Perspectives of community-based organizations on digital health equity interventions: a key informant interview study

BACKGROUND

Health and healthcare are increasingly dependent on internet and digital solutions. Medically underserved communities that experience health disparities are often those who are burdened by digital disparities. While digital equity and digital health equity are national priorities, there is limited evidence about how community-based organizations (CBOs) consider and develop interventions.

METHODS

We conducted key informant interviews in 2022 purposively recruiting from health and welfare organizations engaged in digital equity work. Nineteen individuals from 13 organizations serving rural and/or urban communities from the local to national level participated in semi-structured interviews via Zoom regarding their perspectives on digital health equity interventions. Directed content analysis of verbatim interview transcripts was conducted to identify themes.

RESULTS

Themes emerged at individual, organizational, and societal levels. Individual level themes included potential benefits from digital health equity, internet access challenges, and the need for access to devices and digital literacy. Organizational level themes included leveraging community assets, promising organizational practices and challenges. For the societal level, the shifting complexity of the digital equity ecosystem, policy issues, and data for needs assessment and evaluation were described. Several example case studies describing these themes were provided.

DISCUSSION AND CONCLUSION

Digital health equity interventions are complex, multi-level endeavors. Clear elucidation of the individual, organizational, and societal level factors that may impact digital health equity interventions are necessary to understanding if and how CBOs participate in such initiatives. This study presents unique perspectives directly from CBOs driving programs in this new arena of digital health equity.

The ACTIVATE Digital Health Pilot Program for Diabetes and Hypertension in an Underserved and Rural Community

BACKGROUND

Community health centers and patients in rural and agricultural communities struggle to address diabetes and hypertension in the face of health disparities and technology barriers. The stark reality of these digital health disparities were highlighted during the coronavirus disease 2019 pandemic.

OBJECTIVES

The objective of the ACTIVATE (Accountability, Coordination, and Telehealth in the Valley to Achieve Transformation and Equity) project was to codesign a platform for remote patient monitoring and program for chronic illness management that would address these disparities and offer a solution that fit the needs and context of the community.

METHODS

ACTIVATE was a digital health intervention implemented in three phases: community codesign, feasibility assessment, and a pilot phase. Pre- and postintervention outcomes included regularly collected hemoglobin A1c (A1c) for participants with diabetes and blood pressure for those with hypertension.

RESULTS

Participants were adult patients with uncontrolled diabetes and/or hypertension (n = 50). Most were White and Hispanic or Latino (84%) with Spanish as a primary language (69%), and the mean age was 55. There was substantial adoption and use of the technology: over 10,000 glucose and blood pressure measures were transmitted using connected remote monitoring devices over a 6-month period. Participants with diabetes achieved a mean reduction in A1c of 3.28 percentage points (standard deviation [SD]: 2.81) at 3 months and 4.19 percentage points (SD: 2.69) at 6 months. The vast majority of patients achieved an A1c in the target range for control (7.0-8.0%). Participants with hypertension achieved reductions in systolic blood pressure of 14.81 mm Hg (SD: 21.40) at 3 months and 13.55 mm Hg (SD: 23.31) at 6 months, with smaller reductions in diastolic blood pressure. The majority of participants also reached target blood pressure (less than 130/80).

CONCLUSION

The ACTIVATE pilot demonstrated that a codesigned solution for remote patient monitoring and chronic illness management delivered by community health centers can overcome digital divide barriers and show positive health outcomes for rural and agricultural residents.

Family and personal history of cancer in the All of Us research program for precision medicine

The All of Us (AoU) Research Program is making available one of the largest and most diverse collections of health data in the US to researchers. Using the All of Us database, we evaluated family and personal histories of five common types of cancer in 89,453 individuals, comparing these data to 24,305 participants from the 2015 National Health Interview Survey (NHIS). Comparing datasets, we found similar family cancer history (33%) rates, but higher personal cancer history in the AoU dataset (9.2% in AoU vs. 5.11% in NHIS), Methodological (e.g. survey-versus telephone-based data collection) and demographic variability may explain these between-data differences, but more research is needed.

Patient and researcher stakeholder preferences for use of electronic health record data: a qualitative study to guide the design and development of a platform to honor patient preferences

OBJECTIVE

This qualitative study aimed to understand patient and researcher perspectives regarding consent and data-sharing preferences for research and a patient-centered system to manage consent and data-sharing preferences.

MATERIALS AND METHODS

We conducted focus groups with patient and researcher participants recruited from three academic health centers via snowball sampling. Discussions focused on perspectives on the use of electronic health record (EHR) data for research. Themes were identified through consensus coding, starting from an exploratory framework.

RESULTS

We held two focus groups with patients (n = 12 patients) and two with researchers (n = 8 researchers). We identified two patient themes (1-2), one theme common to patients and researchers (3), and two researcher themes (4-5). Themes included (1) motivations for sharing EHR data, (2) perspectives on the importance of data-sharing transparency, (3) individual control of personal EHR data sharing, (4) how EHR data benefits research, and (5) challenges researchers face using EHR data.

DISCUSSION

Patients expressed a tension between the benefits of their data being used in studies to benefit themselves/others and avoiding risk by limiting data access. Patients resolved this tension by acknowledging they would often share their data but wanted greater transparency on its use. Researchers expressed concern about incorporating bias into datasets if patients opted out.

CONCLUSIONS

A research consent and data-sharing platform must consider two competing goals: empowering patients to have more control over their data and maintaining the integrity of secondary data sources. Health systems and researchers should increase trust-building efforts with patients to engender trust in data access and use.

A Structured Review and Evaluation of Android Mobile Applications for Yoga Support

Although there are hundreds of mobile yoga apps in the app market space, the quality and usefulness of these apps have not been systematically tested. We conducted a structured quality evaluation of apps from the Google Play store, applying the validated Mobile Application Rating Scale (MARS) by two independent raters. 18 out of 250 apps were identified for evaluation after applying inclusion/exclusion criteria. The mean MARS score is 4.11 (out of 5) with SD = 0.38. There was high interrater reliability (ICC = .88; 95% CI 0.85-0.91). Apps performed well on functionality and aesthetics. However, there is much room for improvement in information and engagement. Designers and researchers should focus on improving user engagement and building the evidence base for informational content provided in apps.

Infliximab versus second intravenous immunoglobulin for treatment of resistant Kawasaki disease in the USA (KIDCARE): a randomised, multicentre comparative effectiveness trial

BACKGROUND

Although intravenous immunoglobulin (IVIG) is effective therapy for Kawasaki disease, 10-20% of patients have recrudescent fever as a sign of persistent inflammation and require additional treatment. We aimed to compare infliximab with a second infusion of IVIG for treatment of resistant Kawasaki disease.

METHODS

In this multicentre comparative effectiveness trial, patients (aged 4 weeks to 17 years) with IVIG resistant Kawasaki disease and fever at least 36 h after completion of their first IVIG infusion were recruited from 30 hospitals across the USA. Patients were randomly assigned (1:1) to second IVIG (2 g/kg over 8-12 h) or intravenous infliximab (10 mg/kg over 2 h without premedication), by using a randomly permuted block randomisation design with block size of two or four. Patients with fever 24 h to 7 days following completion of first study treatment crossed over to receive the other study treatment. The primary outcome measure was resolution of fever at 24 h after initiation of study treatment with no recurrence of fever attributed to Kawasaki disease within 7 days post-discharge. Secondary outcome measures included duration of fever from enrolment, duration of hospitalisation after randomisation, and changes in markers of inflammation and coronary artery Z score. Efficacy was analysed in participants who received treatment and had available outcome values. Safety was analysed in all randomised patients who did not withdraw consent. This clinical trial is registered with ClinicalTrials.gov, NCT03065244.

FINDINGS

Between March 1, 2017, and Aug 31, 2020, 105 patients were randomly assigned to treatment and 103 were included in the intention-to-treat population (54 in the infliximab group, 49 in the second IVIG group). Two patients randomised to infliximab did not receive allocated treatment. The primary outcome was met by 40 (77%) of 52 patients in the infliximab group and 25 (51%) of 49 patients in the second IVIG infusion group (odds ratio 0·31, 95% CI 0·13-0·73, p=0·0076). 31 patients with fever beyond 24 h received crossover treatment: nine (17%) in the infliximab group received second IVIG and 22 (45%) in second IVIG group received infliximab (p=0·0024). Three patients randomly assigned to infliximab and two to second IVIG with fever beyond 24h did not receive crossover treatment. Mean fever days from enrolment was 1·5 (SD 1·4) for the infliximab group and 2·5 (2·5) for the second IVIG group (p=0·014). Mean hospital stay was 3·2 days (2·1) for the infliximab group and 4·5 days (2·5) for the second IVIG group (p<0·001). There was no difference between treatment groups for markers of inflammation or coronary artery outcome. 24 (44%) of 54 patients in the infliximab group and 33 (67%) of 49 in the second IVIG group had at least one adverse event. A drop in haemoglobin concentration of at least 2g/dL was seen in 19 (33%) of 58 patients who received IVIG as either their first or second study treatment (three of whom required transfusion) and in three (7%) of 43 who received only infliximab (none required transfusion; p=0·0028). Haemolytic anaemia was the only serious adverse events deemed definitely or probably related to study treatment, and was reported in nine (15%) of 58 patients who received IVIG as either their first or second study treatment and none who received infliximab only.

