Sharing Colorectal Cancer Follow-Up Using an E-Care Plan Between Cancer Services and Primary Health Care

High quality, long term follow-up care for cancer patients needs to be coordinated, comprehensive and tailored to the diverse needs of patients. This study implemented shared follow-up care using an interactive e-care plan that provided a collaborative space to schedule and share goals, tasks and information and support the monitoring of care. Qualitative results identified good relational coordination. Increasing communication from the cancer service is important.

Access to general practice for preventive health care for people who experience severe mental illness in Sydney, Australia: a qualitative study

BACKGROUND

People with lived experience of severe mental illness (PWLE) live around 20years less than the general population. Most deaths are due to preventable health conditions. Improved access to high-quality preventive health care could help reduce this health inequity. This study aimed to answer the question: What helps PWLE access preventive care from their GP to prevent long-term physical conditions?

METHODS

Qualitative interviews (n=10) and a focus group (n=10 participants) were conducted with PWLE who accessed a community mental health service and their carers (n=5). An asset-based framework was used to explore what helps participants access and engage with a GP. A conceptual framework of access to care guided data collection and analysis. Member checking was conducted with PWLE, service providers and other stakeholders. A lived experience researcher was involved in all stages of the study.

RESULTS

PWLE and their carers identified multiple challenges to accessing high-quality preventive care, including the impacts of their mental illness, cognitive capacity, experiences of discrimination and low income. Some GPs facilitated access and communication. Key facilitators to access were support people and affordable preventive care.

CONCLUSION

GPs can play an important role in facilitating access and communication with PWLE but need support to do so, particularly in the context of current demands in the Australian health system. Support workers, carers and mental health services are key assets in supporting PWLE and facilitating communication between PWLE and GPs. GP capacity building and system changes are needed to strengthen primary care's responsiveness to PWLE and ability to engage in collaborative/shared care.

Challenges and solutions to sharing a cancer follow-up e-care plan between a cancer service and general practice

OBJECTIVE

This paper describes the process of developing a shared cancer care approach in follow-up, and identifies the e-health options that support an interactive e-care plan shared between a public cancer service, general practitioners (GPs) and cancer survivors. Type of program/service: The cancer service improvement initiative for shared care in follow-up targets colorectal cancer patients who have completed active treatment and who agree to shared care between specialists, GPs and other care team members. The intiative is supported by an agreed shared care pathway and an interactive e-care plan that is dynamic, can be shared and has functionalities that support collaboration. Design and development: A consultative process with stakeholders (local and state health services, a Primary Health Network, GPs and a consumer) was undertaken. Responses from individual consultations (25 stakeholders) were collated and commonalities identified to inform a workshop with 13 stakeholders to obtain consensus on the care pathway and e-health solution. Implications for policy and practice were identified throughout the process.

OUTCOMES

The stakeholders agreed to a shared care pathway, which included assessment and consent, GP engagement, tailoring the care plan and communicating results and information as tasks are completed. The nurse coordinator monitored care. No interactive e-care plans were available at national, state or local health service levels. A web-based GP interactive e-care plan was selected. The main concerns raised were uncertainty about the security of e-health systems not controlled by the local health service and sharing clinical information with external health providers, engaging GPs, and patient anxiety about the capacity of general practice to provide care. The e-care plan provided a low-risk solution to sharing patient information and supported collaborative care. Challenges to share e-care plans have implications for policy and practice.

LESSONS LEARNT

Stakeholders and the project team agreed that finding an e-health system that supported shared cancer care in follow-up and addressed the security and information sharing concerns could not all be adequately addressed at the local level. A GP interactive e-care plan provides a promising solution to a number of the barriers.

Assessing suitability for long-term colorectal cancer shared care: a scenario-based qualitative study

Background

Shared care is the preferred model for long-term survivorship care by cancer survivors, general practitioners and specialists. However, survivorship care remains specialist-led. A risk-stratified approach has been proposed to select suitable patients for long-term shared care after survivors have completed adjuvant cancer treatment. This study aims to use patient scenarios to explore views on patient suitability for long-term colorectal cancer shared care across the risk spectrum from survivors, general practitioners and specialists.

Methods

Participants completed a brief questionnaire assessing demographics and clinical issues before a semi-structured in-depth interview. The interviews focused on the participant’s view on suitability for long term cancer shared care, challenges and facilitators in delivering it and resources that would be helpful. We conducted thematic analysis using an inductive approach to discover new concepts and themes.

Results

Interviews were conducted with 10 cancer survivors, 6 general practitioners and 9 cancer specialists. The main themes that emerged were patient-centredness, team resilience underlined by mutual trust and stronger system supports by way of cancer-specific training, survivorship care protocols, shared information systems, care coordination and navigational supports.

Conclusions

Decisions on the appropriateness of this model for patients need to be made collaboratively with cancer survivors, considering their trust and relationship with their general practitioners and the support they need. Further research on improving mutual trust and operationalising support systems would assist in the integration of shared survivorship care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-020-01311-w.

Primary health care provider-focused interventions for improving outcomes for people with type 2 diabetes: a rapid review

Objectives and importance of the study: The bulk of care for people with type 2 diabetes occurs in primary health care. This rapid review evaluated the effectiveness of primary health care provider-focused interventions in improving biochemical, clinical, psychological and health-related quality-of-life outcomes in people with type 2 diabetes.

METHODS

We searched Medline, Embase, All EBM Reviews, CINAHL, PsycINFO and grey literature focusing on the Organisation for Economic Co-operation and Development (OECD) member countries. We selected studies that targeted adults with type 2 diabetes, described a provider-focused intervention conducted in primary health care, and included an evaluation component. Four researchers extracted data and each included study was assessed for quality by two researchers.

RESULTS

Of the 15 studies identified, there was one systematic review (high quality), four randomised controlled trials (RCTs) (two strong quality, one each moderate and weak) and 10 cluster RCTs (two strong quality, five moderate, three weak). The range of follow-up periods was 3-32 months. In all but one study, the intervention was compared against usual care. The applied interventions included: computerised and noncomputerised decision support; culturally tailored interventions; feedback to the healthcare provider on quality of diabetes care; practice nurse involvement; and integrated primary and specialist care. All interventions aimed to improve the biochemical outcomes of interest; 13 studies also included clinical, psychological and/or health-related quality-of-life outcomes. Outcome results were mixed.

