Stakeholder engagement in eight comparative effectiveness trials in African Americans and Latinos with asthma

BACKGROUND

The effects of stakeholder engagement, particularly in comparative effectiveness trials, have not been widely reported. In 2014, eight comparative effectiveness studies targeting African Americans and Hispanics/Latinos with uncontrolled asthma were funded by the Patient-Centered Outcomes Research Institute (PCORI) as part of its Addressing Disparities Program. Awardees were required to meaningfully involve patients and other stakeholders. Using specific examples, we describe how these stakeholders substantially changed the research protocols and in other ways participated meaningfully as full partners in the development and conduct of the eight studies.

METHODS

Using the method content analysis of cases, we identified themes regarding the types of stakeholders, methods of engagement, input from the stakeholders, changes made to the research protocols and processes, and perceived benefits and challenges of the engagement process. We used summaries from meetings of the eight teams, results from an engagement survey, and the final research reports as our data source to obtain detailed information. The descriptive data were assessed by multiple reviewers using inductive and deductive qualitative methods and discussed in the context of engagement literature.

RESULTS

Stakeholders participated in the planning, conduct, and dissemination phases of all eight asthma studies. All the studies included clinicians and community representatives as stakeholders. Other stakeholders included patients with asthma, their caregivers, advocacy organizations, and health-system representatives. Engagement was primarily by participation in advisory boards, although six of the eight studies (75%) also utilized focus groups and one-on-one interviews. Difficulty finding a time and location to meet was the most reported challenge to engagement, noted by four of the eight teams (50%). Other reported challenges and barriers to engagement included recruitment of stakeholders, varying levels of enthusiasm among stakeholders, controlling power dynamics, and ensuring that stakeholder involvement was reflected and had true influence on the project.

CONCLUSION

Engagement-driven modifications led to specific changes in study design and conduct that were felt to have increased enrollment and the general level of trust and support of the targeted communities. The level of interaction described, between investigators and stakeholders in each study and between investigator-stakeholder groups, is-we believe-unprecedented and may provide useful guidance for other studies seeking to improve the effectiveness of community-driven research.

Communication Training, Adverse Events, and Quality Measures: 2 Retrospective Database Analyses in Washington State Hospitals

OBJECTIVE

Washington State's HealthPact program was launched in 2011 as part of AHRQ's Patient Safety and Medical Liability Reform initiative. HealthPact delivered interdisciplinary communication training to health-care professionals with the goal of enhancing safety. We conducted 2 exploratory, retrospective database analyses to investigate training impact on the frequency of adverse events (AEs) and select quality measures across 3 time frames: pretraining (2009-2011), transition (2012), and posttraining (2013).

METHODS

Using administrative data from Washington State's Comprehensive Hospital Abstract Reporting System (CHARS) and clinical registry data from the Surgical Care and Outcomes Assessment Program (SCOAP), we compared proportions of AEs and quality measures between HealthPact (n = 4) and non-HealthPact (n = 93-CHARS; n = 48-SCOAP) participating hospitals. Risk ratios enabled comparisons between the 2 groups. Multivariable logistic regression enabled investigation of the association between training and the frequency of AEs.

RESULTS

Approximately 9.4% (CHARS) and 7.7% (SCOAP) of unique patients experienced 1 AE or greater. In CHARS, the odds of a patient experiencing an AE in a HealthPact hospital were initially (pretraining) higher than in a non-HealthPact hospital (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.10-1.17), lower in transition (OR, 0.80; 95% CI, 0.76-0.83) and posttraining (OR, 0.72; 95% CI, 0.69-0.75) periods. In SCOAP, ORs were consistently lower in HealthPact hospitals: pretraining (OR, 0.87; 95% CI, 0.80-0.95), transition (OR, 0.75; 95% CI, 0.70-0.81), and posttraining (OR, 0.63; 95% CI, 0.58-0.68). The proportion of at-risk patients that experienced each individual AE was low (<1%) throughout. Adherence to quality measures was high.

CONCLUSIONS

Interprofessional communication training is an area of intense activity nationwide. A broad-based training initiative may play a role in mitigating AEs.

