Patient-reported outcomes and target effect sizes in pragmatic randomized trials in ClinicalTrials.gov: A cross-sectional analysis

BACKGROUND

Use of patient-reported outcomes (PROs) and patient and public engagement are critical ingredients of pragmatic trials, which are intended to be patient centered. Engagement of patients and members of the public in selecting the primary trial outcome and determining the target difference can better ensure that the trial is designed to inform the decisions of those who ultimately stand to benefit. However, to the best of our knowledge, the use and reporting of PROs and patient and public engagement in pragmatic trials have not been described. The objectives of this study were to review a sample of pragmatic trials to describe (1) the prevalence of reporting patient and public engagement; (2) the prevalence and types of PROs used; (3) how its use varies across trial characteristics; and (4) how sample sizes and target differences are determined for trials with primary PROs.

METHODS AND FINDINGS

This was a methodological review of primary reports of pragmatic trials. We used a published electronic search filter in MEDLINE to identify pragmatic trials, published in English between January 1, 2014 and April 3, 2019; we identified the subset that were registered in ClinicalTrials.gov and explicitly labeled as pragmatic. Trial descriptors were downloaded from ClinicalTrials.gov; information about PROs and sample size calculations were extracted from the manuscript. Chi-squared, Cochran-Armitage, and Wilcoxon rank sum tests were used to examine associations between trial characteristics and use of PROs. Among 4,337 identified primary trial reports, 1,988 were registered in CT.gov, of which 415 were explicitly labeled as pragmatic. Use of patient and public engagement was identified in 39 (9.4%). PROs were measured in 235 (56.6%): 144 (34.7%) used PROs as primary outcomes and 91 (21.9%) as only secondary outcomes. Primary PROs were symptoms (64; 44%), health behaviors (36; 25.0%), quality of life (17; 11.8%), functional status (16; 11.1%), and patient experience (10; 6.9%). Trial characteristics with lower prevalence of use of PROs included being conducted exclusively in children or adults over age 65 years, cluster randomization, recruitment in low- and middle-income countries, and primary purpose of prevention; trials conducted in Europe had the highest prevalence of PROs. For the 144 trials with a primary PRO, 117 (81.3%) reported a sample size calculation for that outcome; of these, 71 (60.7%) justified the choice of target difference, most commonly, using estimates from pilot studies (31; 26.5%), standardized effect sizes (20; 17.1%), or evidence reviews (16; 13.7%); patient or stakeholder opinions were used to justify the target difference in 8 (6.8%). Limitations of this study are the need for trials to be registered in ClinicalTrials.gov, which may have reduced generalizability, and extracting information only from the primary trial report.

CONCLUSIONS

In this study, we observed that pragmatic trials rarely report patient and public engagement and do not commonly use PROs as primary outcomes. When provided, target differences are often not justified and rarely informed by patients and stakeholders. Research funders, scientific journals, and institutions should support trialists to incorporate patient engagement to fulfill the mandate of pragmatic trials to be patient centered.

A scoping review of patient engagement activities during COVID-19: More consultation, less partnership

Background

The COVID-19 pandemic has had a devastating impact on healthcare systems and care delivery, changing the context for patient and family engagement activities. Given the critical contribution of such activities in achieving health system quality goals, we undertook to address the question: What is known about work that has been done on patient engagement activities during the pandemic?

Objective

To examine peer-reviewed and grey literature to identify the range of patient engagement activities, broadly defined (inclusive of engagement to support clinical care to partnerships in decision-making), occurring within health systems internationally during the first six months of the COVID-19 pandemic, as well as key barriers and facilitators for sustaining patient engagement activities during the pandemic.

Methods

The following databases were searched: Medline, Embase and LitCOVID; a search for grey literature focused on the websites of professional organizations. Articles were required to be specific to COVID-19, describe patient engagement activities, involve a healthcare organization and be published from March 2020 to September 2020. Data were extracted and managed using Microsoft Excel. A content analysis of findings was conducted.

Results

Twenty-nine articles were included. Few examples of more genuine partnership with patients were identified (such as co-design and organizational level decision making); most activities related to clinical level interactions (e.g. virtual consultations, remote appointments, family visits using technology and community outreach). Technology was leveraged in almost all reported studies to interact or connect with patients and families. Five main descriptive categories were identified: (1) Engagement through Virtual Care; (2) Engagement through Other Technology; (3) Engagement for Service Improvements/ Recommendations; (4) Factors Impacting Patient Engagement; and (5) Lessons Learned though Patient Engagement.

Conclusions

Evidence of how healthcare systems and organizations stayed connected to patients and families during the pandemic was identified; the majority of activities involved direct care consultations via technology. Since this review was conducted over the first six months of the pandemic, more work is needed to unpack the spectrum of patient engagement activities, including how they may evolve over time and to explore the barriers and facilitators for sustaining activities during major disruptions like pandemics.

Challenging misconceptions about clinical ethics support during COVID-19 and beyond: a legal update and future considerations

The pace of change and, indeed, the sheer number of clinical ethics committees (not to be confused with research ethics committees) has accelerated during the COVID-19 pandemic. Committees were formed to support healthcare professionals and to operationalise, interpret and compensate for gaps in national and professional guidance. But as the role of clinical ethics support becomes more prominent and visible, it becomes ever more important to address gaps in the support structure and misconceptions as to role and remit. The recent case of Great Ormond Street Hospital for Children NHS Foundation Trust v MX, FX and X ([2020] EWHC 1958 (Fam), [21]-[23] and [58]) has highlighted the importance of patient/family representation at clinical ethics committee meetings. The court viewed these meetings as making decisions about such treatment. We argue that this misunderstands the role of ethics support, with treatment decisions remaining with the clinical team and those providing their consent. The considered review by clinical ethics committees of the moral issues surrounding complex treatment decisions is not a matter of determining a single ethical course of action. In this article, we consider current legal understandings of clinical ethics committees, explore current concepts of ethics support and suggest how they may evolve, considering the various mechanisms of the inclusion of patients and their representatives in ethics meetings which is not standard in the UK.

