Evaluating the implementation of a multi-level mHealth study to improve hydroxyurea utilization in sickle cell disease.

Background: Sickle Cell Disease (SCD) is a progressive genetic disease that causes organ damage and reduces longevity. Hydroxyurea is an underutilized evidence-based medication that reduces complications and improves survival in SCD. In a multi-site clinical trial, part of the NIH-funded Sickle Cell Disease Implementation Consortium (SCDIC), we evaluate the implementation of a multi-level and multi-component mobile health (mHealth) patient and provider intervention to target the determinants and context of low hydroxyurea use. Given the complexity of the intervention and contextual variability in its implementation, we combined different behavioral and implementation theories, models, and frameworks to facilitate the evaluation of the intervention implementation. In this report, we describe engagement with stakeholders, planning of the implementation process, and final analytical plan to evaluate the implementation outcomes. Methods: During 19 meetings, a 16-member multidisciplinary SCDIC implementation team created, conceived, and implemented a project that utilized Intervention Mapping to guide designing an intervention and its evaluation plan. The process included five steps: (1) needs assessment of low hydroxyurea utilization, (2) conceptual framework development, (3) intervention design process, (4) selection of models and frameworks, and (5) designing evaluation of the intervention implementation. Results: Behavioral theories guided the needs assessment and the design of the multi-level mHealth intervention. In designing the evaluation approach, we combined two implementation frameworks to best account for the contextual complexity at the organizational, provider, and patient levels: (1) the Consolidated Framework for Implementation Research (CFIR) that details barriers and facilitators to implementing the mHealth intervention at multiple levels (users, organization, intervention characteristics, broader community), and (2) the Technology Acceptance Model (TAM), a conceptual model specific for explaining the intent to use new information technology (including mHealth). The Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) framework was used to measure the outcomes. Discussion: Our research project can serve as a case study of a potential approach to combining different models/frameworks to help organize and plan the evaluation of interventions to increase medication adherence. The description of our process may serve as a blueprint for future studies developing and testing new strategies to foster evidence-based treatments for individuals living with SCD.

A practical framework for encouraging and supporting positive behaviour change in diabetes.

A wide range of diabetes-directed interventions - including novel medications, devices and comprehensive education programmes - have been shown to be effective in clinical trials. But in the real world of diabetes care their efficacy is often dependent upon on how well a clinician is able to support personal engagement and motivation of the person with diabetes to use these new tools and knowledge consistently, and as directed. Although many person-centred motivational and behavioural strategies have been developed, for example, action planning, motivational interviewing and empowerment-based communication, the sheer number and apparent lack of clear differences among them have led to considerable confusion. The primary goal of this review, therefore, is to provide a practical framework that organizes and structures these programmes to enhance their more systematic use in clinical care. Its purpose is to enhance clinician efforts to respectfully encourage and support engagement and motivation for behaviour change in people with diabetes. The three-step framework for organizing and describing the specific clinical processes involved is based on self-determination theory and includes: clinician preparation for a different type of clinical encounter, clinician/person with diabetes relationship building, and clinician utilization of specific behavioural tools. We conclude with practical considerations for application of this framework to the real world of clinical care.

A workplace colorectal cancer screening program in firefighters: lessons learned.

BACKGROUND: Although colorectal cancer (CRC) screening is widely recommended, screening rates remain low. Workplace interventions have the potential to increase rates of screening. AIMS: To evaluate the impact of a workplace CRC screening program targeting active duty and retired firefighters. METHODS: A letter, a fecal immunochemical test (FIT) kit and a survey were mailed to all active duty and retired San Francisco firefighters aged 40 and older during 2008-09. The survey included questions about CRC risk factors and prior CRC screening tests. The primary outcome was return of the completed FIT. RESULTS: FIT kits and surveys were sent to 1203 firefighters. In total, 445 individuals (37%) completed the survey, and 400 (33%) completed the FIT. Forty-five per cent of respondents had had a stool test for blood at some time, although few (8%) had had it within the past year. Thirty-six per cent of respondents said they had had a sigmoidoscopy at some time, although only 15% had had it within the past 5 years and 37% within the past 10 years. Among those aged 50 and older, 59% had had a test for colon cancer at some time. CONCLUSIONS: A workplace intervention can increase CRC screening rates in firefighters. Future studies should focus on the long-term sustainability of this type of program.

