Healthcare systems collaborating to implement a shared decision-making tool in the electronic health record and build evidence on its adoption and use.

Introduction: Shared decision-making (SDM) is a method of care by which patients and clinicians work together to co-create a plan of care. Electronic health record (EHR) integration of SDM tools may increase adoption of SDM. We conducted a "lightweight" integration of a freely available electronic SDM tool, CV Prevention Choice, within the EHRs of three healthcare systems. Here, we report how the healthcare systems collaborated to achieve integration. Methods: This work was conducted as part of a stepped wedge randomized pragmatic trial. CV Prevention Choice was developed using guidelines for HTML5-based web applications. Healthcare systems integrated the tool in their EHR using documentation the study team developed and refined with lessons learned after each system integrated the electronic SDM tool into their EHR. CV Prevention Choice integration populates the tool with individual patient data locally without sending protected health information between the EHR and the web. Data abstraction and secure transfer systems were developed to manage data collection to assess tool implementation and effectiveness outcomes. Results: Time to integrate CV Prevention Choice in the EHR was 12.1 weeks for the first system, 10.4 weeks for the second, and 9.7 weeks for the third. One system required two 1-hour meetings with study team members and two healthcare systems required a single 1-hour meeting. Healthcare system information technology teams collaborated by sharing information and offering improvements to documentation. Challenges included tracking CV Prevention Choice use for reporting and capture of combination medications. Data abstraction required refinements to address differences in how each healthcare system captured data elements. Conclusion: Targeted documentation on tool features and resource mapping supported collaboration of IT teams across healthcare systems, enabling them to integrate a web-based SDM tool with little additional research team effort or oversight. Their collaboration helped overcome difficulties integrating the web application and address challenges to data harmonization for trial outcome analyses.

Implementation of a brief online skills group of dialectical behaviour therapy for emotional dysregulation in Latinx: a withdrawal experimental single-case design.

BACKGROUND: Dialectical behaviour therapy (DBT) skills groups have shown promise as an effective treatment for clients with emotional dysregulation, especially when combined with individual DBT. However, their efficacy is not well established as an online therapy, or in the Latinx population. AIMS: This study aimed to explore satisfaction, retention and effects of an internet-based DBT group added to individual online sessions. METHOD: An ABAB withdrawal experimental single-case design was conducted to evaluate the effect of a brief online DBT skills group on emotional dysregulation, anxiety and depression for five Latinx participants. DBT skills group (phase B) were compared with placebo group sessions (phase A) and fortnightly individual DBT sessions were offered throughout to manage risk. RESULTS: Visual inspection showed a decrease in level of emotional dysregulation and a large effect size according to the Nonoverlap of All Pairs when comparing group DBT and placebo phases. Although depression symptoms decreased after introducing group DBT, anxiety indicators decreased most during the second round of group placebo sessions. DISCUSSION: Whilst only a pilot, this study suggests that online group DBT in Latinx populations is feasible and effective for changing emotional regulation processes but may not effectively target anxiety. Future research might increase the number of DBT sessions in order to enhance learning opportunities and generalization. Replication with larger sample sizes and diverse modalities is needed.

The design and development of an encounter tool to support shared decision making about preventing cardiovascular events.

Patients at high risk for cardiovascular disease (CVD) tend to receive less intensive preventive care. Clinical practice guidelines recommend shared decision making (SDM) to improve the quality of primary CVD prevention. There are tools for use during the clinical encounter that promote SDM, but, to our knowledge, there are no SDM encounter tools that support conversations about available lifestyle and pharmacological options that can lead to preventive care that is congruent with patient goals and CVD risk. Using the best available evidence and human-centered design (iterative design in the context of ultimate use with users), our team developed a SDM encounter tool, CV Prevention Choice. Each subsequent version during the iterative development process was evaluated in terms of content, usefulness, and usability by testing it in real preventive encounters. The final version of the tool includes a calculator that estimates the patient's risk of a major atherosclerotic CVD event in the next 10 years. Lifestyle and medication options are presented, alongside their pros, cons, costs, and other burdens. The risk reduction achieved by the selected prevention program is then displayed to support collaborative deliberation and decision making. A U.S. multicenter trial is estimating the effectiveness of CV Prevention Choice in achieving risk-concordant CV prevention while identifying the best strategies for increasing the adoption of the SDM encounter tool and its routine use in practice.

Psychometric evaluations of the Life Orientation Test-Revised (LOT-R), based on nine samples.