[Beyond empowerment: the emancipated patient or the datoma?]

Digital culture gives the patient an ever greater role in managing their own health, which should be a normal place and time of sharing, based on general principles of democracy. The risk is that life itself becomes pertinent to medicine, as it is objectified in medical terms through increasingly advanced and intrusive digital technologies, and that these end up transforming people into datasets, "datomi". Therefore, strategies and tools must be developed for a "true" participation in the culture of health/disease, which does not mean the exploitation of people transformed into data profiling or direct management by citizens, but a concrete exercise in listening and sharing values, meaning, interests and objectives.

Factors Associated with Lumbar Puncture Participation in Alzheimer's Disease Research

BACKGROUND

Cerebrospinal fluid (CSF) provides insight into the spectrum of Alzheimer's disease (AD) pathology. While lumbar punctures (LPs) for CSF collection are generally considered safe procedures, many participants remain hesitant to participate in research involving LPs.

OBJECTIVE

To explore factors associated with participant willingness to undergo a research LP at baseline and follow-up research study visit.

METHODS

We analyzed data from 700 participants with varying cognition (unimpaired, mild cognitive impairment, and dementia) in the Wisconsin Alzheimer's Disease Research Center. We evaluated the relationship of demographic variables (age, sex, race, ethnicity, and years of education) and clinical variables (waist-to-hip ratio, body mass index, AD parental history, cognitive diagnosis) on decision to undergo baseline LP1. We evaluated the relationship of prior LP1 experience (procedure success and adverse events) with the decision to undergo follow-up LP2. The strongest predictors were incorporated into regression models.

RESULTS

Over half of eligible participants opted into both baseline and follow-up LP. Participants who underwent LP1 had higher mean education than those who declined (p = 0.020). White participants were more likely to choose to undergo LP1 (p < 0.001); 33% of African American participants opted in compared to 65% of white participants. Controlling for age, education, and AD parental history, race was the only significant predictor for LP1 participation. Controlling for LP1 mild adverse events, successful LP1 predicted LP2 participation.

CONCLUSION

Race was the most important predictor of baseline LP participation, and successful prior LP was the most important predictor of follow-up LP participation.

Using Patient and Family Engagement Strategies to Improve Outcomes of Health Information Technology Initiatives: Scoping Review

BACKGROUND

Many health care organizations around the world have implemented health information technologies (ITs) to enhance health service efficiency, effectiveness, and safety. Studies have demonstrated that promising outcomes of health IT initiatives can be obtained when patients and family members participate and engage in the adoption, use, and evaluation of these technologies. Despite knowing this, there is a lack of health care organizations using patient and family engagement strategies to enhance the use and adoption of health ITs, specifically.

OBJECTIVE

This study aimed to answer the following three research questions (RQs): (1) what current frameworks or theories have been used to guide patient and family engagement in health IT adoption, use, implementation, selection, and evaluation?, (2) what studies have been done on patient and family engagement strategies in health IT adoption, use, implementation, selection, and evaluation?, and (3) what patient and family engagement frameworks, studies, or resources identified in the literature can be applied to health IT adoption, use, implementation, selection, and evaluation?

METHODS

This scoping review used a five-step framework developed by Arksey and O'Malley and adapted by Levac et al. These steps include the following: (1) identifying the RQ, (2) identifying relevant studies, (3) selecting studies, (4) charting relevant data, and (5) summarizing and reporting the result. Retrieved academic and grey literature records were evaluated using a literature review software based on inclusion and exclusion criteria by two independent reviewers. If consensus was not achieved, two reviewers would resolve conflicts by discussion. Research findings and strategies were extracted from the studies and summarized in data tables.

RESULTS

A total of 35 academic articles and 23 gray literature documents met the inclusion criteria. In total, 20 of the 35 included studies have been published since 2017. Frameworks found include the patient engagement framework developed by Healthcare Information and Management Systems Society and the patient and family engagement framework proposed by Carman et al. Effective strategies include providing patients with clear expectations and responsibilities and providing reimbursement for time and travel. The gray literature sources outlined key considerations for planning and supporting engagement initiatives such as providing patients with professional development opportunities, and embedding patients in existing governance structures.

CONCLUSIONS

Several studies have reported their findings regarding successful strategies to engage patients and family members in health IT initiatives and the positive impact that can emerge when patients and family members are engaged in such initiatives in an effective manner. Currently, no framework has consolidated all of the key strategies and considerations that were found in this review to guide health care organizations when engaging patients and family members in a health IT-specific project or initiative. Further research to evaluate and validate the existing strategies would be of value.