Development of an Asthma Home-Visit Training Program for Community Health Workers and Their Supervisors in Washington State

The community health worker (CHW) asthma home-visiting model developed by Public Health-Seattle & King County (PHSKC) is an evidence-based approach proven to improve health outcomes and quality of life. In addition, it has been shown to be an effective and culturally appropriate approach to helping people with asthma understand the environmental and behavioral causes of uncontrolled asthma, while acquiring the skills they need to control their asthma. This paper describes the development and implementation of training curricula for CHWs and supervisors in the asthma home visiting program. To facilitate dissemination, this program took advantage of the current healthcare landscape in Washington State resulting from Centers for Medicare & Medicaid Services (CMS) approval of the 1115 Medicaid Waiver project. Key aspects of the training program development included: (1) Engagement: forming a Community Advisory Board with multiple stakeholders to help prioritize training content; (2) Curriculum Development: building the training on evidence-based home-visit protocols previously developed at PHSKC; (3) Implementation of the training program; (4) Evaluation of the training; and (5) Adaptation of the training based on lessons learned. We describe key factors in the training program's improvement including the use of a community-based participatory approach to engage stakeholders at multiple phases of the project and ensure regional adaption; combining in-person and online modules for delivery; and holding learning collaboratives for post-training and technical support. We also outline our training program evaluation plan and the planned evaluation of the home visit program which the trainees will deliver, both of which follow the RE-AIM framework. However, because the COVID-19 pandemic has curtailed training activities and prohibited the trainees from implementation of these CHW home visit practices, our evaluation is currently incomplete. Therefore, this case study provides insight into the adaptation of the training program, but not the delivery of the home visit program, the outcomes of which remain to be seen.

Building a Practice-Based Research Agenda for Wildfire Smoke and Health: A Report of the 2018 Washington Wildfire Smoke Risk Communication Stakeholder Synthesis Symposium

Background: As climate change is expected to result in more frequent, larger fires and associated smoke impacts, creating and sustaining wildfire smoke-resilient communities is an urgent public health priority. Following two summers of persistent and extreme wildfire smoke events in Washington state, the need for additional research on wildfire smoke health impacts, risk communication, and risk reduction, and an associated greater coordination between researcher and practitioner communities, is of paramount importance. Objectives: On 30 October 2018, the University of Washington hosted a Wildfire Smoke Risk Communication Stakeholder Synthesis Symposium in Seattle, Washington. The goals of the symposium were to identify and prioritize practice-based information gaps necessary to promote effective wildfire smoke risk communication and risk reduction across Washington state, foster collaboration among practitioners and academics to address information gaps using research, and provide regional stakeholders with access to the best available health and climate science about current and future wildfire risks. Methods: Seventy-six Washington state practitioners and academics with relevant professional responsibilities or expertise in wildfire smoke and health engaged in small group discussions using the "World Café Method" to identify practice-relevant research needs related to wildfire smoke and health. Notes from each discussion were coded and qualitatively analyzed using a content analysis approach. Discussion: Washington state's public health and air quality practitioners need additional evidence to communicate and reduce wildfire smoke risk. Exposure, health risk, risk communication, behavior change and interventions, and legal and policy research needs were identified, along with the need to develop research infrastructure to support wildfire smoke and health science. Practice-relevant, collaborative research should be prioritized to address this increasing health threat.

Enrolling African-American and Latino patients with asthma in comparative effectiveness research: Lessons learned from 8 patient-centered studies

BACKGROUND

African-American and Latino patients are often difficult to recruit for asthma studies. This challenge is a barrier to improving asthma care and outcomes for these populations.

OBJECTIVES

We sought to examine the recruitment experiences of 8 asthma comparative effectiveness studies that specifically targeted African-American and Latino patients, and identify the solutions they developed to improve recruitment.

METHODS

Case report methodology was used to gather and evaluate information on study design, recruitment procedures and outcomes from study protocols and annual reports, and in-depth interviews with each research team. Data were analyzed for themes, commonalities, and differences.

RESULTS

There were 4 domains of recruitment challenges: individual participant, institutional, research team, and study intervention. Participants had competing demands for time and some did not believe they had asthma. Institutional challenges included organizational policies governing monetary incentives and staff hiring. Research team challenges included ongoing training needs of recruitment staff, and intervention designs often were unappealing to participants because of inconveniences. Teams identified a host of strategies to address these challenges, most importantly engagement of patients and other stakeholders in study design and troubleshooting, and flexibility in data collection and intervention application to meet the varied needs of patients.

