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Proper bowel preparation is essential to successful colonoscopies. The quality of bowel preparation is often poorer in the inpatient settings compared with outpatient settings. This can result in repeat procedures and increased hospital length of stay.The aim of this evidence implementation project was to assess and improve compliance with best practice recommendations for bowel preparation prior to colonoscopy.The project was done in three phases for patients hospitalized at a tertiary adult hospital: the initial audit; clinical practice change that included providing patients with both oral and written education about bowel preparation; and a follow-up audit.The baseline audit showed that the hospital was already fully compliant with two out of four best practice criteria. For two criteria with poor compliance rates at baseline, we improved compliance for criterion 1 (giving patients both oral and written education about bowel preparation) from 8 to 40%, while compliance rate for criterion 4 [using 2 l polyethylene glycol - (PEG) or adding ascorbic acid to 4 l PEG] remained at 0% at the end of the intervention.The JBI evidence implementation program provided a structured approach to analyze colonoscopy bowel preparation practices and develop strategies to align policies with the best practice recommendation of providing written education about bowel preparation. However, there is need for more conclusive evidence to identify the most ideal inpatient bowel preparation formulation.

PurposeThe purpose of this systematic review is to assess evidence of a relationship between health literacy and medication engagement (formerly referred to as medication adherence) among adults with diabetes mellitus in the United States.MethodsLiterature searches were conducted in PubMed, Ovid Medline, CINAHL, Embase, PsycInfo, and Scopus from the inception of each database to April 2020. Studies were included if they met all of the following criteria: (1) conducted in the United States, (2) the population of interest was adults ≥18 years with a diagnosis of type 1 or type 2 diabetes, (3) medication engagement was an outcome variable, (4) a direct and not a mediating relationship between health literacy and medication engagement was assessed, (5) a quantifiable measure of association was reported, and (6) a full-text journal article or dissertation was available. Quality of published evidence was graded according to Joanna Briggs Institute Critical Appraisal Checklists appropriate for the respective study designs identified.ResultsThirteen articles from 11 unique studies were retained in the review, most of which used a cross-sectional design. Four out of 11 studies found a direct positive association between health literacy and medication engagement. Two of the 4 studies with positive findings had significant methodological shortcomings.ConclusionsThere is some evidence that health literacy is associated with medication engagement among adults with diabetes in the United States. Properly designed and executed longitudinal studies are needed to better elucidate the relationship between health literacy and medication engagement among adults with diabetes.

Background: Patients with substance use disorders (SUDs) are more likely to experience serious health problems, high healthcare utilization, and premature death. However, little is known about the contribution of SUDs to medical 30-day readmission risk. We examined the association between SUDs and 30-day all cause readmission among non-pregnant adult in-patients in the US. Methods: We conducted a retrospective study using 2010–2014 data from the Nationwide Readmissions Database. Our primary focus was on opioid use compared to stimulant use (cocaine and amphetamine) identified by ICD-9-CM diagnosis codes in index hospitalizations. Multivariable logistic regression models were used to estimate adjusted odds ratios and 95% CI representing the association between substance use and 30-day readmission, overall and stratified by the principal reason for the index hospitalization. Results: Nearly 118 million index hospitalizations were included in the study, 4% were associated with opioid or stimulant use disorder. Readmission rates for users (19.5%) were higher than for nonusers (15.7%), with slight variation by the type of substance used: cocaine (21.8%), opioid (19.0%), and amphetamine (17.5%). After adjusting for key demographic, socioeconomic, clinical, and health system characteristics, SUDs and stimulant use disorders increased the odds of 30-day all-cause readmission by 20%. Conclusions: Reducing the frequency of inpatient readmission is an important goal for improving the quality of care and ensuring proper transition to residential/outpatient care among patients with SUDs. Differences between groups may suggest directions for further investigation into the distinct needs and challenges of hospitalized opioid- and other drug-exposed patients.

Cost-related medication non-adherence (CRN) is a major population health concern in the United States, especially for patients with chronic conditions. It is associated with disease progression and increases the likelihood of emergency department utilization and hospitalization, thereby increasing overall health care expenditures. In this paper, we describe the prescription medication safety net in the United States and assess its reliability. We also introduce Dispensary of Hope (DoH), a charitable medication distribution network, as a reliable medication access program that is capable of filling gaps in medication coverage for low-income and uninsured Americans. Our critical assessment of the medication safety net in the United States suggests that an expansion of DoH could reduce CRN in the United States, improve chronic illness care, and help health systems achieve the triple aim of improving patient experiences and population health while reducing cost.