Patient/Provider Discussions About Clinical Trial Participation and Reasons for Nonparticipation Among Adolescent and Young Adult Women with Cancer

Purpose: Clinical trial enrollment is low among adolescents and young adults (AYAs) with cancer and may contribute to inferior survival gains in recent years in this population compared with other age groups. We investigated clinical trial participation among AYA women with cancer, and examined whether patients discussed clinical trial participation with their doctor and reasons for nonparticipation. Methods: Women with a diagnosis of breast cancer, thyroid cancer, melanoma, lymphoma, or gynecologic cancer at ages 15-39 years during 2004-2016 were identified from the North Carolina Central Cancer Registry and the Kaiser Permanente Southern California health system. During 2018-2019, a total of 1264 eligible women completed an online survey (response = 13%), which examined survivorship issues among AYAs. Results: Overall, 5% of participants reported that they had participated in a clinical trial. Most women reported that they had not discussed clinical trial participation with a medical provider (76%) and that they did not know whether a relevant trial was available for their cancer (73%). Among those who knew that a trial was available but did not participate, the most commonly reported reasons for nonparticipation included concerns about side effects of the treatment in the trial and concerns that the treatment had not been sufficiently tested. Conclusion: Only a small proportion of AYA women with cancer in our cohort reported discussing a clinical trial with a provider or knowing whether a relevant trial was available. Our findings point to opportunities to improve patient/provider communication to increase clinical trial enrollment among AYAs with cancer.

Role of public involvement in the Royal College of Physicians' Future Hospitals healthcare improvement programme: an evaluation

OBJECTIVES

The Royal College of Physician's (RCP) Future Hospital Programme (FHP) set out a blueprint for a radical new model of care that put patient experience centre stage. This paper reports on the results of an independent evaluation of the FHP and focuses on the role public patient involvement (PPI) played in these projects. The paper explores the perceptions and experiences of those involved in the FHP of how PPI was operationalised in this context, and develops an 'ex-post' programme theory of PPI in the FHP. We conclude by assessing the benefits and challenges of this work.

SETTING

Secondary care. The FHP consisted of eight clinician-led healthcare improvement hospital development sites with two phases.

PARTICIPANTS

Development site clinical teams, patient representatives, the RCP's Patient and Carer Network, members of the FHP team, and fellows and members of the RCP.

DESIGN/METHODS

We conducted an independent evaluation of the FHP using FHP documentation and data collected specifically for the evaluation: qualitative interviews, focus groups and a web-based survey.

RESULTS

The PPI initiatives set out to develop more patient-centred care and improve the patient experience. The mechanisms designed to meet these goals were (1) a programme of PPI in the development site's projects, (2) a better understanding of patient experience and (3) evaluation of patient experience.

CONCLUSION

This evaluation of the FHP identifies some key elements that need to be considered when attempting to more closely integrate PPI and co-production in service re-design. The structure of FHP over two phases enabled learning from phase I to be incorporated into phase II. Having the PPI representatives closely involved, developing communities of practice, and the oversight and measuring activities acted as 'disciplinary structures' that contributed to embedding PPI in the FHP and kept the patient experience at the forefront of the improvement initiatives.

The roles of heavy drinking and drug use in engagement in HIV care among hospitalized substance using individuals with poorly controlled HIV infection

BACKGROUND

Substance use can reduce care engagement for individuals with HIV. However, little is known as to whether heavy drinkers differ from drug users. This study compares heavy drinkers, drug users, and those drinking heavily and using drugs on their HIV care engagement.

METHODS

HIV-infected adult inpatients (n = 801; 67% male; 78% Black) from 11 urban hospitals across the United States participated in a multisite clinical trial to improve patient engagement in HIV care and virologic outcomes. All participants drank heavily and/or used drugs, and had poorly controlled HIV. Participants reported care history at baseline. We compared heavy drinkers, drug users, and those both drinking heavily and using drugs (reference group) on their engagement in care.

RESULTS

Heavy drinkers reported lowest rates of lifetime HIV care, AOR = 0.59 (95% CI = 0.36, 0.97). Groups did not differ in recent care, prescription of HIV medication, medical mistrust, or patient-provider relationship. Drug users evidenced the best medication adherence, AOR = 2.38 (95% CI = 1.33, 4.23). Exploratory analyses indicated that drinkers had lower initial care engagement, but that it increased more rapidly with duration of known HIV infection, with similar rates of recent care. Drinkers had the lowest CD4 counts (B=-0.28, p < 0.0001), but no difference in viral load.

CONCLUSIONS

Heavy drinkers were least likely to have ever been in HIV care. More research is needed to determine why heavy drinkers evidence the lowest initial care engagement and current CD4 counts, and whether drinking intervention early in infection may increase HIV care engagement.

Patient-Friendly Language to Facilitate Treatment Choice for Patients with Cancer

Resources are needed to assist patients in understanding their diagnoses and considering treatment options. This commentary focuses on improving the language used to communicate disease and treatment information so that patients can make informed decisions.

Patient-Informed Treatment Development of Behavioral Smoking Cessation for People With Schizophrenia

The objective of this study was to use qualitative methodology to tailor and refine an existing smoking cessation intervention for the population of people who use cigarettes and are diagnosed with schizophrenia, schizoaffective, or psychotic disorder. Successive cohort design methodology was used to iteratively modify the treatment in response to qualitative participant, therapist, and consultant feedback on the intervention. Qualitative methodology for participant feedback included analysis of semistructured interviews with participants, visualization of app utilization data, and stakeholder feedback from study therapists and consultants. Using the successive cohort design, a tailored multicomponent mobile health smoking cessation intervention was developed. The intervention included mobile contingency management (i.e., financial compensation for confirmed abstinence from smoking), pharmacotherapy for smoking cessation, cognitive-behavioral counseling sessions, and the Stay Quit app for relapse prevention. Two cohorts (N = 13) were completed in the study; after each cohort, the treatment protocol was revised. The intervention is described, as well as the qualitative findings from each cohort and subsequent changes made to the intervention based upon patient and provider feedback. Metrics of patient engagement included treatment adherence (40% in Cohort 1 and 63% in Cohort 2). Both participants and therapists reported that the intervention was helpful. Over one third of participants self-reported abstinence at posttreatment. Since qualitative methodology is often underutilized in mental health treatment development, this study demonstrates the utility of the successive cohort design for treatment development of behavior change interventions for at-risk, vulnerable populations.