CONCLUSIONS

Asthma researchers may have greater success with recruitment by addressing uncertainty among patients about asthma diagnosis, engaging stakeholders in all aspects of study design and implementation, and maximizing flexibility of study and intervention protocols. However, even with such efforts, engagement of African-American and Latino patients in asthma research may remain low. Greater investment in research on engaging these populations in asthma research may ultimately be needed to improve their asthma care and outcomes.

Geographic access to burn center hospitals

CONTEXT

The delivery of burn care is a resource-intensive endeavor that requires specialized personnel and equipment. The optimal geographic distribution of burn centers has long been debated; however, the current distribution of centers relative to geographic area and population is unknown.

OBJECTIVE

To estimate the proportion of the US population living within 1 and 2 hours by rotary air transport (helicopter) or ground transport of a burn care facility.

DESIGN AND SETTING

A cross-sectional analysis of geographic access to US burn centers utilizing the 2000 US census, road and speed limit data, the Atlas and Database of Air Medical Services database, and the 2008 American Burn Association Directory.

MAIN OUTCOME MEASURE

The proportion of state, regional, and national population living within 1 and 2 hours by air transport or ground transport of a burn care facility.

RESULTS

In 2008, there were 128 self-reported burn centers in the United States including 51 American Burn Association-verified centers. An estimated 25.1% and 46.3% of the US population live within 1 and 2 hours by ground transport, respectively, of a verified burn center. By air, 53.9% and 79.0% of the population live within 1 and 2 hours, respectively, of a verified center. There was significant regional variation in access to verified burn centers by both ground and rotary air transport. The greatest proportion of the population with access was highest in the northeast region and lowest in the southern United States.

CONCLUSION

Nearly 80% of the US population lives within 2 hours by ground or rotary air transport of a verified burn center; however, there is both state and regional variation in geographic access to these centers.

Influence of comorbidities and age on outcome following burn injury in older adults

Despite advances in medical and surgical techniques, older adults tend to be at high risk for adverse outcomes following burn injury. The purpose of this study was to examine the relative impacts of age and medical comorbidities on outcome following injury in a cohort of older adults. This was a retrospective study of all patients age 55 and over admitted to the University of Washington Burn Center from 1999 to 2003. To examine the effect of baseline medical comorbidities on outcome, a Charlson Comorbidity Index score was calculated for each patient. Multivariate regression analyses were used to examine the impact of age and comorbidities on mortality and other complications. Patient records were also matched with the National Death Index to determine the effects of age and comorbidities on mortality within 1 year following hospital discharge. A total of 325 patients who were of 55 years and older were admitted to the burn center during the 5-year study period. The overall mortality rate was 18.5%. Mortality was independently associated with age, inhalation injury, and burn size. One-year mortality was significantly associated with those older than age 75 and the Charlson score. Longer length of stay was significantly associated with burn size, inhalation injury, and total number of in-hospital complications. This study demonstrates that patient age-independent of baseline medical comorbidities-and TBSA burn are the most significant factors impacting in-hospital mortality risk following burn injury. Higher number of medical comorbidities was associated with increased mortality risk within 1 year following discharge.

Epidemiology and outcomes of older adults with burn injury: an analysis of the National Burn Repository

Improvements in outcomes for older adults sustaining burn injuries have lagged far behind those of younger patients. As this segment of the population grows, there has been an increasing interest in better understanding the epidemiology and outcomes of injury in older adults. The National Burn Repository (NBR) provides a unique opportunity to examine burn injuries on a national level. We aimed to characterize specific injury and outcome trends in older adult with burns through analysis of the NBR. We examined the records of all patients in the NBR aged 55 and older. To characterize age effects on injury and outcomes, patients were stratified into three age categories: 55 to 64 years, 65 to 74 years, and 75 years and older. Baseline characteristics, details of hospital treatment, mortality, and disposition were compared among these three age groups using chi or analysis of variance. Logistic regression analysis was performed to assess the impact of age on burn mortality. A total of 180,401 patient records were available from 1991 to 2005, of which 23,180 (14%) met age inclusion criteria. Mean burn size (9.6% TBSA) and percent with inhalation injury (11.3%) did not markedly differ by age. Men predominated overall (ratio 1.4:1), although women (4290) outnumbered men (3439) in the oldest age category. Length of stay per TBSA and median hospital charges increased with increasing age category, suggesting higher resource consumption with aging. Mean number of operations per patient, however, decreased with age. Mortality rates and discharge to nonindependent status increased with age. By logistic regression, the adjusted odds ratio for mortality was 2.3 (95% CI 2.1-2.7) in the 65 to 74 age group, and 5.4 (95% CI 4.8-6.1) in the oldest group when compared with the 55 to 64 age group. Mortality rates decreased significantly after 2001 across all age groups. This analysis demonstrates age-dependent differences in resource utilization and mortality risk within the older burn population and highlights the need for a national research agenda focused on management practices and outcomes in older adult with burns.