Considering the rising global burden of diabetes and its complications, effective interventions for addressing barriers to diabetes self-management are needed. Diabetes distress, a psychological barrier to diabetes self-management, has become increasingly recognised in the literature, but effective and feasible ways of addressing it in routine primary care settings are not known. We present the case of a middle-aged non-Hispanic white American woman with poorly controlled diabetes (haemoglobin A1c (HbA1c): 13.9%) and elevated diabetes distress (baseline Diabetes Distress Scale Score: 2.53) who participated in a health coaching intervention. After the 5-month programme, which included eight 45 minute long sessions with a trained health coach, the patient achieved and sustained a 0.8-point reduction in diabetes distress, an improvement in insulin adherence and a 3.6-point reduction in HbA1c. This case demonstrates a novel approach to managing diabetes distress that entails providing patients a safe, nonjudgemental space to express their feelings and explore challenges with diabetes self-management.

Objective: Common diabetes risk screening tools like the American Diabetes Association Diabetes Risk Test (ADADRT) requires survey administration. We studied if diabetes risk can be assessed from routinely available data in the electronic health record (EHR). Methods: ADADRT was administered to 169 participants without preexisting diagnosis of prediabetes or diabetes, following which the EHR was reviewed for information on ADADRT questions. Standard validation measures were calculated using HbA1c as the gold standard. Results: About 27% of the sample had prediabetes or diabetes. Of the 7 ADADRT variables, physical activity was the least available in the EHR. We observed that modifying ADADRT by dropping physical activity and changing the risk threshold from ≥5 to ≥4 preserves its diagnostic accuracy. The modified ADADRT (cutoff at ≥4) was then approximated using EHR data, yielding the following validation measures: proportion of high-risk persons 56.8%, sensitivity 77.8%, specificity 50.8%, positive predictive value 36.5%, negative predictive value 86.3%, Youden Index 28.6, and area under the receiver-operating characteristic curve 0.64. Conclusion: Diabetes risk score can be estimated using routine EHR data. This could mean a quicker eligibility determination for prediabetes testing and referral to the National Diabetes Prevention Program. Disclosure C.C. Chima: None. N. Anikpezie: None. L.S. Pongetti: None. B.C. Wade: None. T. Powell: None. B. Beech: None.

Objective: The use of self-reported data to assess diabetes risk in the general population is a key component of the National Diabetes Prevention Program. The American Diabetes Association Diabetes Risk Test (ADADRT) is a popular tool used for this purpose, yet there is paucity of data on its validity in real-world clinical settings. We assessed the performance of ADADRT in identifying undiagnosed prediabetes or diabetes at a Federally Qualified Health Center serving predominantly African Americans. Methods: The ADADRT was administered to participants without pre-existing diagnosis of prediabetes or diabetes and standard validation measures were calculated using HbA1c as the gold standard. Findings are reported for participants who self-identified as being Black or African American (n = 151). Results: HbA1c identified 25.8% of the sample as having prediabetes or diabetes. At the recommended cutoff for ADADRT (i.e., score ≥5) the following measures were observed: proportion of high-risk persons 47.7%, sensitivity 74.4%, specificity 61.6%, positive predictive value 40.3%, negative predictive value 87.3%, Youden Index 36, and area under the receiver-operating characteristic curve 0.68. Conclusion: ADADRT reasonably identifies low income African Americans with high diabetes risk. Findings are comparable to the precursor to ADADRT as validated with nationally representative data. Disclosure C.C. Chima: None. N. Anikpezie: None. B.C. Wade: None. L.S. Pongetti: None. T. Powell: None. B. Beech: None.