INTERPRETATION

Infliximab is a safe, well tolerated, and effective treatment for patients with IVIG resistant Kawasaki disease, and results in shorter duration of fever, reduced need for additional therapy, less severe anaemia, and shorter hospitalisation compared with second IVIG infusion.

FUNDING

Patient Centered Outcomes Research Institute.

Trust and shared decision-making among individuals with multiple myeloma: A qualitative study

BACKGROUND

Multiple myeloma (MM) is an incurable cancer with complex treatment options. Trusting patient-clinician relationships are essential to promote effective shared decision-making that aligns best clinical practices with patient values and preferences. This study sought to shed light on the development of trust between MM patients and clinicians.

METHODS

Nineteen individual semi-structured interviews were conducted with MM patients within 2 years of initial diagnosis or relapse for this qualitative study. Interviews were recorded and transcripts were coded thematically.

RESULTS

We identified three main themes: (1) externally validated trust describes patients' predisposition to trust or distrust clinicians based on factors outside of patient-clinician interactions; (2) internally validated trust describes how patients develop trust based on interactions with specific clinicians. Internally validated trust is driven primarily by clinician communication practices that demonstrate competence, responsiveness, listening, honesty, and empathy; and (3) trust in relation to shared decision-making describes how patients relate the feeling of trust, or lack thereof, to the process of shared decision-making.

CONCLUSION

Many factors contribute to the development of trust between MM patients and clinicians. While some are outside of clinicians' control, others derive from clinician behaviors and interpersonal communication skills. These findings suggest the possibility that trust can be enhanced through communication training or shared decision-making tools that emphasize relational communication. Given the important role trust plays in shared decision-making, clinicians working with MM patients should prioritize establishing positive, trusting relationships.

Privacy-protecting, reliable response data discovery using COVID-19 patient observations

OBJECTIVE

To utilize, in an individual and institutional privacy-preserving manner, electronic health record (EHR) data from 202 hospitals by analyzing answers to COVID-19-related questions and posting these answers online.

MATERIALS AND METHODS

We developed a distributed, federated network of 12 health systems that harmonized their EHRs and submitted aggregate answers to consortia questions posted at https://www.covid19questions.org. Our consortium developed processes and implemented distributed algorithms to produce answers to a variety of questions. We were able to generate counts, descriptive statistics, and build a multivariate, iterative regression model without centralizing individual-level data.

RESULTS

Our public website contains answers to various clinical questions, a web form for users to ask questions in natural language, and a list of items that are currently pending responses. The results show, for example, that patients who were taking angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers, within the year before admission, had lower unadjusted in-hospital mortality rates. We also showed that, when adjusted for, age, sex, and ethnicity were not significantly associated with mortality. We demonstrated that it is possible to answer questions about COVID-19 using EHR data from systems that have different policies and must follow various regulations, without moving data out of their health systems.

DISCUSSION AND CONCLUSIONS

We present an alternative or a complement to centralized COVID-19 registries of EHR data. We can use multivariate distributed logistic regression on observations recorded in the process of care to generate results without transferring individual-level data outside the health systems.

Informatics-enabled citizen science to advance health equity

The COVID-19 pandemic has once again highlighted the ubiquity and persistence of health inequities along with our inability to respond to them in a timely and effective manner. There is an opportunity to address the limitations of our current approaches through new models of informatics-enabled research and clinical practice that shift the norm from small- to large-scale patient engagement. We propose augmenting our approach to address health inequities through informatics-enabled citizen science, challenging the types of questions being asked, prioritized, and acted upon. We envision this democratization of informatics that builds upon the inclusive tradition of community-based participatory research (CBPR) as a logical and transformative step toward improving individual, community, and population health in a way that deeply reflects the needs of historically marginalized populations.

Assessing the Quality of Electronic Data for 'Fit-for-Purpose' by Utilizing Data Profiling Techniques Prior to Conducting a Survival Analysis for Adults with Acute Lymphoblastic Leukemia

Acute lymphoblastic leukemia affects both children and adults. Rising costs of cancer care and patient burden contribute to the need to study factors influencing outcomes. This study explored the quality of datasets generated from a clinical research institution. The 'fit-for-use' of data prior to examining survival/complications was determined through a systematic approach guided by the Weiskopf et al. 3x3 Data Quality Assessment Framework. Constructs of completeness, correctness, and currency were explored for the data dimensions of patient, variables, and time. There were 11 types of data retrieved. Sufficient data points were found for patient and variable data in each dataset (≥70% of its cells filled with patient level data). Although there was concordance between variables, we found the distribution of lab values and death data to be incorrect. There were missing values for labs ordered and death dates. Our study showed that datasets retrieved can vary, even from the same institution.

Nurse-Led Telephonic Symptom Support for Patients Receiving Chemotherapy

PROBLEM STATEMENT

The use of evidence-informed symptom guides has not been widely adopted in telephonic support.

DESIGN

This is a descriptive study of nurse-led support using evidence-based symptom guides during telephone outreach.

DATA SOURCES

Documentation quantified telephone encounters by frequency, length, and type of patient-reported symptoms. Nurse interviews examined perceptions of their role and the use of symptom guides.

ANALYSIS

Quantitative data were summarized using univariate descriptive statistics, and interviews were analyzed using directed descriptive content analysis.

FINDINGS

Symptom guides were viewed as trusted evidence-based resources, suitable to address common treatment-related symptoms. A threshold effect was a reported barrier of the guides, such that the benefit diminished over time for managing recurring symptoms.

IMPLICATIONS FOR PRACTICE

Telephone outreach using evidence-based symptom guides can contribute to early symptom identification while engaging patients in decision making. Understanding nurse activities aids in developing an economical and high-quality model for symptom support, as well as in encouraging nurses to practice at the highest level of preparation.

Privacy-Protecting, Reliable Response Data Discovery Using COVID-19 Patient Observations.. [PMID: 32995818 PMCID: PMC7523159 DOI: 10.1101/2020.09.21.20196220]

There is an urgent need to answer questions related to COVID-19’s clinical course and associations with underlying conditions and health outcomes. Multi-center data are necessary to generate reliable answers, but centralizing data in a single repository is not always possible. Using a privacy-protecting strategy, we launched a public Questions & Answers web portal (https://covid19questions.org) with analyses of comorbidities, medications and laboratory tests using data from 202 hospitals (59,074 COVID-19 patients) in the USA and Germany. We find, for example, that 8.6% of hospitalizations in which the patient was not admitted to the ICU resulted in the patient returning to the hospital within seven days from discharge and that, when adjusted for age, mortality for hospitalized patients was not significantly different by gender or ethnicity.

Publicly Sharing Knowledge on COVID19 Without Sharing Patient-Level Data: A Privacy-Protecting Multivariate Analysis Approach

Feasibility, Acceptability, and Influence of mHealth-Supported N-of-1 Trials for Enhanced Cognitive and Emotional Well-Being in US Volunteers

Although group-level evidence supports the use of behavioral interventions to enhance cognitive and emotional well-being, different interventions may be more acceptable or effective for different people. N-of-1 trials are single-patient crossover trials designed to estimate treatment effectiveness in a single patient. We designed a mobile health (mHealth) supported N-of-1 trial platform permitting US adult volunteers to conduct their own 30-day self-experiments testing a behavioral intervention of their choice (deep breathing/meditation, gratitude journaling, physical activity, or helpful acts) on daily measurements of stress, focus, and happiness. We assessed uptake of the study, perceived usability of the N-of-1 trial system, and influence of results (both reported and perceived) on enthusiasm for the chosen intervention (defined as perceived helpfulness of the chosen intervention and intent to continue performing the intervention in the future). Following a social media and public radio campaign, 447 adults enrolled in the study and 259 completed the post-study survey. Most were highly educated. Perceived system usability was high (mean scale score 4.35/5.0, SD 0.57). Enthusiasm for the chosen intervention was greater among those with higher pre-study expectations that the activity would be beneficial for them (p < 0.001), those who obtained more positive N-of-1 results (as directly reported to participants) (p < 0.001), and those who interpreted their N-of-1 study results more positively (p < 0.001). However, reported results did not significantly influence enthusiasm after controlling for participants' interpretations. The interaction between pre-study expectation of benefit and N-of-1 results interpretation was significant (p < 0.001), such that those with the lowest starting pre-study expectations reported greater intervention enthusiasm when provided with results they interpreted as positive. We conclude that N-of-1 behavioral trials can be appealing to a broad albeit highly educated and mostly female audience, that usability was acceptable, and that N-of-1 behavioral trials may have the greatest utility among those most skeptical of the intervention to begin with.

