What happens post-pilot testing? A model for revising a disability awareness and competency training program

Disability awareness and competency trainings are an important component of addressing ableism and health equity in the health promotion context. This commentary describes our process of developing, implementing, and refining a disability competency training, the Inclusive Community Exercise Training, for community-based group exercise instructors. The training originated from a partnership between academic researchers, community organizations, and individuals with disabilities. After initial pilot testing, we used feedback from participants to enhance the training. To optimize successful dissemination of this training, we utilized the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, which is widely used in public health. The revision process focused on generalizing content to suit a wider audience, utilizing an eLearning platform for dissemination, and optimizing interactivity to improve learning effectiveness. The commentary emphasizes the lessons learned and the significance of systematic program revision, considering diverse expertise, content tailoring, and the benefits of accessible eLearning platforms.

Association of Clinician Behaviors and Weight Change in School-Aged Children

INTRODUCTION

This study uses clinical practice data to determine whether recommended weight management clinician behaviors are associated with weight status improvement in children aged 6-12 years who are overweight or obese.

METHODS

Electronic health record data (2009-2014) from 52 clinics were used. Weight status was examined from 1 visit to the next as dichotomous improvement (versus worsening or no change) and change in percentage overweight (over sex/age-specific BMI95). The primary predictor was a clinician behavior variable denoting attention to high BMI alone or with assessment of medical risk/comorbidities and was defined using combinations of diagnostic codes and electronic health record orders. Covariates included time between visits and medications associated with weight gain or loss. Adjusted multilevel regression models examined the association of the clinician behavior variable with weight status improvement. Analyses were conducted from 2015 to 2018.

RESULTS

Children (n=7,205) had a mean age of 8.9 years; 45.5% were overweight, 54.5% obese, and 81.1% publicly insured. For 62% of overweight children, and 38%, 21%, and 11% of those in obesity classes 1-3, respectively, no attention to high BMI/medical risk assessment at any visit was identified. Children with evidence of clinician attention to high BMI alone and who underwent a medical risk assessment had significantly greater AOR of improvement in percentage of BMI95 and percentage of BMI95 change: BMI alone, AOR=1.2 (p<0.001) and β= -0.3 (p>0.05); BMI/medical risk, AOR=1.2 and β= -0.5 (both p<0.001). Other factors associated with weight status improvement included prescription medications (1 or more prescriptions associated with either weight loss or none associated with weight gain) and fewer months between visits.

CONCLUSIONS

This is the first study to use electronic health record data to demonstrate that widely recommended clinician behaviors are associated with weight status improvement in children aged 6-12 years who are overweight or obese.

Evaluation of a Multifaceted Intervention to Reduce Health Disparities in Hepatitis C Screening: A Pre-Post Analysis

Hepatitis C virus (HCV) testing in persons born from 1945 to 1965 has had limited adoption despite guidelines, particularly among racial/ethnic minorities and socioeconomically disadvantaged patients, who have a higher prevalence of disease burden. We examined the effectiveness of a multifaceted intervention to improve HCV screening in a large safety-net health system. We performed a multifaceted intervention that included provider and patient education, an electronic medical record-enabled best practice alert, and increased HCV treatment capacity. We characterized HCV screening completion before and after the intervention. To identify correlates of HCV screening, we performed logistic regression for the preintervention and postintervention groups and used a generalized linear mixed model for patients observed in both preintervention and postintervention time frames. Before the intervention, 10.1% of 48,755 eligible baby boomer patients were screened. After the intervention, 34.6% of the 34,093 eligible baby boomers were screened (P < 0.0001). Prior to the intervention, HCV screening was lower among older baby boomers and providers with large patient panels and higher in high-risk subgroups including those with signs of liver disease (e.g., elevated transaminases, thrombocytopenia), human immunodeficiency virus-positive patients, and homeless patients. Postintervention, we observed increased screening uptake in older baby boomers, providers with larger patient panel size, and patients with more than one prior primary care appointment. Conclusion: Our multifaceted intervention significantly increased HCV screening, particularly among older patients, those engaged in primary care, and providers with large patient panels.

Mailed Outreach Program Increases Ultrasound Screening of Patients With Cirrhosis for Hepatocellular Carcinoma

BACKGROUND & AIMS

Surveillance of patients with cirrhosis increases early detection of hepatocellular carcinoma (HCC) and prolongs survival. However, its effectiveness is limited by underuse, particularly among racial/ethnic minorities and individuals of low socioeconomic status. We compared the effectiveness of mailed outreach strategies, with and without patient navigation, in increasing the numbers of patients with cirrhosis undergoing surveillance for HCC in a racially diverse and socioeconomically disadvantaged cohort.