Trends in HIV care cascade engagement among diagnosed people living with HIV in Ontario, Canada: A retrospective, population-based cohort study

Background

The HIV cascade is an important framework for assessing systems of care, but population-based assessment is lacking for most jurisdictions worldwide. We measured cascade indicators over time in a population-based cohort of diagnosed people living with HIV (PLWH) in Ontario, Canada.

Methods

We created a retrospective cohort of diagnosed PLWH using a centralized laboratory database with HIV diagnostic and viral load (VL) test records linked at the individual-level. Individuals enter the cohort with record of a nominal HIV-positive diagnostic test or VL test, and remain unless administratively lost to follow-up (LTFU, >2 consecutive years with no VL test and no VL test in later years). We calculated the annual percent of diagnosed PLWH (cohort individuals not LTFU) between 2000 and 2015 who were in care (≥1 VL test), on ART (as documented on VL test requisition) or virally suppressed (<200 copies/ml). We also calculated time from diagnosis to linkage to care and viral suppression among individuals newly diagnosed with HIV. Analyses were stratified by sex and age. Upper/lower bounds were calculated using alternative indicator definitions.

Results

The number of diagnosed PLWH increased from 8,859 (8,859–11,389) in 2000 to 16,110 (16,110–17,423) in 2015. Over this 16-year period, the percent of diagnosed PLWH who were: in care increased from 81% (63–81%) to 87% (81–87%), on ART increased from 55% (34–60%) to 81% (70–82%) and virally suppressed increased from 41% (23–46%) to 80% (67–81%). Between 2000 and 2014, the percent of newly diagnosed individuals who linked to care within three months of diagnosis or achieved viral suppression within six months of diagnosis increased from 67% to 82% and from 22% to 42%, respectively. Estimates were generally lower for females and younger individuals.

Discussion

HIV cascade indicators among diagnosed PLWH in Ontario improved between 2000 and 2015, but gaps still remain—particularly for younger individuals.

Increased clinical trial enrollment among adolescent and young adult cancer patients between 2006 and 2012-2013 in the United States

BACKGROUND

Stagnant outcomes for adolescents and young adults (AYAs) 15-39 years of age with cancer are partly attributed to poor enrollment onto clinical trials. Initiatives have focused on increasing accrual, but changes at the population-level are unknown. We examined patterns of clinical trial participation over time in AYA patients with cancer.

PROCEDURE

We utilized medical record data from AYAs in two population-based National Cancer Institute Patterns of Care Studies identified through the Surveillance, Epidemiology and End Results Program. Among 3135 AYAs diagnosed with non-Hodgkin lymphoma (NHL), Hodgkin lymphoma, acute lymphoblastic leukemia (ALL), and sarcoma, we used multivariate logistic regression to evaluate patient and provider characteristics associated with clinical trial enrollment. Interaction terms evaluated variation in clinical trial enrollment across patient and provider characteristics by year of diagnosis.

RESULTS

From 2006 to 2012-2013, clinical trial participation increased from 14.8% to 17.9% (P < 0.01). Adjusting for patient and provider characteristics, we found lower clinical trial enrollment among those who were older at diagnosis, diagnosed with NHL vs ALL, treated by adult hematologist/oncologists only (vs pediatric hematologist/oncologists), and of non-Hispanic Black race/ethnicity (vs non-Hispanic White) (P < 0.05 for all). Interaction analyses indicate improved clinical trial enrollment from 2006 to 2012-2013 among young adults 25-29 years of age and the uninsured.

CONCLUSIONS

Although disparities in enrollment onto clinical trials remain for AYAs with cancer, our study identified increasing overall clinical trial participation over time. Further, we identify promising trends in enrollment uptake among AYAs 25-29 years of age and the uninsured.

Non-medical facilitators and barriers towards accessing haemodialysis services: an exploration of ethical challenges

BACKGROUND

Like most of the sub-Saharan countries, Tanzania faces significant increase in the number of patients diagnosed with an end-stage renal disease (ESRD) among which only a few manage to receive chronic haemodialysis services (CHD). Yet little is known about the non-medical facilitators and barriers towards accessing these services and the associated ethical challenges.

METHODS

A phenomenological study design which employed a qualitative approach was used. The study was conducted at the dialysis unit harboured within Muhimbili National Hospital. Data were collected from purposively sampled health care providers and ESRD patients by using in-depth interviews. Text data obtained were analysed based on inductive and deductive content analysis methods to formulate major themes.

RESULTS

Fourteen key informants were interviewed including nephrologists, renal nurses, social workers, nutritionists and ESRD patients. Three major themes were formulated: a) non-medical facilitators towards accessing CHD services which enshrines two sub-themes (membership to health insurance scheme and family support), (b) non-medical barriers towards accessing CHD services which enshrines four sub-themes (affordability of treatment costs, geographical accessibility, availability of CHD resources and acceptability of treatment procedures) and lastly (c) ethical challenges associated with accessing CHD services which also enshrines three sub-themes (dual role of health care providers, patients autonomy in decision making, and treatment disparity).