Purpose Annually, 1%–2% of hospitalized patients are discharged against medical advice (AMA), positioning them at an increased risk of readmission, morbidity, and mortality. Our study aim was to examine 30-day all-cause readmission rates and estimate readmission odds among AMA discharges in the United States, across clinically distinct diagnostic subgroups. Methods We conducted a retrospective, serial cross-sectional analysis of data from the 2010–2017 Nationwide Readmissions Database. Descriptive statistics and 30-day all-cause readmission rates for hospitalizations among adults aged 18 years or older were estimated by major diagnostic subgroup, discharge disposition, and patient and hospital characteristics. Odds ratios and 95% confidence intervals were calculated using multipredictor logistic regression. Results We found the AMA discharge to be an independent predictor of hospital readmission within 30 days, with a 25.6% readmission rate and an overall adjusted likelihood of readmission that was almost double to quadruple that of routine discharges. Furthermore, although hospitalizations experienced decreased odds of readmission after the Hospital Readmission Reduction Program implementation (October 1, 2012), our results demonstrate that the Hospital Readmission Reduction Program did not modify the impact of an AMA discharge on readmission. Conclusion These findings have implications for practice, policies, and interventions aimed at improving care quality, preventing AMA discharge, and reducing hospital readmissions in inpatient settings.

Objective The purpose of this systematic review was to assess the literature regarding access to, and utilization of medication for type 2 diabetes (T2D) and pre-post improvements in diabetes outcomes for adults enrolled in clinic- or pharmacy-based medication assistance programs. Data sources The databases searched were PubMed, CINAHL, Scopus, Embase, Ovid HealthSTAR, PapersFirst, and OpenGrey. Study Selection Databases were searched from the beginning of each database to Feburary 29, 2020. Articles were included if (1) the population of interest was adults 18 years of age or older with a T2D diagnosis, (2) the study addressed access to medication for diabetes patients in a clinic- or pharmacy-based setting, and (3) the study was conducted in the United States. Data extraction Data extracted from the selected studies included location of study, patient inclusion criteria, sample size, medication assistance program description, and reported diabetes medication access and medication related adherence outcomes. Results Eleven articles met the inclusion criteria for the study. The mean reduction in glycated hemoglobin level following the use of medication assistance programs ranged from 0.45 to 0.8. Across studies, the mean number of antihyperglycemic medications used by patients in medication assistance programs ranged from 1 to 1.9. Medication adherence was reported at 45% across studies that reported adherence measures. Conclusion Among the 11 studies identified that assessed access to medication for adults with T2D using clinic- or pharmacy-based medication assistance programs, study findings indicated that many of these programs showed some positive changes in medication access and diabetes-related outcomes.

Objective To describe the rates and temporal trends of inpatient end-of-life care among patients hospitalized with metastatic cancer in the United States. Methods We used data from the Nationwide Inpatient Sample to conduct a cross-sectional analysis of unplanned inpatient hospitalizations of patients aged 18 years or older with metastatic cancer from 2002 to 2011. Multivariable logistic regression was used to assess patient-and hospital-level predictors of discharge to hospice care, palliative care, and in-hospital mortality. Temporal trends in outcomes were characterized with use of joinpoint regression. Results There were an estimated 350,241 unplanned hospitalizations per year of patients with a diagnosis of metastatic cancer. During their inpatient stay, 5.8% of patients received palliative care, and among those discharged alive, 12.2% were referred to hospice care. The rate of inpatient palliative care increased from 2.3% to 13.6%, the rate of discharge to hospice care increased from 4.1% to 15.6%, and the in-hospital mortality rate decreased from more than 14.0% to 9.8%. These patterns were consistent across cancer subtypes, and were most pronounced among patients with extreme risk of mortality. Conclusion Despite increases in the provision of comfort-oriented care to patients with metastatic cancer, few receive such services. We recommend screening protocols in hospitals to identify patients who are good candidates for palliative care consultation and hospice referral.

Objective To describe differences in preferred roles in cancer treatment decision-making and identify associated sociodemographic and health-related factors among adults in the United States. Methods We conducted a cross-sectional analysis of nationally representative data from the 2014 Health Information National Trends Survey. Descriptive statistics were calculated and multivariable logistic regression was conducted to examine associations. Results Half (48.3%) of respondents preferred a collaborative role in decision-making under the supposition of a moderate chance of survival; while 53.4% preferred a more active role when the chance of survival was low. Approximately 7%–8% indicated a preference for a passive role in decision-making, for both low and moderate chances of survival. Several predictors of role preference for cancer treatment decision-making emerged, including age, sex, education, race/ethnicity, and having a regular health care provider. At both low and moderate chances of survival, the college educated were less likely to prefer a passive role, whereas Hispanics were two to three times more likely than whites to indicate a preference for a passive role. Conclusion Adults’ role preference for cancer treatment decision-making may be influenced by sociodemographic and health-related factors. Increased awareness of these factors, paired with enhanced patient–provider communication, may assist health care professionals in providing individualized and high-quality, patient-centered cancer care.

