Do the unlabeled response categories of the Minnesota Living with Heart Failure Questionnaire satisfy the monotonicity assumption of simple-summated scoring?

PURPOSE: Half of the 21-item Minnesota Living with Heart Failure Questionnaire (MLHFQ) response categories are labeled (0 = No, 1 = Very little, 5 = Very much) and half are not (2, 3, and 4). We hypothesized that the unlabeled response options would not be more likely to be chosen at some place along the scale continuum than other response options and, therefore, not satisfy the monotonicity assumption of simple-summated scoring. METHODS: We performed exploratory and confirmatory factor analyses of the MLHFQ items in a sample of 1437 adults in the Better Effectiveness After Transition-Heart Failure study. We evaluated the unlabeled response options using item characteristic curves from item response theory-graded response models for MLHFQ physical and emotional health scales. Then, we examined the impact of collapsing response options on correlations of scale scores with other variables. RESULTS: The sample was 46% female; 71% aged 65 or older; 11% Hispanic, 22% Black, 54% White, and 12% other. The unlabeled response options were rarely chosen. The standard approach to scoring and scores obtained by collapsing adjacent response categories yielded similar associations with other variables, indicating that the existing response options are problematic. CONCLUSIONS: The unlabeled MLHFQ response options do not meet the assumptions of simple-summated scoring. Further assessment of the performance of the unlabeled response options and evaluation of alternative scoring approaches is recommended. Adding labels for response options in future administrations of the MLHFQ should be considered.

Implementing Community Engagement as a Mission at the David Geffen School of Medicine at the University of California, Los Angeles.

This manuscript describes the development and implementation of community engagement as a mission at UCLA's David Geffen School of Medicine (DGSOM) and UCLA Health System, and summarizes survey results documenting existing community-engaged projects and interest between 2010 to 2013.

Implementing Community Engagement as a Mission at the David Geffen School of Medicine at the University of California, Los Angeles.

This manuscript describes the development and implementation of community engagement as a mission at UCLA's David Geffen School of Medicine (DGSOM) and UCLA Health System, and summarizes survey results documenting existing community-engaged projects and interest between 2010 to 2013.

Barriers and facilitators to routine distribution of patient decision support interventions: a preliminary study in community-based primary care settings.

BACKGROUND: A growing body of literature documents the value of decision support interventions (DESIs) in facilitating patient participation in preference sensitive decision making, but little is known about their implementation in routine care. OBJECTIVE: This study explored barriers and facilitators to prescribing DESIs in primary care. SETTING AND PARTICIPANTS: Four community-based primary care practices across Los Angeles County serving diverse low and middle income populations participated. DESIGN: The first phase focused on implementing DESI prescribing into routine care. Weekly academic detailing visits served to identify barriers to DESI prescribing, generate ethnographic field notes and record DESI prescriptions. The second phase explored the impact of a financial incentive on DESI prescribing. At the project's conclusion, each physician completed an in-depth interview. RESULTS: The four practices prescribed an average of 6.5 DESIs a month (range 3.6-9.2) during Phase I. The financial incentive increased DESI prescribing by 71% to 11.1 per month (range 3.5-21.4). The estimated percentages of patients who viewed the DESI were 37.9 and 43.9% during Phases I and II, respectively. Qualitative data suggest that physician buy-in with the project goal was crucial to DESI distribution success. Competing demands and time pressures were persistent barriers. The effects of the financial incentive were mixed. CONCLUSIONS: This study confirmed the importance of physician engagement when implementing DESIs and found mixed effects for providing financial incentives. The relatively low rate of DESI viewing suggests further research on increasing patient uptake of these interventions in routine practice is necessary.

Persistent barriers and strategic practices: why (asking about) the everyday matters in diabetes care.

PURPOSE: The purpose of this study was to explore the everyday barriers to and practices of low-income patients managing their diabetes. METHODS: The study team conducted semistructured qualitative interviews with 20 patients with type 2 diabetes who were receiving care at safety-net clinics in Southern California. Transcripts were analyzed using grounded theory to identify emergent themes across participants. RESULTS: Participants described managing diabetes with limited financial resources as often a game of balance and negotiation, whereby purchasing healthy foods is abandoned because of a more pressing concern in their life. Although participants described strategic attempts at incorporating healthy dietary practices for diabetes management into their daily decisions, these efforts were significantly impeded by the existence of persistent and seemingly insurmountable barriers. CONCLUSIONS: Although the challenges that low-income patients face in managing their diabetes may seem insurmountable at times, there are several ways that health care providers can help reduce the burden of these challenges, including tailoring their recommendations to incorporate the everyday socioeconomic environment of patients and engaging in clear, open communication with patients.

Evaluation of a behavior support intervention for patients with poorly controlled diabetes.

BACKGROUND: Disease management programs that include ongoing telephone support for patients with diabetes have shown promise, but published studies have enrolled few socially and economically disadvantaged patients. METHODS: We conducted a randomized controlled trial with 201 patients with poorly controlled type 2 diabetes mellitus (72% African American or Latino; 74% with incomes of ≤$15,000). Participants were randomized to an intervention package consisting of a 24-minute video behavior support intervention with a workbook and 5 sessions of telephone coaching by a trained diabetes nurse or a 20-page brochure developed by the National Diabetes Education Program. Study measures were completed at baseline, 1 month, and 6 months. Participants' review of the intervention materials was assessed at 1 month. The primary trial end point was hemoglobin A(1c) value. Secondary end points included lipid levels, blood pressure, diabetes knowledge, and self-care behaviors. Data were analyzed with repeated measures analysis of variance. RESULTS: Most participants in both groups (94%) reviewed the intervention provided, and 73% of participants assigned to the experimental group completed 5 sessions of telephone coaching. There was a significant overall reduction in mean (SD) hemoglobin A(1c) value from baseline (9.6% [2.0%]) to 6 months (9.1% [1.9%]) (P < .001), but differences between groups were nonsignificant. Differences on other clinical measures (lipid levels and blood pressure) and measures of diabetes knowledge and self-care behaviors were also nonsignificant. CONCLUSIONS: There was no significant effect of the experimental intervention compared with the control condition. The dose of intervention provided was less than in previously published studies. More intensive interventions may be necessary for the most disadvantaged patients. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00668590.

Seniors' perceptions of prescription drug advertisements: a pilot study of the potential impact on informed decision making.

OBJECTIVE: To conduct a pilot study exploring seniors' perceptions of direct-to-consumer advertising (DTCA) of prescription drugs and how the advertisements might prepare them for making informed decisions with their physicians. METHODS: We interviewed 15 seniors (ages 63-82) individually after they each watched nine prescription drug advertisements recorded from broadcast television. Grounded Theory methods were used to identify core themes related to the research questions. RESULTS: Four themes emerged from the interviews about DTCA: (1) awareness of medications was increased, (2) information was missing or misleading and drugs were often perceived as more effective than clinical evidence would suggest, (3) most seniors were more strongly influenced by personal or vicarious experience with a drug - and by their physician - than by DTCA, and (4) most seniors were circumspect about the information in commercial DTCA. CONCLUSIONS: DTCA may have some limited benefit for informed decision making by seniors, but the advertisements do not provide enough detailed information and some information is misinterpreted. PRACTICAL IMPLICATIONS: Physicians should be aware that many patients may misunderstand DTCA, and that a certain amount of time may be required during consultations to correct these misconceptions until better advertising methods are employed by the pharmaceutical industry.