The Personal Health Network Mobile App for Chemotherapy Care Coordination: Qualitative Evaluation of a Randomized Clinical Trial

BACKGROUND

Cancer care coordination addresses the fragmented and inefficient care of individuals with complex care needs. The complexity of care coordination can be aided by innovative technology. Few examples of information technology-enabled care coordination exist beyond the conventional telephone follow-up. For this study, we implemented a custom-designed app, the Personal Health Network (PHN)-a Health Insurance Portability and Accountability Act-compliant social network built around a patient to enable patient-centered health and health care activities in collaboration with clinicians, care team members, caregivers, and others designated by the patient. The app facilitates a care coordination intervention for patients undergoing chemotherapy.

OBJECTIVE

This study aimed to understand patient experiences with PHN technology and assess their perspectives on the usability and usefulness of PHNs with care coordination during chemotherapy.

METHODS

A two-arm randomized clinical trial was conducted to compare the PHN and care coordination with care coordination alone over a 6-month period beginning with the initiation of chemotherapy. A semistructured interview guide was constructed based on a theoretical framework of technology acceptance addressing usefulness, usability, and the context of use of the technology within the participant's life and health care setting. All participants in the intervention arm were interviewed on completion of the study. Interviews were recorded and transcribed verbatim. A summative thematic analysis was completed for the transcribed interviews. Features of the app were also evaluated.

RESULTS

A total of 27 interviews were completed. The resulting themes included the care coordinator as a partner in care, learning while sick, comparison of other technology to make sense of the PHN, communication, learning, usability, and usefulness. Users expressed that the nurse care coordinators were beneficial to them because they helped them stay connected to the care team and answered their questions. They shared that the mobile app gave them access to the health information they were seeking. Users expressed that the mobile app would be more useful if it was fully integrated with the electronic health record.

CONCLUSIONS

The findings highlight the value of care coordination from the perspectives of cancer patients undergoing chemotherapy and the important role of technology, such as the PHN, in enhancing this process by facilitating better communication and access to information regarding their illness.

Citizen science to further precision medicine: from vision to implementation

The active involvement of citizen scientists in setting research agendas, partnering with academic investigators to conduct research, analyzing and disseminating results, and implementing learnings from research can improve both processes and outcomes. Adopting a citizen science approach to the practice of precision medicine in clinical care and research will require healthcare providers, researchers, and institutions to address a number of technical, organizational, and citizen scientist collaboration issues. Some changes can be made with relative ease, while others will necessitate cultural shifts, redistribution of power, recommitment to shared goals, and improved communication. This perspective, based on a workshop held at the 2018 AMIA Annual Symposium, identifies current barriers and needed changes to facilitate broad adoption of a citizen science-based approach in healthcare.

Development of an individualized asynchronous sensor-based telerehabilitation program for patients undergoing total knee replacement: Participatory design

Telerehabilitation programs can be employed to establish communication between patients and healthcare professionals and empower patients performing their training remotely. This study aimed to identify patients’ requirements after a total knee replacement following a self-training rehabilitation program, leading to the design and development of a telerehabilitation program that can meet the stakeholders’ actual needs. System design, development, and testing were conducted in five iterations based on a participatory design approach. Data collection was performed using interviews, observations, prototyping, and questionnaires. It was found that the main barriers facing the existing rehabilitation program were a lack of clear communication, lack of relevant information, and healthcare professional’s feedback. The participants emphasized the main themes of communication, information, training, and motivation in the process of design and development. In using the telerehabilitation program, the patients reported a high level of user-friendliness, flexibility, and a sense of security. This study has identified obstacles in the current rehabilitation program and revealed the potential effectiveness of using asynchronous communication and sensor-based technologies by employing participatory design and development. A higher level of portability and flexibility were observed. However, future studies and development are required to investigate the overall usability and reliability of the telerehabilitation program.

Engaging heart failure patients from a clinical data research network: A survey on willingness to participate in different types of research

The willing participation of patients in clinical research is a critical element in national efforts to collect health data for precision medicine and large cohort studies. However, recruiting patients is challenging. Clinical data research networks (CDRN) have primarily been used for observational studies, but may be able to enhance recruitment efforts. We need a better understanding of patient motivation and preferences for research participation and their interest in different types of research activities, particularly among those who are already represented in CDRNs. We surveyed a heart failure patient cohort constructed from EHRs in a CDRN to assess research participation. Results showed that CDRN recruitment is feasible. Respondents were most interested in completing a one-time survey and giving a blood sample one time. They were least interested in a study about weight control that require surgery. We found statistically significant associations between race and research activity interests.

Conceptual Framework to Guide Intervention Research Across the Trajectory of Dementia Caregiving

This article presents a comprehensive conceptual framework designed to foster research in the changing needs of caregivers and persons with dementia as they move through their illness trajectory. It builds on prior theoretical models and intervention literature in the field, while at the same time addressing notable gaps including inadequate attention to cultural issues; lack of longitudinal research; focus on primary caregivers, almost to the exclusion of the person with dementia and other family members; limited outcome measures; and lack of attention to how the culture of health care systems affects caregivers' quality of life. The framework emphasizes the intersectionality of caregiving, sociocultural factors, health care systems' factors, and dementia care needs as they change across time. It provides a template to encourage longitudinal research on reciprocal relationships between caregiver and care recipient because significant changes in the physical and/or mental health status of one member of the dyad will probably affect the physical and/or mental health of the partner. This article offers illustrative research projects employing this framework and concludes with a call to action and invitation to researchers to test components, share feedback, and participate in continued refinement to more quickly advance evidence-based knowledge and practice in the trajectory of dementia caregiving.

Technology and Caregiving: Emerging Interventions and Directions for Research

An array of technology-based interventions has increasingly become available to support family caregivers, primarily focusing on health and well-being, social isolation, financial, and psychological support. More recently the emergence of new technologies such as mobile and cloud, robotics, connected sensors, virtual/augmented/mixed reality, voice, and the evermore ubiquitous tools supported by advanced data analytics, coupled with the integration of multiple technologies through platform solutions, have opened a new era of technology-enabled interventions that can empower and support family caregivers. This paper proposes a conceptual framework for identifying and addressing the challenges that may need to be overcome to effectively apply technology-enabled solutions for family caregivers. The paper identifies a number of challenges that either moderate or mediate the full use of technologies for the benefit of caregivers. The challenges include issues related to equity, inclusion, and access; ethical concerns related to privacy and security; political and regulatory factors affecting interoperability and lack of standards; inclusive/human-centric design and issues; and inherent economic and distribution channel difficulties. The paper concludes with a summary of research questions and issues that form a framework for global research priorities.

Assessing the performance of the Asian/Pacific islander identification algorithm to infer Hmong ethnicity from electronic health records in California

OBJECTIVE

This study assesses the performance of the North American Association of Central Cancer Registries Asian/Pacific Islander Identification Algorithm (NAPIIA) to infer Hmong ethnicity.

DESIGN AND SETTING

Analyses of electronic health records (EHRs) from 1 January 2011 to 1 October 2015. The NAPIIA was applied to the EHR data, and self-reported Hmong ethnicity from a questionnaire was used as the gold standard. Sensitivity, specificity, positive (PPV) and negative predictive values (NPVs) were calculated comparing the source data ethnicity inferred by the algorithm with the self-reported ethnicity from the questionnaire.

PARTICIPANTS

EHRs indicating Hmong, Chinese, Vietnamese and Korean ethnicity who met the original study inclusion criteria were analysed.

RESULTS

The NAPIIA had a sensitivity of 78%, a specificity of 99.9%, a PPV of 96% and an NPV of 99%. The prevalence of Hmong population in the sample was 3.9%.

CONCLUSION

The high sensitivity of the NAPIIA indicates its effectiveness in detecting Hmong ethnicity. The applicability of the NAPIIA to a multitude of Asian subgroups can advance Asian health disparity research by enabling researchers to disaggregate Asian data and unmask health challenges of different Asian subgroups.

Are providers prepared for genomic medicine: interpretation of Direct-to-Consumer genetic testing (DTC-GT) results and genetic self-efficacy by medical professionals

Background

Precision medicine is set to deliver a rich new data set of genomic information. However, the number of certified specialists in the United States is small, with only 4244 genetic counselors and 1302 clinical geneticists. We conducted a national survey of 264 medical professionals to evaluate how they interpret genetic test results, determine their confidence and self-efficacy of interpreting genetic test results with patients, and capture their opinions and experiences with direct-to-consumer genetic tests (DTC-GT).