METHODS

We performed a prospective study of patients with documented or suspected cirrhosis at a large safety-net health system from December 2014 through March 2016. Patients were assigned randomly (1:1:1) to groups that received mailed invitations for an ultrasound screening examination (n = 600), mailed invitations for an ultrasound screening examination and patient navigation (barrier assessment and motivational education for patients who declined screening; n = 600), or usual care (visit-based screening; n = 600). Patients who did not respond to outreach invitations within 2 weeks received up to 3 reminder telephone calls. The primary outcome was completion of abdominal imaging within 6 months of randomization.

RESULTS

Baseline characteristics were similar among groups. Cirrhosis was documented, based on International Classification of Diseases, 9th revision, codes, for 79.6% of patients, and suspected, based on noninvasive markers of fibrosis, for 20.4%. In an intent-to-treat analysis, significantly greater proportions of patients who received the mailed invitation and navigation (47.2%) or the mailed invitation alone (44.5%) underwent HCC screening than patients who received usual care (24.3%) (P < .001 for both comparisons). However, screening rates did not differ significantly between outreach the outreach groups (P = .25). The effects of the outreach program were consistent in all subgroups, including Caucasian vs non-Caucasian race, documented vs suspected cirrhosis, Child-Pugh A vs B cirrhosis, and receipt of gastroenterology care.

CONCLUSIONS

In a prospective study, we found outreach strategies to double the percentage of patients with cirrhosis who underwent ultrasound screening for HCC. However, adding patient navigation to telephone reminders provided no significant additional benefit. ClinicalTrials.gov no: NCT02312817.

A biopsychosocial model of pain and depression in rheumatoid arthritis: a 12-month longitudinal study

OBJECTIVE

To cross-validate a biopsychosocial model using physical disability, helplessness and passive coping to predict depression and pain in rheumatoid arthritis (RA).

METHODS

Clinical and psychological measures were collected from 157 RA patients at three time points over a period of 12 months. Path analysis was used for cross-sectional and longitudinal prediction of depression and pain.

RESULTS

Helplessness and passive coping were found to be significant mediators of the relationship between the physical disability and future depression and pain. Cross-sectionally, the predictive model could account for 52-94% of the variance of pain and 37-71% of the variance of depression. Longitudinally, the predictive model could explain 29-43% of the variance of pain and 21-33% of the variance of depression.

CONCLUSIONS

These results suggest that physical disability, helplessness and passive coping have a significant impact on the levels of pain and depression experienced by RA patients.

Coping with stress in the workplace: implications for new health professionals

Because health care professionals must provide high-quality care while simultaneously adjusting to the new demands of a rapidly changing health care system, work stress and possibly even burnout are prevalent issues for both senior professionals and recent health science graduates upon entry into the workforce. This article examines the experience of stress and the importance of coping abilities, particularly focusing on students enrolled in health professional courses and those who have recently entered the workforce. It also presents research pertaining to whether newly graduated health professionals are coping effectively with the demands of work. Suggestions for improving stress-coping abilities are given.

The impact of passive coping on rheumatoid arthritis pain

OBJECTIVE

To determine the ability of coping to predict pain.

METHODS

Data on 111 rheumatoid arthritis (RA) patients (86 women and 25 men) were gathered from a mail survey. Statistical analyses were conducted on a range of clinical and psychological variables: physical disability, disease duration, pain, depression, helplessness, and passive and active coping. Pain was measured with both the pain subscale of the Arthritis Impact Measurement Scales and a visual analogue scale, and coping was measured with the Vanderbilt Pain Management Inventory.

RESULTS

A series of multiple regression analyses revealed that the optimal predictors of pain in RA were physical disability and passive coping, which accounted for 40% of the variance associated with pain. Path analysis revealed that passive coping mediates between the physical disability and pain, and between physical disability and depression.

CONCLUSION

The results of this study have implications for the overall management of RA. In addition to the medical treatment, the experience of pain and depression in RA should be addressed through an intervention programme designed to enhance coping strategies.

