Designing a valid randomized pragmatic primary care implementation trial: the my own health report (MOHR) project

Medical Assistant Health Coaching for Type 2 Diabetes in Primary Care: Results From a Pragmatic Cluster Randomized Controlled Trial

OBJECTIVE

This cluster (clinic-level) randomized controlled trial (RCT) compared medical assistant (MA) health coaching (MAC) with usual care (UC) among at-risk adults with type 2 diabetes in two diverse real-world primary care environments: a federally qualified health center (FQHC; Neighborhood Healthcare) and a large nonprofit private insurance-based health system (Scripps Health).

RESEARCH DESIGN AND METHODS

A total of 600 adults with type 2 diabetes who met one or more of the following criteria in the last 90 days were enrolled: HbA1c ≥8% and/or LDL cholesterol ≥100 mg/dL and/or systolic blood pressure (SBP) ≥140 mmHg. Participants at MAC clinics received in-person and telephone self-management support from a specially trained MA health coach for 12 months. Electronic medical records were used to examine clinical outcomes in the overall sample. Behavioral and psychosocial outcomes were evaluated in a subsample (n = 300).

RESULTS

All clinical outcomes improved significantly over 1 year in the overall sample (P < 0.001). The reduction in HbA1c was significantly greater in the MAC versus UC group (unstandardized Binteraction = -0.06; P = 0.002). A significant time by group by site interaction also showed that MAC resulted in greater improvements in LDL cholesterol than UC at Neighborhood Healthcare relative to Scripps Health (Binteraction = -1.78 vs. 1.49; P < 0.05). No other statistically significant effects were observed.

CONCLUSIONS

This was the first large-scale pragmatic RCT supporting the real-world effectiveness of MAC for type 2 diabetes in U.S. primary care settings. Findings suggest that this team-based approach may be particularly effective in improving diabetes outcomes in FQHC settings.

Aligning the planning, development, and implementation of complex interventions to local contexts with an equity focus: application of the PRISM/RE-AIM Framework

For the fields of implementation science and health equity, understanding and being responsive to local contexts is of utmost importance to better inform the development, implementation, and evaluation of healthcare and public health interventions to increase their uptake and sustainment. Contexts are multi-level and include political, historical, economic, and social factors that influence health, as well as organizational characteristics, reflecting the richness of members' views, resources, values, and needs. Poor alignment between solutions and those contextual characteristics could have an impact on inequities. The PRISM (Practical Robust Implementation and Sustainability Model) is a context-based implementation science framework that incorporates RE-AIM outcomes (Reach, Effectiveness, Adoption, Implementation, Maintenance) and offers guidance to researchers, practitioners, and their patient and community partners on how to conceptualize, assess, and address contextual domains with a focus on health equity. Drawing from systems thinking, participatory engagement, and health equity principles, this commentary expands on previous work to 1) offer a novel perspective on how to align an intervention's core functions and forms with the PRISM's contextual domains, and 2) foster an ongoing and iterative engagement process with diverse partners throughout the research and practice process using a co-creation approach. We recommend intervention-to-context alignment through iterative cycles. To that end, we present the RE-AIM Framework's 'outcomes cascade' to illustrate touch points of opportunity and gaps within and across each of the five RE-AIM outcomes to illustrate 'where things go wrong'. We present a case study to illustrate and offer recommendations for research and practice efforts to increase contextual responsiveness, and enhance alignment with context before, during, and after implementation efforts and to ensure equity is being addressed. We strive to make a conceptual contribution to advance the field of pragmatic research and implementation of evidence-based practices through the application of the contextually-based PRISM framework with a focus on health equity.

Development of a Health Behavior Screening Tool for Deaf College Students

Young adults who are Deaf or Hard-of-Hearing (D/HH) face behavioral health risks similar to hearing adults. Despite the emphasis on health behavior screening in health care settings, a brief screening tool in American Sign Language (ASL) does not exist. This manuscript describes the development and pilot testing of an online survey in ASL called the Deaf Health Behavior Report. The Deaf Health Behavior Report includes standardized questions for general health, health behaviors, and psychosocial topics. We invited all D/HH students at a university in Southern California to complete the Deaf Health Behavior Report. A total of 31 D/HH students completed the survey. The most prevalent health risks were related to nutrition, stress, and binge drinking. The Deaf Health Behavior Report is a useful tool for health promotion efforts on college campuses and in general health settings.

Feasibility of Patient Navigation for Care Planning in Primary Care

Objectives:

To help better control chronic conditions we need to address root causes of poor health like unhealthy behaviors, mental health, and social needs. However, addressing these needs in primary care is difficult. One solution may be connecting patients with a navigator for support creating a personal care goal.

Methods:

As part of an RCT to evaluate a feasible approach to care planning, 24 clinicians from 12 practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN) and 87 intervention patients with uncontrolled chronic conditions participated in a care planning intervention. We had a structured process to guide patients, train navigators, and adapt the navigation process to meet the needs of each practice.

Results:

Only 1 practice had bandwidth for staff to serve as a patient navigator, even for extra pay. For the other 11 practices, a research team member needed to provide navigation services. On average, patients wanted 25 weeks of support to complete care plans. The average time patients needed to speak with navigators on the phone was 7 min and 3 s. In exit interviews, patients consistently shared how motivational it was to have a caring person check in on them, offer help, and hold them accountable.

Conclusion:

Patient navigation to address care plans should be feasible. The time commitment is minimal. It does not require intensive training, and primary care is already doing much of this work. Yet, given the burden and competing demands in primary care, this help cannot be offered without additional resources.

Patient Preferences for Discussing and Acting on Health-Related Needs in Primary Care

Background:

Addressing social needs, health behaviors, and mental health may help patients more than traditional medical care. However, these root causes of poor health are difficult to address and the role of primary care is unclear. This qualitative study assesses patient’s willingness and motivations to discuss and accept assistance for these needs from their primary care team.

Methods:

In July and August of 2020, semi-structured virtual interviews were conducted with family medicine patients (n = 6) and residents of low resource neighborhoods (n = 11) in Richmond, Virginia. Interviews were conducted over Zoom. We conducted a qualitative analysis of patient and resident interview transcripts. A rapid qualitative analysis approach and immersion-crystallization processes were used to identify themes and categories.

Results:

Interviewees reported varying degrees of comfort discussing topics with their health care team. They were less comfortable discussing needs they considered outside the realm of “traditional primary care” including finances, transportation, and housing, but interviewees expressed willingness to discuss these needs under certain conditions. Important factors were a strong patient-clinician relationship to create a trusted and safe space for discussion, adequate time for discussion during visits, communication of practices’ ability to provide resources to help patients, and ensuring appropriate high quality referrals.

Conclusions:

Primary care provides opportunity for identifying and addressing needs that adversely impact health. Some needs are more sensitive for patients to work with their care team on, though, there was willingness to work on any need when a strong provider relationship and clinic structure for providing support were in place. This study highlights critical care delivery factors which may be used to enhance patient comfort accepting support for their needs and ultimately improve clinical care and chronic disease management.

Exploring the Relationship Between Community Program Location and Community Needs

INTRODUCTION

Health behaviors, mental health, and social needs impact health, but addressing these needs is difficult. Clinicians can partner with community programs to provide patients support. The relationship between program location and community need is uncertain.

METHODS

We identified and geolocated community programs in Richmond, Virginia, that aid with 9 domains of needs (mental health, smoking, unhealthy alcohol use, nutrition, physical activity, transportation, financial, housing, food insecurity). For each census tract, we identified needs from public data sources. We used 2 methods to compare program location and need: (1) hotspot analysis and (2) a negative binomial regression model.

RESULTS

We identified 280 community programs that provide aid for the 9 domains. Programs most often provided financial assistance (n = 121) and housing support (n = 73). The regression analysis showed no relationship between the number of community programs and the level of need in census tracts, with 2 exceptions. There was a positive association between financial programs and financial need and a negative association between housing programs and housing need.

CONCLUSIONS

Community programs are generally not colocated with need. This poses a barrier for people who need help addressing these domains.

Stakeholder input on a care planning tool to address unhealthy behaviors, mental health needs, and social risks: The value of different stakeholder perspectives

This report describes how stakeholder groups informed a web-based care planning tool's development for addressing root causes of poor health. Stakeholders included community members (n = 6), researchers (n = 6), community care providers (n = 9), and patients (n = 17). Feedback was solicited through focus groups, semi-structured interviews, and user experience observations and then qualitatively analyzed to identify themes. Each group contributed a unique perspective. Researchers wanted evidence-based content; community members and providers focused on making goals manageable; patients wanted care team support and simple action-oriented language. Our findings highlight the benefits of stakeholder input. Blending perspectives from multiple groups results in a more robust intervention design.

Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation

BACKGROUND

Health services have traditionally been developed to focus on specific diseases or medical specialties. Involving consumers as partners in planning, delivering and evaluating health services may lead to services that are person-centred and so better able to meet the needs of and provide care for individuals. Globally, governments recommend consumer involvement in healthcare decision-making at the systems level, as a strategy for promoting person-centred health services. However, the effects of this 'working in partnership' approach to healthcare decision-making are unclear. Working in partnership is defined here as collaborative relationships between at least one consumer and health provider, meeting jointly and regularly in formal group formats, to equally contribute to and collaborate on health service-related decision-making in real time. In this review, the terms 'consumer' and 'health provider' refer to partnership participants, and 'health service user' and 'health service provider' refer to trial participants. This review of effects of partnership interventions was undertaken concurrently with a Cochrane Qualitative Evidence Synthesis (QES) entitled Consumers and health providers working in partnership for the promotion of person-centred health services: a co-produced qualitative evidence synthesis.

OBJECTIVES

To assess the effects of consumers and health providers working in partnership, as an intervention to promote person-centred health services.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL databases from 2000 to April 2019; PROQUEST Dissertations and Theses Global from 2016 to April 2019; and grey literature and online trial registries from 2000 until September 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs of 'working in partnership' interventions meeting these three criteria: both consumer and provider participants meet; they meet jointly and regularly in formal group formats; and they make actual decisions that relate to the person-centredness of health service(s).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened most titles and abstracts. One review author screened a subset of titles and abstracts (i.e. those identified through clinical trials registries searches, those classified by the Cochrane RCT Classifier as unlikely to be an RCT, and those identified through other sources). Two review authors independently screened all full texts of potentially eligible articles for inclusion. In case of disagreement, they consulted a third review author to reach consensus. One review author extracted data and assessed risk of bias for all included studies and a second review author independently cross-checked all data and assessments. Any discrepancies were resolved by discussion, or by consulting a third review author to reach consensus. Meta-analysis was not possible due to the small number of included trials and their heterogeneity; we synthesised results descriptively by comparison and outcome. We reported the following outcomes in GRADE 'Summary of findings' tables: health service alterations; the degree to which changed service reflects health service user priorities; health service users' ratings of health service performance; health service users' health service utilisation patterns; resources associated with the decision-making process; resources associated with implementing decisions; and adverse events.

MAIN RESULTS

We included five trials (one RCT and four cluster-RCTs), with 16,257 health service users and more than 469 health service providers as trial participants. For two trials, the aims of the partnerships were to directly improve the person-centredness of health services (via health service planning, and discharge co-ordination). In the remaining trials, the aims were indirect (training first-year medical doctors on patient safety) or broader in focus (which could include person-centredness of health services that targeted the public/community, households or health service delivery to improve maternal and neonatal mortality). Three trials were conducted in high income-countries, one was in a middle-income country and one was in a low-income country. Two studies evaluated working in partnership interventions, compared to usual practice without partnership (Comparison 1); and three studies evaluated working in partnership as part of a multi-component intervention, compared to the same intervention without partnership (Comparison 2). No studies evaluated one form of working in partnership compared to another (Comparison 3). The effects of consumers and health providers working in partnership compared to usual practice without partnership are uncertain: only one of the two studies that assessed this comparison measured health service alteration outcomes, and data were not usable, as only intervention group data were reported. Additionally, none of the included studies evaluating this comparison measured the other primary or secondary outcomes we sought for the 'Summary of findings' table. We are also unsure about the effects of consumers and health providers working in partnership as part of a multi-component intervention compared to the same intervention without partnership. Very low-certainty evidence indicated there may be little or no difference on health service alterations or health service user health service performance ratings (two studies); or on health service user health service utilisation patterns and adverse events (one study each). No studies evaluating this comparison reported the degree to which health service alterations reflect health service user priorities, or resource use. Overall, our confidence in the findings about the effects of working in partnership interventions was very low due to indirectness, imprecision and publication bias, and serious concerns about risk of selection bias; performance bias, detection bias and reporting bias in most studies.

AUTHORS' CONCLUSIONS

The effects of consumers and providers working in partnership as an intervention, or as part of a multi-component intervention, are uncertain, due to a lack of high-quality evidence and/or due to a lack of studies. Further well-designed RCTs with a clear focus on assessing outcomes directly related to partnerships for patient-centred health services are needed in this area, which may also benefit from mixed-methods and qualitative research to build the evidence base.

Patient perspectives on tablet-based technology to collect risk factor information in primary care

BACKGROUND

Primary care provides an opportunity to introduce prevention strategies and identify risk behaviours. Algorithmic information technology such as the Risk Factor Identification Tool (RFIT) can support primary care counseling. This study explores the integration of the tablet-based RFIT in primary care clinics to support exploration of patient risk factor information.

METHODS

Qualitative study to explore patients' perspectives of RFIT. RFIT was implemented in two primary care clinics in Manitoba, Canada. There were 207 patients who completed RFIT, offered to them by eight family physicians. We conducted one-on-one patient interviews with 86 patients to capture the patient's perspective. Responses were coded and categorized into five common themes.

RESULTS

RFIT had a completion rate of 86%. Clinic staff reported that very few patients declined the use of RFIT or required assistance to use the tablet. Patients reported that the tablet-based RFIT provided a user-friendly interface that enabled self-reflection while in the waiting room. Patients discussed the impact of RFIT on the patient-provider interaction, utility for the clinician, their concerns and suggested improvements for RFIT. Among the patients who used RFIT 12.1% smoked, 21.2% felt their diet could be improved, 9.3% reported high alcohol consumption, 56.4% reported less than 150 min of PA a week, and 8.2% lived in poverty.

CONCLUSION

RFIT is a user-friendly tool for the collection of patient risk behaviour information. RFIT is particularly useful for patients lacking continuity in the care they receive. Information technology can promote self-reflection while providing useful information to the primary care clinician. When combined with practical tools and resources RFIT can assist in the reduction of risk behaviours.

Using Information Technology to Assess Patient Risk Factors in Primary Care Clinics: Pragmatic Evaluation

BACKGROUND

Tobacco use, physical inactivity, and poor diet are associated with morbidity and premature death. Health promotion and primary prevention counseling, advice, and support by a primary care provider lead to behavior change attempts among patients. However, although physicians consider preventative health important, there is often a larger focus on symptom presentation, acute care, and medication review.

OBJECTIVE

This study evaluated the feasibility, adoption, and integration of the tablet-based Risk Factor Identification Tool (RFIT) that uses algorithmic information technology to support obtainment of patient risk factor information in primary care clinics.

METHODS

This is a pragmatic developmental evaluation. Each clinic developed a site-specific implementation plan adapted to their workflow. The RFIT was implemented in 2 primary care clinics located in Manitoba. Perceptions of 10 clinic staff and 8 primary care clinicians informed this evaluation.

RESULTS

Clinicians reported a smooth and fast transfer of RFIT responses to an electronic medical record encounter note. The RFIT was used by 207 patients, with a completion rate of 86%. Clinic staff reported that approximately 3%-5% of patients declined the use of the RFIT or required assistance to use the tablet. Among the 207 patients that used the RFIT, 22 (12.1%) smoked, 39 (21.2%) felt their diet could be improved, 20 (12.0%) reported high alcohol consumption, 103 (56.9%) reported less than 150 minutes of physical activity a week, and 6 (8.2%) patients lived in poverty. Clinicians suggested that although a wide variety of patients were able to use the tablet-based RFIT, implemented surveys should be tailored to patient subgroups.

CONCLUSIONS

Clinicians and clinic staff positively reviewed the use of information technology in primary care. Algorithmic information technology can collect, organize, and synthesize individual health information to inform and tailor primary care counseling to the patients' context and readiness to change. The RFIT is a user-friendly tool that provides an effective method for obtaining risk factor information from patients. It is particularly useful for subsets of patients lacking continuity in the care they receive. When implemented within a context that can support practical interventions to address identified risk factors, the RFIT can inform brief interventions within primary care.