CONCLUSIONS

All interventions had mixed impacts on the outcomes of interest except the one study testing a decision aid, which did not show any improvement. A number of interventions are already available in Australia but need wider adoption. Other effective interventions are yet to be broadly adopted, and need to be evaluated for their applicability, feasibility and sustainability in the Australian context.

Linking observational data from general practice, hospital admissions and diabetes clinic databases: can it be used to predict hospital admission?

BACKGROUND

Linking process of care data from general practice (GP) and hospital data may provide more information about the risk of hospital admission and re-admission for people with type-2 diabetes mellitus (T2DM). This study aimed to extract and link data from a hospital, a diabetes clinic (DC). A second aim was to determine whether the data could be used to predict hospital admission for people with T2DM.

METHODS

Data were extracted using the GRHANITE™ extraction and linkage tool. The data from nine GPs and the DC included data from the two years prior to the hospital admission. The date of the first hospital admission for patients with one or more admissions was the index admission. For those patients without an admission, the census date 31/03/2014 was used in all outputs requiring results prior to an admission. Readmission was any admission following the index admission. The data were summarised to provide a comparison between two groups of patients: 1) Patients with a diagnosis of T2DM who had been treated at a GP and had a hospital admission and 2) Patients with a diagnosis of T2DM who had been treated at a GP and did not have a hospital admission.

RESULTS

Data were extracted for 161,575 patients from the three data sources, 644 patients with T2DM had data linked between the GPs and the hospital. Of these, 170 also had data linked with the DC. Combining the data from the different data sources improved the overall data quality for some attributes particularly those attributes that were recorded consistently in the hospital admission data. The results from the modelling to predict hospital admission were plausible given the issues with data completeness.

CONCLUSION

This project has established the methodology (tools and processes) to extract, link, aggregate and analyse data from general practices, hospital admission data and DC data. This study methodology involved the establishment of a comparator/control group from the same sites to compare and contrast the predictors of admission, addressing a limitation of most published risk stratification and admission prediction studies. Data completeness needs to be improved for this to be useful to predict hospital admissions.

Influence of nalidixic acid on tandem heterotrophic-autotrophic kinetics in a "NIPHO" activated sludge reactor

This work analyzes the effect of nalidixic acid (NAL) on the kinetics of the heterotrophic and autotrophic biomass growth within a "NIPHO" activated sludge reactor treating municipal wastewater. Thus, the effect of this chemical in the degradation rates of carbon and nitrogen sources and net biomass growth rate is evaluated. Activated sludge samples were taken at three different operation conditions, changing the values of hydraulic retention time (2.8-3.8 h), biomass concentration (1400-1700 mgVSS L^-1), temperature (12.6-14.8 °C), and sludge retention time (11.0-12.6 day). A respirometric method was applied to model the kinetic performance of heterotrophic and autotrophic biomass in absence and presence of NAL, and a multivariable statistical analysis was carried out to characterize the influence of the operation variables on the kinetic response of the system, which was finally optimized. The results showed that there was no inhibitory effect of NAL on heterotrophic biomass, with an increase of net heterotrophic biomass growth rate from 1.70 to 6.73 mgVSS L^-1 h^-1 at the most favorable period. By contrast, the autotrophic biomass was negatively affected by NAL, reducing the value of net autotrophic biomass growth rate from 25.37 to 10.29 mgVSS L^-1 h^-1 at the best operation conditions. In general, biomass concentration and temperature had the highest influence on the degradation rate of carbon and nitrogen sources, whereas hydraulic retention time and sludge retention time were the most influential on net heterotrophic and autotrophic biomass growth rates.

Primary health care-level interventions targeting health literacy and their effect on weight loss: a systematic review

Background

Enhancing individual’s health literacy for weight loss is important in addressing the increasing burden of chronic disease due to overweight and obesity. We conducted a systematic review and narrative synthesis to determine the effectiveness of lifestyle interventions aimed at improving adults’ knowledge and skills for weight loss in primary health care.

The literature search included English-language papers published between 1990 and 30 June 2013 reporting research conducted within Organisation for Economic Cooperation and Development member countries. Twelve electronic databases and five journals were searched and this was supplemented by hand searching. The study population included adults (≥18 years old) with a body mass index (BMI) ≥25 kg/m² and without chronic disease at baseline. We included intervention studies with a minimum 6 month follow-up. Three reviewers independently extracted data and two reviewers independently assessed study quality by using predefined criteria. The main outcome was a change in measured weight and/or BMI over 6 or 12 months.

Results

Thirteen intervention studies, all targeting diet, physical activity and behaviour change to improve individuals’ knowledge and/or skills for weight loss, were included with 2,089 participants. Most (9/13) of these studies were of a ‘weak’ quality. Seven studies provided training to the intervention deliverers. The majority of the studies (11/13) showed significant reduction in weight and/or BMI in at least one follow-up visit. There were no consistent associations in outcomes related to the mode of intervention delivery, the number or type of providers involved or the intensity of the intervention.

Conclusions

There was evidence for the effectiveness of interventions that focussed on improving knowledge and skills (health literacy) for weight loss. However, there was insufficient evidence to determine relative effectiveness of individual interventions. The lack of studies measuring socio-economic status needs to be addressed in future research as the rates of obesity are high in disadvantaged population groups.

Integrating electronic health record information to support integrated care: practical application of ontologies to improve the accuracy of diabetes disease registers

BACKGROUND

Information in Electronic Health Records (EHRs) are being promoted for use in clinical decision support, patient registers, measurement and improvement of integration and quality of care, and translational research. To do this EHR-derived data product creators need to logically integrate patient data with information and knowledge from diverse sources and contexts.

OBJECTIVE

To examine the accuracy of an ontological multi-attribute approach to create a Type 2 Diabetes Mellitus (T2DM) register to support integrated care.

METHODS

Guided by Australian best practice guidelines, the T2DM diagnosis and management ontology was conceptualized, contextualized and validated by clinicians; it was then specified, formalized and implemented. The algorithm was standardized against the domain ontology in SNOMED CT-AU. Accuracy of the implementation was measured in 4 datasets of varying sizes (927-12,057 patients) and an integrated dataset (23,793 patients). Results were cross-checked with sensitivity and specificity calculated with 95% confidence intervals.

RESULTS

Incrementally integrating Reason for Visit (RFV), medication (Rx), and pathology in the algorithm identified nearly100% of T2DM cases. Incrementally integrating the four datasets improved accuracy; controlling for sample size, data incompleteness and duplicates. Manual validation confirmed the accuracy of the algorithm.