The application of genetic information for regulatory standard setting under the clean air act: a decision-analytic approach

In 2002, the U.S. Environmental Protection Agency (EPA) released an "Interim Policy on Genomics," stating a commitment to developing guidance on the inclusion of genetic information in regulatory decision making. This statement was followed in 2004 by a document exploring the potential implications. Genetic information can play a key role in understanding and quantifying human susceptibility, an essential step in many of the risk assessments used to shape policy. For example, the federal Clean Air Act (CAA) requires EPA to set National Ambient Air Quality Standards (NAAQS) for criteria pollutants at levels to protect even sensitive populations from adverse health effects with an adequate margin of safety. Asthmatics are generally regarded as a sensitive population, yet substantial research gaps in understanding genetic susceptibility and disease have hindered quantitative risk analysis. This case study assesses the potential role of genomic information regarding susceptible populations in the NAAQS process for fine particulate matter (PM(2.5)) under the CAA. In this initial assessment, we model the contribution of a single polymorphism to asthma risk and mortality risk; however, multiple polymorphisms and interactions (gene-gene and gene-environment) are known to play key roles in the disease process. We show that the impact of new information about susceptibility on estimates of population risk or average risk derived from large epidemiological studies depends on the circumstances. We also suggest that analysis of a single polymorphism, or other risk factor such as health status, may or may not change estimates of individual risk enough to alter a particular regulatory decision, but this depends on specific characteristics of the decision and risk information. We also show how new information about susceptibility in the context of the NAAQS for PM(2.5) could have a large impact on the estimated distribution of individual risk. This would occur if a group were consequently identified (based on genetic and/or disease status), that accounted for a disproportionate share of observed effects. Our results highlight certain conditions under which genetic information is likely to have an impact on risk estimates and the balance of costs and benefits within groups, and highlight critical research needs. As future studies explore more fully the relationship between exposure, genetic makeup, and disease status, the opportunity for genetic information and disease status to play pivotal roles in regulation can only increase.

Time to School Re-Entry After Burn Injury Is Quite Short

Returning to school is an important indicator of functional aptitude and emotional adjustment in school-aged patients after burn injury. Only two reports in the burn literature provide objective data on time to school re-entry. However, these analyses did not address the impact of patient and burn injury characteristics on time to return to school. The purpose of this study was to determine the time for school re-entry and to identify the factors associated with re-entry time in a cohort of burned children treated at our burn center. We performed a retrospective review of all school age children treated at our burn center from 1997 to 2003 who were entered into a federally funded longitudinal research database for patients with severe burn injury. Time to school re-entry after discharge was calculated for each patient, and multivariate regression was used to identify the factors associated with longer time to return to school. A total of 64 patients were included in this study. The average time to school re-entry was 10.5 days (range, 0-40) and the median time was 7.5 days. Gender (male), age, and length of hospital stay were significantly associated (P < .05) with longer time to return to school. The average time to school return is quite short. Further studies are needed to increase understanding of the factors influencing longer time to re-entry and also to examine children's experiences upon re-entry.