Medical assistant health coaching ("MAC") for type 2 diabetes in diverse primary care settings: A pragmatic, cluster-randomized controlled trial protocol

In the US, nearly 11% of adults were living with diagnosed diabetes in 2017, and significant type 2 diabetes (T2D) disparities are experienced by socioeconomically disadvantaged, racial/ethnic minority populations, including Hispanics. The standard 15-min primary care visit does not allow for the ongoing self-management support that is needed to meet the complex needs of individuals with diabetes. "Team-based" chronic care delivery is an alternative approach that supplements physician care with contact from allied health personnel in the primary care setting (e.g., medical assistants; MAs) who are specially trained to provide ongoing self-management support or "health coaching." While rigorous trials have shown MA health coaching to improve diabetes outcomes, less is known about if and how such a model can be integrated within real world, primary care clinic workflows. Medical Assistant Health Coaching for Type 2 Diabetes in Diverse Primary Care Settings - A Pragmatic, Cluster-Randomized Controlled Trial will address this gap. Specifically, this study compares MA health coaching versus usual care in improving diabetes clinical control among N = 600 at-risk adults with T2D, and is being conducted at four primary care clinics that are part of two health systems that serve large, ethnically/racially, and socioeconomically diverse populations in Southern California. Electronic medical records are used to identify eligible patients at both health systems, and to examine change in clinical control over one year in the overall sample. Changes in behavioral and psychosocial outcomes are being evaluated by telephone assessment in a subset (n = 300) of participants, and rigorous process and cost evaluations will assess potential for sustainability and scalability.

Real-world experiences with generating real-world evidence: Case Studies from PCORI's pragmatic clinical Studies program

BACKGROUND

Over the last decade, randomized studies evaluating outcomes of health care interventions conducted in real-world settings-often termed "pragmatic trials"-have come to be seen as an important means of obtaining relevant, actionable evidence to guide health care decisions. Despite extensive writing on methodological considerations in pragmatic trial design, limited information exists regarding the practical and logistical challenges encountered in carrying out rigorous randomized evaluations in highly representative, real-world contexts.

METHODS

The Patient Centered Outcomes Research Institute (PCORI) convened an expert panel in 2017 to examine common tradeoffs in study design and implementation through 3 "case studies" of in-progress, PCORI-funded pragmatic trials. This paper summarizes the findings of this panel, using the 3 examples to illustrate common implementation challenges encountered in pragmatic trials.

RESULTS

Investigators aimed to generate highly generalizable findings that could address real-world clinical decisions; however, practical considerations required that each study incorporate traditionally "explanatory" elements to achieve a "fit-for-purpose" approach to design and implementation. Within individual studies, efforts to balance pragmatic versus explanatory perspectives often involved multiple, diverse aspects of trial design and implementation, and the aspects of design and implementation where investigators reported encountering such tradeoffs varied across the three cases we examined.

CONCLUSIONS

Efforts to generate rigorous evidence that is generalizable to "real-world" practice require continuous and iterative efforts to balance "pragmatic" and "explanatory" perspectives. In each study examined, these tradeoffs were guided both by an overriding effort to maintain pragmatism and practical considerations that varied depending on the research question and study context.

Enhanced care planning and clinical-community linkages versus usual care to address basic needs of patients with multiple chronic conditions: a clinician-level randomized controlled trial

Background

Many patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical management of MCC may have limited benefit if patients are struggling to address their basic life needs. Health systems and communities increasingly recognize the need to address these issues and are experimenting with and investing in new models for connecting patients with needed services. Yet primary care clinicians, whose regular contact with patients makes them more familiar with patients’ needs, are often not included in these systems.

Methods

We are starting a clinician-level cluster-randomized controlled trial to evaluate how primary care clinicians can participate in these community and hospital solutions and whether doing so is effective in controlling MCC. Sixty clinicians in the Virginia Ambulatory Care Outcomes Research Network will be matched by age and sex and randomized to usual care (control condition) or enhanced care planning with clinical-community linkage support (intervention). From the electronic health record we will identify all patients with MCC, including cardiovascular disease or risks, diabetes, obesity, or depression. A baseline assessment will be mailed to up to 50 randomly selected patients for each clinician (3000 total). Ten respondents per clinician (600 patients total) with uncontrolled MCC will be randomly selected for study inclusion, with oversampling of minorities. The intervention includes two components. First, we will use an enhanced care planning tool, My Own Health Report (MOHR), to screen patients for health behavior, mental health, and social needs. Patients will be supported by a patient navigator, who will help patients prioritize needs, create care plans, and write a personal narrative to guide the care team. Patients will update care plans every 1 to 2 weeks. Second, we will create community-clinical linkage to help address patients’ needs. The linkage will include community resource registries, personnel to span settings (patient navigators and a community health worker), and care team coordination across team members through MOHR.

Discussion

This study will help inform efforts by primary care clinicians to help address unhealthy behaviors, mental health needs, and social risks as a strategy to better control MCC.

Trial registration

ClinicalTrials.gov: NCT03885401. Registered on 19 September 2019.

Maternal adverse childhood experiences are associated with binge drinking during pregnancy in a dose-dependent pattern: Findings from the All Our Families cohort

BACKGROUND

Binge drinking (BD) is a serious risk factor for fetal alcohol spectrum disorders (FASD) and associated with more severe forms of the disorder. Thus, special attention to specific risk factors for BD adjacent to and during pregnancy is warranted.

OBJECTIVES

(1) To examine the role that maternal adverse childhood experiences (ACEs) may play in BD in the 12 months before pregnancy and during pregnancy in a sample of women with moderate to high socioeconomic status; and (2) to examine the sociodemographic correlates of BD before and during pregnancy within this sample.

PARTICIPANTS AND SETTING

This secondary analysis (N = 1663) was derived from the All Our Families prospective cohort study collected in Alberta, Canada between 2008-2011.

METHODS

Data were collected using three mailed surveys completed by women during and after pregnancy. An established scale examined maternal ACEs before 18 years. Adjusted logistic regression models tested associations between ACE score and BD before and during pregnancy.

RESULTS

Approximately 5 in 10 (48.3 %) and 1 in 10 (10.0 %) women reported ≥1 BD episode before and during pregnancy; respectively. In adjusted models, a woman's ACE score was associated with BD pre-pregnancy in a weak, nonmonotonic fashion; and during pregnancy in a moderate, dose-response fashion. Overall, ACEs resulted in two to three-fold increase in the odds of BD during pregnancy.

CONCLUSIONS

Maternal ACEs were common in this middle to upper-middle income, well-educated sample and impacted the next generation through BD in pregnancy. These findings combine with others to speak to the public health significance of maternal ACEs on alcohol-related behaviour among expectant mothers across the socioeconomic spectrum, and the need for targeted evidence-based interventions for this population.

An Adaptive, Contextual, Technology-Aided Support (ACTS) System for Chronic Illness Self-Management

Policy Points Fundamental changes are needed in how complex chronic illness conditions are conceptualized and managed. Health management plans for chronic illness need to be integrated, adaptive, contextual, technology aided, patient driven, and designed to address the multilevel social environment of patients' lives. Such primary care-based health management plans are feasible today but will be even more effective and sustainable if supported by systems thinking, technological advances, and policies that create and reinforce home, work, and health care collaborations.

CONTEXT

The current health care system is failing patients with chronic illness, especially those with complex comorbid conditions and social determinants of health challenges. The current system combined with unsustainable health care costs, lack of support for primary care in the United States, and aging demographics create a frightening probable future.

METHODS

Recent developments, including integrated behavioral health, community resources to address social determinants, population health infrastructure, patient-centered digital-health self-management support, and complexity science have the potential to help address these alarming trends. This article describes, first, the opportunity to integrate these trends and, second, a proposal for an integrated, patient-directed, adaptive, contextual, and technology-aided support (ACTS) system, based on a patient's life context and home/primary care/work-setting "support triangle."

FINDINGS

None of these encouraging trends is a panacea, and although most have been described previously, they have not been integrated. Here we discuss an example of integration using these components and how our proposed model (termed My Own Health Report) can be applied, along with its strengths, limitations, implications, and opportunities for practice, policy, and research.

CONCLUSIONS

This ACTS system builds on and extends the current chronic illness management approaches. It is feasible today and can produce even more dramatic improvements in the future.

Can the Routine Use of Patient-Reported Outcome Measures Improve the Delivery of Person-Centered Diabetes Care? A Review of Recent Developments and a Case Study

PURPOSE OF REVIEW

In recent years, the recommendation for and use of patient-reported outcome measures (PROMs) in routine diabetes care has significantly increased. We review recent evidence and highlight key opportunities and challenges related to the active clinical use of PROMs to support person-centered diabetes care and focus areas for future research in the area.

RECENT FINDINGS

Recent pragmatic studies support that integration of multi-dimensional PROMs for diabetes in clinical care as part of a care improvement strategy can be acceptable for and valued by people with diabetes (PWD) and healthcare professionals (HCPs) and may improve multiple aspects of quality of care, including screening, medical care monitoring and decision support, individualization of self-management support and goal-setting, and broader benefits related to active patient participation and person-centred diabetes care. We identify multiple intervention, individual, and care setting characteristics, which influence acceptability, feasibility, implementation, and effectiveness of PROMs in routine care. Recent clinical PROM studies highlight the value of mixed methods research and systematic involvement of PWD, clinicians, and other stakeholders in the design and implementation of questionnaires for patient input in routine diabetes care. We identified a new significant trend towards participatory development of multi-dimensional PROMs with the aim of IT-enabled integration into routine diabetes care to facilitate multiple components of person-centered diabetes care and better clinical, quality of life, and cost outcomes. While results from large-scale randomized controlled studies are still limited, a growing number of pragmatic implementation studies support that user-centric PROM interventions have the potential to facilitate significant improvements in care for PWD.