Onycholysis as a complication of systemic chemotherapy: report of five cases associated with prolonged weekly paclitaxel therapy and review of the literature

BACKGROUND

Onycholysis has been reported in association with the use of several noncytotoxic drugs and with chemotherapy in 135 patients. Onycholysis may be precipitated by exposure to ultraviolet radiation.

METHODS

The authors studied 91 patients who received paclitaxel and 187 patients who received doxorubicin.

RESULTS

Onycholysis occurred in 5 of 21 patients who received > 6 courses of weekly paclitaxel, developing in the summer months in all 5 patients. It did not occur in patients who received fewer weekly paclitaxel courses or those who were treated every 3 weeks. Onycholysis did not occur in 187 patients who received doxorubicin. Review of the literature revealed that onycholysis is nearly exclusively associated with anthracycline and taxane therapy.

CONCLUSIONS

Prolonged weekly paclitaxel, other taxanes, and anthracyclines cause onycholysis in some patients, which may be precipitated by exposure to sunlight. Patients receiving these drugs should protect their nails from sunlight.

The creation of a profession leader role in an academic health sciences centre

The introduction and administration of any new role in a dynamic changing environment requires strong leadership and specific, purposeful administrative strategies. This article describes the development of a professional leader role at one campus of a recently merged academic health sciences centre. Understanding the operational challenges may help other healthcare organizations that wish to introduce and refine professional leadership roles.

The effect of microdebriders on tissue for histological diagnosis

Microdebriders are an innovation in endonasal surgery which enable accurate and precise removal of tissue without damaging the surrounding mucosa. Concern has been expressed, however, that the instrument may render excised tissue unsuitable for histological diagnosis. This problem is further compounded by the fact that the Hummer (Stryker UK Ltd) microdebrider does not incorporate a mechanism for collecting specimens at the time of removal. Twenty-one patients with sinonasal polyposis underwent endoscopic sinus surgery using the microdebrider. Specimens were collected at the time of surgery via an in-line specimen trap. Simultaneous conventional biopsies of adjacent tissue were taken for comparison. The tissue was fixed in formalin then routinely processed to paraffin wax prior to staining with haematoxylin and eosin (H&E). A histological diagnosis was made in all 21 patients. A single unsuspected transitional cell papilloma was found. The remaining 20 specimens consisted of inflammatory nasal polypi. In two non-caseating granulomas were identified. Traumatic artefact was limited to the respiratory epithelium. The sub-epithelial tissue was unaffected and metaplastic epithelium appeared intact. The use of microdebriders does not preclude the submission of tissue for histological analysis. Tissue obtained has limited artefact and is suitable for pathological diagnosis.

Delayed repair: the role of glutathione in a rat incisional wound model

Glutathione is a low molecular weight tripeptide that is a major intracellular antioxidant, modulates DNA synthesis, and may regulate signal transduction mechanisms. Our previous studies in rats suggested that intracellular stores of glutathione were sensitive to skin ischemia and, therefore, may regulate the early temporal course of wound healing. A 4-cm incision was placed on a rat's back and in vivo wound strength was measured over time. Animals were depleted of glutathione using L-buthionine-(S,R)-sulfoximine (BSO), an inhibitor of the enzyme gamma-glutamylcysteine synthetase. Some animals were treated in combination with allopurinol/BSO or with allopurinol alone. The data demonstrated at 4 days that BSO treatment produced a fourfold reduction in glutathione (3.51 +/- 1.78) over baseline (16.15 +/- 2.18) levels and twofold reduction (5.0 +/- 1.1) over untreated sham controls (11.1 +/- 2.3) (P < 0.05). Allopurinol provided no protection to glutathione levels. BSO treatment alone reduced wound burst strength compared to the other groups (P < 0.05). Allopurinol treatment enhanced wound strength over sham controls and BSO groups at 9 days after wounding (P < 0.05). Hydroxyproline content in wounds accumulated faster by Day 4 in the BSO-treatment groups compared to sham controls (P < 0.05), whereas the BSO-treatment groups had lower hydroxyproline levels measured at Day 6 (P < 0.05). These data provide the first evidence that wound healing is related to the temporal course of glutathione metabolism. The effect may not be related to oxidant stress since allopurinol provided enhanced wound burst strength without protecting wound glutathione levels.

