Objective: Transportation workers, including drivers, are at high risk of developing diabetes but are a challenging workforce to reach for public health initiatives. We evaluated an innovative, ...culturally-tailored Diabetes Prevention Program (DPP) designed to strengthen driver behavioral engagement and program outcomes as part of a collaboration with the CT State Employer and the drivers’ Labor Union. The DPP included behavior and psychosocial assessments and health coaching to meet ADA Psychosocial Care Guideline recommendations.
Methods: Outcomes were: program attendance, weight loss, and physical activity level. Drivers (N=117) attended informational sessions, completed DPP screening, and signed up for a 1-year DPP at 11 work sites. Standard DPP group education was enriched with group and individual health coaching sessions that targeted behavioral and psychosocial barriers. Health coaches (N=3) developed customized educational resources and used validated behavior and psychosocial barriers assessments.
Results: Participants (N=98, 84% of enrolled) were: 97.8% male, mean age=49.0±8.9 yrs., baseline weight=245±48.6 lbs., gender 95% male, race 76% White, Ethnicity 13.6% Latino. One year results showed: mean attendance=70.8% ≥ 22 sessions and N=418 coaching sessions using individual driver behavior and psychosocial diagnostic results to compliment DPP group work. Behavior and psychosocial assessments completed were: Health literacy N=86, Self-management (Meal plan, Physical activity) N=77, Behavioral health N=80, Bodily pain N=83, Poor sleep N=92. Mean weight loss=14.0±11.5 lbs. with 63.3% achieving ≥5% body weight, and 89.8% ≥150 min/week of physical activity. Mean HbA1c improved from 5.7%±0.8 to 5.3%±0.6.
Conclusions: Drivers with challenging work schedules at high risk of developing diabetes were strongly engaged in a tailored, behaviorally-focused, enriched DPP that showed strong weight loss and physical activity improvements at the end of the one year DPP.
Disclosure
G. Welch: Stock/Shareholder; Self; Silver Fern Healthcare LLC. S.M. Downs: Employee; Self; WellSpark Health. M. Videtto: None. A.M. Griswold: None.
Obesity increases both the risk and mortality associated with many types of cancer including that of the breast. In mice, obesity increases both incidence of spontaneous tumors and burden of ...transplanted tumors. Our findings identify leptin, an adipose secreted cytokine, in promoting increased mammary tumor burden in obese mice and provide a link between this adipokine and cancer. Using a transplantable tumor that develops spontaneously in the murine mammary tumor virus-Wnt-1 transgenic mice, we show that tumors transplanted into obese leptin receptor (LepRb)-deficient (db/db) mice grow to eight times the volume of tumors transplanted into lean wild-type (WT) mice. However, tumor outgrowth and overall tumor burden is reduced in obese, leptin-deficient (ob/ob) mice. The residual tumors in ob/ob mice contain fewer undifferentiated tumor cells (keratin 6 immunopositive) compared with WT or db/db mice. Furthermore, tumors in ob/ob mice contain fewer cells expressing phosphorylated Akt, a growth promoting kinase activated by the LepRb, compared with WT and db/db mice. In vivo limiting dilution analysis of residual tumors from ob/ob mice indicated reduced tumor initiating activity suggesting fewer cancer stem cells (CSCs). The tumor cell populations reduced by leptin deficiency were identified by fluorescence-activated cell sorting and found to express LepRb. Finally, LepRb expressing tumor cells exhibit stem cell characteristics based on the ability to form tumorspheres in vitro and leptin promotes their survival. These studies provide critical new insight on the role of leptin in tumor growth and implicate LepRb as a CSC target.
Abstract
Objective
To examine screening strategies for identifying problematic sleep in a diverse sample of infants.
Methods
Parents of infants (5–19 months; N = 3,271) presenting for a primary care ...visit responded to five screening items and the Infant Sleep Questionnaire (ISQ), a validated measure of problematic infant sleep. If parents responded affirmatively to any screening item, primary care providers received a prompt to evaluate. For each of the screening questions, we examined differences in item endorsement and criterion related validity with the ISQ. Using conceptual composites of night waking and sleep difficulty, prevalence, criterion-related validity, and concurrent demographic correlates were analyzed.
Results
Infants were primarily of Black race (50.1%) or Hispanic ethnicity (31.7%), with the majority (63.3%) living in economically distressed communities. Rates of problematic sleep ranged from 7.4%, for a single item assessing parental perception of an infant having a sleep problem, to 74.0%, for a single item assessing night wakings requiring adult intervention. Items assessing sleep difficulty had high (95.0–97.8%) agreement with the ISQ in identifying infants without problematic sleep, but low agreement (24.9–34.0%) in identifying those with problematic sleep. The opposite was true for items assessing night waking, which identified 91.0–94.6% of those with sleep problems but only 31.8–46.9% of those without.