Patient Experience in Primary Care: A Systematic Review of CG-CAHPS Surveys

The National Academy of Medicine's (NAM) vision for 21st-century health care underscored the need for increased patient engagement and charged health-care researchers to develop tools to evaluate patient experience. The most widely studied patient experience tools are the Consumer Assessments of Healthcare Providers and Systems (CAHPS) surveys. The Clinician and Group (CG)-CAHPS survey is the preferred patient experience survey for primary care, and thus a systematic review of patient reports from the CG-CAHPS empirical literature is ideal to appreciate the voice of health-care consumers. This systematic review revealed patient subjective reports regarding the acceptability of health-care delivery models, the effectiveness of interventions, the timeliness of care in different practice climates, and their responses to quality improvement initiatives. The synthesized results inform clinicians, organizations, and the health-care system where to prioritize and how to adapt services to efficiently provide equitable care, achieving the NAM's vision for a patient-centered US health-care system.

Stakeholder perspectives on costs and resource expenditures: tools for addressing economic issues most relevant to patients, providers, and clinics

Cost and other resources required are often primary considerations in whether a potential program or policy will be adopted or implemented and an important element in determining value. However, few economic analyses are conducted from the perspective of patient/family or small-scale stakeholders such as local clinics. We outline and discuss alternative cost assessment and resource expenditures options from the perspective of these small, proximal stakeholders. The perspective of these persons differs from larger societal or health plan perspectives, and often differs across individuals in terms of what they value and the types of expenditures about which they are concerned. We discuss key features of the perspectives of patients, health care clinics, and local leaders, and present brief examples and sample templates for collection of consumer/stakeholder relevant cost and return on investment issues. These tools can be used prospectively and iteratively during program planning, intervention delivery, summative analysis, and preparation for dissemination stages. There is an important need for this type of feasible, pragmatic, rapid, and iterative cost and resource expenditure analysis directly relevant to patients/families, small local stakeholders and their organizations. Future research on and use of these approaches is recommended.

Online Resources for Dissemination and Implementation Science: Meeting Demand and Lessons Learned

A dramatically increased interest in dissemination and implementation (D&I) science, with relatively few training programs for D&I scientists, highlights the need for innovative ways to deliver educational materials, training, and resources. We described nine interactive, web-based D&I science resources appropriate for trainees and Clinical and Translational Science Awards. We used audience feedback and design thinking to develop resources iteratively. Primary target users are T3–T4 researchers, although T2 researchers can benefit from “designing for dissemination” resources. Workforce development resources were used in D&I science workshops, as stand-alone, self-directed resources, and for consultations and trainings. We assessed resource design (purpose, functionality), usage, user experience and engagement. Educational resources addressed included: D&I science basics, pragmatic trials, getting proposals funded, designing for dissemination, and D&I science theory selection. We reviewed the purpose, functionality, status, and usage of these interactive resources. All resources engaged users; provided interactive feedback for learners; and linked users to additional learning resources. Online resources can be valuable for preparing clinical and translational mentees for research consultations, as follow-up training activities, and as D&I workforce development resources. The resources described are publicly available and we encourage their use, further development, and evaluation by Clinical and Translational Science Awards and other programs.

Pragmatic dissemination and implementation research models, methods and measures and their relevance for nursing research

BACKGROUND

Pragmatic dissemination and implementation (D&I) research approaches can benefit patient care because they emphasize real-world settings and populations. Nurse scientists have an opportunity to reduce the gap between science and practice by using pragmatic D&I research and sustainability strategies.

PURPOSE

This article discusses pragmatic models, methods, and measures used in D&I research and their relevance for nursing research and enhancing population health.

METHODS

Summary of pragmatic D&I models and related methods for designing a pragmatic studies. We discuss the RE-AIM framework and the PRECIS-2 planning aid and figure in detail. A case study is provided and application to nursing research is discussed.

DISCUSSION

Successful translation of pragmatic D&I research demands an approach that addresses external validity, and customization at multiple levels including the patient, clinician, and setting. Context is critically important, and it is never too early to design for dissemination.

CONCLUSIONS

Pragmatic D&I approaches are needed to speed research translation, reduce avoidable waste of funding, improve clinical care, and enhance population health. Pragmatic D&I research is an area of tremendous opportunity for the nursing science community.

Gene-Metabolite Interaction in the One Carbon Metabolism Pathway: Predictors of Colorectal Cancer in Multi-Ethnic Families

For personalized healthcare, the purpose of this study was to examine the key genes and metabolites in the one-carbon metabolism (OCM) pathway and their interactions as predictors of colorectal cancer (CRC) in multi-ethnic families. In this proof-of-concept study, we included a total of 30 participants, 15 CRC cases and 15 matched family/friends representing major ethnic groups in southern California. Analytics based on supervised machine learning were applied, with the target variable being specified as cancer, including the ensemble method and generalized regression (GR) prediction. Elastic Net with Akaike's Information Criterion with correction (AICc) and Leave-One-Out cross validation GR methods were used to validate the results for enhanced optimality, prediction, and reproducibility. The results revealed that despite some family members sharing genetic heritage, the CRC group had greater combined gene polymorphism-mutations than the family controls (p < 0.1) for five genes including MTHFR C677T, MTHFR A1298C, MTR A2756G, MTRR A66G, and DHFR 19bp. Blood metabolites including homocysteine (7 µmol/L), methyl-folate (40 nmol/L) with total gene mutations (≥4); age (51 years) and vegetable intake (2 cups), and interactions of gene mutations and methylmalonic acid (MMA) (400 nmol/L) were significant predictors (all p < 0.0001) using the AICc. The results were validated by a 3% misclassification rate, AICc of 26, and >99% area under the receiver operating characteristic curve. These results point to the important roles of blood metabolites as potential markers in the prevention of CRC. Future intervention studies can be designed to target the ways to mitigate the enzyme-metabolite deficiencies in the OCM pathway to prevent cancer.

Using the Infrastructure of State Aging Services to Promote Prevention Behavior

Introduction

State infrastructure for aging services, such as programs in county senior centers, can help promote prevention of chronic disease and reach large numbers of older adults. The objective of our study was to assess how well such infrastructure can support prevention efforts.

Methods

The University of Pittsburgh CDC Prevention Research Center partnered with the Pennsylvania Department of Aging APPRISE program to deliver the 10 Keys to Healthy Aging program. APPRISE is a Medicare counseling program offered at senior centers; the 10 Keys is a series of behavior-activation workshops for people aged 50 or older that cover recommendations of the US Preventive Services Task Force and other evidence-based recommendations for health promotion. We assessed implementation, increases in prevention knowledge, and maintenance of prevention behavior.

Results

From 2013 through 2016, 1,534 adults at 83 sites participated in the program; 1,044 (68.1%) completed at least 8 of 10 Keys workshops. A total of 736 adults (mean [standard deviation] age, 74.9 [8.3] y) voluntarily completed a 14-item pretest and posttest of prevention knowledge; respondents’ knowledge score increased from 61.5% to 78.5% correct (P < .001). In a subsample (n = 339) reporting on their own prevention behaviors at baseline, quiz scores and prevention behaviors were correlated (r = 0.30, P < .001). In monthly telephone follow-up with 147 respondents over 6 months, maintenance of prevention behaviors was strong in the areas of physical activity and hypertension management and significantly higher for people completing a greater number of Keys workshops.

Conclusion

Prevention behavior can be activated in aging services settings and can be incorporated into daily routines.

Gene-environment interactions and predictors of breast cancer in family-based multi-ethnic groups

Breast cancer (BC) is the most common cancer in women worldwide and second leading cause of cancer-related death. Understanding gene-environment interactions could play a critical role for next stage of BC prevention efforts. Hence, the purpose of this study was to examine the key gene-environmental factors affecting the risks of BC in a diverse sample. Five genes in one-carbon metabolism pathway including MTHFR 677, MTHFR 1298, MTR 2756, MTRR 66, and DHFR 19bp together with demographics, lifestyle, and dietary intake factors were examined in association with BC risks. A total of 80 participants (40 BC cases and 40 family/friend controls) in southern California were interviewed and provided salivary samples for genotyping. We presented the first study utilizing both conventional and new analytics including ensemble method and predictive modeling based on smallest errors to predict BC risks. Predictive modeling of Generalized Regression Elastic Net Leave-One-Out demonstrated alcohol use (p = 0.0126) and age (p < 0.0001) as significant predictors; and significant interactions were noted between body mass index (BMI) and alcohol use (p = 0.0027), and between BMI and MTR 2756 polymorphisms (p = 0.0090). Our findings identified the modifiable lifestyle factors in gene-environment interactions that are valuable for BC prevention.

