Background. Safe opioid prescribing and effective pain care are particularly important issues in the United States, where decades of widespread opioid prescribing have contributed to high rates of ...opioid use disorder. Because of the importance of clinician-patient communication in effective pain care and recent initiatives to curb rising opioid overdose deaths, this study sought to understand how clinicians and patients communicate about the risks, benefits, and goals of opioid therapy during primary care visits. Methods. We recruited clinicians and patients from six primary care clinics across three health systems in the Midwest United States. We audio-recorded 30 unique patients currently receiving opioids for chronic noncancer pain from 12 clinicians. We systematically analyzed transcribed, clinic visits to identify emergent themes. Results. Twenty of the 30 patient participants were females. Several patients had multiple pain diagnoses, with the most common diagnoses being osteoarthritis (n = 10), spondylosis (n = 6), and low back pain (n = 5). We identified five themes: 1) communication about individual-level and population-level risks, 2) communication about policies or clinical guidelines related to opioids, 3) communication about the limited effectiveness of opioids for chronic pain conditions, 4) communication about nonopioid therapies for chronic pain, and 5) communication about the goal of the opioid tapering. Conclusions. Clinicians discuss opioid-related risks in varying ways during patient visits, which may differentially affect patient experiences. Our findings may inform the development and use of more standardized approaches to discussing opioids during primary care visits.
Chronic pain leads to reduced quality of life for patients, and strains health systems worldwide. In the US and some other countries, the complexities of caring for chronic pain are exacerbated by ...individual and public health risks associated with commonly used opioid analgesics. To help understand and improve pain care, this article uses the data frame theory of sensemaking to explore how primary care clinicians in the US manage their patients with chronic noncancer pain. We conducted Critical Decision Method interviews with ten primary care clinicians about 30 individual patients with chronic pain. In these interviews, we identified several patients, social/environmental, and clinician factors that influence the frames clinicians use to assess their patients and determine a pain management plan. Findings suggest significant ambiguity and uncertainty in clinical pain management decision making. Therefore, interventions to improve pain care might focus on supporting sensemaking in the context of clinical evidence rather than attempting to provide clinicians with decontextualized and/or algorithm-based decision rules. Interventions might focus on delivering convenient and easily interpreted patient and social/environmental information in the context of clinical practice guidelines.
Abstract
Background
For complex patients with chronic conditions, electronic health records (EHRs) contain large amounts of relevant historical patient data. To use this information effectively, ...clinicians may benefit from visual information displays that organize and help them make sense of information on past and current treatments, outcomes, and new treatment options. Unfortunately, few clinical decision support tools are designed to support clinical sensemaking.
Objective
The objective of this study was to describe a decision-centered design process, and resultant interactive patient information displays, to support key clinical decision requirements in chronic noncancer pain care.
Methods
To identify key clinical decision requirements, we conducted critical decision method interviews with 10 adult primary care clinicians. Next, to identify key information needs and decision support design seeds, we conducted a half-day multidisciplinary design workshop. Finally, we designed an interactive prototype to support the key clinical decision requirements and information needs uncovered during the previous research activities.
Results
The resulting Chronic Pain Treatment Tracker prototype summarizes the current treatment plan, past treatment history, potential future treatments, and treatment options to be cautious about. Clinicians can access additional details about each treatment, current or past, through modal views. Additional decision support for potential future treatments and treatments to be cautious about is also provided through modal views.
Conclusion
This study designed the Chronic Pain Treatment Tracker, a novel approach to decision support that presents clinicians with the information they need in a structure that promotes quick uptake, understanding, and action.
Decision support system designs often do not align with the information environments in which clinicians work. These work environments may increase Clinicians' cognitive workload and harm their ...decision making. The objective of this study was to identify information needs and decision support requirements for assessing, diagnosing, and treating chronic noncancer pain in primary care. We conducted a qualitative study involving 30 interviews with 10 primary care clinicians and a subsequent multidisciplinary systems design workshop. Our analysis identified four key decision requirements, eight clinical information needs, and four decision support design seeds. Our findings indicate that clinicians caring for chronic pain need decision support that aggregates many disparate information elements and helps them navigate and contextualize that information. By attending to the needs identified in this study, decision support designers may improve Clinicians' efficiency, reduce mental workload, and positively affect patient care quality and outcomes.
Abstract Understanding the role of socio-sexual cognitions and religiosity on adolescent sexual behavior could guide adolescent sexual health efforts. The present study utilized longitudinal data ...from 328 young women to assess the role of religion and socio-sexual cognitions on sexual behavior accrual (measuring both coital and non-coital sexual behavior). In the final triple conditional trajectory structural equation model, religiosity declined over time and then increased to baseline levels. Additionally, religiosity predicted decreased sexual conservatism and decreased sexual conservatism predicted increased sexual behavior. The final models are indicative of young women's increasing accrual of sexual experience, decreasing sexual conservatism and initial decreasing religiosity. The results of this study suggest that decreased religiosity affects the accrual of sexual experience through decreased sexual conservatism. Effective strategies of sexual health promotion should include an understanding of the complex role of socio-sexual attitudes with religiosity.