Oxidant stress: the role of the glutathione redox cycle in skin preconditioning

The role of the glutathione redox cycle in cellular protection form skin necrosis during the ischemic stress response (preconditioning) is unknown. In this series of experiments, we tested the hypothesis that oxidant stress reduces available total glutathione during injury and contributes to skin necrosis in flaps. Dorsal skin flaps (10 x 4 cm) were raised as acute flaps and skin grafts were obtained from the flaps at 0, 1, 4, 6, 12, or 24 hr. Some flaps were preconditioned as bipedicle flaps for 24, 48, 72, or 96 hr and the distal attachment divided before skin grafts were obtained 24 hr later. Flap survival was measured at 7 days. Total glutathione (GSH) and oxidized GSH (GSSG) were extracted and their levels determined enzymatically. Tissue GSH reductase (GR) activity was assayed with a spectrofluorometer and expressed as mumoles of NADPH oxidized/hr/g. Biochemical data were compared between the proximal and distal ends of the flaps using a two-tailed Student t test while differences between groups were compared using ANOVA. Skin necrosis was 5.4 +/- 0.12 cm in the distal ends at 7 days in acute flaps, while there was no skin necrosis in flaps preconditioned for 7 days. In acute flaps, total GSH levels fell precipitously in the distal end at 24 hr (P < 0.05). However, after 72 hr of preconditioning, the GSH levels in the distal end of the flap remained elevated while GSSG levels were undetectable. At 24 hr of ischemia, GR activity was 79 +/- 4 in the distal ends of acute flaps, while after preconditioning and 24 hr of ischemia, the GR activity increased to 172 +/- 13 in the distal ends (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Job sharing of a director of nursing position: an evaluation report

The authors report on a job-share experience of Director of Nursing position at a large teaching hospital. A number of methods are used to evaluate this interim four month experience. Using aspects of administrative theory and the results of this evaluation, a conceptual framework is provided and suggestions are made that they may assist nurse and non-nurse administrators when considering future middle management job sharing arrangements in their organizations.

Structural and perceived medical dominance: a study of barriers to nurses' workplace satisfaction

Current literature on the sociology of healthy views medical dominance as a structural feature of the health division of labour and a body of literature has developed exploring the structural components that contribute to the subordination of the allied health professions. In this paper, Friedson's four factor definition of medical dominance was employed to provide a framework for assessing the degree to which structural medical dominance of the nursing profession impinges on nurses' perceptions of dominance and how structural and perceived medical dominance affects nurses' workplace satisfaction. A 69 item questionnaire covering aspects of doctor/nurse, doctor/patient, nurse/patient and nurse/hospital administration relationships was developed. One hundred and thirty nurses completed the questionnaire in which they ranked their own level of professional satisfaction and their perceptions of level of doctors' professional satisfaction. Results indicated that nurses were dissatisfied with many aspects of their work environment, i.e. pay and working conditions and experienced very high levels of dissatisfaction with their professional status. Nurses perceived doctors as being highly satisfied and as having more control over a range of procedures intrinsic to the delivery of health care, and the medical profession to be a more powerful and higher status profession that was held in greater regard by the public and other allied health professionals than nursing. The implications of the perceived discrepancy in nurses' and doctors, workplace satisfaction are discussed in terms of the structural barriers created by medical dominance. Implications of the findings for nurse education and nurse practitioners are also discussed, together with suggestions for further research.

Medicine and the health professions: issues of dominance, autonomy and authority

Medical dominance of health care has traditionally been the organising principle in health care delivery. Medical power is manifested through the professional autonomy of doctors, through their pivotal role in the economics of health services, through dominance over allied health occupational groups, through administrative influence, and through the collective influence of medical associations. Using Friedson's four factor definition of medical dominance, a structured interview schedule was developed to examine one aspect of medical dominance, that is, doctors' control over the allied health professions. Ninety interviews were carried out with a sample of nurses, physiotherapists, occupational therapists, speech pathologists and psychologists working in various health care settings in metropolitan Sydney, seeking their perceptions on the way in which the medical profession interacts with their occupational group. The findings indicate that a significant proportion (73%) of health professionals did not feel regarded as professional equals by doctors. Nor did they feel that doctors had an adequate knowledge and understanding of their professions (73%). However, the majority (74%) felt that they had sufficient autonomy and were able to discuss doctors' instructions and offer advice or suggestions to doctors. Length of service significantly contributed to perceptions of professional autonomy amongst allied health professionals. These results support the view that the increased autonomy of the allied health professions has not impinged on medical dominance in the health care delivery system. Recommendations for further research and the training of medical and allied health professionals are made.