Personalized Nutrition-Genes, Diet, and Related Interactive Parameters as Predictors of Cancer in Multiethnic Colorectal Cancer Families

To personalize nutrition, the purpose of this study was to examine five key genes in the folate metabolism pathway, and dietary parameters and related interactive parameters as predictors of colorectal cancer (CRC) by measuring the healthy eating index (HEI) in multiethnic families. The five genes included methylenetetrahydrofolate reductase (MTHFR) 677 and 1298, methionine synthase (MTR) 2756, methionine synthase reductase (MTRR 66), and dihydrofolate reductase (DHFR) 19bp, and they were used to compute a total gene mutation score. We included 53 families, 53 CRC patients and 53 paired family friend members of diverse population groups in Southern California. We measured multidimensional data using the ensemble bootstrap forest method to identify variables of importance within domains of genetic, demographic, and dietary parameters to achieve dimension reduction. We then constructed predictive generalized regression (GR) modeling with a supervised machine learning validation procedure with the target variable (cancer status) being specified to validate the results to allow enhanced prediction and reproducibility. The results showed that the CRC group had increased total gene mutation scores compared to the family members (p < 0.05). Using the Akaike’s information criterion and Leave-One-Out cross validation GR methods, the HEI was interactive with thiamine (vitamin B1), which is a new finding for the literature. The natural food sources for thiamine include whole grains, legumes, and some meats and fish which HEI scoring included as part of healthy portions (versus limiting portions on salt, saturated fat and empty calories). Additional predictors included age, as well as gender and the interaction of MTHFR 677 with overweight status (measured by body mass index) in predicting CRC, with the cancer group having more men and overweight cases. The HEI score was significant when split at the median score of 77 into greater or less scores, confirmed through the machine-learning recursive tree method and predictive modeling, although an HEI score of greater than 80 is the US national standard set value for a good diet. The HEI and healthy eating are modifiable factors for healthy living in relation to dietary parameters and cancer prevention, and they can be used for personalized nutrition in the precision-based healthcare era.

Behavioral and mental health risk factor profiles among diverse primary care patients

Behavioral and mental health risk factors are prevalent among primary care patients and contribute substantially to premature morbidity and mortality and increased health care utilization and costs. Although prior studies have found most adults screen positive for multiple risk factors, limited research has attempted to identify factors that most commonly co-occur, which may guide future interventions. The purpose of this study was to identify subgroups of primary care patients with co-occurring risk factors and to examine sociodemographic characteristics associated with these subgroups. We assessed 12 behavioral health risk factors in a sample of adults (n=1628) receiving care from nine primary care practices across six U.S. states in 2013. Using latent class analysis, we identified four distinct patient subgroups: a 'Mental Health Risk' class (prevalence=14%; low physical activity, high stress, depressive symptoms, anxiety, and sleepiness), a 'Substance Use Risk' class (29%; highest tobacco, drug, alcohol use), a 'Dietary Risk' class (29%; high BMI, poor diet), and a 'Lower Risk' class (27%). Compared to the Lower Risk class, patients in the Mental Health Risk class were younger and less likely to be Latino/Hispanic, married, college educated, or employed. Patients in the Substance Use class tended to be younger, male, African American, unmarried, and less educated. African Americans were over 7 times more likely to be in the Dietary Risk versus Lower Risk class (OR 7.7, 95% CI 4.0-14.8). Given the heavy burden of behavioral health issues in primary care, efficiently addressing co-occurring risk factors in this setting is critical.

Predictors of the Healthy Eating Index and Glycemic Index in Multi-Ethnic Colorectal Cancer Families

For personalized nutrition in preparation for precision healthcare, we examined the predictors of healthy eating, using the healthy eating index (HEI) and glycemic index (GI), in family-based multi-ethnic colorectal cancer (CRC) families. A total of 106 participants, 53 CRC cases and 53 family members from multi-ethnic families participated in the study. Machine learning validation procedures, including the ensemble method and generalized regression prediction, Elastic Net with Akaike’s Information Criterion with correction and Leave-One-Out cross validation methods, were applied to validate the results for enhanced prediction and reproducibility. Models were compared based on HEI scales for the scores of 77 versus 80 as the status of healthy eating, predicted from individual dietary parameters and health outcomes. Gender and CRC status were interactive as additional predictors of HEI based on the HEI score of 77. Predictors of HEI 80 as the criterion score of a good diet included five significant dietary parameters (with intake amount): whole fruit (1 cup), milk or milk alternative such as soy drinks (6 oz), whole grain (1 oz), saturated fat (15 g), and oil and nuts (1 oz). Compared to the GI models, HEI models presented more accurate and fitted models. Milk or a milk alternative such as soy drink (6 oz) is the common significant parameter across HEI and GI predictive models. These results point to the importance of healthy eating, with the appropriate amount of healthy foods, as modifiable factors for cancer prevention.

Chronic care coordination by integrating care through a team-based, population-driven approach: a case study

Patients with chronic conditions frequently experience behavioral comorbidities to which primary care cannot easily respond. This study observed a Vermont family medicine practice with integrated medical and behavioral health services that use a structured approach to implement a chronic care management system with Lean. The practice chose to pilot a population-based approach to improve outcomes for patients with poorly controlled Type 2 diabetes using a stepped-care model with an interprofessional team including a community health nurse. This case study observed the team's use of Lean, with which it designed and piloted a clinical algorithm composed of patient self-assessment, endorsement of behavioral goals, shared documentation of goals and plans, and follow-up. The team redesigned workflows and measured reach (patients who engaged to the end of the pilot), outcomes (HbA1c results), and process (days between HbA1c tests). The researchers evaluated practice member self-reports about the use of Lean and facilitators and barriers to move from pilot to larger scale applications. Of 20 eligible patients recruited over 3 months, 10 agreed to participate and 9 engaged fully (45%); 106 patients were controls. Relative to controls, outcomes and process measures improved but lacked significance. Practice members identified barriers that prevented implementation of all changes needed but were in agreement that the pilot produced useful outcomes. A systematized, population-based, chronic care management service is feasible in a busy primary care practice. To test at scale, practice leadership will need to allocate staffing, invest in shared documentation, and standardize workflows to streamline office practice responsibilities.

RE-AIM in Clinical, Community, and Corporate Settings: Perspectives, Strategies, and Recommendations to Enhance Public Health Impact

The RE-AIM Framework is a planning and evaluation model that has been used in a variety of settings to address various programmatic, environmental, and policy innovations for improving population health. In addition to the broad application and diverse use of the framework, there are lessons learned and recommendations for the future use of the framework across clinical, community, and corporate settings. The purposes of this article are to: (A) provide a brief overview of the RE-AIM Framework and its pragmatic use for planning and evaluation; (B) offer recommendations to facilitate the application of RE-AIM in clinical, community, and corporate settings; and (C) share perspectives and lessons learned about employing RE-AIM dimensions in the planning, implementation, and evaluation phases within these different settings. In this article, we demonstrate how the RE-AIM concepts and elements within each dimension can be applied by researchers and practitioners in diverse settings, among diverse populations and for diverse health topics.

Intentional research design in implementation science: implications for the use of nomothetic and idiographic assessment

The advancement of implementation science is dependent on identifying assessment strategies that can address implementation and clinical outcome variables in ways that are valid, relevant to stakeholders, and scalable. This paper presents a measurement agenda for implementation science that integrates the previously disparate assessment traditions of idiographic and nomothetic approaches. Although idiographic and nomothetic approaches are both used in implementation science, a review of the literature on this topic suggests that their selection can be indiscriminate, driven by convenience, and not explicitly tied to research study design. As a result, they are not typically combined deliberately or effectively. Thoughtful integration may simultaneously enhance both the rigor and relevance of assessments across multiple levels within health service systems. Background on nomothetic and idiographic assessment is provided as well as their potential to support research in implementation science. Drawing from an existing framework, seven structures (of various sequencing and weighting options) and five functions (Convergence, Complementarity, Expansion, Development, Sampling) for integrating conceptually distinct research methods are articulated as they apply to the deliberate, design-driven integration of nomothetic and idiographic assessment approaches. Specific examples and practical guidance are provided to inform research consistent with this framework. Selection and integration of idiographic and nomothetic assessments for implementation science research designs can be improved. The current paper argues for the deliberate application of a clear framework to improve the rigor and relevance of contemporary assessment strategies.