Conclusions
Screening strategies for identifying problematic infant sleep yielded highly variable prevalence rates and associated factors, depending on whether the strategy emphasized parent-perceived sleep difficulty or night wakings. The strategy that is most appropriate will depend on the system’s goals.
To (1) describe outcomes from a computer decision support system (CDSS) for pediatric obstructive sleep apnea (OSA) detection in primary care; and (2) identity the prevalence of children meeting ...criteria for an OSA referral.
A CDSS for OSA was implemented in two urban primary care clinics. Parents of children (age 2 to 11 years) presenting to the clinic were asked if their child snored regularly, with a positive response resulting in six additional OSA screening items. Primary care providers (PCPs) received a prompt for all snoring children, listing applicable OSA signs and symptoms and recommending further evaluation and referral for OSA.
A total of 2,535 children were screened for snoring, identifying 475 snoring children (18.7%). Among snoring children, PCPs referred 40 (15.4%) for further evaluation. The prevalence of additional OSA signs and symptoms ranged from 3.5% for underweight to 43.7% for overweight. A total of 74.7% of snoring children had at least one additional sign or symptom and thus met American Academy of Pediatrics guidelines criteria for an OSA referral.
A CDSS can be used to support PCPs in identifying children at risk for OSA. Most snoring children met criteria for further evaluation. It will be important to further evaluate this referral threshold as well as the readiness of the sleep medicine field to meet this need.
Registry: ClinicalTrials.gov, Title: Evidence-based Diagnosis and Management of Pediatric Obstructive Sleep Apnea in Primary Care, Identifier: NCT02781376, URL: https://clinicaltrials.gov/ct2/show/NCT02781376.
Background
Little is known about how primary care clinicians (PCCs) approach chronic pain management in the current climate of rapidly changing guidelines and the growing body of research about risks ...and benefits of opioid therapy.
Objective
To better understand PCCs’ approaches to managing patients with chronic pain and explore implications for technological and administrative interventions.
Design
We conducted adapted critical decision method interviews with 20 PCCs. Each PCC participated in 1–5 interviews.
Participants
PCCs interviewed had a mean of 14 years of experience. They were sampled from 13 different clinics in rural, suburban, and urban health settings across the state of Indiana.
Approach
Interviews included discussion of participants’ general approach to managing chronic pain, as well as in-depth discussion of specific patients with chronic pain. Interviews were audio recorded. Transcripts were analyzed thematically.
Key Results
PCCs reflected on strategies they use to encourage and motivate patients. We identified four associated strategic themes: (1) developing trust, (2) eliciting information from the patient, (3) diverting attention from pain to function, and (4) articulating realistic goals for the patient. In discussion of chronic pain management, PCCs often explained their beliefs about opioid therapy. Three themes emerged: (1) Opioid use tends to reduce function, (2) Opioids are often not effective for long-term pain treatment, and (3) Response to pain and opioids is highly variable.
Conclusions
PCC beliefs about opioid therapy generally align with the clinical evidence, but may have some important gaps. These findings suggest the potential value of interventions that include improved access to research findings; organizational changes to support PCCs in spending time with patients to develop rapport and trust, elicit information about pain, and manage patient expectations; and the need for innovative clinical cognitive support.
The 2016 Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain aimed to assist primary care clinicians in safely and effectively prescribing opioids for ...chronic noncancer pain. Individual states, payers, and health systems issued similar policies imposing various regulations around opioid prescribing for patients with chronic pain. Experts argued that healthcare organizations and clinicians may be misapplying the federal guideline and subsequent opioid prescribing policies, leading to an inadequate pain management. The objective of this study was to understand how primary care clinicians involve opioid prescribing policies in their treatment decisions and in their conversations with patients with chronic pain.
We conducted a secondary qualitative analysis of data from 64 unique primary care visits and 87 post-visit interviews across 20 clinicians from three healthcare systems in the Midwestern United States. Using a multistep process and thematic analysis, we systematically analyzed data excerpts addressing opioid prescribing policies.
Opioid prescribing policies influenced clinicians' treatment decisions to not initiate opioids, prescribe fewer opioids overall (theme #1), and begin tapering and discontinuation of opioids (theme #2) for most patients with chronic pain. Clinical precautions, described in the opioid prescribing policies to monitor use, were directly invoked during visits for patients with chronic pain (theme #3).