CONCLUSION

Integrating multiple data elements within an EHR using ontology-based case-finding algorithms can improve the accuracy of the diagnosis and compensate for suboptimal data quality, and hence creating a dataset that is more fit-for-purpose. This clinical and pragmatic application of ontologies to EHR data improves the integration of data and the potential for better use of data to improve the quality of care.

Development of a Methodological Approach for Data Quality Ontology in Diabetes Management

The role of ontologies in chronic disease management and associated challenges such as defining data quality (DQ) and its specification is a current topic of interest. In domains such as Diabetes Management, a robust Data Quality Ontology (DQO) is required to support the automation of data extraction semantically from Electronic Health Record (EHR) and access and manage DQ, so that the data set is fit for purpose. A five steps strategy is proposed in this paper to create the DQO which captures the semantics of clinical data. It consists of: (1) Knowledge acquisition; (2) Conceptualization; (3) Semantic modeling; (4) Knowledge representation; and (5) Validation. The DQO was applied to the identification of patients with Type 2 Diabetes Mellitus (T2DM) in EHRs, which included an assessment of the DQ of the EHR. The five steps methodology is generalizable and reusable in other domains.

Validating an ontology-based algorithm to identify patients with type 2 diabetes mellitus in electronic health records

BACKGROUND

Improving healthcare for people with chronic conditions requires clinical information systems that support integrated care and information exchange, emphasizing a semantic approach to support multiple and disparate Electronic Health Records (EHRs). Using a literature review, the Australian National Guidelines for Type 2 Diabetes Mellitus (T2DM), SNOMED-CT-AU and input from health professionals, we developed a Diabetes Mellitus Ontology (DMO) to diagnose and manage patients with diabetes. This paper describes the manual validation of the DMO-based approach using real world EHR data from a general practice (n=908 active patients) participating in the electronic Practice Based Research Network (ePBRN).

METHOD

The DMO-based algorithm to query, using Semantic Protocol and RDF Query Language (SPARQL), the structured fields in the ePBRN data repository were iteratively tested and refined. The accuracy of the final DMO-based algorithm was validated with a manual audit of the general practice EHR. Contingency tables were prepared and Sensitivity and Specificity (accuracy) of the algorithm to diagnose T2DM measured, using the T2DM cases found by manual EHR audit as the gold standard. Accuracy was determined with three attributes - reason for visit (RFV), medication (Rx) and pathology (path) - singly and in combination.

RESULTS

The Sensitivity and Specificity of the algorithm were 100% and 99.88% with RFV; 96.55% and 98.97% with Rx; and 15.6% and 98.92% with Path. This suggests that Rx and Path data were not as complete or correct as the RFV for this general practice, which kept its RFV information complete and current for diabetes. However, the completeness is good enough for this purpose as confirmed by the very small relative deterioration of the accuracy (Sensitivity and Specificity of 97.67% and 99.18%) when calculated for the combination of RFV, Rx and Path. The manual EHR audit suggested that the accuracy of the algorithm was influenced by data quality such as incorrect data due to mistaken units of measurement and unavailable data due to non-documentation or documented in the wrong place or progress notes, problems with data extraction, encryption and data management errors.

CONCLUSION

This DMO-based algorithm is sufficiently accurate to support a semantic approach, using the RFV, Rx and Path to define patients with T2DM from EHR data. However, the accuracy can be compromised by incomplete or incorrect data. The extent of compromise requires further study, using ontology-based and other approaches.

Multidisciplinary care: experience of patients with complex needs

The rapidly increasing prevalence of diabetes with its high morbidity and mortality raises the need for an integrated multidisciplinary service from health care providers across health sectors. The aim of this study was to explore the diabetic patients' experience of multidisciplinary care, in particular their perceptions, perceived barriers and facilitators. Thirteen patients with type-2 diabetes admitted to the emergency department of a local hospital in NSW were interviewed and completed a demographic questionnaire. Results showed that patients found it inconvenient to be referred to many health professionals because of multiple physical and psychosocial barriers. Separate sets of instructions from different health professionals were overwhelming, confusing and conflicting. Lack of a dedicated coordinator of care, follow up and support for self-management from health professionals were factors that contributed to patients' challenges in being actively involved in their care. The presence of multiple co-morbidities made it more difficult for patients to juggle priorities and 'commitments' to many health professionals. In addition, complex socioeconomic and cultural issues, such as financial difficulties, lack of transport and language barriers, intensified the challenge for these patients to navigate the health system independently. Few patients felt that having many health professionals involved in their care improved their diabetes control. Communication among the multidisciplinary care team was fragmented and had a negative effect on the coordination of care. The patients' perspective is important to identify the problems they experience and to formulate strategies for improving multidisciplinary care for patients with diabetes.

Electronic health records and disease registries to support integrated care in a health neighbourhood: an ontology-based methodology

Disease registries derived from Electronic Health Records (EHRs) are widely used for chronic disease management (CDM). However, unlike national registries which are specialised data collections, they are usually specific to an EHR or organization such as a medical home. We approached registries from the perspective of integrated care in a health neighbourhood, considering data quality issues such as semantic interoperability (consistency), accuracy, completeness and duplication. Our proposition is that a realist ontological approach is required to systematically and accurately identify patients in an EHR or data repository of EHRs, assess intrinsic data quality and fitness for use by members of the multidisciplinary integrated care team. We report on this approach as applied to routinely collected data in an electronic practice based research network in Australia.

Ontological specification of quality of chronic disease data in EHRs to support decision analytics: a realist review

This systematic review examined the current state of conceptualization and specification of data quality and the role of ontology based approaches to develop data quality based on "fitness for purpose" within the health context. A literature review was conducted of all English language studies, from January 2000-March 2013, which addressed data/information quality, fitness for purpose of data, used and implemented ontology-based approaches. Included papers were critically appraised with a "context-mechanism-impacts/outcomes" overlay. We screened 315 papers, excluded 36 duplicates, 182 on abstract review and 46 on full-text review; leaving 52 papers for critical appraisal. Six papers conceptualized data quality within the "fitness for purpose" definition. While most agree with a multidimensional definition of DQ, there is little consensus on a conceptual framework. We found no reports of systematic and comprehensive ontological approaches to DQ based on fitness for purpose or use. However, 16 papers used ontology-specified implementations in DQ improvement, with most of them focusing on some dimensions of DQ such as completeness, accuracy, correctness, consistency and timeliness. The majority of papers described the processes of the development of DQ in various information systems. There were few evaluative studies, including any comparing ontological with non-ontological approaches, on the assessment of clinical data quality and the performance of the application.