Abstract—Studies have found links between organizational structure and performance of public organizations. Considering the wide variation in uptake of malaria interventions and outcomes across Nigeria, this exploratory study examined how differences in administrative location (a dimension of organizational structure), the effectiveness of administrative processes (earmarking and financial control, and communication), leadership (use of data in decision making, state ownership, political will, and resourcefulness), and external influences (donor influence) might explain variations in performance of state malaria programs in Nigeria. We hypothesized that states with malaria program administrative structures closer to state governors will have greater access to resources, greater political support, and greater administrative flexibility and will therefore perform better. To assess these relationships, we conducted semistructured interviews across three states with different program administrative lo...

Background: Diabetes distress (DD), a type of psychological distress specific to people with diabetes, is strongly associated with difficulties in performing self-care and inability to meet glycemic targets. Despite increased recognition of the need to manage DD, interventions that are both feasible and effective for reducing DD in routine care settings are not yet known. A pilot study showed that health coaching (HC) has some efficacy in addressing DD, but no adequately powered study has implemented a pragmatic research design capable of assessing the real-world effectiveness of HC in reducing DD. Objective: The aim of this study is to describe the rationale and design of an ongoing clinical trial, Coaching and Education for Diabetes Distress trial, that seeks to assess whether HC effectively reduces DD among primary care patients with diabetes and whether HC is more effective than an educational program targeting DD. Methods: The 2-arm randomized controlled trial is taking place at an academic family medicine practice in Houston, Texas. Both arms will receive usual care, which includes education about DD. In addition, the intervention arm will receive 8 HC sessions over a 5-month period. The primary outcome measure is reduction in DD over a 6-month period. Additional outcome measures include changes in hemoglobin A1c and self-care practices (medication-taking, dietary, and physical activity behaviors). Results: As of March 2019, screening and recruitment are ongoing, and the results are expected by July 2020. Conclusions: HC is feasible in primary care and has been successfully applied to improving chronic disease self-management and outcomes. This study will provide evidence as to whether it has significant value in addressing important unmet psychological and behavioral needs of patients with diabetes. Trial Registration: ClinicalTrials.gov NCT03617146; https://clinicaltrials.gov/ct2/show/NCT03617146 (Archived by WebCite at http://www.webcitation.org/76Va37dbO) International Registered Report Identifier (IRRID): DERR1-10.2196/12166

—In 2014, Nigeria shifted its malaria policy and strategy from control to elimination. Studies show that data-driven decision making is essential to achieving elimination. It is therefore important that policy makers have access to and use good quality and relevant data to inform program decisions. This article presents findings from an assessment of availability, quality, and use of malaria data in three states in Nigeria, namely, Akwa-Ibom, Cross River, and Niger, as part of a larger study on how organizational structure affects outcomes of malaria programs. A literature search to determine the availability and range of malaria data in Nigeria was conducted, followed by 65 key informant interviews to understand how malaria data are used in the study states. It was observed that the District Health Information System (DHIS) was the major source of data used in managing programs; however, the range of malaria indicators in the DHIS is limited, lacking indicators such as active case detection and e...

Aims Information on the burden and risk factors for diabetes-depression comorbidity in the US is sparse. We used data from the largest all-payer, nationally-representative inpatient database in the US to estimate the prevalence, temporal trends, and risk factors for comorbid depression among adult diabetic inpatients. Methods We conducted a retrospective analysis using the 2002–2014 Nationwide Inpatient Sample databases. Depression and other comorbidities were identified using ICD-9-CM codes. Logistic regression was used to investigate the association between patient characteristics and depression. Results The rate of depression among patients with type 2 diabetes increased from 7.6% in 2002 to 15.4% in 2014, while for type 1 diabetes the rate increased from 8.7% in 2002 to 19.6% in 2014. The highest rates of depression were observed among females, non-Hispanic whites, younger patients, and patients with five or more chronic comorbidities. Conclusions The prevalence of comorbid depression among diabetic inpatients in the US is increasing rapidly. Although some portion of this increase could be explained by the rising prevalence of multimorbidity, increased awareness and likelihood of diagnosis of comorbid depression by physicians and better documentation as a result of the increased adoption of electronic health records likely contributed to this trend.

