Implementation and evolution of a regional chronic disease self-management program.

OBJECTIVE: To establish a comprehensive, community-based program to improve and sustain self-management support for individuals with chronic diseases and complement office-based strategies to support behaviour change. PARTICIPANTS: Health service delivery organizations. SETTING: The Champlain Local Health Integration Network (LHIN), a health district in Eastern Ontario. INTERVENTION: We created Living Healthy Champlain (LHC), a regional organization providing peer leader training and coordination for the group Stanford Chronic Disease Self-Management Program (CDSMP); skills training and mentorship in behaviour change approaches for health care providers; and support to organizations to integrate self-management support into routine practice. We used the RE-AIM framework to evaluate the overall program's impact by exploring its reach, effectiveness, adoption, implementation and maintenance. OUTCOME: A total of 232 Stanford CDSMP sessions (63 during the pilot project and 169 post-pilot) have been held at 127 locations in 24 cities across the Champlain LHIN, reaching approximately 4,000 patients. The effectiveness of the service was established through ongoing evidence reviews, a focus group and a pre-post utilization study of the pilot. LHC trained over 300 peer volunteers to provide the Stanford CDSMP sessions, 98 of whom continue to activelyhost workshops. An additional 1,327 providers have been trained in other models of self-management support, such as Health Coaching and Motivational Interviewing. Over the study period, LHC grew from a small pilot project to a regional initiative with sustainable provincial funding and was adopted by the province as a model for similar service delivery across Ontario. CONCLUSION: A community-based self-management program working in partnership with primary care can be effectively and broadly implemented in support of patients living with chronic conditions.

Improving awareness, accountability, and access through health coaching: qualitative study of patients' perspectives.

OBJECTIVE: To assess patients' experiences with and perceptions of health coaching as part of their ongoing care. DESIGN: A qualitative research design using semistructured interviews that were recorded and transcribed verbatim.Setting Ottawa, Ont. PARTICIPANTS: Eleven patients (> 18 years of age) enrolled in a health coaching pilot program who were at risk of or diagnosed with type 2 diabetes. METHODS: Patients' perspectives were assessed with semistructured interviews. Interviews were conducted with 11 patients at the end of the pilot program, using a stratified sampling approach to ensure maximum variation. MAIN FINDINGS: All patients found the overall experience with the health coaching program to be positive. Patients believed the health coaching program was effective in increasing awareness of how diabetes affected their bodies and health, in building accountability for their health-related actions, and in improving access to care and other health resources. CONCLUSION: Patients perceive one-on-one health coaching as an acceptable intervention in their ongoing care. Patients enrolled in the health coaching pilot program believed that there was an improvement in access to care, health literacy, and accountability,all factors considered to be precursors to behavioural change.

Health coaching in primary care: a feasibility model for diabetes care.

BACKGROUND: Health coaching is a new intervention offering a one-on-one focused self-management support program. This study implemented a health coaching pilot in primary care clinics in Eastern Ontario, Canada to evaluate the feasibility and acceptability of integrating health coaching into primary care for patients who were either at risk for or diagnosed with diabetes. METHODS: We implemented health coaching in three primary care practices. Patients with diabetes were offered six months of support from their health coach, including an initial face-to-face meeting and follow-up by email, telephone, or face-to-face according to patient preference. Feasibility was assessed through provider focus groups and qualitative data analysis methods. RESULTS: All three sites were able to implement the program. A number of themes emerged from the focus groups, including the importance of physician buy-in, wide variation in understanding and implementing of the health coach role, the significant impact of different systems of team communication, and the significant effect of organizational structure and patient readiness on Health coaches' capacity to perform their role. CONCLUSIONS: It is feasible to implement health coaching as an integrated program within small primary care clinics in Canada without adding additional resources into the daily practice. Practices should review their organizational and communication processes to ensure optimal support for health coaches if considering implementing this intervention.

Navigating change: how outreach facilitators can help clinicians improve patient outcomes.

OBJECTIVE: The objective of this study was to describe outreach facilitation as an effective method of assisting and supporting primary care practices to improve processes and delivery of care. METHODS: We spent 4 years working with 83 practices in Eastern Ontario, Canada, on the Improved Delivery of Cardiovascular Care through the Outreach Facilitation program. RESULTS: Primary care practices, even if highly motivated, face multiple challenges when providing quality patient care. Outreach facilitation can be an effective method of assisting and supporting practices to make the changes necessary to improve processes and delivery of care. Multiple jurisdictions use outreach facilitation for system redesign, improved efficiencies, and advanced access. CONCLUSIONS: The development and implementation of quality improvement programs using practice facilitation can be challenging. Our research team has learned valuable lessons in developing tools, finding resources, and assisting practices to reach their quality improvement goals. These lessons can lead to improved experiences for the practices and overall improved outcomes for the patients they serve.

Robotic-assisted laparoscopic myomectomy versus abdominal myomectomy: a comparative analysis of surgical outcomes and costs.