CONCLUSION

Non-medical facilitators to access CHD benefits few patients whereas non-medical barriers leave many ESRD patients untreated or partially treated. On the other hand, ethical challenges like treatment inequality are quickly gaining momentum. There is a need for guideline highlighting importance, position, and limitation of non-medical factors in the delivery of CHD services in Tanzania and other developing countries.

Patient Activation Changes as a Potential Signal for Changes in Health Care Costs: Cohort Study of US High-Cost Patients

BACKGROUND

Programs to improve quality of care and lower costs for the highest utilizers of health services are proliferating, yet such programs have difficulty demonstrating cost savings.

OBJECTIVE

In this study, we explore the degree to which changes in Patient Activation Measure (PAM) levels predict health care costs among high-risk patients.

PARTICIPANTS

De-identified claims, demographic data, and serial PAM scores were analyzed on 2155 patients from multiple medical groups engaged in an existing Center for Medicare and Medicaid Innovation-funded intervention over 3 years designed to activate and improve care coordination for high-risk patients.

DESIGN

In this prospective cohort study, four levels of PAM (from low to high) were used as the main predictor variable. We fit mixed linear models for log₁₀ of allowed charges in follow-up periods in relation to change in PAM, controlling for baseline PAM, baseline costs, age, sex, income, and baseline risk score.

MAIN MEASURES

Total allowed charges were derived from claims data for the cohort. PAM scores were from a separate database managed by the local practices.

KEY RESULTS

A single PAM level increase was associated with 8.3% lower follow-up costs (95% confidence interval 2.5-13.2%).

CONCLUSIONS

These findings contribute to a growing evidence base that the change in PAM score could serve as an early signal indicating the impact of interventions designed for high-cost, high-needs patients.

Reflections on 500 Call-in Radio Shows

Pharmacy educators, whether in didactic classes, laboratory settings, or experiential opportunities, search for ways to incorporate "real life" patient questions and concerns into the educational process. This practice not only enhances the educational opportunities for students, it also prepares them for questions and concerns that they will inevitably face as practicing professionals. This commentary describes listener calls from 500, live, call-in radio shows. There is no accurate way to directly assess information that patients do not know or understand. The author suggests using commonly asked pharmacy-based questions, directly from the public, as a proxy to identify the information most desired by patients. The author assumes that radio callers are not calling to ask questions when they already know the answers. Thus, having identified the information most desired by radio-show callers, pharmacist educators, no matter the setting, can be provided with a ready-made resource that lists the most common concerns from over 6,000 radio callers. The author recommends educators use this resource and apply real patient questions and concerns during the educational process, furthermore, opportunities to use this resource are provided.

Unique Review Criteria and Patient and Stakeholder Reviewers: Analysis of PCORI's Approach to Research Funding

OBJECTIVE

The Patient-Centered Outcomes Research Institute (PCORI) uses a unique approach to Merit Review that includes patients and stakeholders as reviewers with scientists, and includes unique review criteria (patient-centeredness and active engagement of end users in the research). This study assessed the extent to which different reviewer types influence review scores and funding outcomes, the emphasis placed on technical merit compared to other criteria by a multistakeholder panel, and the impact of the in-person discussion on agreement among different reviewer types.

METHODS

Cross-sectional analysis of administrative data from PCORI online and in-person Merit Review (N = 1312 applications from the five funding cycles from November 2013 to August 2015). Linear and logistic regression models were used to analyze the data.

RESULTS

For all reviewer types, final review scores were associated with at least one review criterion score from each of the three reviewer types. The strongest predictor of final overall scores for all reviewer types was scientists' prediscussion ratings of technical merit. All reviewers' prediscussion ratings of the potential to improve health care and outcomes, and scientists' ratings of technical merit and patient-centeredness, were associated with funding success. For each reviewer type, overall impact scores from the online scoring were changed on at least half of the applications at the in-person panel discussion. Score agreement across reviewer types was greater after panel discussion.

CONCLUSIONS

Scientist, patient, and stakeholder views all contribute to PCORI Merit Review of applications for research funding. Technical merit is critical to funding success but patient and stakeholder ratings of other criteria also influence application disposition.

Dilemmas of Representation: Patient Engagement in Health Professions Education

The role of the patient in bedside teaching has long been a matter of consideration in health professions education. Recent iterations of patient engagement include patients as storytellers, members of curriculum planning committees, guest lecturers, and health mentors. While these forms of patient engagement are reported to have many benefits for learners, educators, and the patients themselves, there is concern that such programs may not be representative of the diversity of patients that health care professionals will encounter throughout their careers. This problem of representation has vexed not only educators but also sociologists and political scientists studying patients' and the public's involvement in arenas such as health services research, policy, and organizational design.In this Perspective, the authors build on these sociological and political science approaches to expand our understanding of the problem of representation in patient engage-ment. In doing so, the authors' reconfiguration of the problem sheds new light on the dilemma of representation. They argue for an understanding of representation that not only is inclusive of who is being represented but that also takes seriously what is being represented, how, and why. This argument has implications for educators, learners, administrators, and patient participants.

How effective and cost-effective are innovative combinatorial technologies and practices for supporting older people with long-term conditions to remain well in the community? An evaluation protocol for an NHS Test Bed in North West England

INTRODUCTION

The Lancashire and Cumbria Innovation Alliance (LCIA) Test Bed is a partnership between the National Health Service in England, industry (led by Philips) and Lancaster University. Through the implementation of a combination of innovative health technologies and practices, it aims to determine the most effective and cost-effective ways of supporting frail older people with long-term conditions to remain well in the community. Among the Test Bed's objectives are to improve patient activation and the ability of older people to self-care at home, reduce healthcare system utilisation, and deliver increased workforce productivity.

