Barriers to Enhanced Recovery after Surgery after Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Enhanced Recovery after Surgery (ERAS) protocols lead to expedited discharges and decreased cost. Bariatric centers have adopted such programs for safely discharging patients after sleeve gastrectomy (LSG) on the first postoperative day (POD1). Despite pathways, some bariatric patients cannot be discharged on POD1. STUDY DESIGN: We performed a retrospective review of patients undergoing LSG, from 2013 through 2016, in a center of excellence, using a standardized enhanced recovery pathway. Patient variables and perioperative factors were analyzed, including multivariate regressions, for predictors of early discharge. RESULTS: There were 573 patients who underwent LSG (83% female, mean age of 46.3 ± 11.7 years, and BMI of 46.0 ± 6.6 kg/m2). Mean hospital stay was 1.7 days ± 1.0 SD. Early discharge occurred in 38.2% of patients. Independently, early operating room start times and treated obstructive sleep apnea were associated with earlier discharge (p < 0.05). In contrast, preoperative opioid use, history of psychiatric illness, chronic kidney disease, and revision cases delayed discharge (p < 0.05). Age, sex, American Society of Anesthesiologists (ASA) class, diabetes, congestive heart failure, hypertension, distance to home, and insurance status were not significant. On regression modeling, early operating room start time and treated obstructive sleep apnea (OSA) reduced length of stay (LOS) (p < 0.05), while creatinine >1.5 mg/dL, ejection fraction < 50%, and increased case duration increased LOS (p < 0.05). Fifteen patients were readmitted within 30 days (2.6%). CONCLUSIONS: Several clinical and operative factors affect early discharge after LSG. Knowing factors that enhance the success of ERAS as well as the causes and corrections for failed implementation allow teams to optimally direct care pathway resources.

Meeting the information needs of lower income cancer survivors: results of a randomized control trial evaluating the american cancer society's "I can cope".

The American Cancer Society is a leader in the development of cancer survivorship resources. One resource of the American Cancer Society is the I Can Cope program, an educational program for cancer survivors and their families. Evaluations of this program indicate that cancer patients highly rate its objectives. Yet, there are gaps in the understanding of the full impact of the program on diverse cancer survivors. In this study, the authors used a randomized trial to evaluate the program. Participants included 140 low-income survivors (79% Black; 38% breast cancer) from community hospitals who were randomized to 4 sessions of I Can Cope (learning about cancer; understanding cancer treatments; relieving cancer pain; and keeping well in mind and body) or 4 sessions of a wellness intervention (humor, meditation, relaxation, and music therapy). The authors' primary outcome was "met information needs." After controlling for covariates, their analysis indicated that I Can Cope was no more effective than the wellness intervention in addressing survivor information needs relative to the learning objectives. Participants provided high overall ratings for both interventions. Self-efficacy for obtaining advice about cancer, age, education, and income were associated with information needs. Educational programs tailored to levels of self-efficacy and patient demographics may be needed.

Interdisciplinary treatment of patients with multiple sclerosis and chronic pain: a descriptive study.

The objective of this study was to examine the efficacy of an interdisciplinary pain rehabilitation program in a multiple sclerosis (MS) population by evaluating changes in mood, pain, and functioning. This descriptive study examined 20 patients with chronic pain and MS who were admitted to the Cleveland Clinic's Chronic Pain Rehabilitation Program (CPRP) between 2000 and 2009. At both admission to and discharge from the CPRP, measures of pain, depression, and functioning were obtained using a pain visual analogue scale (VAS), the Beck Depression Inventory (BDI), the Depression Anxiety Stress Scale (DASS), and the Pain Disability Index (PDI). Outcomes for the MS patients were compared with those of patients without MS who had participated in the same program. The results showed that MS patients who completed the CPRP reported dramatic decreases in pain and depression and an increase in daily functioning. The benefits received by MS patients from the program were similar to those received by patients without MS. Thus programs like the CPRP can result in significant improvements in pain, depression, and functioning among people with MS.

Recruitment of low income, predominantly minority cancer survivors to a randomized trial of the I Can Cope cancer education program.