Introduction Despite guidelines for evidence-based diagnosis of pediatric obstructive sleep apnea (OSA) recommending that all children are screened for snoring, studies have found low rates of ...screening for snoring in primary care. The aim of the current study is to evaluate the efficacy of a computer decision support tool on primary care provider (PCP) documentation of snoring. Methods In 2015 we introduced a computer decision support module (Child Health Improvement through Computer Automation for Snoring; CHICA-Snore) in five urban pediatric primary care clinics. In CHICA-Snore, parents receive a screening item asking if their child snores, delivered via an electronic tablet in the waiting room. PCPs receive an automated prompt in the electronic health record for snoring children, encouraging them to evaluate the child for OSA. We extracted data from the charts of a random sample of 194 children whose parents reported snoring between August 2015 and February 2016. All primary care visits for each child were reviewed during two time periods: 1) one year prior to the visit in which the parent reported snoring (baseline); and 2) the visit at which the parent reported snoring (CHICA Snore). Chi-square analysis was conducted to compare rates of snoring documentation between the two time points. Results Participants were 194 snoring children between the ages of 3 and 12 years seen by 27 PCPs. Children had a mean age of 8.1 years (SD=2.5), were 55.7% male, and the majority (93.8%) had Medicaid insurance. The most common race/ethnicity was black non-hispanic (58.2%), followed by white hispanic (24.2%) and white non-hispanic (10.3%). PCP documentation of snoring increased significantly with CHICA-Snore, (18.8% at baseline and 64.0% with CHICA-Snore; p<.01). Conclusion A computer decision support system significantly improved PCP documentation of snoring, an important initial step on the path towards OSA detection and treatment. Next steps are to evaluate the impact of CHICA-Snore and other decision support tools on OSA referrals and other more downstream effects. Support (If Any) This project was made possible by an award from the American Academy of Sleep Medicine Foundation.
: Paxillin, a cytoskeletal focal adhesion adaptor protein, has been shown to be transcriptionally up‐regulated and phosphorylated by human epidermal growth factor receptor‐2 (HER2) signaling in ...vitro. Paxillin expression may also correlate with HER2 amplification in breast cancer patients. In the current study, we sought to explore the relationship further between paxillin expression and clinicopathologic features and clinical outcome in breast cancer. A total of 314 primary invasive breast carcinomas were assessed for paxillin expression via immunohistochemistry. Paxillin immunoreactivity was compared with estrogen receptor/progesterone receptor status, HER2 status by silver in situ hybridization, age, tumor size, stage, Bloom–Richardson grade, nodal status, disease‐free survival (DFS), and overall survival (OS). Paxillin expression was identified in 27.7% of breast carcinomas as diffuse cytoplasmic staining and the expression correlated with HER2 overexpression (p < 0.001). The influence of paxillin on clinical outcome, in particular the response to chemotherapy, appeared to differ depending on the HER2 status of the tumor. For the subset of HER2 nonamplified cases treated with chemotherapy, patients whose tumor showed a loss of paxillin expression demonstrated a significantly lengthened DFS and OS. In contrast, loss of paxillin expression in the HER2 amplified subset of patients who received chemotherapy correlated with a significantly worse outcome. These data suggest that paxillin up‐regulation may be a part of the HER2 pathway in some breast cancers and, furthermore, paxillin expression may also influence the clinical response to chemotherapy, depending upon the HER2 status of a given patient’s tumor. Further study of a role for paxillin expression in predicting response to cytotoxic regimens or targeted treatments is warranted.
Justice-involved youth endorse high rates of mental health problems. Juvenile probation is the most common disposition in the justice system and juvenile probation officers (JPOs) are crucial for ...connecting justice-involved youth with appropriate care. We examined the role of mental health competency on the use of self-report case management strategy types (deterrence, restorative justice, and treatment) by JPOs and whether jurisdiction-level differences were relevant. Results suggest that mental health competency predicted use of restorative justice and treatment strategies and all three strategy types varied at the county level. The role of mental health competency in use of treatment strategies is relevant to connecting justice-involved youth to mental health care. Furthermore, a substantial amount of the variance predicting the use of all three strategies was accounted for at the county level.
Although diabetes after total pancreatectomy and islet autotransplantation (TP-IAT) is one of the biggest concerns for TP-IAT recipients and physicians, reliable prediction of post-TP-IAT glycemic ...control remains unestablished. This study was conducted to identify early predictors of insulin independence and goal glycemic control by hemoglobin A1c (HbA1c) ≤ 6.5% after TP-IAT.
In this single-center, retrospective study, patients who underwent TP-IAT (n = 227) were reviewed for simple metabolic markers or surrogate indices of β-cell function obtained 3 mo after TP-IAT as part of standard clinical testing. Long-term metabolic success was defined as (1) insulin independence and (2) HbA1c ≤ 6.5% 1, 3, and 5 y after TP-IAT. Single- and multivariate modeling used 3-mo markers to predict successful outcomes.
Of the 227 recipients, median age 31 y, 30% male, 1 y after TP-IAT insulin independence, and HbA1c ≤ 6.5% were present in 39.6% and 72.5%, respectively. In single-predictor analyses, most of the metabolic markers successfully discriminated between those attaining and not attaining metabolic goals. Using the best model selected by random forests analysis, we accurately predicted 1-y insulin independence and goal HbA1c control in 77.3% and 86.4% of the patients, respectively. A simpler "clinically feasible" model using only transplanted islet dose and BETA-2 score allowed easier prediction at a small accuracy loss (74.1% and 82.9%, respectively).
Metabolic testing measures performed 3 mo after TP-IAT were highly associated with later diabetes outcomes and provided a reliable prediction model, giving valuable prognostic insight early after TP-IAT and help to identify recipients who require early intervention.
PDF
