, tailored self-management intervention (N = 174) or health risk appraisal with feedback control (N = 161). Primary outcome measures included the Community Healthy Activities Model Program for Seniors Questionnaire, diet, and psychosocial assessments at baseline and 2 months., Results: For 301 participants who completed the 2-month follow-up, the intervention significantly improved all PA (p < .01) and moderate PA (metabolic equivalents > 3.0, p < 01) relative to controls. Baseline cluster analyses grouped participant activity patterns into three categories. At 2 months, cluster assignment differentially predicted change in calories expended in moderate, rote, sport, and lifestyle PA., Conclusions: A computer-assisted, multifaceted approach to PA demonstrated improvement after 2 months. The results suggest that individuals are capable of adjusting their activity patterns to maximize their PA.

Background: A major problem in the dissemination of most interventions found to be efficacious is that they are of limited or unknown generalizability., Objective: To document the "robustness," or external validity, of a computer-assisted diabetes self-management program across different patient characteristics, healthcare settings (mixed payer vs health maintenance organization), intervention staff, and outcomes., Study Design: A randomized controlled trial evaluating a computer-assisted behavior change program for adult patients with type 2 diabetes mellitus (n = 217) vs a computerized health risk assessment., Methods: Outcomes were identified using the RE-AIM framework and included program adoption among physicians, reach across patient groups, implementation, and behavioral (fat intake and physical activity) and biological (glycosylated hemoglobin and lipid levels) effectiveness measures., Results: The program achieved 41% patient participation, variable adoption across healthcare settings (76% of health maintenance organization physicians vs 18% of non-health maintenance organization physicians participated), good implementation, and improvement in behavioral outcomes. There were few significant interactions between treatment condition and patient characteristics, type of healthcare setting, or interventionist experience on effectiveness measures., Conclusions: Patients and physicians were willing to participate in a computer-assisted dietary and physical activity goal-setting intervention, although participation varied by healthcare setting. Interventionists from different backgrounds successfully delivered the intervention, and the results appear robust across various patient and delivery characteristics.

Objective: There is a well-documented gap between diabetes care guidelines and the services received by patients in most health care settings. This report presents 12-month follow-up results from a computer-assisted, patient-centered intervention to improve the level of recommended services patients received from a variety of primary care settings., Research Design and Methods: A total of 886 patients with type 2 diabetes under the care of 52 primary care physicians participated in the Diabetes Priority Program. Physicians were stratified and randomized to intervention or control conditions and evaluated on two primary outcomes: number of recommended laboratory screenings and recommended patient-centered care activities completed from the National Committee on Quality Assurance/American Diabetes Association Provider Recognition Program (PRP). Secondary outcomes were evaluated using the Problem Areas in Diabetes 2 quality of life scale, lipid and HbA1c levels, and the Patient Health Questionnaire-9 depression scale., Results: The program was well implemented and significantly improved both the number of laboratory assays and patient-centered aspects of diabetes care patients received compared with those in the control condition. There was overall improvement on secondary outcomes of lipids, HbA1c, quality of life, and depression scores; between-condition differences were not significant., Conclusions: Staff in small, mixed-payer primary care offices can consistently implement a patient-centered intervention to improve PRP measures of quality of diabetes care. Alternative explanations for why these process improvements did not lead to improved outcomes, and suggested directions for future research are discussed.

Burrows within black-tailed prairie dog (Cynomys ludovicianus) colonies on the Rocky Mountain Arsenal National Wildlife Refuge, Colorado, were dusted with deltamethrin insecticide to reduce flea (Insecta: Siphonaptera) abundance. Flea populations were monitored pre- and posttreatment by combing prairie dogs and collecting fleas from burrows. A single application of deltamethrin significantly reduced populations of the plague vector Oropsylla hirsuta, and other flea species on prairie dogs and in prairie dog burrows for at least 84 d. A plague epizootic on the Rocky Mountain Arsenal National Wildlife Refuge caused high mortality of prairie dogs on some untreated colonies, but did not appear to affect nearby colonies dusted with deltamethrin.

Purpose: This study reports on methods and strategies employed to increase participation rates in diabetes interventions and discusses the reach and representativeness of the Diabetes Priority Program., Methods: A passive mail-out procedure was used to contact patients of participating primary care physicians. Patients who did not return the refusal postcard were contacted. Several attempts were made to contact potential participants. Brochures, "wrong number" postcards, posters, and reports for clinic staff were strategies used to increase participation., Results: The recruitment process resulted in a participation rate of 83% among patients who were contacted and eligible. These participants appeared to be representative of both nonparticipants and persons with diabetes in Colorado. In contrast, a low percentage of primary care physicians, estimated at 3%, took part in the program despite efforts to make the program brief, nonintrusive, and compatible with usual care., Conclusions: Recruitment is currently challenging and will become even more difficult with the privacy regulations that affect healthcare research and the public distrust of solicitations. To increase participation rates, it is important that the clinic staff promotes and supports the program, and that participant lists are accurate and adequate in size.