Bone marrow levels of 25 hydroxy vitamin D are not depressed in cases of hip fracture compared with controls

There is little information on tissue as distinct from plasma levels of vitamin D metabolites in cases of hip fracture compared with controls. Femoral neck fractures in the elderly are associated with increased cortical remodelling and endosteal resorption, leading to regional increases in porosity and reduced cortical thickness. Vitamin D metabolites play a central role in the maintenance of normal serum calcium levels and may, through interactions with parathyroid hormone, exert an important influence on bone structure. To investigate whether hip fracture might be associated with tissue vitamin D deficiency, we have measured by radioimmunoassay the levels of 25 hydroxy vitamin D (25 (OH)D) in bone marrow samples extracted from the proximal femurs of 16 female subjects who had suffered fracture (mean age = 82.1 years, standard error (se) 1.9) and nine sex matched post mortem controls (mean age = 83.8 years, se 2.5). Twenty five (OH)D concentrations were significantly greater in the fracture cases (median = 3.7, IQR = 2.5-3.9 ng/g) than in the control group (median = 1.5, IQR = 0.9-2.3 ng/g; P = 0.0007, non-parametric Wilcoxon/Kruskal-Wallis test). It was suggested in the 1970s that bone loss and hip fracture risk in the UK were driven by vitamin D deficiency. Our results suggest that the alterations in femoral neck bone microstructure and remodelling in hip fracture cannot be assigned to the single cause of relative deficiency of vitamin D. Vitamin D deficiency or insufficiency may nevertheless increase remodelling and loss of bone tissue and contribute causally to a minority of hip fractures.

EHR-based disease registries to support integrated care in a health neighbourhood: an ontology-based methodology

Disease registries derived from Electronic Health Records (EHRs) are widely used for chronic disease management. We approached registries from the perspective of integrated care in a health neighbourhood, considering data quality issues such as semantic interoperability (consistency), accuracy, completeness and duplication. Our proposition is that a realist ontological approach is required to accurately identify patients in an EHR or data repository, assess data quality and fitness for use by the multidisciplinary integrated care team. We report on this approach with routinely collected data in a practice based research network in Australia.

Data extraction from electronic health records - existing tools may be unreliable and potentially unsafe

BACKGROUND

The increasing use of routinely collected data in electronic health record (EHR) systems for business analytics, quality improvement and research requires an extraction process fit for purpose. Little is known about the quality of EHR data extracts. We examined the accuracy of three data extraction tools (DETs) with two EHR systems in Australia.

METHODS

The hardware, software environment and extraction instructions were kept the same for the extraction of relevant demographic and clinical data for all active patients with diabetes. The counts of identified patients and their demographic and clinical information were compared by EHR and DET.

RESULTS

The DETs identified different numbers of diabetics and measures of quality of care under the same conditions.

DISCUSSION

Current DETs are not reliable and potentially unsafe. Proprietary EHRs and DETs must support transparency and independent testing with standardised queries. Quality control within an appropriate policy and legislative environment is essential.

Gender differences in health-related quality of life of Australian chronically-ill adults: patient and physician characteristics do matter

BACKGROUND

The aims of this study were to explore the health-related quality of life (HRQoL) in a large sample of Australian chronically-ill patients (type 2 diabetes and/or hypertension/ischaemic heart disease), to investigate the impact of characteristics of patients and their general practitioners on their HRQoL and to examine clinically significant differences in HRQoL among males and females.

METHODS

This was a cross-sectional study with 193 general practitioners and 2181 of their chronically-ill patients aged 18 years or more using the standard Short Form Health Survey (SF-12) version 2. SF-12 physical component score (PCS-12) and mental component score (MCS-12) were derived using the standard US algorithm. Multilevel regression analysis (patients at level 1 and general practitioners at level 2) was applied to relate PCS-12 and MCS-12 to patient and general practitioner (GP) characteristics.

RESULTS

Employment was likely to have a clinically significant larger positive effect on HRQoL of males (regression coefficient (B) (PCS-12) = 7.29, P < 0.001, effect size = 1.23 and B (MCS-12) = 3.40, P < 0.01, effect size = 0.55) than that of females (B(PCS-12) = 4.05, P < 0.001, effect size = 0.78 and B (MCS-12) = 1.16, P > 0.05, effect size = 0.16). There was a clinically significant difference in HRQoL among age groups. Younger men (< 39 years) were likely to have better physical health than older men (> 59 years, B = -5.82, P < 0.05, effect size = 0.66); older women tended to have better mental health (B = 5.62, P < 0.001, effect size = 0.77) than younger women. Chronically-ill women smokers reported clinically significant (B = -3.99, P < 0.001, effect size = 0.66) poorer mental health than women who were non-smokers. Female GPs were more likely to examine female patients than male patients (33% vs. 15%, P < 0.001) and female patients attending female GPs reported better physical health (B = 1.59, P < 0.05, effect size = 0.30).

CONCLUSIONS

Some of the associations between patient characteristics and SF-12 physical and/or mental component scores were different for men and women. This finding underlines the importance of considering these factors in the management of chronically-ill patients in general practice. The results suggest that chronically ill women attempting to quit smoking may need more psychological support. More quantitative studies are needed to determine the association between GP gender and patient gender in relation to HRQoL.

Differential vasodilation of human placental and myometrial arteries related to myofilament Ca(2+)-desensitization and the expression of Hsp20 but not MYPT1