OBJECTIVE: To compare clinical and effectiveness outcomes between robotic-assisted laparoscopic myomectomy (RALM) and abdominal myomectomy (AM). STUDY DESIGN: Records were reviewed for the first 27 RALM procedures at our institution. Age, BMI, insurance status, race, uterine size, and operative indication were used to select comparable patients who had undergone AM. Clinical and efficiency outcomes were compared stratifying for uterine size, specimen weight, and matched propensity scores. RESULTS: IV hydromorphone use was significantly lower for RALM (P < 0.01), with no significant differences in blood loss or complications. RALM patients had significantly shorter hospital stays; however, total hospital charges were higher (P < 0.0001). This likely reflects longer operating room time (P < 0.0001), which was magnified as specimen size increased (P < 0.0001). CONCLUSION: RALM patients require less IV hydromorphone, have shorter hospital stays, and have generally equivalent clinical outcomes compared with AM patients. Additionally, as specimen size increased, the operative efficiency of RALM decreased compared with AM.

Distinct types of fibrocyte can differentiate from mononuclear cells in the presence and absence of serum.

BACKGROUND: Fibrocytes are bone-marrow derived cells, expressing both haematopoietic and stromal cell markers, which contribute to tissue repair as well as pathological fibrosis. The differentiation of fibrocytes remains poorly characterised and this has limited understanding of their biology and function. In particular two methods are used to generate fibrocytes in vitro that differ fundamentally by the presence or absence of serum. METHODOLOGY/PRINCIPAL FINDINGS: We show here that fibrocytes grown in the absence of serum (SF) differentiate more efficiently from peripheral blood mononuclear cells than CD14(+) monocytes, and respond to serum by losing their spindle-shaped fibrocyte morphology. Although fibrocytes generated in the presence of serum (SC) express the same range of markers, they differentiate more efficiently from CD14(+) monocytes and do not change their morphology in response to serum. Transcriptional analysis revealed that both types of fibrocyte are distinct from each other, fibroblasts and additional monocyte-derived progeny. The gene pathways that differ significantly between SF and SC fibrocytes include those involved in cell migration, immune responses and response to wounding. CONCLUSIONS/SIGNIFICANCE: These data show that SF and SC fibrocytes are distinct but related cell types, and suggest that they will play different roles during tissue repair and fibrosis where changes in serum proteins may occur.

Are women who have had a preterm singleton delivery at increased risk of preterm birth in a subsequent twin pregnancy?

Our objective was to determine whether preterm birth of a singleton is associated with an increased risk of preterm birth of twins in a subsequent pregnancy. We identified all women who delivered a singleton followed by twins at Northwestern Memorial Hospital during a 10-year period. Using a cohort study design, we compared women with preterm singleton deliveries to women with term singleton deliveries with regard to their subsequent twin pregnancy outcomes. Two hundred ninety-three were identified who delivered a singleton followed by twins. Women who delivered a preterm singleton were significantly more likely to deliver subsequent preterm twins (73.9% versus 44.4%, odds ratio 3.5, 95% confidence interval 1.4 to 9.3). This significant difference persisted in multivariable analysis after controlling for ethnicity (adjusted odds ratio 3.3, 95% confidence interval 1.3 to 8.7). We concluded that preterm birth of a singleton is associated with an increased risk of preterm delivery in a subsequent twin gestation.

Are women who have had a preterm twin delivery at greater risk of preterm birth in a subsequent singleton pregnancy?

OBJECTIVE: The purpose of this study was to determine whether preterm birth of twins is associated with an increased risk of preterm birth in a subsequent singleton pregnancy. STUDY DESIGN: All patients who delivered a twin gestation and a subsequent singleton pregnancy at Northwestern Memorial Hospital during a 10-year period were identified. We used a cohort study design, comparing the outcomes of the singleton pregnancies in women with preterm twin deliveries to those pregnancies with term twin deliveries. RESULTS: One hundred sixty-seven women delivered twins followed by a singleton pregnancy. Women whose twin delivery was preterm (n = 99) were more likely than those who had delivered a term twin pregnancy (n = 68) to deliver a subsequent preterm singleton pregnancy (13.1% vs 2.9%; odds ratio, 5.0; 95% CI, 1.1, 22.9). CONCLUSION: Preterm birth of twins is associated with an increased risk of preterm delivery in a subsequent singleton pregnancy.

The Pinochet case: cosmopolitanism and intermestic human rights.

This article explores the Pinochet case, widely heralded as a landmark, as a case of 'intermestic' human rights that raises difficult normative and empirical questions concerning cosmopolitan justice. The article is a contribution to the sociology of human rights from the perspective of methodological cosmopolitanism, developing conceptual tools and methods to study how cosmopolitanizing state institutions and cultural norms are inter-related. The argument is made that in order to understand issues of cosmopolitan justice, sociologists must give more consideration to political culture.