OBJECTIVE: The aim of this study was to examine psychometric properties of the Life Orientation Test-Revised (LOT-R). DESIGN AND MAIN OUTCOME MEASURES: The LOT-R was administered in five clinical samples, three samples of the adult general population, and one sample of adolescents. Seven of the studies were performed in Germany and two in Colombia. All of the sample sizes were above 300. RESULTS: Cronbach's alpha coefficients were between .57 and .75 for the eight adult samples, the correlations between the scales optimism and pessimism ranged from -.05 to -.37, and the coefficients of temporal stability (test-retest correlations) of the scales ranged from .43 to .69. There were no systematic age and gender effects observed in the nine studies. While the one-factor model of confirmatory factor analyses showed clearly insufficient fit indices among all of the samples, the two-factor model fit was markedly better. CONCLUSIONS: The LOT-R proved to be a suitable instrument for measuring dispositional optimism in patients and in the general population, though the sum score should be viewed with caution. Studies comparing the LOT-R mean scores of different samples need not take age and gender distributions into account.

The Multi-Component Gratitude Measure in Spanish for youth: An adaptation of the MCGM in Colombia.

The present study explored the psychometric properties of the Multi-Component Gratitude Measure (MCGM), in Spanish with a sample of Colombian children. The sample was composed of 540 schoolchildren between 8-12 years old (265 females, mean age 10.04 years; 75 males, mean age 10.08 years). The MCGM aims to examine more comprehensively the moral virtue of gratitude as a construct with 3 components (emotional, conative/attitudinal, and behavioral) distributed across 6 subscales. We translated the MCGM into Spanish and validated the factor structure in a principal component analysis, basing the analysis on the 6 subscales. We corroborated that gratitude can be understood as a complex, multi-component construct from children's perspectives. Overall, the MCGM subscales showed good reliability coefficients between 0.7 and 0.9. Confirmatory factor analysis indicated that a 4-factor model structure (obtained in the PCA) presented the best-adjusted fit indices. Factor 1 represented the feelings subscale, factor 2 represented the attitudinal component, and factors 3 and 4 the behavioral component. Convergent validity was evaluated with other instruments of gratitude, along with additional variables including positive emotion, prosocial behavior and wellbeing, in a subsample of 210 children. Multiple sources of evidence indicate that the translated and validated measure, the MCGM-Spanish Youth (MCGM-SY), is an instrument with good reliability and validity for measuring gratitude in Spanish-speaking children.

Increasing risk-concordant cardiovascular care in diverse health systems: a mixed methods pragmatic stepped wedge cluster randomized implementation trial of shared decision making (SDM4IP).

BACKGROUND: The primary prevention of cardiovascular (CV) events is often less intense in persons at higher CV risk and vice versa. Clinical practice guidelines recommend that clinicians and patients use shared decision making (SDM) to arrive at an effective and feasible prevention plan that is congruent with each person's CV risk and informed preferences. However, SDM does not routinely happen in practice. This study aims to integrate into routine care an SDM decision tool (CV PREVENTION CHOICE) at three diverse healthcare systems in the USA and study strategies that foster its adoption and routine use. METHODS: This is a mixed method, hybrid type III stepped wedge cluster randomized study to estimate (a) the effectiveness of implementation strategies on SDM uptake and utilization and (b) the extent to which SDM results in prevention plans that are risk-congruent. Formative evaluation methods, including clinician and stakeholder interviews and surveys, will identify factors likely to impact feasibility, acceptability, and adoption of CV PREVENTION CHOICE as well as normalization of CV PREVENTION CHOICE in routine care. Implementation facilitation will be used to tailor implementation strategies to local needs, and implementation strategies will be systematically adjusted and tracked for assessment and refinement. Electronic health record data will be used to assess implementation and effectiveness outcomes, including CV PREVENTION CHOICE reach, adoption, implementation, maintenance, and effectiveness (measured as risk-concordant care plans). A sample of video-recorded clinical encounters and patient surveys will be used to assess fidelity. The study employs three theoretical approaches: a determinant framework that calls attention to categories of factors that may foster or inhibit implementation outcomes (the Consolidated Framework for Implementation Research), an implementation theory that guides explanation or understanding of causal influences on implementation outcomes (Normalization Process Theory), and an evaluation framework (RE-AIM). DISCUSSION: By the project's end, we expect to have (a) identified the most effective implementation strategies to embed SDM in routine practice and (b) estimated the effectiveness of SDM to achieve feasible and risk-concordant CV prevention in primary care. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04450914 . Posted June 30, 2020 TRIAL STATUS: This study received ethics approval on April 17, 2020. The current trial protocol is version 2 (approved February 17, 2021). The first subject had not yet been enrolled at the time of submission.

Prevention of adolescent depression in the Spanish-speaking world.

This paper aims at presenting programs targeted at the prevention of adolescent depression applied with Spanish-speaking populations that have been developed in Spanish-speaking countries and are mostly published in Spanish. These programs have been developed under different cultural contexts in Spain and Latin-America. The main goal of this paper is to make the studies and movements of the Spanish-speaking literature in this field accessible to the non-Spanish-speaking part of the research community. Therefore, after an introduction referring to possible cultural differences regarding depression in general and epidemiological basics, several programs are introduced. In total 11 programs will be shortly presented and discussed. After revising the programs it can be concluded that in the Spanish-speaking world many programs have been developed and conducted following current state of the art-approaches for adolescent depression prevention. Further research is needed especially targeting possible cultural and contextual aspects of prevention measures and their efficacy and efficiency.