METHODS AND ANALYSIS

Patients aged 55 years and over are recruited to four cohorts defined by their risk of hospital admission, with long-term conditions including chronic obstructive pulmonary disease, dementia, diabetes and heart failure. The programme is determined on an individual basis, with a range of technologies available. The evaluation is adopting a two-phase approach: phase 1 includes a bespoke patient survey and a mass matched control analysis; and phase 2 is using observational interviews with patients, and weekly diaries, action learning meetings and focus groups with members of staff and other key stakeholders. Phase 1 data analysis consists of a statistical evaluation of the effectiveness of the programme. A health economic analysis of its costs and associated cost changes will be undertaken. Phase 2 data will be analysed thematically with the aid of Atlas.ti qualitative software. The evaluation is located within a logic model framework, to consider the processes, management and participation that may have implications for the Test Bed's success.

ETHICS AND DISSEMINATION

The LCIA Test Bed evaluation has received ethical approval from the Health Research Authority and Lancaster University's Faculty of Health and Medicine Research Ethics Committee. A range of dissemination methods are adopted, including deliberative panels to validate findings and develop outcomes for policy and practice.

Insights in Public Health: In What Ways are Hawaii's HIV Prevention Services Engaging Gay Male Couples and Using Technology?

Partner-oriented services and Health Information and Communication technology (HICT) in the forms of mHealth (eg, smartphone applications), eHealth (eg, interactive websites), telemedicine, and social media play an important and growing role in HIV prevention. Accordingly, the present study sought to describe: (1) the primary and secondary HIV prevention services available in Hawai'i, (2) the prevention services that are available for gay male couples and partners, and (3) the prevention services that use HICT. Information about prevention services and use of HICT were obtained from websites and phone calls made to 19 organizations in the state, including the Hawai'i Department of Health. Overall, partner-oriented services were limited and only 1 couples-based service was currently being offered. Technology, namely social media, was used by 14 organizations, primarily to increase HIV awareness and advertise events. These findings may inform how best to adapt and better leverage the use of innovative technological tools to help expand access to HIV testing and counseling, sexual health education, and case management services for gay male couples and other MSM populations in the state.

Increasing the Continuity of Care between Primary Care Provider and a Psychiatric Hospital in Singapore

INTRODUCTION

People who have a mental illness and who are stable on their current treatment may be suitable for follow-up care with a community-based general practitioner. A general practitioner-partnership programme was designed in an institute in Singapore to facilitate the transition to community services. However, the rates of successful referrals were low.

METHODS

Our study followed the format of a quality improvement project, and used administrative data from April 2014 to June 2016 to gauge the impact of the interventions chosen to improve uptake of referrals. Three potential areas of improvement were found based on interviews with 25 service users.

RESULTS

During the 11 months of pre-intervention period (April 2014 to February 2015), 64% of potentially suitable service users (152 of 238 referrals) transitioned to community services. Low transition was linked to 3 identified causes and consequently, case managers developed personalised financial counselling for service users, assisted in the application for financial supports, and dispelled misconceptions about service provider inability to treat mental illness. Over the 16 months of intervention period (March 2015 to June 2016), the follow-up rate for referrals rose to 92% (260 / 283 referrals).

CONCLUSION

Given that financial support entitlements change, it is important for case managers to remain aware of changing policy. Misconceptions of service provider qualifications may have a great impact on service user's willingness to seek services from primary care providers.

Current State and Future Trends to Optimize the Care of Chronic Kidney Disease in African Americans

BACKGROUND

African Americans (AAs) suffer the widest gaps in chronic kidney disease (CKD) outcomes compared to Caucasian Americans (CAs) and this is because of the disparities that exist in both health and healthcare. In fact, the prevalence of CKD is 3.5 times higher in AAs compared to CAs. The disparities exist at all stages of CKD. Importantly, AAs are 10 times more likely to develop hypertension-related kidney failure and 3 times more likely to progress to kidney failure compared to CAs.

SUMMARY

Several factors contribute to these disparities including genetic and social determinants, late referrals, poor care coordination, medication adherence, and low recruitment in clinical trials. Key Messages: The development and implementation of CKD-related evidence-based approaches, such as clinical and social determinant assessment tools for medical interventions, more widespread outreach programs, strategies to improve medication adherence, safe and effective pharmacological treatments to control or eliminate CKD, as well as the use of health information technology, and patient-engagement programs for improved CKD outcomes may help to positively impact these disparities among AAs.

Use of patient decision aids increased younger women's reluctance to begin screening mammography: a systematic review and meta-analysis

BACKGROUND

As breast cancer screening guidelines have changed recently, additional investigation is needed to understand changes in women's behavior after using breast cancer screening patient decision aids (BCS-PtDAs) and the potential effect on mammography utilization. This systematic review and meta-analysis sought to evaluate the effect of BCS-PtDAs on changes in women's intentions to undergo screening mammography and whether women deciding to begin or discontinue screening mammography displayed similar changes in screening intentions after using a BCS-PtDA.

METHODS

We searched Medline, Scopus, PsycINFO, CENTRAL, Health and Psychosocial Instruments, Health Technology Assessment Database, PsycARTICLES, and cited references in eligible papers for randomized controlled trials (RCTs) and observational studies, published through August 24, 2016. The proportions of women who did and not intend to undergo screening and who were uncertain about undergoing screening mammography were pooled, using risk ratios (RR) and random effects. According to the protocol, RCTs or observational studies and any language were considered eligible for systematic review if they included data about women for which shared decision making is recommended.