Gene Environment Interactions and Predictors of Colorectal Cancer in Family-Based, Multi-Ethnic Groups

For the personalization of polygenic/omics-based health care, the purpose of this study was to examine the gene-environment interactions and predictors of colorectal cancer (CRC) by including five key genes in the one-carbon metabolism pathways. In this proof-of-concept study, we included a total of 54 families and 108 participants, 54 CRC cases and 54 matched family friends representing four major racial ethnic groups in southern California (White, Asian, Hispanics, and Black). We used three phases of data analytics, including exploratory, family-based analyses adjusting for the dependence within the family for sharing genetic heritage, the ensemble method, and generalized regression models for predictive modeling with a machine learning validation procedure to validate the results for enhanced prediction and reproducibility. The results revealed that despite the family members sharing genetic heritage, the CRC group had greater combined gene polymorphism rates than the family controls (p < 0.05), on MTHFR C677T, MTR A2756G, MTRR A66G, and DHFR 19 bp except MTHFR A1298C. Four racial groups presented different polymorphism rates for four genes (all p < 0.05) except MTHFR A1298C. Following the ensemble method, the most influential factors were identified, and the best predictive models were generated by using the generalized regression models, with Akaike's information criterion and leave-one-out cross validation methods. Body mass index (BMI) and gender were consistent predictors of CRC for both models when individual genes versus total polymorphism counts were used, and alcohol use was interactive with BMI status. Body mass index status was also interactive with both gender and MTHFR C677T gene polymorphism, and the exposure to environmental pollutants was an additional predictor. These results point to the important roles of environmental and modifiable factors in relation to gene-environment interactions in the prevention of CRC.

Linking Data From Health Surveys and Electronic Health Records: A Demonstration Project in Two Chicago Health Center Clinics

Introduction

Monitoring and understanding population health requires conducting health-related surveys and surveillance. The objective of our study was to assess whether data from self-administered surveys could be collected electronically from patients in urban, primary-care, safety-net clinics and subsequently linked and compared with the same patients’ electronic health records (EHRs).

Methods

Data from self-administered surveys were collected electronically from a convenience sample of 527 patients at 2 Chicago health centers from September through November, 2014. Survey data were linked to EHRs.

Results

A total of 251 (47.6%) patients who completed the survey consented to having their responses linked to their EHRs. Consenting participants were older, more likely to report fair or poor health, and took longer to complete the survey than those who did not consent. For 8 of 18 categorical variables, overall percentage of agreement between survey data and EHR data exceeded 80% (sex, race/ethnicity, pneumococcal vaccination, self-reported body mass index [BMI], diabetes, high blood pressure, medication for high blood pressure, and hyperlipidemia), and of these, the level of agreement was good or excellent (κ ≥0.64) except for pneumococcal vaccination (κ = 0.40) and hyperlipidemia (κ = 0.47). Of 7 continuous variables, agreement was substantial for age and weight (concordance coefficients ≥0.95); however, with the exception of calculated survey BMI and EHR–BMI (concordance coefficient = 0.88), all other continuous variables had poor agreement.

Conclusions

Self-administered and web-based surveys can be completed in urban, primary-care, safety-net clinics and linked to EHRs. Linking survey and EHR data can enhance public health surveillance by validating self-reported data, completing gaps in patient data, and extending sample sizes obtained through current methods. This approach will require promoting and sustaining patient involvement.

SPIRIT trial: A phase III pragmatic trial of an advance care planning intervention in ESRD

Advance care planning (ACP) is a central tenet of dialysis care, but the vast majority of dialysis patients report never engaging in ACP discussions with their care providers. Over the last decade, we have developed and iteratively tested SPIRIT (Sharing Patient's Illness Representation to Increase Trust), a theory-based, patient- and family-centered advance care planning intervention. SPIRIT is a six-step, two-session, face-to-face intervention to promote cognitive and emotional preparation for end-of-life decision making for patients with ESRD and their surrogates. In these explanatory trials, SPIRIT was delivered by trained research nurses. Findings consistently revealed that patients and surrogates in SPIRIT showed significant improvement in preparedness for end-of-life decision making, and surrogates in SPIRIT reported significantly improved post-bereavement psychological outcomes after the patient's death compared to a no treatment comparison condition. As a critical next step, we are conducting an effectiveness-implementation study. This study is a multicenter, clinic-level cluster randomized pragmatic trial to evaluate the effectiveness of SPIRIT delivered by dialysis care providers as part of routine care in free-standing outpatient dialysis clinics, compared to usual care plus delayed SPIRIT implementation. Simultaneously, we will evaluate the implementation of SPIRIT, including sustainability. We will recruit 400 dyads of patients at high risk of death in the next year and their surrogates from 30 dialysis clinics in four states. This trial of SPIRIT will generate novel, meaningful insights about improving ACP in dialysis care.

TRIAL REGISTRATION

ClinicalTrials.govNCT03138564, registered 05/01/2017.

The impact of behavioral and mental health risk assessments on goal setting in primary care

Patient-centered health risk assessments (HRAs) that screen for unhealthy behaviors, prioritize concerns, and provide feedback may improve counseling, goal setting, and health. To evaluate the effectiveness of routinely administering a patient-centered HRA, My Own Health Report, for diet, exercise, smoking, alcohol, drug use, stress, depression, anxiety, and sleep, 18 primary care practices were randomized to ask patients to complete My Own Health Report (MOHR) before an office visit (intervention) or continue usual care (control). Intervention practice patients were more likely than control practice patients to be asked about each of eight risks (range of differences 5.3-15.8 %, p < 0.001), set goals for six risks (range of differences 3.8-16.6 %, p < 0.01), and improve five risks (range of differences 5.4-13.6 %, p < 0.01). Compared to controls, intervention patients felt clinicians cared more for them and showed more interest in their concerns. Patient-centered health risk assessments improve screening and goal setting.Trial RegistrationClinicaltrials.gov identifier: NCT01825746.

Development, Feasibility, and Small-Scale Implementation of a Web-Based Prognostic Tool-Surveillance, Epidemiology, and End Results Cancer Survival Calculator

BACKGROUND

Population datasets and the Internet are playing an ever-growing role in the way cancer information is made available to providers, patients, and their caregivers. The Surveillance, Epidemiology, and End Results Cancer Survival Calculator (SEER*CSC) is a Web-based cancer prognostic tool that uses SEER data, a large population dataset, to provide physicians with highly valid, evidence-based prognostic estimates for increasing shared decision-making and improving patient-provider communication of complex health information.

OBJECTIVE

The aim of this study was to develop, test, and implement SEER*CSC.

METHODS

An iterative approach was used to develop the SEER*CSC. Based on input from cancer patient advocacy groups and physicians, an initial version of the tool was developed. Next, providers from 4 health care delivery systems were recruited to do formal usability testing of SEER*CSC. A revised version of SEER*CSC was then implemented in two health care delivery sites using a real-world clinical implementation approach, and usage data were collected. Post-implementation follow-up interviews were conducted with site champions. Finally, patients from two cancer advocacy groups participated in usability testing.

RESULTS

Overall feedback of SEER*CSC from both providers and patients was positive, with providers noting that the tool was professional and reliable, and patients finding it to be informational and helpful to use when discussing their diagnosis with their provider. However, use during the small-scale implementation was low. Reasons for low usage included time to enter data, not having treatment options in the tool, and the tool not being incorporated into the electronic health record (EHR). Patients found the language in its current version to be too complex.

CONCLUSIONS

The implementation and usability results showed that participants were enthusiastic about the use and features of SEER*CSC, but sustained implementation in a real-world clinical setting faced significant challenges. As a result of these findings, SEER*CSC is being redesigned with more accessible language for a public facing release. Meta-tools, which put different tools in context of each other, are needed to assist in understanding the strengths and limitations of various tools and their place in the clinical decision-making pathway. The continued development and eventual release of prognostic tools should include feedback from multidisciplinary health care teams, various stakeholder groups, patients, and caregivers.

Understanding the applicability of results from primary care trials: lessons learned from applying PRECIS-2

OBJECTIVE

To compare two approaches for trial teams to apply PRECIS-2 to pragmatic trials: independent scoring and scoring following a group discussion.

STUDY DESIGN AND SETTING

We recruited multidisciplinary teams who were conducting or had conducted trials in primary care in collaboration with the Pragmatic Clinical Trials Unit, Queen Mary University of London. Each team carried out two rounds of scoring on the nine PRECIS-2 domains: first independently using an online version of PRECIS-2 and second following a discussion.

RESULTS

Seven teams took part in the study. Before the discussion, within-team agreement in scores was generally poor and not all raters were able to score all domains; agreement improved after the discussion. The PRECIS-2 wheels suggested that the trials were pragmatic, although some domains were more pragmatic than others.