Methods

Participants were grouped into two categories, genetic specialists (genetic counselors and clinical geneticists) and medical providers (primary care, internists, physicians assistants, advanced nurse practitioners, etc.). The survey (full instrument can be found in the Additional file 1) presented three genetic test report scenarios for interpretation: a genetic risk for diabetes, genomic sequencing for symptoms report implicating a potential HMN7B: distal hereditary motor neuropathy VIIB diagnosis, and a statin-induced myopathy risk. Participants were also asked about their opinions on DTC-GT results and rank their own perceived level of preparedness to review genetic test results with patients.

Results

The rates of correctly interpreting results were relatively high (74.4% for the providers compared to the specialist’s 83.4%) and age, prior genetic test consultation experience, and level of trust assigned to the reports were associated with higher correct interpretation rates. The self-selected efficacy and the level of preparedness to consult on a patient’s genetic results were higher for the specialists than the provider group.

Conclusion

Specialists remain the best group to assist patients with DTC-GT, however, primary care providers may still provide accurate interpretation of test results when specialists are unavailable.

STRENGTHENING FAMILY CAREGIVING THROUGH INNOVATIVE TECHNOLOGY SOLUTIONS

Technology has the potential to enhance the repertoire of tools for family caregiving to address the complexities of caring for older adults. There are examples of technology-enabled interventions helping older adults remain independent and safe in their home; easing the financial, physical, and psychological challenges of family caregiving; assisting in the management of chronic illness; improving socialization and support; offering information and resources on a “just in time” basis; and improving the quality of care and quality of life for both older adults and their family caregivers. This session will review eight evidence-based, technology-enabled solutions for family caregivers, including technology solutions that address medication adherence, falls prevention, personal emergency response, remote monitoring, telehealth, dementia tracking, social engagement, and care training. Key drivers for successful application of these interventions (e.g., technology, analytics, user experience design) as well as barriers to scaling (e.g., accessibility, affordability, regulation) will be reviewed.

Patient Commitment to Health (PACT-Health) in the Heart Failure Population: A Focus Group Study of an Active Communication Framework for Patient-Centered Health Behavior Change

Background

Over 6 million Americans have heart failure, and 1 in 8 deaths included heart failure as a contributing cause in 2016. Lifestyle changes and adherence to diet and exercise regimens are important in limiting disease progression. Health coaching and public commitment are two interactive communication strategies that may improve self-management of heart failure.

Objective

This study aimed to conduct patient focus groups to gain insight into how best to implement health coaching and public commitment strategies within the heart failure population.

Methods

Focus groups were conducted in two locations. We studied 2 patients in Oakland, California, and 5 patients in Los Angeles, California. Patients were referred by local cardiologists and had to have a diagnosis of chronic heart failure. We used a semistructured interview tool to explore several patient-centered themes including medication adherence, exercise habits, dietary habits, goals, accountability, and rewards. We coded focus group data using the a priori coding criteria for these domains.

Results

Medication adherence barriers included regimen complexity, forgetfulness, and difficulty coping with side effects. Participants reported that they receive little instruction from care providers on appropriate exercise and dietary habits. They also reported personal and social obstacles to achieving these objectives. Participants were in favor of structured goal setting, use of online social networks, and financial rewards as a means of promoting health lifestyles. Peers were viewed as better motivating agents than family members.

Conclusions

An active communication framework involving dissemination of diet- and exercise-related health information, structured goal setting, peer accountability, and financial rewards appears promising in the management of heart failure.

Native American Youth Citizen Scientists Uncovering Community Health and Food Security Priorities

Citizen science based on principles of community-based participatory research involves the co-creation of research among citizens and professional researchers in substantive aspects of scientific inquiry including equitable contributions to governance, research questions, data collection, analysis, application of findings, and dissemination. This article reports on a citizen science project conducted by 12 youth in the Karuk Tribe collaborating with university scientists. The youth participated in a research leadership development program conducted in their community located in rural/remote northern California. The youth led a community health and food security assessment survey using a mobile application tool (n = 212). They uncovered community concerns about the health of residents and healthfulness of food choices in schools, as well as a significant difference related to confidence in making healthy food choices between those who are and are not physically active. The Tribe applied the study findings with youth in alignment with cultural values and practices investing in developing community gardens, improving school food quality, and promoting native food practices that incorporate physical activities such as hiking, gathering, and preserving food. This study offers lessons for research collaborations among citizen scientists from communities underrepresented in health research and university scientists.

Examining the Needs of Patient Stakeholders as Research Partners in Health Data Networks for Translational Research

Patient stakeholders are getting increasingly involved in research health data networks, particularly as research partners. However, tools do not exist to help effectively orient, educate, and engage patient stakeholders as they take on these roles. Using a human centered design approach, we conducted a patient stakeholder needs assessment qualitative study to identify key user needs to drive design recommendations for development of an online education and engagement tool for research health data networks. We found three key needs related to multiple role identities, motivations and expectations for participation on research teams, and patient journeys. Design recommendations derived from the needs assessment are discussed that can support future tool design and testing.

The Kawasaki Disease Comparative Effectiveness (KIDCARE) trial: A phase III, randomized trial of second intravenous immunoglobulin versus infliximab for resistant Kawasaki disease

BACKGROUND

Although intravenous immunoglobulin (IVIG) is effective therapy for Kawasaki disease (KD), the most common cause of acquired heart disease in children, 10-20% of patients are IVIG-resistant and require additional therapy. This group has an increased risk of coronary artery aneurysms (CAA) and there has been no adequately powered, randomized clinical trial in a multi-ethnic population to determine the optimal therapy for IVIG-resistant patients.

OBJECTIVES

The primary outcome is duration of fever in IVIG-resistant patients randomized to treatment with either infliximab or a second IVIG infusion. Secondary outcomes include comparison of inflammatory markers, duration of hospitalization, and coronary artery outcome. An exploratory aim records parent-reported outcomes including signs, symptoms and treatment experience.

METHODS

The KIDCARE trial is a 30-site randomized Phase III comparative effectiveness trial in KD patients with fever ≥36 h after the completion of their first IVIG treatment. Eligible patients will be randomized to receive either a second dose of IVIG (2 g/kg) or infliximab (10 mg/kg). Subjects with persistent or recrudescent fever at 24 h following completion of the first study treatment will cross-over to the other treatment arm. Subjects will exit the study after their first outpatient visit (5-18 days following last study treatment). The parent-reported outcomes, collected daily during hospitalization and at home, will be compared by study arm.

CONCLUSION

This trial will contribute to the management of IVIG-resistant patients by establishing the relative efficacy of a second dose of IVIG compared to infliximab and will provide data regarding the patient/parent experience of these treatments.

Diagnostic Performance of Multidetector Computerized Tomography in the Detection of Abdominal Complications Early and Late After Liver Transplantation: A 10-Year Experience

BACKGROUND

Multidetector computerized tomography (MDCT) is considered to be a fast noninvasive diagnostic technique for the evaluation of postoperative complications in patients with liver transplantation (LT). However, its role has not been fully established in the diagnosis for detecting complications after liver transplantation. The aim of this work was to evaluate the diagnostic performance of MDCT for detecting abdominal complications in the early and late periods after LT.

METHODS

We retrospectively enrolled 75 patients who had undergone LT from March 2006 to January 2010, followed by MDCT from March 2006 to November 2017. Patients were divided into 2 groups according to the timing after LT: within the first 3 months (early period) or ≥3 months after LT (late period). We evaluated vascular, biliary, and other complications on MDCT. Angiography, endoscopic retrograde cholangiography, and percutaneous transhepatic cholangiography were used as reference standards.

RESULTS

We initially found 77 complications in 45 patients (60.0%) with the use of MDCT. After comparison with the reference standards, 83 complications were diagnosed in 49 patients (65.3%). Forty-seven complications (34 vascular, 10 biliary, 3 other complications) were diagnosed in 33 patients (44.0%) during the early period, and 36 complications (6 vascular, 20 biliary, 10 other complications) were detected in 27 patients (36.0%) in the late period. The sensitivity, specificity, and diagnostic accuracy of MDCT for diagnosing overall complications were, respectively, 93.6%, 90.2%, and 92.0% in the early period (for vascular complications: 97.1%, 92.6%, and 94.3%,; for biliary complications: 80.0%, 100%, and 97.7%) and 77.8%, 98.1%, and 89.8% in the late period (for vascular complications: 83.3%, 100%, and 98.9%; for biliary complications: 65.0%, 98.6%, and 90.9%).

CONCLUSIONS

Although MDCT in the late period should be interpreted with caution in patients with suspected biliary complication, MDCT is a reliable diagnostic technique for the identification of early and late abdominal complications after LT.