Endothelial-dependent regulation of vascular tone occurs in part via protein kinase G1α-mediated changes in smooth muscle myofilament sensitivity to Ca(2+). Tissue-specific differences in PKG-dependent relaxation have been attributed to altered expression of myofilament-associated proteins that are substrates for PKG binding. These include the alternative splicing of the myosin targeting subunit (MYPT1) of myosin light chain phosphatase to yield leucine zipper positive (LZ(+)) and negative (LZ(-)) isovariants, with the former being required for PKG-mediated relaxation, and/or altered expressions of telokin, vasodilator-stimulated phosphoprotein (VASP) or heat shock protein Hsp20. During human pregnancy the uterine and placental circulations remain distinct entities and, as such, their mechanisms of vascular tone regulation may differ. Indeed, the sensitivity of myometrial arteries to endothelial-dependent agonists has been suggested to be greater than that of placental arteries. We tested the hypothesis that this was related to tissue-specific changes in PKG-mediated myofilament Ca(2+)-desensitization and/or the expressions of PKG-interacting myofilament-associated proteins. Permeabilized human placental and myometrial arteries were constricted with maximal activating Ca(2+) (pCa 4.5), or sub-maximal Ca(2+) (pCa 6.7) and the thrombane mimetic U46619, and exposed to 8-Br-cGMP. In each case, relaxation was significantly greater in myometrial arteries (e.g. relaxation in pCa 4.5 to 8-Br-cGMP was 49 ± 9.7%, n = 7) than placental arteries (relaxation of 23 ± 6.6%, n = 6, P < 0.05). MYPT1 protein levels, or MYPT1 LZ(+)/LZ(-) mRNA ratios, were similar for both artery types. Of other proteins examined, only Hsp20 expression was significantly elevated in myometrial arteries than placental arteries. These results demonstrate that the reduced human placental artery relaxation to PKG stimulation lies partly at the level of myofilament (de)activation and may be related to a lower expression of Hsp20 than in myometrial arteries.

The Teamwork Study: enhancing the role of non-GP staff in chronic disease management in general practice

There is evidence for a team-based approach in the management of chronic disease in primary health care. However, the standard of care is variable, probably reflecting the limited organisational capacity of health services to provide the necessary structured and organised care for this group of patients. This study aimed to evaluate the impact of a structured intervention involving non-GP staff in GP practices on the quality of care for patients with diabetes or cardiovascular disease. A cluster randomised trial was undertaken across 60 GP practices. The intervention was implemented in 30 practices with staff and patients interviewed at baseline and at 12–15 months follow up. The change in team roles was evaluated using a questionnaire completed by practice staff. The quality of care was evaluated using the Patient Assessment of Chronic Illness Care questionnaire. We found that although the team roles of staff improved in the intervention practices and there were significant differences between practices, there was no significant difference between those in the intervention and control groups in patient-assessed quality of care after adjusting for baseline-level score and covariates at the 12-month follow up. Practice team roles were not significantly associated with change in Patient Assessment of Chronic Illness Care scores. Patients with multiple conditions were more likely to assess their quality of care to be better. Thus, although previous research has shown a cross-sectional association between team work and quality of care, we were unable to replicate these findings in the present study. These results may be indicative of insufficient time for organisational change to result in improved patient-assessed quality of care, or because non-GP staff roles were not sufficiently focussed on the aspects of care assessed. The findings provide important information for researchers when designing similar studies.

Towards an ontology for data quality in integrated chronic disease management: a realist review of the literature

PURPOSE

Effective use of routine data to support integrated chronic disease management (CDM) and population health is dependent on underlying data quality (DQ) and, for cross system use of data, semantic interoperability. An ontological approach to DQ is a potential solution but research in this area is limited and fragmented.

OBJECTIVE

Identify mechanisms, including ontologies, to manage DQ in integrated CDM and whether improved DQ will better measure health outcomes.

METHODS

A realist review of English language studies (January 2001-March 2011) which addressed data quality, used ontology-based approaches and is relevant to CDM.

RESULTS

We screened 245 papers, excluded 26 duplicates, 135 on abstract review and 31 on full-text review; leaving 61 papers for critical appraisal. Of the 33 papers that examined ontologies in chronic disease management, 13 defined data quality and 15 used ontologies for DQ. Most saw DQ as a multidimensional construct, the most used dimensions being completeness, accuracy, correctness, consistency and timeliness. The majority of studies reported tool design and development (80%), implementation (23%), and descriptive evaluations (15%). Ontological approaches were used to address semantic interoperability, decision support, flexibility of information management and integration/linkage, and complexity of information models.

CONCLUSION

DQ lacks a consensus conceptual framework and definition. DQ and ontological research is relatively immature with little rigorous evaluation studies published. Ontology-based applications could support automated processes to address DQ and semantic interoperability in repositories of routinely collected data to deliver integrated CDM. We advocate moving to ontology-based design of information systems to enable more reliable use of routine data to measure health mechanisms and impacts.

A systematic review of interventions in primary care to improve health literacy for chronic disease behavioral risk factors

BACKGROUND

To evaluate the effectiveness of interventions used in primary care to improve health literacy for change in smoking, nutrition, alcohol, physical activity and weight (SNAPW).

METHODS

A systematic review of intervention studies that included outcomes for health literacy and SNAPW behavioral risk behaviors implemented in primary care settings.We searched the Cochrane Library, Johanna Briggs Institute, Medline, Embase, CINAHL, Psychinfo, Web of Science, Scopus, APAIS, Australasian Medical Index, Google Scholar, Community of Science and four targeted journals (Patient Education and Counseling, Health Education and Behaviour, American Journal of Preventive Medicine and Preventive Medicine).Study inclusion criteria: Adults over 18 years; undertaken in a primary care setting within an Organisation for Economic Co-operation and Development (OECD) country; interventions with at least one measure of health literacy and promoting positive change in smoking, nutrition, alcohol, physical activity and/or weight; measure at least one outcome associated with health literacy and report a SNAPW outcome; and experimental and quasi-experimental studies, cohort, observational and controlled and non-controlled before and after studies.Papers were assessed and screened by two researchers (JT, AW) and uncertain or excluded studies were reviewed by a third researcher (MH). Data were extracted from the included studies by two researchers (JT, AW). Effectiveness studies were quality assessed. A typology of interventions was thematically derived from the studies by grouping the SNAPW interventions into six broad categories: individual motivational interviewing and counseling; group education; multiple interventions (combination of interventions); written materials; telephone coaching or counseling; and computer or web based interventions. Interventions were classified by intensity of contact with the subjects (High ≥ 8 points of contact/hours; Moderate >3 and <8; Low ≤ 3 points of contact hours) and setting (primary health, community or other).Studies were analyzed by intervention category and whether significant positive changes in SNAPW and health literacy outcomes were reported.

RESULTS

52 studies were included. Many different intervention types and settings were associated with change in health literacy (73% of all studies) and change in SNAPW (75% of studies). More low intensity interventions reported significant positive outcomes for SNAPW (43% of studies) compared with high intensity interventions (33% of studies). More interventions in primary health care than the community were effective in supporting smoking cessation whereas the reverse was true for diet and physical activity interventions.

CONCLUSION

Group and individual interventions of varying intensity in primary health care and community settings are useful in supporting sustained change in health literacy for change in behavioral risk factors. Certain aspects of risk behavior may be better handled in clinical settings while others more effectively in the community. Our findings have implications for the design of programs.