Anxiety and depression in the general population in Colombia: reference values of the Hospital Anxiety and Depression Scale (HADS).

PURPOSE: The objective of this study was to generate normative values and to test psychometric properties of the Hospital Anxiety and Depression Scale (HADS) for the general population of Colombia. While there are several normative studies in Europe, Latin American normative values are missing. The identification of people with mental distress requires norms obtained for the specific country. METHODS: A representative face-to-face household study (n = 1,500) was conducted in 2012. The survey questionnaire contained the HADS, several other questionnaires, and sociodemographic variables. RESULTS: HADS mean values (anxiety: M = 4.61 ± 3.64, depression: M = 4.30 ± 3.91) were similar to those reported from European studies. Females were more anxious and depressed than males. The depression scale showed a nearly linear age dependency with increasing scores for old people. Mean scores and percentiles (75 and 90%) are presented for each age decade for both genders. Both anxiety and depression correlated significantly with the total score of the multidimensional fatigue inventory and with the mental component summary score of the quality of life questionnaire SF-8. Internal consistency coefficients of both scales were satisfying, but confirmatory factorial analysis results only partially supported the two-dimensional structure of the questionnaire. CONCLUSION: This study supports the reliability of the HADS in one Latin American country. The normative scores can be used to compare a patient's score with those derived from a reference group. However, the generalizability to other Latin American regions requires further research.

Factores de riesgo psicosociales y ambientales asociados a trastornos mentales / Psychosocial and environmental risk factors associated with mental disorders

En Colombia, son escasos los estudios sobre la asociación de los factores psicosociales y medioambientales con trastornos mentales de mayor prevalencia; tales estudios son necesarios debido al contexto de violencia, inseguridad social e inestabilidad laboral y económica del país. El objetivo de este estudio fue identificar los factores de riesgo psicosociales y ambientales de los trastornos mentales, en los usuarios de servicios de psicología de Colombia. Para ello, se aplicaron el Mini International Neuropsychiatric Interview y un cuestionario de evaluación del Eje IV del DSM-IV-TR, a 490 participantes. Se utilizaron análisis descriptivos y de factores de riesgo. Como factor de riesgo para la depresión, se identificaron los problemas de vivienda, acceso a los servicios de asistencia sanitaria, los relativos al grupo primario, los económicos, del ambiente social y los problemas laborales. Para la ansiedad generalizada se identificaron los problemas económicos y los relativos a la enseñanza. Para los trastornos de pánico, fueron relevantes los problemas relacionados con el ambiente social, y para la fobia social, los problemas de enseñanza, los laborales y el ambiente social.

In Colombia, there are few studies on the association of psychosocial and environmental factors with the most prevalent mental disorders; such studies are important due to the context of violence, social insecurity, and job and economic instability in the country. The objective of this study was to identify the psychosocial and environmental risk factors for mental disorders, in users of psychologicalservices in Colombia. The Mini International Neuropsychiatric Interview and a Questionnaire to evaluate the Axis-IV of the DSM-IV-TR were applied to 490 participants.The analysis comprised descriptive statistics and risk factors. As riskfactors for depression, there were identified housing problems, access to health care services, problems related to the primary group, economics, problems of the social environment, and labor. For generalized anxiety, there were identified economic and education issues. For panic disorders, the risk factors were related to social environment, and for social phobia, the risk factors were problems in education,work and social environment.

Human papillomavirus infection and P53 codon 72 genotypes in a Hispanic population at high-risk for cervical cancer.

Cervical cancer mortality is high in Texas, especially among Hispanic women living in south Texas and adjacent Mexico. Though human papillomavirus (HPV) infection has a causal role in the development of cervical cancer, there are no published data on the prevalence of HPV genotypes in this underscreened region. We studied 398 Hispanic women on both sides of the border along the lower Rio Grande River to determine the prevalence of HPV genotypes and risk factors for cervical cancer. Using a nested PCR system HPV was detected in 62% of cervical specimens, including all the known high-risk HPV genotypes, with HPV16 and HPV18 the most frequent (30.6% and 23.0%, respectively). Multiple infections were common (29.4% of the infected specimens), and where this occurred we were more likely to find high-risk HPV genotypes. We examined host p53 codon 72 genotype frequencies and found that patients with cervical abnormalities and women with HPV16 and HPV18 infections had a lower genotype frequency of the homozygous (AA) previously reported to be associated with cervical cancer, than uninfected women with no abnormalities. In this US/Mexico border population high rates of potentially oncogenic HPV viruses and multiple infections are consistent with observed elevated cervical cancer rates. These data are further evidence that in this underserved population HPV infections are associated with high rates of malignancy, but that host p53 genotypic variations are unlikely to be primary factors in oncogenesis.