PSA screening: determinants of primary-care physician practice patterns.

BACKGROUND: The effect of practice guidelines and the European Randomised Screening for Prostate Cancer (ERSPC) and Prostate, Lung, Colorectal and Ovarian (PLCO) trials on PSA screening practices of primary-care physicians (PCPs) is unknown. METHODS: We conducted a national cross-sectional on-line survey of a random sample of 3010 PCPs from July to August 2010. Participants were queried about their knowledge of prostate cancer, PSA screening guidelines, the ERSPC and PLCO trials, and about their PSA screening practices. Factors associated with PSA screening were identified using multivariable linear regression. RESULTS: A total of 152 (5%) participants opened and 89 completed the on-line survey, yielding a response rate of 58% for those that viewed the invitation. Eighty percent of respondents correctly identified prostate cancer risk factors. In all, 51% and 64% reported that they discuss and order PSA screening for men aged 50-75 years, respectively. Fifty-four percent were most influenced by the US Preventative Services Task Force (USPSTF) guidelines. Also, 21% and 28% of respondents stated that their PSA screening practices were influenced by the ERSPC and PLCO trials, respectively. Medical specialty was the only variable associated with propensity to screen, with family medicine physicians more likely to use PSA screening than internists (ß=0.21, P=0.02). CONCLUSIONS: Half of the physicians surveyed did not routinely discuss PSA screening with eligible patients. The impact of the ERSPC and PLCO trials on PSA screening practices was low among US PCPs. USPSTF recommendations for PSA screening continue to be the strongest influence on PCPs' propensity to use PSA screening.

Weight management: what patients want from their primary care physicians.

OBJECTIVE: The researchers wanted to determine the weight management experiences of patients in primary care, and what those patients want from their physicians. STUDY DESIGN: Patients completed a survey in a primary care waiting room. Afterward they were measured for body mass index (BMI). POPULATION: A total of 410 consecutive adult patients in 2 primary care practices at the University of California, San Francisco, were approached, and 366 (89%) completed the survey. OUTCOMES MEASURED: The primary outcomes were patient attitudes about weight loss, previous weight management experiences with their current physicians, and future preferences for weight management within the primary care relationship. RESULTS: Ninety-seven percent of the obese patients (BMI > 30), 84% of the overweight patients (BMI=25-30), and 39% of the non-overweight patients (BMI < 25) thought they needed to lose weight. Forty-nine percent of the obese patients, 24% of the overweight patients, and 12% of the non-overweight patients had discussed weight with their current physicians. The types of weight management assistance that patients most wanted from their physicians were: (1) dietary advice, (2) help with setting realistic weight goals, and (3) exercise recommendations. CONCLUSIONS: Although most patients believe they should lose weight, this is often not discussed during office visits. Most patients (especially those who are overweight or obese) want more help with weight management than they are getting from their primary care physicians.

Eosinophilia in Wegener's granulomatosis.

Significant eosinophilia is a prominent feature in Churg-Strauss syndrome but has only rarely been described in Wegener's granulomatosis (WG). We describe two Wegener's granulomatosis patients with > 30% eosinophilia on their initial presentations. Other etiologies that could account for their eosinophilia were excluded. Both patients had pulmonary alveolar hemorrhage, sinusitis, arthritis, high-titer cytoplasmic antineutrophil cytoplasmic antibodies (cANCA), and proteinase-3 antibodies, but no evidence of renal disease. Herein we discuss eosinophilia, the differential diagnosis of pulmonary infiltrates and eosinophilia, the role of cANCA in vasculitis and autoimmune disease, compare Wegener's granulomatosis and Churg-Strauss syndrome, and review possible pathogenic mechanisms.