RESULTS

We ultimately included six studies with screening intention data for 2040 women. Compared to usual care, the use of BCS-PtDAs in three RCTs resulted in significantly more women deciding not to undergo screening mammography (RR 1.48 [95% CI 1.04-2.13]; P = 0.03), particularly for younger (38-50 years) women (1.77 [1.34-2.34]; P < 0.001). The use of BCS-PtDAs had a non-significant effect on the intentions of older women (69-89 years) to discontinue screening.

CONCLUSIONS

The use of BCS-PtDAs increased younger women's reluctance to undergo screening for breast cancer. The implementation of such BCS-PtDAs in clinical practice would be expected to result in a 77% increase in the number of younger women (aged 38-50) who do not intend to be screened, and as a consequence, may reduce utilization of screening mammography.

REGISTRATION

The protocol of this review is registered in the PROSPERO database, #CRD42016036695.

Operationalizing Precision Cardiovascular Medicine: Three Innovations

For precision medicine to become a reality, we propose three changes. First, healthcare deliverables must be prioritized, enabling translation of knowledge to the clinic. Second, physicians and patients must be convinced to participate, requiring additional infrastructure in health systems. Third, discovery science must evolve to shift the preclinical landscape for innovation. We propose a change in the fundamental relationship between basic and clinical science: rather than two distinct entities between which concepts must be translated, we envision a natural hybrid of these approaches, wherein discovery science and clinical trials coincide in the same health systems and patient populations.

Digital health assessment in rheumatology: current and future possibilities

Digital assessment and graphical feedback of patient-reported outcome measures such as the Health Assessment Questionnaire (HAQ) could increase empowerment and involvement of patients in their own care process. The App ecosystem that Reade is building is an example of how digital assessment using mobile devices can be integrated into existing hospital IT infrastructure.

Giving patients a starring role in their own care: a bibliometric analysis of the on-going literature debate

BACKGROUND

Patient-centred care has been advocated as a key component of high-quality patient care, yet its meanings and related actions have been difficult to ascertain.

OBJECTIVE

To map the use of different terms related to the process of giving patients a starring role in their own care and clarify the possible boundaries between terms that are often mixed.

METHODS

A literature search was conducted using different electronic databases. All records containing the search terms 'patient engagement', 'patient activation', 'patient empowerment', 'patient involvement', 'patient adherence', 'patient compliance' and 'patient participation' were collected. Identified literature was then analysed using the Statistical Package for Social Science (SPSS). The number of yearly publications, most productive countries, cross-concepts articles and various scientific fields dealing with the multidisciplinary concepts were identified.

RESULTS

Overall, 58 987 papers were analysed. Correspondence analysis revealed three temporal trends. The first period (2002-2004) focused on compliance and adherence, the second period (2006-2009) focused on the relationship between participation and involvement, and the third one (2010-2013) emphasized empowerment. Patient activation and patient engagement followed the temporal development trend connected to the 'immediate future'.

DISCUSSION AND CONCLUSIONS

The bibliometric trend suggests that the role of patient in the health-care system is changing. In the last years, the patient was viewed as a passive receptor of medical prescription. To date, the need to consider patients as active partners of health-care planning and delivery is growing. In particular, the term patient engagement appears promising, not only for its increasing growth of interest in the scholarly debate, but also because it offers a broader and better systemic conceptualization of the patients' role in the fruition of health care. To build a shared vocabulary of terms and concepts related to the active role of patients in the health-care process may be envisaged as the first operative step towards a concrete innovation of health-care organizations and systems.

Research essentials

THERE IS an increasing recognition of the importance of involving patients, family members and the public in health research. This involvement is commonly termed patient and public involvement (PPI) and refers to an 'active partnership between the public and researchers'. This is different to children, young people and/or parents being participants in a research project. Effective PPI ensures that research does not just focus on professionally driven priorities, but addresses what actually matters to children, young people and their families.

Innovations in health information technologies for chronic pulmonary diseases

Asthma and chronic obstructive pulmonary disease (COPD) are common chronic obstructive lung disorders in the US that affect over 49 million people. There is no cure for asthma or COPD, but clinical guidelines exist for controlling symptoms that are successful in most patients that adhere to their treatment plan. Health information technologies (HITs) are revolutionizing healthcare by becoming mainstream tools to assist patients in self-monitoring and decision-making, and subsequently, driving a shift toward a care model increasingly centered on personal adoption and use of digital and web-based tools. While the number of chronic pulmonary disease HITs is rapidly increasing, most have not been validated as clinically effective tools for the management of disease. Online communities for asthma and COPD patients are becoming sources of empowerment and support, as well as facilitators of patient-centered research efforts. In addition to empowering patients and facilitating disease self-management, HITs offer promise to aid researchers in identifying chronic pulmonary disease endotypes and personalized treatments based on patient-specific profiles that integrate symptom occurrence and medication usage with environmental and genomic data.

Coordinating Care: Shifts in Perspective

Effective coordination of care has consistently been a challenge for clinicians, care providers, and systems of health care. The health care system is inherently fraught with unorganized and disparate parts including multiple points of entry. A review of the current issues and the leadership implications is explored in this article with an emphasis on patients becoming more actively engaged in managing their care journey across the continuum. A case study of a primary care clinic in Annapolis, Maryland, is described to illustrate the application of evidence-based leadership skills, knowledge, and a framework to transform health care to more effectively engage patients in their care. As the constant on the continuum of care, the engaged patient is in the unique position to manage coordination, thus ensuring continuity.