Which providers can bridge the health literacy gap in lifestyle risk factor modification education: a systematic review and narrative synthesis

Background

People with low health literacy may not have the capacity to self-manage their health and prevent the development of chronic disease through lifestyle risk factor modification. The aim of this narrative synthesis is to determine the effectiveness of primary healthcare providers in developing health literacy of patients to make SNAPW (smoking, nutrition, alcohol, physical activity and weight) lifestyle changes.

Methods

Studies were identified by searching Medline, Embase, Cochrane Library, CINAHL, Joanna Briggs Institute, Psychinfo, Web of Science, Scopus, APAIS, Australian Medical Index, Community of Science and Google Scholar from 1 January 1985 to 30 April 2009. Health literacy and related concepts are poorly indexed in the databases so a list of text words were developed and tested for use. Hand searches were also conducted of four key journals. Studies published in English and included males and females aged 18 years and over with at least one SNAPW risk factor for the development of a chronic disease. The interventions had to be implemented within primary health care, with an aim to influence the health literacy of patients to make SNAPW lifestyle changes. The studies had to report an outcome measure associated with health literacy (knowledge, skills, attitudes, self efficacy, stages of change, motivation and patient activation) and SNAPW risk factor.

The definition of health literacy in terms of functional, communicative and critical health literacy provided the guiding framework for the review.

Results

52 papers were included that described interventions to address health literacy and lifestyle risk factor modification provided by different health professionals. Most of the studies (71%, 37/52) demonstrated an improvement in health literacy, in particular interventions of a moderate to high intensity.

Non medical health care providers were effective in improving health literacy. However this was confounded by intensity of intervention. Provider barriers impacted on their relationship with patients.

Conclusion

Capacity to provide interventions of sufficient intensity is an important condition for effective health literacy support for lifestyle change. This has implications for workforce development and the organisation of primary health care.

The University of NSW electronic practice based research network: disease registers, data quality and utility

INTRODUCTION

Accurate well-maintained registers are a prerequisite to co-ordinated care of patients with chronic diseases. Their effectiveness in enabling improved management is dependent on the quality of the information captured. This paper provides an overview into the methodology and data quality of the electronic Practice Based Research Network.

METHODS

Clinical records with no identifying information are routinely extracted from four general practices. The data are linked in the data warehouse. Data quality is assessed for completeness, correctness and consistency. Reports on data quality are given back to practices and semi-structured interviews provide information to interpret the results and discuss how data quality could be improved.

FINDINGS

Data quality is mostly complete for sex and date of birth but indigenous status, smoking and weight were incomplete. There are generally high levels of correctness and internal consistency. Completeness of records in assisting the management of diabetes patients using the annual cycle of care was poor. GPs often use the progress notes to enter information during the consultation and coding diagnoses was considered onerous.

DISCUSSION

The routine capture of electronic clinical health records from primary health care and health services can be used to monitor performance and improve the quality of clinical records. There is a need for accurate and comprehensive clinical records to ensure the safety and quality of clinical practice. Understanding the true reasons for poor data quality is complex. Having a community-based research network may assist in answering some of these questions.

CONCLUSION

Electronic health records are increasingly being used for secondary research and evaluation, beyond the primary purpose of supporting clinical care. The data must be of sufficient quality to support these purposes.

Data quality and fitness for purpose of routinely collected data--a general practice case study from an electronic practice-based research network (ePBRN)

The practice-based research network (PBRN) is a resource to recruit research participants; conduct developmental and pilot studies; and coordinate multicentre research, teaching, clinical care and quality assurance programs. It is a community-based laboratory for translational, clinical and health services research. The mining of clinical information systems of PBRNs can be used to monitor performance at the service unit level. However, are the routinely collected data of ePBRNs fit for the abovementioned purposes? We describe the establishment and governance of an ePBRN which included general practice and community health and hospital units, The general practice data quality was examined, using diabetes as the context, for completeness, correctness and consistency and assessed on its fitness for research, audit and quality assurance purposes. The quality of social determinants data was generally good while risk factors data were variable. Issues and strategies for improving data quality are discussed.

Health reform: is routinely collected electronic information fit for purpose?

OBJECTIVE

Little has been reported about the completeness and accuracy of data in existing Australian clinical information systems. We examined the accuracy of the diagnoses of some chronic diseases in an ED information system (EDIS), a module of the NSW Health electronic medical record (EMR), and the consistency of the reports generated by the EMR.

METHODS

A list of ED attendees and those admitted was generated from the EDIS, using specific (e.g. angina) and possible clinical terms (e.g. chest pain) for the selected chronic diseases. This EDIS list was validated with an audit of discharge summaries, and compared with a list generated, using similar specific and possible Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT), from the underlying EMR database.

RESULTS

Of the 33,115 ED attendees, 2559 had diabetes mellitus (DM), cardiovascular disease or asthma/chronic obstructive pulmonary disease; of these 2559, 876 were admitted. Discharge summaries were missing for 12-15% of patients. Only three-quarters or fewer of the diagnoses were confirmed by the discharge summary audit, best for DM and worst for cardiovascular disease. Proportion of agreement between the lists generated from the EDIS and EMR was best for DM and worst for asthma/chronic obstructive pulmonary disease. Possible reasons for this discrepancy are technical, such as use of different extraction terms or system inconsistency; or clinical, such as data entry, decision-making, professional behaviour and organizational performance.

CONCLUSIONS

Variations in information quality and consistency of the EDIS/EMR raise concerns about the 'fitness for purpose' of the information for care and planning, information sharing, research and quality assurance.

Patients Assessment of Chronic Illness Care (PACIC) in two Australian studies: structure and utility

AIMS

To validate the Patients Assessment of Chronic Illness Care (PACIC) among patients with chronic disease in the Australian context and to examine the relationship between patient-assessed quality of care and patient and practice characteristics.

METHODS

Cross-sectional analysis of baseline data in two independent health service intervention studies that involved patients with type 2 diabetes, ischaemic heart disease and/or hypertension in general practice. The first study involved 2552 patients from 60 urban and rural general practices. The second involved 989 patients from 26 practices in Sydney. Patients were mailed a questionnaire, which included the PACIC and Short Form Health Survey. Factor analysis was performed and the factor scores and total PACIC were analysed using multi-level regression models against practice and patient characteristics.