CONCLUSION

PRECIS-2 can facilitate information exchange within trial teams. To apply PRECIS-2 successfully, we recommend a discussion between those with detailed understanding of what usual care is for the intervention, the trial's design including operational and technical aspects, and the PRECIS-2 domains. For some cluster-randomized trials, greater insight may be gained by plotting two PRECIS-2 wheels, one at the individual participant level and another at the cluster level.

Factors Related to Implementation and Reach of a Pragmatic Multisite Trial: The My Own Health Report (MOHR) Study

BACKGROUND

Contextual factors relevant to translating healthcare improvement interventions to different settings are rarely collected systematically. This study articulates a prospective method for assessing and describing contextual factors related to implementation and patient reach of a pragmatic trial in primary care.

METHODS

In a qualitative case-series, contextual factors were assessed from the My Own Health Report (MOHR) study, focused on systematic health risk assessments and goal setting for unhealthy behaviors and behavioral health in nine primary care practices. Practice staff interviews and observations, guided by a context template were conducted prospectively at three time points. Patient reach was calculated as percentage of patients completing MOHR of those who were offered MOHR and themes describing contextual factors were summarized through an iterative, data immersion process.These included practice members' motivations towards MOHR, practice staff capacity for implementation, practice information system capacity, external resources to support quality improvement, community linkages, and implementation strategy fit with patient populations.

CONCLUSIONS

Systematically assessing contextual factors prospectively throughout implementation of quality improvement initiatives helps translation to other health care settings. Knowledge of contextual factors is essential for scaling up of effective interventions.

Efficiency of "Prescribe Vida Saludable", a health promotion innovation. Pilot phase

OBJECTIVE

"Prescribe Vida Saludable" (PVS) is an organisational innovation designed to optimise the promotion of multiple healthy habits in primary healthcare. It aims to estimate the cost effectiveness and cost-utility of prescribing physical activity in the pilot phase of the PVS programme, compared to the routine clinical practice of promoting physical activity in primary healthcare.

METHODS

An economic evaluation of the quasi-experimental pilot phase of PVS was carried out. In the four control centres, a systematic sample was selected of 194 patients who visited the centre in a single year and who did not comply with physical activity recommendations. In the four intervention centres, 122 patients who received their first physical activity prescription were consecutively enrolled. The costs were evaluated from the perspective of the PVS programme using bottom-up methodology. The effectiveness (proportion of patients who changed their physical activity) as well as the utility were evaluated at baseline and after 3 months. The incremental cost-utility ratio (ICUR) and the incremental cost-effectiveness ratio (ICER) were calculated and a sensitivity analysis was performed with bootstrapping and 1,000 replications.

RESULTS

Information was obtained from 35% of control cases and 62% of intervention cases. The ICUR was €1,234.66/Quality Adjusted Life Years (QALY) and the ICER was €4.12. In 98.3% of the simulations, the ICUR was below the €30,000/QALY threshold.

CONCLUSIONS

The prescription of physical activity was demonstrably within acceptable cost-utility limits in the pilot PVS phase, even from a conservative perspective.

Metric properties of the "prescribe healthy life" screening questionnaire to detect healthy behaviors: a cross-sectional pilot study

Background

Feasible and valid assessment of healthy behaviors is the first step for integrating health promotion in routine primary care. Therefore, the aim of this study was to develop and evaluate the validity and reliability of the “prescribe healthy life” screening questionnaire, a brief tool for detecting physical activity levels, consumption of fruit and vegetables, tobacco use and patients’ compliance with minimal recommendations.

Methods

An observational cross-sectional study to determine the reliability and validity of this questionnaire by means of mixed (qualitative and quantitative) methods. Thirteen healthcare professionals designed the questionnaire. One hundred and twenty-six patients from three primary care health centers within Osakidetza (Basque Health Service, Spain) filled in the “Prescribe Healthy Life” Screening Questionnaire and completed an accelerometry record, the PREDIMED Food Frequency Questionnaire and a co-oximetry as gold standards for physical activity, dietary intake and tobacco use, respectively. Correlations, sensitivities, specificities, likelihood ratios and test-retest reliability were calculated. Additionally, the feasibility and utility of the questionnaire were evaluated.

Results

Both reliability and concurrent validity for the consumption of fruit and vegetables (r_spearman = 0.59, r_spearman = 0.50) and tobacco use (r_spearman = 0.76, r = 0.69) as their overall performance in the detection of unhealthy diet (accuracy = 76.8%, LR + = 3.1 and LR- = 0.31) and smokers (accuracy = 86.8%, LR + = 6.1 and LR- = 0.05) were good. Meanwhile, the reproducibility (0.38), the correlation between the minutes of physical activity (0.34) and LR+ (1.00) for detection of physical activity were low. On average the questionnaire was considered by patients easy to understand, easy to fill in, short (5–6 min) and useful.

Conclusion

The “Prescribe Healthy Life” Screening Questionnaire, PVS-SQ, has proved to be a simple and practical tool for use in the actual context of primary care, with guarantees of validity and reliability for the diet and tobacco scales. However, the physical activity scale show unsatisfactory results, and alternative questions ought to be tested.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3898-8) contains supplementary material, which is available to authorized users.

Integrating Physical Activity in Primary Care Practice

Based on a collaborative symposium in 2014 hosted by the Society of Behavioral Medicine (SBM) and the American College of Sports Medicine (ACSM), this paper presents a model for physical activity counseling for primary care physicians (PCPs). Most US adults do not meet national recommendations for physical activity levels. Socioecological factors drive differences in physical activity levels by geography, sex, age, and racial/ethnic group. The recent Patient Protection and Affordable Care Act incentivizes PCPs to offer patients physical activity counseling. However, PCPs have reported socioecological barriers to physical activity counseling and also patient barriers to physical activity, spanning from the individual to the environmental (eg, lack of safe spaces for physical activity), policy (eg, reimbursement policies), and organizational (eg, electronic medical record protocols, worksite norms/policies) levels. The aims of this paper are to: 1) discuss barriers to PCP counseling for physical activity; 2) provide evidence-based strategies and techniques to help PCPs address these counseling barriers; and 3) suggest practical steps for PCPs to counsel patients on physical activity using strategies and supports from policy, the primary care team, and other support networks.

An Individualized Approach to Cancer Screening Decisions in Older Adults: A Multilevel Framework

Guidelines for optimal cancer screening in older adults remain unclear, particularly for adults over the age of 75. While cancer screening in older adults may benefit some in good health, it may cause unnecessary burdens in others with limited life expectancy. Thus, a systematic approach to enable individualized cancer screening decisions in older adults is needed. We suggest a framework that guides such decisions through evidence-based approaches from multiple interactions, and that involves the patient, clinician, and healthcare system. An individualized approach considers differences in disease risk rather than the chronological age of the patient. This paper presents a comprehensive framework that depicts the independent and converging levels of influences on individualized cancer screening decisions in older adults. This Individualized Decisions for Screening (IDS) framework recognizes the reality of these interrelationships, including the tensions that arise when behaviors and outcomes are valued differently at the patient, clinician, and healthcare organization levels. Person-centered approaches are essential to advancing multilevel research of individualized cancer screening decisions among older adults.

Implementation of health risk assessments with family health history: barriers and benefits

Health risk assessments provide an opportunity to emphasise health promotion and disease prevention for individuals and populations at large. A key component of health risk assessments is the detailed collection of family health history information. This information is helpful in determining risk both for common chronic conditions and more rare diseases as well. While the concept of health risk assessments has been around since the Framingham Heart Study was launched in the 1950s, and such assessments are commonly performed in the workplace today, the US healthcare system has been slow to embrace them and the emphasis on prevention that they represent. Before wider implementation of health risk assessments within healthcare can be seen, several concerns must be addressed: (1) provider impact, (2) patient impact, (3) validity of patient-entered data and (4) health outcomes effect. Here, we describe recent developments in health risk assessment design that are helping to address these issues.

Texercise select effectiveness: an examination of physical activity and nutrition outcomes

Given the role of physical activity (PA) and good nutrition to delay the onset and progression of most chronic conditions, effective interventions are needed to influence lifestyle behaviors of community-dwelling populations. The purpose of this study is to examine the effectiveness of Texercise Select to improve health indicators, PA, and dietary behaviors, and confidence to engage in healthful behaviors. Texercise Select, a 12-week exercise program, was delivered. Baseline and 12-week follow-up assessments were collected from 220 participants with baseline data who were aged 45 years and older for this non-randomized one-group pre-post design trial. Linear mixed models were fitted for continuous outcome variables and GEE models with logit link function for binary outcome variables. Significant improvements (P < 0.05) were seen in physical activity scores (d = 0.64 for aerobic activity), weekly fruit/vegetable consumption (d = 0.31), daily water consumption (d = 0.29), as well as PA- and nutrition-related confidence (d =0.38 and 0.21, respectively) and social support (d =0.45). Programs rooted in best practices show promise for positively impacting large numbers of participants and becoming sustainably embedded in communities over time.