Quality improvement in an integrated urban healthcare system: a necessary journey.

Public hospitals and clinics in the United States provide health care for the needs of large numbers of people who are medically indigent, homeless, chronically mentally ill, and suffer medical and social disorders associated with poverty. These "safety-net" healthcare providers traditionally struggle with barriers to providing high-quality, patient-sensitive care, including decaying physical facilities, burdensome bureaucracies, underfunded capital equipment and construction programs, and complex, politically driven budgets and governance. However, these same institutions now must compete for their own Medicaid and Medicare clientele because the private sector is marketing to those patients. They also must continue to provide increasing services to growing numbers of uninsured patients. To accomplish this, these institutions must reinvent themselves as patient-focused, high-quality, cost-effective healthcare providers. The Denver Health system is the public safety-net provider for the city and county of Denver. This large public institution has instituted a multifaceted performance-improvement program. The program includes training employees for patient-focused service, implementing continuous quality-improvement practices, instituting clinical pathways, revising the preexisting ambulatory quality-management program, reengineering key aspects of ambulatory clinic services, and redesigning the hospital-based patient-care services. Major successes have been achieved in some initiatives, but not in all. Many key "lessons learned" may guide others.

Value of health, incidence of depression, and level of self-esteem in low-income mothers of pre-school children.

Nurses are continually promoting health and healthy lifestyles. This contribution requires that nurses understand client values and priorities. Traditionally, women have had responsibility for their own and their families' health. Nurses must recognize and understand the complex influences shaping the value women place on health. The literature indicates that women want to participate actively in their own health care by assuming more responsibility for their health and well-being. This research evolved as a result of nursing student and faculty interactions with mothers of pre-school children enrolled in a Headstart program. During these experiences, observations related to the needs of the mothers included poor health practices (smoking, being overweight), lack of motivation, statements of feeling depressed, difficulty making decisions, feelings of being overwhelmed by parenting demands, powerlessness, and disenfranchisement. This descriptive, correlational study was designed to determine the value of health, incidence of depression, and characteristics of self-esteem among low-income mothers of pre-school children. This sample of convenience was comprised of 133 low-income mothers who responded to a mailed survey. Three instruments were used in the study: the Wallston and Wallston Health Values Scale, the Center for Epidemiologic Studies Depression Scale (CES-D), and the Rosenberg Self-Esteem Scale. Data were analyzed by collection of frequency of response, which was then converted to a percentage. To determine if differences existed in respect to demographic variables, ANOVA (self-esteem and depression) and Chi Square (health) measures were used. Participation in activities outside the home accounted for a significant difference in self-esteem. Mothers involved in activities reported higher self-esteem. The findings suggest that participation in activities may increase self-esteem and lower depression. Over three-quarters (85%) of mothers placed a high value on health. Based on their high valuing of health and the potential for increasing self-esteem through activity, it can be concluded that the women in this sample will benefit from planned health activities. It is also anticipated that, because of the strong relationship between self-esteem and depression, women who participate in these activities will demonstrate lower levels of depression.

Expression of a Drosophila melanogaster acetylcholine receptor-related gene in the central nervous system.

We isolated Drosophila melanogaster genomic sequences with nucleotide and amino acid sequence homology to subunits of vertebrate acetylcholine receptor by hybridization with a Torpedo acetylcholine receptor subunit cDNA probe. Five introns are present in the portion of the Drosophila gene encoding the unprocessed protein and are positionally conserved relative to the human acetylcholine receptor alpha-subunit gene. The Drosophila genomic clone hybridized to salivary gland polytene chromosome 3L within region 64B and was termed AChR64B. A 3-kilobase poly(A)-containing transcript complementary to the AChR64B clone was readily detectable by RNA blot hybridizations during midembryogenesis, during metamorphosis, and in newly enclosed adults. AChR64B transcripts were localized to the cellular regions of the central nervous system during embryonic, larval, pupal, and adult stages of development. During metamorphosis, a temporal relationship between the morphogenesis of the optic lobe and expression of AChR64B transcripts was observed.