Data Visualizations to Support Health Practitioners' Provision of Personalized Care for Patients With Cancer and Multiple Chronic Conditions: User-Centered Design Study

BACKGROUND

There exists a challenge of understanding and integrating various types of data collected to support the health of individuals with multiple chronic conditions engaging in cancer care. Data visualization has the potential to address this challenge and support personalized cancer care.

OBJECTIVE

The aim of the study was to assess the health care practitioners' perceptions of and feedback regarding visualizations developed to support the care of individuals with multiple chronic conditions engaging in cancer care.

METHODS

Medical doctors (n=4) and registered nurses (n=4) providing cancer care at an academic medical center in the western United States provided feedback on visualization mock-ups. Mock-up designs were guided by current health informatics and visualization literature and the Munzner Nested Model for Visualization Design. User-centered design methods, a mock patient persona, and a scenario were used to elicit insights from participants. Directed content analysis was used to identify themes from session transcripts. Means and SDs were calculated for health care practitioners' rankings of overview visualizations.

RESULTS

Themes identified were data elements, supportive elements, confusing elements, interpretation, and use of visualization. Overall, participants found the visualizations useful and with the potential to provide personalized care. Use of color, reference lines, and familiar visual presentations (calendars, line graphs) were noted as helpful in interpreting data.

CONCLUSIONS

Visualizations guided by a framework and literature can support health care practitioners' understanding of data for individuals with multiple chronic conditions engaged in cancer care. This understanding has the potential to support the provision of personalized care.

A mobile system for the improvement of heart failure management: Evaluation of a prototype

Management of heart failure is complex, often involving interaction with multiple providers, monitoring of symptoms, and numerous medications. Employing principles of user-centered design, we developed a high- fidelity prototype of a mobile system for heart failure self-management and care coordination. Participants, including both heart failure patients and health care providers, tested the mobile system during a one-hour one-on-one session with a facilitator. The facilitator interviewed participants about the strengths and weaknesses of the prototype, necessary features, and willingness to use the technology. We performed a qualitative content analysis using the transcripts of these interviews. Fourteen distinct themes were identified in the analysis. Of these themes, integration, technology literacy, memory, and organization were the most common. Privacy was the least common theme. Our study suggests that this integration is essential for adoption of a mobile system for chronic disease management and care coordination.

Abstract WMP111: Assessing Caregiver Commitment and Capacity

Care transitions for individuals with disabling conditions, such as stroke, are often ineffective and inefficient, resulting in unmet patient and caregiver (CG) needs, increased safety risks, high rates of preventable readmissions, and increased health care costs. This is particularly problematic for stroke patients transitioning from an inpatient rehabilitation facility (IRF) to home. There is no assessment instrument specifically designed to evaluate a family member’s commitment and capacity to assume the caregiving role following a stroke survivor (SS) discharge from an IRF or sub-acute facility. This is critically needed to facilitate the development of tailored care plans and interventions to mitigate risks associated with the crisis of stroke and the associated health effects on the CG and SS. The purpose of this study is determine the psychometric properties of the Preparedness Assessment for the Transition Home after Stroke (PATH-s) instrument. The PATH-s instrument is a 25-item, 4-point scale based on the foundational work of B. Lutz (Co-Investigator). A prospective cohort study was conducted to establish the psychometric properties of the PATH-s instrument using a convenience sample of 184 SSs and their family caregivers during IRF admission. Data collection from SSs and CGs at IRF admission was conducted to determine the quality of the items, internal consistency, reliability, construct validity, and criterion-related validity. We will describe the characteristics of CG responses on the PATH-s instrument during IRF in addition to correlation with other measures (general health, perceived stress, depression). This novel instrument can support a primary prevention strategy to identify gaps in preparedness for stroke survivor-caregiver dyads following the complex transition from IRF to home, with the long-range goal to mitigate the effects of suboptimal preparation and the associated adverse effects associated with this transition on the health of CGs and SSs. Once gaps are identified, care plans can be tailored to address gaps and better prepare caregivers for the transition home.

Metastasectomy for recurrent or metastatic biliary tract cancers: A single center experience

PURPOSE

To assess efficacy or long-term result of metastasectomy for recurrent or metastatic biliary tract carcinoma (BTC), we conducted a retrospective review of the outcomes of metastasectomy for recurrent or metastatic BTCs, comprising intrahepatic cholangiocellular carcinoma (IHCCC), proximal and distal common bile duct cancer (pCBDC and dCBDC), gallbladder cancer (GBC), and ampulla of Vater cancer (AoVC).

PATIENTS AND METHODS

The clinicopathological features and outcomes of BTC patients who underwent surgical resection for the primary and metastatic disease at the Gachon University Gil Medical Centre from 2003 to 2013 were reviewed retrospectively.

RESULTS

We found 19 eligible patients. Primary sites were GBC (seven patients, 37%), IHCCC (five patients, 26%), dCBDC (three patients, 16%), pCBDC (two patients, 11%), and AoVC (two patients, 11%). Eight patients (42%) had synchronous metastasis whereas 11 (58%) had metachronous metastasis. The most common metastatic site was liver (nine patients, 47%), lymph node (nine patients, 47%), and peritoneum (three patients, 16%). Nine patients (47%) achieved R0 resection, whereas four (21%) and six (32%) patients had R1 and R2 resection, respectively. With a median follow-up period of 26.7 months, the estimated median overall survival (OS) was 18.2 months (95% confidence interval, 13.6-22.9 months). Lower Eastern Cooperative Oncology Group performance status (P = 0.023), metachronous metastasis (P = 0.04), absence of lymph node metastasis (P = 0.009), lower numbers of metastatic organs (P < 0.001), normal postoperative CA19-9 level (P = 0.034), and time from diagnosis to metastasectomy more than 1 year (P = 0.019) were identified as prognostic factors for a longer OS after metastasectomy.

CONCLUSIONS

For recurrent or metastatic BTCs, metastasectomy can be a viable option for selected patients.

Added Value from Secondary Use of Person Generated Health Data in Consumer Health Informatics

Introduction: Various health-related data, subsequently called Person Generated Health Data (PGHD), is being collected by patients or presumably healthy individuals as well as about them as much as they become available as measurable properties in their work, home, and other environments. Despite that such data was originally just collected and used for dedicated predefined purposes, more recently it is regarded as untapped resources that call for secondary use. Method: Since the secondary use of PGHD is still at its early evolving stage, we have chosen, in this paper, to produce an outline of best practices, as opposed to a systematic review. To this end, we identified key directions of secondary use and invited protagonists of each of these directions to present their takes on the primary and secondary use of PGHD in their sub-fields. We then put secondary use in a wider perspective of overarching themes such as privacy, interpretability, interoperability, utility, and ethics. Results: We present the primary and secondary use of PGHD in four focus areas: (1) making sense of PGHD in augmented Shared Care Plans for care coordination across multiple conditions; (2) making sense of PGHD from patient-held sensors to inform cancer care; (3) fitting situational use of PGHD to evaluate personal informatics tools in adaptive concurrent trials; (4) making sense of environment risk exposure data in an integrated context with clinical and omics-data for biomedical research. Discussion: Fast technological progress in all the four focus areas calls for a societal debate and decision-making process on a multitude of challenges: how emerging or foreseeable results transform privacy; how new data modalities can be interpreted in light of clinical data and vice versa; how the sheer mass and partially abstract mathematical properties of the achieved insights can be interpreted to a broad public and can consequently facilitate the development of patient-centered services; and how the remaining risks and uncertainties can be evaluated against new benefits. This paper is an initial summary of the status quo of the challenges and proposals that address these issues. The opportunities and barriers identified can serve as action items individuals can bring to their organizations when facing challenges to add value from the secondary use of patient-generated health data.

MAP2K1 Mutation in Colorectal Cancer Patients: Therapeutic Challenge Using Patient-Derived Tumor Cell Lines

BACKGROUND: The MAP2K1 K57T mutation is known to be a potential mechanism of primary and secondary resistance to EGFR inhibitors in metastatic colorectal cancer (CRC) and has also been reported to promote resistance to BRAF and MEK inhibitors. It is important to overcome therapeutic resistance to EGFR inhibitors to improve the treatment outcomes of metastatic CRC. METHODS: We established patient-derived tumor cells (PDCs) from metastatic lesions that newly appeared during treatment with a BRAF inhibitor (LGX-818) plus an EGFR inhibitor (cetuximab) in a patient with BRAF-mutant CRC. To investigate therapeutic options to overcome acquired resistance due to MAP2K1 mutation in BRAF-mutant CRC, we performed cell viability assays using the PDCs. RESULTS: We tested whether the PDCs were resistant to an EGFR inhibitor (cetuximab) and a BRAF inhibitor (sorafenib) as these cells were established at the time of resistance to the EGFR plus BRAF inhibitors. Moreover, the anti-tumor effect of AZD6244 (MEK inhibitor) was evaluated because PDCs harbored a MAP2K1 mutation at the time of resistance to the EGFR plus BRAF inhibitors. MTT proliferation assays showed that monotherapy with cetuximab, sorafenib, or AZD6244 did not suppress cell viability. We next tested viability of the PDCs to combination treatment with cetuximab plus AZD6244 and sorafenib plus AZD6244. Proliferation of PDCs was significantly inhibited by sorafenib and AZD6244, but not by cetuximab plus AZD6244. Investigation of the combined effect of sorafenib and AZD6244 using the calculated combination index (CI) showed synergistic effects of sorafenib and AZD6244 in combination therapy applied to PDCs with the MAP2K1 K57T mutation. CONCLUSION: Our results suggest that combination treatment with BRAF and MEK inhibitors might be a novel treatment strategy for MAP2K1 K57T-mutant CRC. This finding will be helpful to guide treatment of patients with CRC that is resistant to EGFR inhibitors.