National study of chronic disease self-management: age comparison of outcome findings

INTRODUCTION

The adult population is increasingly experiencing one or more chronic illnesses and living with such conditions longer. The Chronic Disease Self-Management Program (CDSMP) helps participants cope with chronic disease-related symptomatology and improve their health-related quality of life. Nevertheless, the long-term effectiveness of this evidence-based program on older adults as compared to the middle-aged populations has not been examined in a large-scale, national rollout.

METHOD

We identified baseline characteristics of CDSMP participants aged 65 years or older (n = 687, M = 74.8 years) in the National Study of CDSMP from 2010 to 2012. Comparisons were made to middle-aged participants aged 50 to 64 (n = 325, M = 58.3 years). Assessments were conducted at baseline and 12-month follow-up. Linear and generalized linear mixed models were performed to assess changes in primary and secondary outcomes, controlling the key sociodemographics and number of chronic conditions.

RESULTS

All primary outcomes (i.e., social/role activities limitation, depression, communication with doctors) significantly improved in both the older and middle-aged cohorts. Although improvements in illness symptomatology (e.g., fatigue, pain, shortness of breath, and sleep problems) were similar across both cohorts, only the middle-aged cohort benefitted significantly in terms of overall quality of life and unhealthy mental health days. Effect sizes were larger among the middle-aged population who were also more likely to enter the program in poorer health and be from minority backgrounds.

CONCLUSIONS

The current study documented improved health outcomes but more so among the middle-aged population. Findings suggest the importance of examining how age and interacting life circumstances may affect chronic disease self-management.

Improving quality of care and long-term health outcomes through continuity of care with the use of an electronic or paper patient-held portable health file (COMMUNICATE): study protocol for a randomized controlled trial

BACKGROUND

The advantages of patient-held portable health files (PHF) and personal health records (PHR), paper or electronic, are said to include improved health-care provider continuity-of-care and patient empowerment in maintaining health. Top-down approaches are favored by public sector government and health managers. Bottom-up approaches include systems developed directly by health-care providers, consumers and industry, implemented locally on devices carried by patient-consumers or shared via web-based portals. These allow individuals to access, manage and share their health information, and that of others for whom they are authorized, in a private, secure and confidential environment. Few medical record technologies have been evaluated in randomized trials to determine whether there are important clinical benefits of these interventions. The COMMUNICATE trial will assess the acceptability and long-term clinical outcomes of an electronic and paper patient-held PHF.

METHODS/DESIGN

This is a 48-month, open-label pragmatic, superiority, parallel-group design randomized controlled trial. Subjects (n = 792) will be randomized in a 1:1:1 ratio to each of the trial arms: the electronic PHF added to usual care, the paper PHF added to usual care and usual care alone (no PHF). Inclusion criteria include those 60 years or older living independently in the community, but who have two or more chronic medical conditions that require prescription medication and regular care by at least three medical practitioners (general and specialist care). The primary objective is whether use of a PHF compared to usual care reduces a combined endpoint of deaths, overnight hospitalizations and blindly adjudicated serious out-of-hospital events. All primary analyses will be undertaken masked to randomized arm allocation using intention-to-treat principles. Secondary outcomes include quality of life and health literacy improvements.

DISCUSSION

Lack of blinding creates potential for bias in trial conduct and ascertainment of clinical outcomes. Mechanisms are provided to reduce bias, including balanced study contact with all participants, a blinded adjudication committee determining which out-of-hospital events are serious and endpoints that are objective (overnight hospitalizations and mortality). The PRECIS tool provides a summary of the trial's design on the Pragmatic-Explanatory Continuum.

TRIAL REGISTRATION

Registered with Clinicaltrials.gov (identifier: NCT01082978) on 8 March 2010.

Using the principles of complex systems thinking and implementation science to enhance maternal and child health program planning and delivery

Traditionally, epidemiologic methodologies have focused on measurement of exposures, outcomes, and program impact through reductionistic, yet complex statistical modeling. Although not new to the field of epidemiology, two frameworks that provide epidemiologists with a foundation for understanding the complex contexts in which programs and policies are implemented were presented to maternal and child health (MCH) professionals at the 2012 co-hosted 18th Annual MCH Epidemiology Conference and 22nd CityMatCH Urban Leadership Conference. The complex systems approach offers researchers in MCH the opportunity to understand the functioning of social, medical, environmental, and behavioral factors within the context of implemented public health programs. Implementation science provides researchers with a framework to translate the evidence-based program interventions into practices and policies that impact health outcomes. Both approaches offer MCH epidemiologists conceptual frameworks with which to re-envision how programs are implemented, monitored, evaluated, and reported to the larger public health audience. By using these approaches, researchers can begin to understand and measure the broader public health context, account for the dynamic interplay of the social environment, and ultimately, develop more effective MCH programs and policies.

Frequency and prioritization of patient health risks from a structured health risk assessment

PURPOSE

To describe the frequency and patient-reported readiness to change, desire to discuss, and perceived importance of 13 health risk factors in a diverse range of primary care practices.

METHODS

Patients (n = 1,707) in 9 primary care practices in the My Own Health Report (MOHR) trial reported general, behavioral, and psychosocial risk factors (body mass index [BMI], health status, diet, physical activity, sleep, drug use, stress, anxiety or worry, and depression). We classified responses as "at risk" or "healthy" for each factor, and patients indicated their readiness to change and/or desire to discuss identified risk factors with providers. Patients also selected 1 of the factors they were ready to change as most important. We then calculated frequencies within and across these factors and examined variation by patient characteristics and across practices.

RESULTS

On average, patients had 5.8 (SD = 2.12; range, 0-13) unhealthy behaviors and mental health risk factors. About 55% of patients had more than 6 risk factors. On average, patients wanted to change 1.2 and discuss 0.7 risks. The most common risks were inadequate fruit/vegetable consumption (84.5%) and overweight/obesity (79.6%). Patients were most ready to change BMI (33.3%) and depression (30.7%), and most wanted to discuss depression (41.9%) and anxiety or worry (35.2%). Overall, patients rated health status as most important.

CONCLUSIONS

Implementing routine comprehensive health risk assessments in primary care will likely identify a high number of behavioral and psychosocial health risks. By soliciting patient priorities, providers and patients can better manage counseling and behavior change.

Practice-based research networks (PBRNs) are promising laboratories for conducting dissemination and implementation research

Dissemination and implementation science addresses the application of research findings in varied health care settings. Despite the potential benefit of dissemination and implementation work to primary care, ideal laboratories for this science have been elusive. Practice-based research networks (PBRNs) have a long history of conducting research in community clinical settings, demonstrating an approach that could be used to execute multiple research projects over time in broad and varied settings. PBRNs also are uniquely structured and increasingly involved in pragmatic trials, a research design central to dissemination and implementation science. We argue that PBRNs and dissemination and implementation scientists are ideally suited to work together and that the collaboration of these 2 groups will yield great value for the future of primary care and the delivery of evidence-based health care.

The cancer prevention and control research network: An interactive systems approach to advancing cancer control implementation research and practice

BACKGROUND

Although cancer research has advanced at a rapid pace, a gap remains between what is known about how to improve cancer prevention and control (CPC) and what is implemented as best practices within health care systems and communities. The Cancer Prevention and Control Research Network (CPCRN), with more than 10 years of dissemination and implementation research experience, aims to accelerate the uptake and use of evidence-based CPC interventions.

METHODS

The collective work of the CPCRN has facilitated the analysis and categorization of research and implementation efforts according to the Interactive Systems Framework for Dissemination and Implementation (ISF), providing a useful heuristic for bridging the gap between prevention research and practice. The ISF authors have called for examples of its application as input to help refine the model.

RESULTS

We provide examples of how the collaborative activities supported by the CPCRN, using community-engaged processes, accelerated the synthesis and translation of evidence, built both general and innovation-specific capacity, and worked with delivery systems to advance cancer control research and practice.

CONCLUSIONS

The work of the CPCRN has provided real-world examples of the application of the ISF and demonstrated that synthesizing and translating evidence can increase the potential that evidence-based CPC programs will be used and that capacity building for both the support system and the delivery system is crucial for the successful implementation and maintenance of evidence-based cancer control.

IMPACT

Adoption and implementation of CPC can be enhanced by better understanding ISF systems and intervening to improve them.