Policy implications of genetic information on regulation under the Clean Air Act: the case of particulate matter and asthmatics

The U.S. Clean Air Act (CAA) explicitly guarantees the protection of sensitive human subpopulations from adverse health effects associated with air pollution exposure. Identified subpopulations, such as asthmatics, may carry multiple genetic susceptibilities to disease onset and progression and thus qualify for special protection under the CAA. Scientific advances accelerated as a result of the groundbreaking Human Genome Project enable the quantification of genetic information that underlies such human variability in susceptibility and the cellular mechanisms of disease. In epidemiology and regulatory toxicology, genetic information can more clearly elucidate human susceptibility essential to risk assessment, such as in support of air quality regulation. In an effort to encourage the incorporation of genomic information in regulation, the U.S. Environmental Protection Agency (EPA) has issued an Interim Policy on Genomics. Additional research strategy and policy documents from the National Academy of Science, the U.S. EPA, and the U.S. Department of Health and Human Services further promote the expansion of asthma genetics research for human health risk assessment. Through a review of these government documents, we find opportunities for the inclusion of genetic information in the regulation of air pollutants. In addition, we identify sources of information in recent scientific research on asthma genetics relevant to regulatory standard setting. We conclude with recommendations on how to integrate these approaches for the improvement of regulatory health science and the prerequisites for inclusion of genetic information in decision making.

Ki-ras proto-oncogene mutations in sporadic colorectal adenomas: relationship to histologic and clinical characteristics

BACKGROUND & AIMS

[corrected] The goal of this study was to examine the relationship between Ki-ras mutations in colorectal adenomas and characteristics of both the subject (age, gender, and family/personal history of colonic neoplasia) and the adenoma (multiplicity, size, location, and histologic features).

METHODS

Ki-ras mutations were detected by direct sequencing in 738 adenomatous polyps removed at baseline from 639 participants in a nutritional trial of adenoma recurrence.

RESULTS

Ki-ras mutations were detected in 17.2% of the adenomas. Ki-ras mutations were unrelated to gender, family, or personal history of colonic neoplasia, location within the colorectum, or adenoma multiplicity, but were more common in older subjects (P = 0.01 for trend), in larger adenomas (P < 0.0001 for trend), in adenomas with villous histology (odds ratio [OR], 3.2; 95% confidence interval [CI], 2.1-4.9 vs. tubular), and in adenomas with high-grade dysplasia (32.0% vs. 13.6%; OR, 3.0; 95% CI, 1.9-4.6 vs. low-grade dysplasia). Multivariate analysis showed Ki-ras mutations to be independently associated with subject age (P = 0.01 for trend), tubulovillous/villous histology (OR, 2.3; 95% CI, 1.5-3.7), and high-grade dysplasia (OR, 1.9; 95% CI, 1.2-3.1). Adenoma size was not independently related to Ki-ras mutation.

CONCLUSIONS

Ki-ras mutations are associated with the histologic features of adenoma progression (villous histology and high-grade dysplasia) rather than with adenoma growth.

Effect of subacute ibuprofen dosing on rectal mucosal prostaglandin E2 levels in healthy subjects with a history of resected polyps

Nonsteroidal antiinflammatory drugs are among the most promising chemopreventive agents for colorectal cancer. Although the mechanism by which nonsteroidal antiinflammatory drugs exert such effects remains to be further characterized, their best known pharmacological effect is inhibition of prostaglandin synthetase, which leads to decreases in tissue prostaglandin levels. We conducted a randomized, double-blind, controlled study to examine the effect of daily ibuprofen treatment on the rectal mucosal prostaglandin E2 (PGE2) levels in healthy subjects with a history of resected polyps. Study participants (n = 27) completed a 2-week run-in period and were then randomized to take a single, daily dose of ibuprofen (300 or 600 mg) or of a placebo for 4 weeks. Rectal biopsy specimens were taken before and after the run-in period and at 2 and 4 weeks after the ibuprofen/placebo treatment. Notably large between- and within-subject variability in the rectal mucosal PGE2 content was seen. The changes in PGE2 levels after ibuprofen/placebo treatment correlated with the baseline PGE2 content. After adjustment of the baseline values, 2 weeks of 300 mg/day of ibuprofen treatment resulted in significantly more suppression of PGE2 levels than that observed after the placebo treatment (55% versus 22% suppression from baseline; P = 0.033). Although other ibuprofen treatment schedules and doses appeared to result in suppression in the PGE2 levels, the suppression was not statistically significant because of the large variability in this measurement. Because lower doses are associated with fewer adverse effects, a dose of 300 mg of ibuprofen/day should be considered for future Phase II chemoprevention studies. Stratifying study participants, based on their baseline PGE2 levels and inclusion of a larger number of study subjects, are recommended for future trials where the rectal mucosal PGE2 level is to be used as a surrogate end point biomarker.