This report describes recruitment of minority cancer survivors for a randomized trial of I Can Cope, a support program of the American Cancer Society. Survivor Education and Evaluation (SURE), was designed to recruit patients, age 19 and older, with a primary cancer diagnosis. Recruitment was primarily carried out in a public hospital in Birmingham, Alabama. Of 373 patients approached, 226 were eligible for the study, 175 consented, and 140 were randomized during the 20-month recruitment period. Only 43 declined participation. This resulted in a 61.9% recruitment yield. The mean age of participants was 54.2 years (SD=10.9), 92 (65.7%) were female, and 111 (79.3%) were African American. Twenty-three different cancers were represented including breast (37.1%), colorectal (12.1%), hematologic (12.9%), and lung (7.1%). Over half (63%) had been diagnosed within 12 months. The experience of the SURE project provides evidence for optimism in recruiting racial minorities to cancer research studies.

Medication adherence among rural, low-income hypertensive adults: a randomized trial of a multimedia community-based intervention.

PURPOSE: Examine the effectiveness of a community-based, multimedia intervention on medication adherence among hypertensive adults. DESIGN: Randomized controlled trial. SETTING: Rural south Alabama. SUBJECTS: Low-income adults (N  =  434) receiving medication at no charge from a public health department or a Federally Qualified Health Center. INTERVENTION: Both interventions were home-based and delivered via computer by a community health advisor. The adherence promotion (AP) intervention focused on theoretical variables related to adherence (e.g., barriers, decisional balance, and role models). The cancer control condition received general cancer information. MEASURES: Adherence was assessed by pill count. Other adherence-related variables, including barriers, self-efficacy, depression, and sociodemographic variables, were collected via a telephone survey. ANALYSIS: Chi-square analysis tested the hypothesis that a greater proportion of participants in the AP intervention are ≥80% adherent compared to the control group. General linear modeling examined adherence as a continuous variable. RESULTS: Participants receiving the intervention did not differ from individuals in the control group (51% vs. 49% adherent, respectively; p  =  .67). Clinic type predicted adherence (p < .0001), as did forgetting to take medications (p  =  .01) and difficulty getting to the clinic to obtain medications (p < .001). CONCLUSIONS: Multilevel interventions that focus on individual behavior and community-level targets (e.g., how health care is accessed and delivered) may be needed to improve medication adherence among low-income rural residents.

Tailoring cancer education and support programs for low-income, primarily African American cancer survivors.

PURPOSE/OBJECTIVES: to identify the information and stress-management topics of most interest to low-income, predominantly African American cancer survivors. RESEARCH APPROACH: descriptive, cross sectional. SETTING: outpatient oncology clinic in a public hospital in Birmingham, Alabama. PARTICIPANTS: 25 patients with cancer; 12 were men, 22 were African Americans, and 16 had a 12th-grade education or less. METHODOLOGIC APPROACH: patients ranked potential topics to be included in an educational curriculum. MAIN RESEARCH VARIABLES: quantitative rankings of information and stress-management priorities. FINDINGS: learning about cancer, understanding cancer treatments, relieving cancer pain, and keeping well in mind and body were the most highly ranked topics among those offered within the American Cancer Society's I Can Cope curriculum, which also included supportive topics such as mobilizing social support. The preferred stress-management topics were humor therapy, music therapy, meditation, and relaxation; lower-ranked topics included pet therapy and art as therapy. CONCLUSIONS: cancer survivors appear most interested in topics specific to their illness and treatment versus supportive topics. Stress management also received high rankings. INTERPRETATION: nurses have a key role in providing patient education and support. Tailoring education programs may better target specific needs and improve the quality of cancer care of underserved patients.

Taking less than prescribed: medication nonadherence and provider-patient relationships in lower-income, rural minority adults with hypertension.

Control of hypertension remains poor, and lack of adherence to medication is considered a primary reason. Few studies have examined the reasons for medication nonadherence in African American, lower-income, rural adults receiving medications at no personal cost. Moreover, our understanding of how the provider-patient relationship influences adherence in this population is limited. In this study, the authors (1) examined reasons for taking less medication than prescribed and (2) examined the association between provider-patient variables and medication adherence. A total of 434 participants (94.8% African American) were included. The most frequently endorsed reasons for taking less medication than prescribed were not having blood pressure medicine when it was time to take a dose (36%), running out of medicine (35%), bothered by side effects (29%), and a change in one's daily routine (27%). Nonadherent individuals were significantly more likely to report discomfort with asking the health provider questions (74% vs 63%), were more likely to report that health care visits were stressful (25% vs 16%), and exhibited more depressive symptoms (58% vs 45%). Adherent patients had lower blood pressure (systolic: 133±15.8 mm Hg vs 138±17.6 mm Hg, P value=.002; diastolic: 80±9.8 mm Hg vs 83±11 mm Hg, P value=.003) than individuals who were less adherent. Clinicians providing care to rural, poor hypertensive patients should routinely assess self-management behaviors, logistical barriers, and emotional health. Creating clinical encounters that minimize the stressful nature of the visit and encourage patient question-asking behavior may also be important for the optimal management of hypertension.