Promotion of physical activity in patients with non-communicable diseases in Luxembourg: a follow-up of the Sport-Sante inventory from 2014

Regular practice of physical activity (PA) has many health benefits in both healthy individuals and in people with non-communicable diseases (NCDs). In order to disseminate this evidence and to strengthen the promotion of PA in people with NCDs, the Sport-Santé project was created in Luxembourg and officially launched in April 2015. In 2014, a stocktaking of the different organizations offering PA for people with NCDs was realized in order to develop the Sport-Santé project. Different communication tools were used to promote Sport-Santé as well as the aforementioned organizations. The present study aimed to re-evaluate the offers of PA for people with NCDs in Luxembourg one year after the launch of the project. The organizations offering PA for people with NCDs (orthopaedics, obesity and overweight, neurology and rare diseases, oncology and cardiology) were screened in 2014 and in 2016. The number of weekly offered hours of PA for people with NCDs were collected and the participation rate was observed. Participants (192 in 2014 and 196 in 2016) volunteered to answer a survey, which contained questions regarding their age, sex, time since enrolment, travel distance, former and current PA participation, and type of recruitment. Additional items regarding prescription and refund were explored only in 2016. In 2016, more than 55 hours per week of PA were offered for people with NCDs in Luxembourg (≈44 hours per week were identified in 2014). However, this increase was not statistically significant. No difference was observed between 2014 and 2016 regarding the participation rate (2014: 8.9 ± 5.1 participants per hour; 2016: 8.4 ± 5.7 participants per hour). Participants were younger in 2016 than in 2014. The time since enrolment was shorter in 2016 than in 2014. No difference between 2014 and 2016 was observed for travel distance, sex distribution, former and current PA participation, and type of recruitment. Participants were mainly recruited by the healthcare professionals. More than 69 % of the participants would like to receive a medical prescription for the PA. Fifty-two percent of the participants would appreciate a refund of the participation fees by their health insurance. The increasing efforts of Sport-Santé and the organizations offering PA for people with NCDs lead to increase the offer. However, the participation rate remains unchanged. The decrease in age and in time since enrolment observed in 2016 could be explained by the creation of new activities, a larger participant's turnover or high number of withdrawals among long-term participants. Even if participants are mainly recruited by healthcare professionals, this type of recruitment can be attributed to very few idealists. All healthcare professionals should be aware of the offers of Sport-Santé and advise their patients to participate in a PA program. It is now time to advance the idea of prescription of PA as a privileged treatment option and to convince the policymakers to take action against sedentary behaviours in Luxembourg. Nevertheless, this type of promotion is not enough to increase the number of participants and additional strategies must be explored and developed. The best sustainable strategies are always those that approach the problem from different viewpoints.

Patient Engagement: Opportunities and Challenges for Nursing and Health Care Professionals

Patient (citizen) engagement argued as a critical initiative for the transformation of health care and improving health outcomes. Health care is experiencing patients that have expectations for value, transparency, choice, and engagement. However, meaningfully engaging patients in their own health care has often proven to be difficult. This panel will present commentary, research and educational initiatives, representing multiple and global perspectives on patient engagement. Global efforts in education to prepare the needed workforce will also be addressed. The audience will have an opportunity to share multiple perspectives and experiences within the panel framework.

The need for patient-centred clinical research in idiopathic pulmonary fibrosis

Patient-centredness is an accepted term and is perceived by healthcare professionals to be morally and ethically desirable. We are motivated by the belief that this approach will improve the patient-professional experience of the decision-making process and improve health outcomes. We acknowledge that patients, either as participants or as co-investigators, have positive contributions to make to research. As the idiopathic pulmonary fibrosis (IPF) community enters a new era of clinical research activity we consider that there is greater capacity for patient involvement and partnership.Patient involvement in research can be optimised through collaborations in the research design, study conduct, and dissemination. There is increasing interest in using patient- reported outcomes (PROs), such as health-related quality of life, and symptoms measures to inform decision-making and ensure patient perspectives are taken into account. PROs are an essential component of specialist IPF services, to monitor and improve care delivery and to measure and benchmark performance. In clinical trials, PROs can additionally be used to define entry criteria, evaluate efficacy of an intervention, and evaluate adverse events. We suggest that there is a much wider scope for including patient-centred PROs in clinical research and for creative thought in developing patient co-investigator roles.Participation in research activity requires highly refined decision-making processes, particularly in a condition such as IPF, which has an often unpredictable trajectory. The IPF research landscape has changed and the design and conduct of clinical trials in IPF requires some radical rethinking. It is accepted that involving patients in the role of co-investigators will impact the research questions we ask and result in study designs that are patient-centred. IPF clinical trials have been hindered by the lack of availability of validated, disease-specific questionnaires. A conservative approach appears to have been taken to the inclusion of generic symptom or quality of life measures as PRO endpoints. Thus, the impact of new drugs on the quality of life of research participants demonstrates only minimal benefit. It is time to refocus on a patient-centred approach with regards to the co-investigator role, PRO development, and research participants.

Re-engineering shared decision-making

Shared decision-making is widely accepted as the gold standard of clinical care. Numerous obstacles to achieving shared decision-making have been identified, including patient factors, physician factors and systemic factors. Until now, the paradigm is seldom successfully implemented in clinical practice, raising questions about the practicality of the process recommended for its use. A re-engineered model is proposed in which physicians elicit and prioritise patients' goals of care and then help translate those goals into treatment options, after clarifying the patient's underlying health status. Preliminary evidence suggests that each step of this revised process is feasible and that patients and physicians are comfortable with this strategy. Adoption of this model, after further testing, would allow the goal of shared decision-making to be realised.