Opioid prescribing policies have multidimensional influence on clinician treatment decisions for patients with chronic pain. Our findings may inform future studies to explore mechanisms for aligning pressures around opioid prescribing, stemming from various opioid prescribing policies, with the need to deliver individualized pain care.
The objective of this qualitative study is to better understand primary care clinician decision making for managing chronic pain. Specifically, we focus on the factors that influence changes to ...existing chronic pain management plans. Limitations in guidelines and training leave clinicians to use their own judgment and experience in managing the complexities associated with treating patients with chronic pain. This study provides insight into those judgments based on clinicians' first-person accounts. Insights gleaned from this study could inspire innovations aimed at supporting primary care clinicians (PCCs) in managing chronic pain.
We conducted 89 interviews with PCCs to obtain their first-person perspective of the factors that influenced changes in treatment plans for their patients. Interview transcripts were analyzed thematically by a multidisciplinary team of clinicians, cognitive scientists, and public health researchers.
Seven themes emerged through our analysis of factors that influenced a change in chronic pain management: 1) change in patient condition; 2) outcomes related to treatment; 3) nonadherent patient behavior; 4) insurance constraints; 5) change in guidelines, laws, or policies; 6) approaches to new patients; and 7) specialist recommendations.
Our analysis sheds light on the factors that lead PCCs to change treatment plans for patients with chronic pain. An understanding of these factors can inform the types of innovations needed to support PCCs in providing chronic pain care. We highlight key insights from our analysis and offer ideas for potential practice innovations.
Abstract
Objectives
The Chronic Pain Treatment Tracker (Tx Tracker) is a prototype decision support tool to aid primary care clinicians when caring for patients with chronic noncancer pain. This ...study evaluated clinicians' perceived utility of Tx Tracker in meeting information needs and identifying treatment options, and preferences for visual design.
Methods
We conducted 12 semi-structured interviews with primary care clinicians from four health systems in Indiana. The interviews were conducted in two waves, with prototype and interview guide revisions after the first six interviews. The interviews included exploration of Tx Tracker using a think-aloud approach and a clinical scenario. Clinicians were presented with a patient scenario and asked to use Tx Tracker to make a treatment recommendation. Last, participants answered several evaluation questions. Detailed field notes were collected, coded, and thematically analyzed by four analysts.
Results
We identified several themes: the need for clinicians to be presented with a comprehensive patient history, the usefulness of Tx Tracker in patient discussions about treatment planning, potential usefulness of Tx Tracker for patients with high uncertainty or risk, potential usefulness of Tx Tracker in aggregating scattered information, variability in expectations about workflows, skepticism about underlying electronic health record data quality, interest in using Tx Tracker to annotate or update information, interest in using Tx Tracker to translate information to clinical action, desire for interface with visual cues for risks, warnings, or treatment options, and desire for interactive functionality.
Conclusion
Tools like Tx Tracker, by aggregating key information about past, current, and potential future treatments, may help clinicians collaborate with their patients in choosing the best pain treatments. Still, the use and usefulness of Tx Tracker likely relies on continued improvement of its functionality, accurate and complete underlying data, and tailored integration with varying workflows, care team roles, and user preferences.
Children with attention-deficit hyperactivity disorder (ADHD) have ongoing needs that impair home and school functioning. Group visit models are a promising way to deliver timely parenting support ...but family and provider acceptance has not previously been examined. The objective was to describe the acceptability of ADHD group visits in busy pediatric clinics based on caregivers, child participants and facilitators.
Data were analyzed from school-age children and caregivers who participated in one of two 12-month long randomized controlled studies of the ADHD group visit model from 2012 to 2013 or 2014 to 2015. Feedback was obtained using semi-structured questions at each study end, by telephone or at the last group visit. Sessions were audio-recorded, transcribed and themes were extracted by participant type.
A total of 34 caregivers, 41 children and 9 facilitators offered feedback. Caregivers enjoyed the "support group" aspect and learning new things from others. Caregivers reported improved understanding of ADHD and positive changes in the relationship with their child. Children were able to recall specific skills learned including how skills helped at home or school. Facilitators acknowledged systems-level challenges to offering group visits but felt the group format helped increase understanding of families' needs, improved overall care, and provided innovative ways to engage with families.
The majority of comments from families and facilitators highlighted a variety of benefits of the use of a group visit model for ADHD chronic care. Despite systems-level barriers to implementation, families and facilitators felt the benefits outweighed the challenges.
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