RESULTS

Factor analysis revealed a two-factor solution with similar loading of PACIC items in both studies: one for shared decision making and self-management and the other for planned care. Practice characteristics were not related to PACIC scores. Scores were related to patient characteristics - education, retirement, type and number and duration of conditions.

CONCLUSIONS

The two-factor structure of the PACIC found in these Australian studies is different from the five-factor structure found in the US and the European studies. This may be related to differences in the way patients interact with the health system especially the use of Team Care plans. The association of total scores with patient characteristics was consistent with those found in other studies including a lack of association with gender, age and ethnicity. These findings should be taken into consideration when comparing patient-assessed quality of care between countries using this tool.

THE ACTION OF RENIN ON RABBITS WITH RENAL HYPERTENSION

Our results lead us to believe that renin in the form in which it is extracted from the kidney cannot be the agent causing chronic renal hypertension. The reasons against accepting renin as the pressor substance responsible for the hypertension of renal ischemia may be summed up as follows:- 1. The high blood pressure levels of renal ischemia cannot be approximated by any constant injection of renin that will maintain a sustained increase in normal animals. 2. The ratio of size of response to size of dose becomes progressively less as the amount of the dose is increased. If the hypertension of renal ischemia were due to a large elaboration of renin in the body, a small dose injected would be expected to have much less effect than in a normal individual. This is not the case; the response of the hypertensive animal to a given dose of renin is the same. Also animals with increased blood pressure due to a constant infusion of renin respond differently qualitatively and quantitatively to renin than do animals hypertensive from renal ischemia. 3. Since renin exhibits the phenomenon of tachyphylaxis one cannot explain the sustained hypertension of renal ischemia as due to a substance toward which the body becomes refractory as more and more of it is given. If tolerance results from the presence in the renin preparation of an antagonistic contaminant which persists longer in the body than the pressor agent, renal hypertension is definitely not caused by renin. This follows from our observations that rabbits hypertensive from renal ischemia, and in which tolerance is produced, maintain the blood pressure they had before injection of any renin.

Readiness for organisational change among general practice staff

BACKGROUND

Increasing demands on general practice to manage chronic disease may warrant organisational change at the practice level. Staff's readiness for organisational change can act as a facilitator or barrier to implementing interventions aimed at organisational change.

OBJECTIVES

To explore general practice staff readiness for organisational change and its association with staff and practices characteristics.

METHODS

This is a cross-sectional study of practices in three Australian states involved in a randomised control trial on the effectiveness of an intervention to enhance the role of non-general practitioner staff in chronic disease management. Readiness for organisational change, job satisfaction and practice characteristics were assessed using questionnaires.

RESULTS

502 staff from 58 practices completed questionnaires. Practice characteristics were not associated with staff readiness for change. A multilevel regression analysis showed statistically significant associations between staff readiness for organisational change (range 1 to 5) and having a non-clinical staff role (vs general practitioner; B=-0.315; 95% CI -0.47 to -0.16; p<0.001), full-time employment (vs part-time; B=0.175, 95% CI 0.06 to 0.29; p<0.01) and lower job satisfaction (B=-0.277, 95% CI -0.40 to -0.15; p<0.001).

CONCLUSIONS

The results suggest that different approaches are needed to facilitate change which addresses the mix of practice staff. Moderately low job satisfaction may be an opportunity for organisational change.

Facilitating teamwork in general practice: moving from theory to practice

The aims of this paper are to describe the development of an intervention to improve teamwork and systems in general practice that support the care of patients with diabetes, ischaemic heart disease and hypertension and to identify the challenges to implementing the intervention. Effective teamwork in general practice encompasses general practitioners (GP), clinical and non-clinical staff, each with clearly defined roles and opportunities to provide feedback and input into how the practice is run and chronic disease managed. The intervention implemented in this study provided an opportunity for key members of general practice teams to work with a facilitator on changes to improve teamwork over three practice visits over 6–12 months. Facilitators had experience in practice support and goal setting, an understanding of the Medicare Items and knowledge about teamwork and systems. The visits focussed on the specific needs and capacities of each practice, assisting the team to set manageable goals and building systems that best utilise the systemic and human resources available. Successful implementation of sustained change depended on strong leadership in the practice and cooperation between team members as well as clear and achievable goals being set. Structured facilitation of teamwork in general practice should focus on goal setting and the development of leadership and communication rather than delivery of information or resources.

Engaging participants in a complex intervention trial in Australian General Practice

Background

The paper examines the key issues experienced in recruiting and retaining practice involvement in a large complex intervention trial in Australian General Practice.

Methods

Reflective notes made by research staff and telephone interviews with staff from general practices which expressed interest, took part or withdrew from a trial of a complex general practice intervention.

Results

Recruitment and retention difficulties were due to factors inherent in the demands and context of general practice, the degree of engagement of primary care organisations (Divisions of General Practice), perceived benefits by practices, the design of the trial and the timing and complexity of data collection.

Conclusion

There needs to be clearer articulation to practices of the benefits of the research to participants and streamlining of the design and processes of data collection and intervention to fit in with their work practices. Ultimately deeper engagement may require additional funding and ongoing participation through practice research networks.

Trial Registration

Current Controlled Trials ACTRN12605000788673

Quality of diabetes care - a comparison of division diabetes registers

BACKGROUND

Several recent government policies aim to narrow the gap between optimal and current quality of care in the management of type 2 diabetes. This study examines trends in the quality of care and intermediate outcomes for patients between 1995 and 2004.

METHODS

Two dissimilar divisions of general practice in Sydney's southwest gathered diabetes patient data from 1995-2004 from participating general practices. Variables included frequency of assessment, body mass index, glycosylated haemoglobin, systolic blood pressure and total cholesterol.

RESULTS

Positive and significant changes occurred in glycosylated haemoglobin, total cholesterol and systolic blood pressure for patients in both divisions, though the mean values did not achieve guideline targets. There was no significant change in body mass index. There were significant differences between the divisions in most variables.

DISCUSSION

The current package of incentives and supports for diabetes care in general practice may be having a positive effect, however with more than half of the patients in this study having suboptimal control of their diabetes, there is a clear need for further systematic and multidisciplinary support.