Personal communication in primary and secondary cancer prevention: evolving discussions, emerging challenges.

Over the past several years, the science of cancer communication has been recognized as integral to the dissemination of cancer prevention and control strategies in both the general population as well as higher-risk groups. In this article we draw upon current literature and small group discussion in the 2008 Society for Behavioral Medicine Cancer Special Interest Group Pre-Conference Workshop on Cancer Communication to identify current findings, critical challenges, and future opportunities regarding personal communication of primary and secondary prevention of cancer. We organize our article with six critical questions: (1) What are the most important directions of research in this area? (2) Does personal cancer communication work through rational processes, or are affective and nonrational processes also involved? (3) Are our efforts adequate to reach underserved populations? (4) Are naturalistic communicative contexts given adequate consideration? (5) Has the field been adequately informed by social psychological and communication theories? (6) What are the best outcomes to document communication effectiveness? Our goals are to initiate thought and collaborative efforts among communication, public health, and behavioral science experts, as well as to establish research priorities at the interface of communication and cancer prevention and control sciences.

Cancer and patient-physician communication.

As patients are increasingly involved in the selection of their care, communication between health care providers and patients takes on new importance. The present article reviews the most common approaches to improve patient communication, distinguishing among patient-directed and provider-directed approaches, as well as introducing multimedia programs designed to enhance communication. We conclude by delineating new critical areas for future research including peer-to-peer patient communication and the challenges brought on by new technologies.

Relationship of health behavior theories with self-efficacy among insufficiently active hypertensive African-American women.

OBJECTIVE: While self-efficacy plays an important role in physical activity, relatively little research has examined this construct in minorities. This study identified theoretical correlates associated with self-efficacy among insufficiently active, hypertensive Black women. METHODS: Correlates of self-efficacy to: (1) overcoming barriers to physical activity; (2) making time for activity; and (3) "sticking with" physical activity were studied. RESULTS: Sixty-one women (M=50.48+/-4.2 years) participated. We accounted for 32% of the variance in confidence in overcoming barriers. Women confident in overcoming barriers reported less worry about physical activity. The TTM processes of change were also in the model: consciousness raising, environmental reevaluation, counter conditioning, and self-liberation. We accounted for 16% of the variance in "making time" self-efficacy. An aversiveness barrier (e.g., physical activity is boring, physical activity is hard work) was the dominant variable in the model. Confidence to 'stick with' physical activity was associated with self-reevaluation (i.e., reflection on how personal values correspond to behavior). Social support and competing demands were not associated with self-efficacy. CONCLUSIONS: Consistent with Social Cognitive Theory, results suggest that self-efficacy is behavior specific and each measure likely provides unique information. PRACTICE IMPLICATIONS: Interventions should be tailored to address specific self-efficacy types.

Characteristics of insufficiently active hypertensive Black women who volunteer to be in a physical activity promotion intervention: an application of social cognitive theory and the transtheoretical model.

BACKGROUND: Hypertension is a significant public health problem for Black American women. Increasing physical activity is an effective way to manage hypertension. However, Black women are among the least physically active racial/ethnic/gender group. In this paper we identify the positive resources and areas of need among insufficiently active Black hypertensive women who presented to a study to increase their level of physical activity. METHODS: Women completed questionnaires to assess self-efficacy to overcome barriers to physical activity, confidence to use self-motivation to engage in behaviors supportive of a physically active lifestyle, friend and family social support for physical activity, and behavioral and cognitive strategies associated with physical activity. RESULTS: Sixty-one insufficiently active Black hypertensive women participated in the study. The mean age of the sample was 50.48+/-4.2 years. The mean body mass index was 35.97+/-6.88 kg/m2. Resting blood pressure was 133.28/78.21+/-16.41/8.96 mm Hg. According to the Transtheoretical Model stages of change, 88.52% of the sample was in contemplation. Women reported a moderate level of confidence to overcome barriers, a moderate level of confidence to use self-motivation, and reported that barriers rarely interfered with their ability to be physically active. However, women had little friend or family support for physical activity and only rarely used behavioral strategies to encourage their activity. CONCLUSION: To further support this population, physical activity interventions should focus on developing social support networks and teaching a variety of behavioral strategies important to the adoption of an active lifestyle.