Obesity: a chronic relapsing progressive disease process. A position statement of the World Obesity Federation

This paper considers the argument for obesity as a chronic relapsing disease process. Obesity is viewed from an epidemiological model, with an agent affecting the host and producing disease. Food is the primary agent, particularly foods that are high in energy density such as fat, or in sugar-sweetened beverages. An abundance of food, low physical activity and several other environmental factors interact with the genetic susceptibility of the host to produce positive energy balance. The majority of this excess energy is stored as fat in enlarged, and often more numerous fat cells, but some lipid may infiltrate other organs such as the liver (ectopic fat). The enlarged fat cells and ectopic fat produce and secrete a variety of metabolic, hormonal and inflammatory products that produce damage in organs such as the arteries, heart, liver, muscle and pancreas. The magnitude of the obesity and its adverse effects in individuals may relate to the virulence or toxicity of the environment and its interaction with the host. Thus, obesity fits the epidemiological model of a disease process except that the toxic or pathological agent is food rather than a microbe. Reversing obesity will prevent most of its detrimental effects.

Psychosocial outcomes in active treatment through survivorship

OBJECTIVE

The objective of the study is to understand potential differences in psychosocial outcomes from active treatment to survivorship.

METHODS

Using the Medical Expenditure Panel Survey Experiences with Cancer Survivorship Supplement (n = 1360), we examined and compared psychosocial outcomes among respondents in active treatment with survivors by year(s) since treatment ended. Survey-weighted regression models were used to test associations between year(s) since treatment and depressive symptoms (Patient Health Questionnaire-2), psychological distress (K6), and cancer-specific worry related to recurrence.

RESULTS

Unadjusted estimates showed no significant differences in depressive symptoms or psychological distress between those in active treatment and cancer survivors at any time posttreatment. In contrast, the prevalence of cancer-specific worry was lowest among survivors more than 5 years since treatment (10%), slightly higher among those with less than 1 year since treatment (15%), and highest among those in active treatment (32%). In models controlled for sociodemographic and health-related covariates, the year(s) since treatment ended was inversely associated with the odds of cancer-specific worry but was not associated with depressive symptoms or psychological distress.

CONCLUSIONS

In this population-based sample, worry about cancer recurrence may diminish with years since treatment ended, while depressive symptoms and distress are persistent across the trajectory. These findings highlight unmet psychosocial needs among cancer survivors and demonstrate the importance of targeted interventions across the survivorship continuum.

Comparative analysis of stakeholder experiences with an online approach to prioritizing patient-centered research topics

OBJECTIVE

Little evidence exists about effective and scalable methods for meaningful stakeholder engagement in research. We explored patient/caregiver experiences with a high-tech online engagement approach for patient-centered research prioritization, compared their experiences with those of professional stakeholders, and identified factors associated with favorable participant experiences.

METHODS

We conducted 8 online modified-Delphi (OMD) panels. Panelists participated in 2 rating rounds with a statistical feedback/online discussion round in between. Panels focused on weight management/obesity, heart failure, and Kawasaki disease. We recruited a convenience sample of adults with any of the 3 conditions (or parents/guardians of Kawasaki disease patients), clinicians, and researchers. Measures included self-reported willingness to use OMD again, the panelists' study participation and online discussion experiences, the system's perceived ease of use, and active engagement metrics.

RESULTS

Out of 349 panelists, 292 (84%) completed the study. Of those, 46% were patients, 36% were clinicians, and 19% were researchers. In multivariate models, patients were not significantly more actively engaged (Odds ratio (OR) = 1.69, 95% confidence interval (CI), 0.94-3.05) but had more favorable study participation (β = 0.49; P  ≤ .05) and online discussion (β = 0.18; P  ≤ .05) experiences and were more willing to use OMD again (β = 0.36; P  ≤ .05), compared to professional stakeholders. Positive perceptions of the OMD system's ease of use (β = 0.16; P  ≤ .05) and favorable study participation (β = 0.26; P  ≤ .05) and online discussion (β = 0.57; P  ≤ .05) experiences were also associated with increased willingness to use OMD in the future. Active engagement was not associated with online experience indices or willingness to use OMD again.

CONCLUSION

Online approaches to engaging large numbers of stakeholders are a promising and efficient adjunct to in-person meetings.

Living Donor Liver Transplantation in a Patient With Extensive Portomesenteric Venous Thrombosis: Case Report

Extensive portomesenteric venous thrombus preventing restoration of adequate portal venous flow used to be considered a contraindication to liver transplantation. The subject was a 49-year-old male with hepatitis B cirrhosis and extensive thrombosis of portal, splenic, and superior mesenteric veins, and two large collateral vessels; one dilated and tortuous inferior to the pancreaticoduodenal vein and relevant to splanchnic venous return and the other a dilated coronary vein relevant to splenic venous return. During operation, the portal vein was anastomosed to these large collateral vessels using cryopreserved iliac vein. In conclusion, portal reconstruction with large collateral vessels in living-donor liver transplantation could be used selectively for patients with extensive portomesenteric venous thrombosis.

Factors affecting willingness to share electronic health data among California consumers

Background

Robust technology infrastructure is needed to enable learning health care systems to improve quality, access, and cost. Such infrastructure relies on the trust and confidence of individuals to share their health data for healthcare and research. Few studies have addressed consumers’ views on electronic data sharing and fewer still have explored the dual purposes of healthcare and research together. The objective of the study is to explore factors that affect consumers’ willingness to share electronic health information for healthcare and research.

Methods

This study involved a random-digit dial telephone survey of 800 adult Californians conducted in English and Spanish. Logistic regression was performed using backward selection to test for significant (p-value ≤ 0.05) associations of each explanatory variable with the outcome variable.

Results

The odds of consent for electronic data sharing for healthcare decreased as Likert scale ratings for EHR impact on privacy worsened, odds ratio (OR) = 0.74, 95% CI [0.60, 0.90]; security, OR = 0.80, 95% CI [0.66, 0.98]; and quality, OR = 0.59, 95% CI [0.46–0.75]. The odds of consent for sharing for research was greater for those who think EHR will improve research quality, OR = 11.26, 95% CI [4.13, 30.73]; those who value research benefit over privacy OR = 2.72, 95% CI [1.55, 4.78]; and those who value control over research benefit OR = 0.49, 95% CI [0.26, 0.94].

Conclusions

Consumers’ choices about electronically sharing health information are affected by their attitudes toward EHRs as well as beliefs about research benefit and individual control. Design of person-centered interventions utilizing electronically collected health information, and policies regarding data sharing should address these values of importance to people. Understanding of these perspectives is critical for leveraging health data to support learning health care systems.

[CHANGES IN BRAIN ELECTRICAL ACTIVITY PATTERNS IN RATS WITH DIFFERENT SUSCEPTIBILITY TO SEIZURES IN LITHIUM-PILOCARPINE MODEL OF STATUS EPILEPTICUS]

The intracranial EEG was continuously registered in Krushinskii-Molodkina rats with inherited susceptibility to audiogenic seizures and in Wistar rats, which are resistant to the audiogenic convulsions in the lithium-pilocarpine model of status epilepticus (SE). The recordings were done from somatosensory, auditory and visual cortical areas, caudate nucleus, hippocampus and dorso-medial nucleus of thalamus. We found that SE was induced in Krushinskii-Molodkina rats by intramuscular injections of pilocarpine at a minimum dose of 15 mg/kg, while in Wistar rats with a dose of 25 mg/kg. We describe six successive EEG patterns during SE. We identified behavioral convulsive manifestations associated with each phase of the SE. Rats of both strains had the same sequence and the main properties of EEG patterns, except the latency of phase 1 (Krushinskii-Molodkina rats 13 + 3 min vs. Wistar rats 23 + 2 min). In conclusion, the rats with susceptibility to audiogenic seizures have increased sensitivity to the pilocarpine, but the development and time-course of SE in rats of both strains did not differ.