BACKGROUND: Health aid to Nigeria increased tremendously in the last decade and a significant portion of the funds were earmarked for HIV-associated programs. Studies on the impact of HIV-specific aid on the delivery of non-HIV health services in sub-Saharan Africa have yielded mixed results. This study assessed if there is a spillover effect of HIV-specific aid on childhood vaccinations in Nigeria. METHODS: Multivariate logistic regression models were used to estimate the effect of aid disbursements in a previous year on the receipt of vaccines at the individual level in a given year. Estimations were done for approximately 11 700 children using data from demographic and health surveys conducted in Nigeria in 2003 and 2008. RESULTS: US$1 increase in HIV aid per capita was associated with a decrease in the probability of receipt of vaccines by 8-31%: polio first dose decreased by 8%; polio final dose by 9%; diphtheria-pertussis-tetanus (DPT) first dose by 11%; DPT final dose by 19%; measles by 31%; final doses of polio and DPT plus measles vaccine by 8%. CONCLUSIONS: HIV-specific aid had a negative spillover effect on immunization services in Nigeria over the study period. Donors may need to rethink their funding strategies in favour of more horizontal approaches. (c) The Author 2015. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions please e-mail: journals.permissions@oup.com.

Objective: To study the risks for hypertension, glucose intolerance and overweight forty years after fetal or childhood exposure to famine afflicting Biafra during the Nigerian civil war (1967-1970). Design: Prospective cohort study performed in June 27 – July 31, 2009. Setting: Enugu, Nigeria. Participants: Adults (n=1,339) born before (1965-67), during (1968-January 1970), or after (1971-73) the years of famine. Main outcome measures: Blood pressure (BP), random plasma glucose and anthropometrics, as well as prevalence of hypertension (BP >140/90 mmHg), impaired glucose tolerance (IGT; p-glucose 7.8-11.0 mmol/l), diabetes (DM; p-glucose ≥11.1 mmol/l), or overweight (BMI >25 kg/m2). Results: Fetal-infant exposure to famine was associated with elevated systolic (+7 mmHg; p< 0.001) and diastolic (+5 mmHg; p< 0.001) BP, increased p-glucose (+0.3 mmol/L; p < 0.04) and waist circumference (+ 3cm, p< 0.001), increased risk of systolic hypertension (adjusted OR 2.87; 95% CI 1.90-4.34), IGT (OR 1.65; 95% CI 1.02-2.69) and overweight (OR 1.41; 95% CI 1.03-1.93) as compared to people born after the famine. The effect of fetal-infant famine on BP was seen in both women and men, whereas the effect on IGT was seen in men only, and the increased risk of overweight was confined to women. Conclusions: Fetal and infant undernutrition is associated with significantly increased risk of hypertension and impaired glucose tolerance in 40-year-old Nigerians. Prevention of undernutrition during pregnancy and in infancy should therefore be given high priority in health, education, and economic agendas.

BackgroundSub-Saharan Africa is facing rapidly increasing prevalences of cardiovascular disease, obesity, diabetes and hypertension. Previous and ongoing undernutrition among pregnant women may contribute to this development as suggested by epidemiological studies from high income countries linking undernutrition in fetal life with increased burden of non-communicable diseases in later life. We undertook to study the risks for hypertension, glucose intolerance and overweight forty years after fetal exposure to famine afflicted Biafra during the Nigerian civil war (1967-1970).Methods and findingsCohort study performed in June 27-July 31, 2009 in Enugu, Nigeria. Adults (n = 1,339) born before (1965-67), during (1968-January 1970), or after (1971-73) the years of famine were included. Blood pressure (BP), random plasma glucose (p-glucose) and anthropometrics, as well as prevalence of hypertension (BP>140/90 mmHg), impaired glucose tolerance (IGT; p-glucose 7.8-11.0 mmol/l), diabetes (DM; p-glucose ≥11.1 mmol/l), or overweight (BMI>25 kg/m(2)) were compared between the three groups. Fetal-infant exposure to famine was associated with elevated systolic (+7 mmHg; pConclusionsFetal and infant undernutrition is associated with significantly increased risk of hypertension and impaired glucose tolerance in 40-year-old Nigerians. Prevention of undernutrition during pregnancy and in infancy should therefore be given high priority in health, education, and economic agendas.