Hippocampal involvement in the expression of kindling-induced fear in rats

Kindling dramatically increases fearful behavior in rats. Because kindling-induced fear increases in magnitude as rats receive more stimulations, kindling provides a superb opportunity to study the nature and neural mechanisms of fear sensitization. Interestingly, these changes in behavior are accompanied by increased binding to inhibitory receptors and decreased binding to excitatory receptors in the CA1 and dentate gyrus regions of the hippocampus. This led us to hypothesize that kindling-induced fear may result from an increased inhibitory tone within hippocampal circuits. To test this hypothesis, we investigated FOS protein immunoreactivity in hippocampal and amygdalar regions of kindled rats that were exposed to an unfamiliar open field. We found that FOS immunoreactivity was significantly decreased in the CA1 region, dentate gyrus, and perirhinal cortex of kindled rats compared to sham-stimulated rats. These results support our hypothesis that kindling-induced fear may be produced by inhibition within hippocampal circuits. They also suggest that neural changes within the hippocampus may be important for the sensitization of fear.

A shift from normal to high glucose levels stimulates cell proliferation in drug sensitive MCF-7 human breast cancer cells but not in multidrug resistant MCF-7/ADR cells which overproduce PKC-betaII

Glucose concentration may be an important factor in breast cancer cell proliferation because the prevalence of breast cancer is high in diabetic patients. To determine the role of protein kinase C (PKC)-betaII in regulating MCF-7 cell proliferation at different glucose concentrations, the effects of glucose and a PKC-betaII-specific inhibitor (CGP53353) were examined in cultures of MCF-7 human breast cancer cell line and its multidrug resistant variant (MCF-7/ADR). Cell proliferation and DNA synthesis of MCF-7 were increased when glucose concentration in the culture medium was increased from normal (5.5 mM) to high (25 mM) levels. However, MCF-7/ADR cell proliferation and DNA synthesis were unaffected by the increase in glucose. PKC-betaII protein and the corresponding mRNA levels were 4- to 5-fold higher in MCF-7/ADR than in MCF-7 cells. High glucose-induced decreases of PKC-betaII protein and mRNA levels were observed during the DNA synthesis phase in MCF-7 but not in MCF-7/ADR cells. Decreases in PKC-betaII mRNA and protein levels below a critical threshold in response to high glucose levels may account for glucose-stimulated proliferation of MCF-7 cells. Cultures of multidrug resistant MCF-7/ADR cells reach maximal cell density in medium containing normal (5.5 mM) glucose levels and are not induced to grow further in response to high (25 mM) glucose. Our results demonstrate a link between high glucose-induced PKC-betaII isozyme down-regulation with concomitant acceleration of cell cycle progression in MCF-7 cells.

Implementing a research-based protocol: an interactive approach

Endotracheal suctioning (ETS) is a common procedure done in the critical care environment. There are many different practices related to ETS. With the proliferation of research studies about ETS, a change in practice is needed to incorporate these research findings. The authors present a creative teaching strategy that was used to implement a research-based ETS protocol.

Recovery from experimental parkinsonism in primates with GM1 ganglioside treatment

A parkinsonian syndrome can be produced in nonhuman primates by administration of the neurotoxin 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP). Parkinsonian-like symptoms induced acutely by MPTP were ameliorated after treatment with GM1 ganglioside, a substance shown to have neurotrophic effects on the damaged dopamine system in rodents. Treatment with GM1 ganglioside also increased striatal dopamine and metabolite levels and enhanced the dopaminergic innervation of the striatum as demonstrated by tyrosine hydroxylase immunohistochemistry. These results suggest that GM1 ganglioside may hold promise as a therapeutic agent for the treatment of Parkinson's disease.

Molecular divergence of the serotype-specific plasmid (pSLT) among strains of Salmonella typhimurium of human and veterinary origin and comparison of pSLT with the serotype specific plasmids of S. enteritidis and S. dublin

Molecular variants of the serotype-specific plasmid (SSP) of Salmonella typhimurium (pSLT) were recognised in clinical and veterinary isolates by restriction enzyme fingerprinting. Three had undergone minor DNA rearrangements, whereas two had acquired resistance determinants to a wide range of antimicrobial agents including gentamicin, trimethoprim, tetracycline, streptomycin, ampicillin (Ap) and kanamycin (Km). One of the latter was the result of co-integrate formation with an IncX, conjugative R-plasmid that specified ApKm resistance. The co-integrate plasmid (pOG669) was incompatible with, and displaced, pSLT and its molecular variants. The restriction fingerprints of SSPs of S. enteritidis and S. dublin were compared with pSLT. All were related at the 35% level on the basis of a Dice coefficient of similarity. The SSPs of S. enteritidis and S. dublin were incompatible with the co-integrate plasmid pOG669. Whereas in S. enteritidis this resulted from incompatibility with the pSLT component (the SSP was compatible with the IncX component), the converse was found with S. dublin.

Restriction enzyme fingerprinting of enterobacterial plasmids: a simple strategy with wide application

Restriction enzyme fingerprints were generated from purified plasmid DNA from 324 clinical isolates that belonged to 7 enterobacterial genera and 88 single plasmids in Escherichia coli K 12 according to the following strategy. Purified plasmid DNA was digested with PstI. The number of fragments detected in a 0.8 agarose gel was used to determine which 2 of 6 restriction enzymes including PstI was most likely to provide a fingerprint comprising sufficient fragments to ensure specificity but sufficiently few to allow easy visual assessment and minimize coincidental matching. When PstI produced greater than 20 fragments, EcoRI and HindIII were used; when PstI generated less than 6 fragments Bsp 1286 and AvaII were used and SmaI was employed when between 6 and 20 fragments were obtained from PstI digests. Using a minimum of 12 fragments from a combination of 2 enzymes as the criterion for characterizing a strain/plasmid, satisfactory 2-enzyme fingerprints were obtained from 87% of the strains and plasmids studied using PstI and no more than two additional enzymes per strain. Of the remaining 54 strains, 51 harboured only small plasmids (less than 10 kb) and 3 produced satisfactory fingerprints when digested with a fourth enzyme.

Effects of a home-based activity program. A study with low fitness elementary school children

A home-based behavioral program utilizing contingency contracts and parent-determined rewards was employed in a changing criterion design to modify children's physical activity levels and subsequent measures of health fitness. Children were initially diagnosed as being low in health fitness. Following diagnosis, the child's parents, with support from a trained physical education teacher (parenter), recorded baseline physical activity levels during nonschool hours. During intervention the level of physical activity was systematically increased by setting specific criterion levels of activity for each week. Levels of physical activity increased markedly during the extended 9-12 week intervention phase. Improvements in health fitness criterion measures were recorded. The implications for application and future research involving parents in areas related to physical education were discussed.