HE4 promotes collateral resistance to cisplatin and paclitaxel in ovarian cancer cells

Background

Chemotherapy resistance presents a difficult challenge in treating epithelial ovarian cancer patients, particularly when tumors exhibit resistance to multiple chemotherapeutic agents. A few studies have shown that elevated serum levels of the ovarian cancer biomarker HE4 correlate with tumor chemoresistance, response to treatment, and survival. Here, we sought to confirm our previous results that HE4 contributes to collateral resistance to cisplatin and paclitaxel in vitro and uncover factors that may contribute to HE4-mediated chemoresistance.

Methods

MTS assays and western blots for cleaved PARP were used to assess resistance of HE4-overexpressing SKOV3 and OVCAR8 clones to cisplatin and paclitaxel. CRISPR/Cas technology was used to knockdown HE4 in HE4-overexpressing SKOV3 cells. A microarray was conducted to determine differential gene expression between SKOV3 null vector-transfected and HE4-overexpressing clones upon cisplatin exposure, and results were validated by quantitative RT-PCR. Regulation of mitogen activated protein kinases (MAPKs) and tubulins were assessed by western blot.

Results

HE4-overexpressing SKOV3 and OVCAR8 clones displayed increased resistance to cisplatin and paclitaxel. Knockdown of HE4 in HE4-overexpressing SKOV3 cells partially reversed chemoresistance. Microarray analysis revealed that HE4 overexpression resulted in suppression of cisplatin-mediated upregulation of EGR1, a MAPK-regulated gene involved in promoting apoptosis. Upregulation of p38, a MAPK activated in response to cisplatin, was suppressed in HE4-overexpressing clones. No differences in extracellular signal-regulated kinase (ERK) activation were noted in HE4-overexpressing clones treated with 25 μM cisplatin, but ERK activation was partially suppressed in HE4-overexpressing clones treated with 80 μM cisplatin. Furthermore, treatment of cells with recombinant HE4 dramatically affected ERK activation in SKOV3 and OVCAR8 wild type cells. Recombinant HE4 also upregulated α-tubulin and β-tubulin levels in SKOV3 and OVCAR8 cells, and microtubule associated protein tau (MAPT) gene expression was increased in SKOV3 HE4-overexpressing clones.

Conclusions

Overexpression of HE4 promotes collateral resistance to cisplatin and paclitaxel, and downregulation of HE4 partially reverses this chemoresistance. Multiple factors could be involved in HE4-mediated chemoresistance, including deregulation of MAPK signaling, as well as alterations in tubulin levels or stability.

Electronic supplementary material

The online version of this article (doi:10.1186/s13048-016-0240-0) contains supplementary material, which is available to authorized users.

Psychosocial outcomes among cancer survivors who receive a treatment summary or survivorship care plan

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Background: Treatment summaries (TSs) and survivorship care plans (SCPs) were expected to bridge patient-provider communication challenges and better address the unique needs of cancer survivors. While interest in TSs and SCPs has been growing, acceptance and implementation has been slow and findings from studies of their effectiveness have been mixed, overall. Our study examines independent associations of receipt of TSs and SCPs with psychosocial outcomes of cancer survivors. Methods: The study sample included survivors completing the 2012 LIVESTRONG Survey for People Affected by Cancer (n = 5,156). Logistic regression was used to model three distinct psychosocial outcomes: having relationship concerns (yes/no), distress (defined as a rating of 6 or higher on the NCCN Distress Thermometer), and moderate or severe cancer-specific worry (yes/no) as functions of TS receipt, SCP receipt and important confounding variables (age, sex, race/ethnicity, marital status, employment, income, education and health insurance). Results: Among cancer survivors, only 51% received a TS and only 16% received a SCP. Survivors who received a TS or SCP had significantly lower odds of relationship concerns (TS: OR = 0.62; 95% CI 0.52, 0.75; SCP: OR = 0.73; 95% CI 0.57, 0.94); distress (TS: OR = 0.74; 95% CI 0.65, 0.85; SCP: OR = 0.81; 95% CI 0.68, 0.97); and moderate or severe cancer-specific worry (TS: OR = 0.76; 95% CI: 0.67-0.85; SCP: OR = 0.78; 95% CI: 0.67-0.92). Other covariates consistently associated with psychosocial concerns included younger age, being unemployed and income ≤ $60,000. Conclusions: Many cancer survivors do not receive a TS or SCP. Receipt of either document was associated with reporting better psychosocial outcomes, suggesting that TSs and SCPs may not be reaching cancer survivors with psychosocial health problems. Survivors with psychosocial concerns may benefit from targeted survivorship care.

Parenting experiences of cancer survivors with young children in the 2012 LIVESTRONG Survey for People Affected by Cancer

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Background: When a parent is diagnosed with cancer, family functioning may be disrupted, placing children at risk. Little is known, however, about the parenting experiences of cancer survivors. Methods: Among cancer survivors with children age ≤ 20 years at diagnosis (n = 2,375) in the 2012 LIVESTRONG Survey for People Affected by Cancer, we used logistic regression to model the odds that 1) children were not fully emotionally supported or that 2) cancer affected survivors’ ability to provide care for their children. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. Predictors included age of youngest child at diagnosis ( ≤ 10 years versus 11-20 years), survivor report of high distress, and confidence obtaining emotional support. Models also controlled for important sociodemographic covariates. Results: Among survivors, 50% reported that their children were not fully emotionally supported, and 58% reported that cancer affected their ability to provide care for their children. Significant predictors of children not being fully emotionally supported included: government insurance (OR 1.5; 95% CI 1.0-2.1); annual income ≤ $60,000 (OR 1.6; 95% CI 1.3-2.1); being retired (OR 1.7; 95% CI 1.2-2.4); or female (OR 1.4; 95% CI 1.1-1.7). Significant predictors of cancer interfering with the ability to provide care for children included: female sex (OR 2.2; 95% CI 1.8-2.7), survivor report of high distress (OR 1.6, 95% CI 1.4-2.0), having a child ≤ 10 years (OR 2.5; 95% CI 2.0-3.2), or a child who was not fully emotionally supported (OR 1.5; 95% CI 1.3-1.9). Survivors with confidence in their ability to obtain emotional support were less likely to report that cancer interfered with their ability to provide care (OR 0.8; 95% CI 0.6-0.9). Conclusions: Many cancer survivors with young children at diagnosis report that cancer or its treatment affects their ability to provide care, or that their children are not fully emotionally supported. Increased attention to the psychosocial needs of parenting cancer survivors is warranted, particularly among women, those with public insurance, lower incomes, children ≤ 10 years and survivors who report high distress levels or inadequate emotional support.

Variability in empathic fear response among 11 inbred strains of mice

Empathy is an important emotional process that involves the ability to recognize and share emotions with others. We have previously developed an observational fear learning (OFL) behavioral assay to measure empathic fear in mice. In the OFL task, a mouse is conditioned for context-dependent fear when it observes a conspecific demonstrator receiving aversive stimuli. In the present study, by comparing 11 different inbred mouse strains that are commonly used in the laboratory, we found that empathic fear response was highly variable between different strains. Five strains--C57BL/6J, C57BL/6NTac, 129S1/SvImJ, 129S4/SvJae and BTBR T(+) Itpr3(tf) /J--showed observational fear (OF) responses, whereas AKR/J, BALB/cByJ, C3H/HeJ, DBA/2J, FVB/NJ and NOD/ShiLtJ mice exhibited low empathic fear response. Importantly, day 2 OF memory was significantly correlated with contextual memory in the classical fear conditioning among the 11 strains. Innate differences in anxiety, locomotor activity, sociability and preference for social novelty were not significantly correlated with OFL. Interestingly, early adolescent C57BL/6J mice exhibited an increase in acquisition of OF. The level of OFL in C57BL/6J strain was not affected by sex or strains of the demonstrator. Taken together, these data strongly suggest that there are naturally occurring OFL-specific genetic variations modulating empathic fear behaviors in mice. The identification of causal genes may uncover novel genetic pathways and underlying neural mechanisms that modulate empathic fear and, ultimately, provide new targets for therapeutic intervention in human mental disorders associated with impaired empathy.

A Personal Health Network for Chemotherapy Care Coordination: Evaluation of Usability Among Patients

Cancer is a top concern globally. Cancer care suffers from lack of coordination, silos of information, and high cost. Interest is emerging in person-centered technology to assist with coordination to address these challenges. This study evaluates the usability of the "personal health network" (PHN), a novel solution leveraging social networking and mobile technologies, among individuals undergoing chemotherapy and receiving care coordination. Early results from interviews of 12 participants in a randomized pragmatic trial suggest that they feel more connected to the healthcare team using the PHN, find value in access to the patient education library, and are better equipped to organize the many activities that occur during chemotherapy. Improvements are needed in navigation, connectivity, and integration with electronic health records. Findings contribute to improvements in the PHN and informs a roadmap for potentially greater impact in technology-enabled cancer care coordination.

A Mobile Care Coordination System for the Management of Complex Chronic Disease

There is global concern about healthcare cost, quality, and access as the prevalence of complex and chronic diseases, such as heart disease, continues to grow. Care for patients with complex chronic disease involves diverse practitioners and multiple transitions between medical centers, physician practices, clinics, community resources, and patient homes. There are few systems that provide the flexibility to manage these varied and complex interactions. Participatory and user-centered design methodology was applied to the first stage of building a mobile platform for care coordination for complex, chronic heart disease. Key informant interviews with patients, caregivers, clinicians, and care coordinators were conducted. Thematic analysis led to identification of priority user functions including shared care plan, medication management, symptom management, nutrition, physical activity, appointments, personal monitoring devices, and integration of data and workflow. Meaningful stakeholder engagement contributes to a person-centered system that enhances health and efficiency.

Health information technology adoption in California community health centers

OBJECTIVES

National and state initiatives to spur adoption of electronic health records (EHRs) and health information exchange (HIE) among providers in rural and underserved communities have been in place for 15 years. Our goal was to systematically assess the impact of these initiatives by quantifying the level of adoption and key factors associated with adoption among community health centers in California.

STUDY DESIGN

Cross-sectional statewide survey.

METHODS

We conducted a telephone survey of all California primary care community health centers (CHCs) from August to September 2013. Multiple logistic regressions were fit to test for associations between various practice characteristics and adoption of EHRs, meaningful use-certified EHRs, and HIE. For the multivariable model, we included those variables which were significant at the P = .10 level in the univariate tests.

RESULTS

We received responses from 194 CHCs (73.5% response rate). Adoption of any EHRs (80.3%) and meaningful use-certified EHRs (94.6% of those with an EHR) was very high. Adoption of HIE is substantial (48.7%) and took place within a few years (mean = 2.61 years; SD = 2.01). More than half (54.7%) of CHCs are able to receive data into the EHR indicating some level of interoperability. Patient engagement capacity is moderate, with 21.6% offering a PHR, and 55.2% electronic visit summaries. Rural location and belonging to a multi-site clinic organization both increase the odds of adoption of EHRs, HIE, and electronic visit summary, with the odds ratio ranging from 0.63 to 3.28 (all P values < .05).

CONCLUSIONS

Greater adoption of health information technology (IT) in rural areas may be the result of both federal and state investments. As CHCs lack access to capital for investments, continued support of technology infrastructure may be needed for them to further leverage health IT to improve healthcare.

Predictors of financial difficulties and work modifications among cancer survivors in the United States

PURPOSE

The aim of this study is to examine predictors of cancer-related financial difficulties and work modifications in a national sample of cancer survivors.

METHODS

Using the 2011 Medical Expenditure Panel Survey and Experiences with Cancer Survivorship Supplement, the prevalence of financial difficulties and work modifications was examined. Logistic regression and survey weights were used to model these outcomes as functions of sociodemographic and health covariates separately among survivors in active treatment and survivors under age 65 years.

RESULTS

Among all survivors, 33.2% reported any financial concern, with 17.9% reporting financial difficulties such as debt or bankruptcy. Among working survivors, 44.0% made any work modification and 15.3% made long-term work modifications (e.g., delayed or early retirement). Among those in active treatment, predictors of financial difficulty included: race/ethnicity other than white, non-Hispanic [OR = 8.0; 95% CI 2.2-28.4]; income <200% of federal poverty level (FPL) [OR = 15.7; 95% CI 2.6-95.2] or between 200 and 400% of FPL [OR = 8.2; 95% CI 1.3-51.4]; residence in a non-metropolitan service area [OR = 6.4; 95% CI 1.6-25.0]; and good/fair/poor self-rated health [OR = 3.8; 95% CI 1.0-14.2]. Among survivors under age 65 years, predictors of long-term work modifications included good/fair/poor self-rated health [OR = 4.1; 95% CI 1.6-10.2], being married [OR = 2.2; 95% CI 1.0-4.7], uninsured [OR = 3.5; 95% CI 1.3-9.3], or publicly insured [OR = 9.0; 95% CI 3.3-24.4].

CONCLUSIONS

A substantial proportion of cancer survivors experience cancer-related financial difficulties and work modifications, particularly those who report race/ethnicity other than white, non-Hispanic, residence in non-metropolitan areas, worse health status, lower income, and public or no health insurance.

IMPLICATIONS FOR CANCER SURVIVORS

Attention to the economic impact of cancer treatment is warranted across the survivorship trajectory, with particular attention to subgroups at higher risk.

A system to build distributed multivariate models and manage disparate data sharing policies: implementation in the scalable national network for effectiveness research

Background Centralized and federated models for sharing data in research networks currently exist. To build multivariate data analysis for centralized networks, transfer of patient-level data to a central computation resource is necessary. The authors implemented distributed multivariate models for federated networks in which patient-level data is kept at each site and data exchange policies are managed in a study-centric manner.

Objective The objective was to implement infrastructure that supports the functionality of some existing research networks (e.g., cohort discovery, workflow management, and estimation of multivariate analytic models on centralized data) while adding additional important new features, such as algorithms for distributed iterative multivariate models, a graphical interface for multivariate model specification, synchronous and asynchronous response to network queries, investigator-initiated studies, and study-based control of staff, protocols, and data sharing policies.

Materials and Methods Based on the requirements gathered from statisticians, administrators, and investigators from multiple institutions, the authors developed infrastructure and tools to support multisite comparative effectiveness studies using web services for multivariate statistical estimation in the SCANNER federated network.

Results The authors implemented massively parallel (map-reduce) computation methods and a new policy management system to enable each study initiated by network participants to define the ways in which data may be processed, managed, queried, and shared. The authors illustrated the use of these systems among institutions with highly different policies and operating under different state laws.

Discussion and Conclusion Federated research networks need not limit distributed query functionality to count queries, cohort discovery, or independently estimated analytic models. Multivariate analyses can be efficiently and securely conducted without patient-level data transport, allowing institutions with strict local data storage requirements to participate in sophisticated analyses based on federated research networks.

Comparison of consumers' views on electronic data sharing for healthcare and research

New models of healthcare delivery such as accountable care organizations and patient-centered medical homes seek to improve quality, access, and cost. They rely on a robust, secure technology infrastructure provided by health information exchanges (HIEs) and distributed research networks and the willingness of patients to share their data. There are few large, in-depth studies of US consumers' views on privacy, security, and consent in electronic data sharing for healthcare and research together.

OBJECTIVE

This paper addresses this gap, reporting on a survey which asks about California consumers' views of data sharing for healthcare and research together.

MATERIALS AND METHODS

The survey conducted was a representative, random-digit dial telephone survey of 800 Californians, performed in Spanish and English.

RESULTS

There is a great deal of concern that HIEs will worsen privacy (40.3%) and security (42.5%). Consumers are in favor of electronic data sharing but elements of transparency are important: individual control, who has access, and the purpose for use of data. Respondents were more likely to agree to share deidentified information for research than to share identified information for healthcare (76.2% vs 57.3%, p < .001).

DISCUSSION

While consumers show willingness to share health information electronically, they value individual control and privacy. Responsiveness to these needs, rather than mere reliance on Health Insurance Portability and Accountability Act (HIPAA), may improve support of data networks.

CONCLUSION

Responsiveness to the public's concerns regarding their health information is a pre-requisite for patient-centeredness. This is one of the first in-depth studies of attitudes about electronic data sharing that compares attitudes of the same individual towards healthcare and research.

Associations between the GNB3 C825T polymorphism and obesity-related metabolic risk factors in Korean obese women

PURPOSE

It is important to identify a 'metabolically unhealthy obese' subset with higher cardiovascular risk among obese individuals. We investigated the associations between the GNB3 C825T polymorphism and obesity-related metabolic risk factors among Korean obese women.

METHODS

This study was a sub-investigation of a double-blind randomized controlled trial that examined the additive effect of or list at on weight loss with sibutramine. A sample of 111 obese women were divided into T-carriers (CT/TT) or a homozygous CC group, according to the presence of the 825T allele at GNB3. These groups were compared to determine their associations with obesity-related metabolic risk factors, i.e., fasting plasma glucose, serum lipids, serum insulin/insulin resistance, and abdominal fat amounts.

RESULTS

The allele frequencies of the GNB3 polymorphism were C allele = 59.5% and T allele = 40.5%. The T allele was found to be significantly associated with greater visceral fat and higher serum lipids, and these significances remained robust after adjusting for potential covariates.

CONCLUSIONS

The GNB3 825T polymorphism is significantly associated with greater visceral fat and higher serum lipids in Korean obese women and it suggests that the GNB3 C825T is a determinant of obesity-related metabolic traits in this population.