Health Services Research Program Research Articles

Cognitive behavioral therapy for chronic pain supported by digital patient feedback and artificial intelligence: Do patients with socioeconomic risk factors benefit?

BackgroundIn a recent comparative effectiveness trial, patients with chronic pain receiving cognitive behavioral therapy supported by artificial intelligence and digital feedback (AI-CBT-CP) were more likely to report clinically meaningful improvements in pain-related disability and intensity at six months than patients randomized to standard telephone CBT-CP. Concerns persist about the impact of AI and digital interventions among socially disadvantaged patients. We examined variation in the proportion of patients completing all treatment sessions and reporting clinically meaningful improvements in pain-related disability and intensity across subgroups of patients defined by social determinants of health (SDOH). MethodsSDOH indicators included age, race, gender, education, income, marital status, geographic access, and clinical severity. Multivariate models with interaction terms tested SDOH indicators as potential moderators of treatment engagement and response to AI-CBT-CP versus standard telephone CBT-CP. FindingsRoughly half of participants (52.9 %) were 65+ years of age, 10.8 % were women, and 19.1 % reported Black race or multiple racial identities. Relatively favorable session completion was observed among patients randomized to AI-CBT-CP across SDOH subgroup, with no groups more likely to complete all session weeks when receiving standard telephone CBT-CP. The relative benefits of AI-CBT-CP in terms of pain-related disability and intensity were generally confirmed across SDOH subgroups. AI-CBT-CP had a greater relative impact on pain-related disability among patients <65 years old (p = .002). In none of the SDOH subgroups, did standard telephone CBT-CP have a greater impact on pain-related disability or intensity than AI-CBT-CP. InterpretationThese findings do not suggest that patients with SDOH disadvantages experience poorer treatment engagement or outcomes when offered CBT-CP supported by AI and digital feedback instead of standard telephone CBT-CP. AI-CBT-CP can help overcome treatment access barriers without exacerbating disparities, benefiting underserved populations with chronic pain. FundingUS Department of Veterans Affairs Health Services Research and Development program.

The impact of post-hospital remote monitoring of COVID-19 patients using pulse oximetry: A national observational study using hospital activity data

SummaryBackgroundThere was a national roll out of ‘COVID Virtual Wards’ (CVW) during England's second COVID-19 wave (Autumn 2020 – Spring 2021). These services used remote pulse oximetry monitoring for COVID-19 patients following discharge from hospital. A key aim was to enable rapid detection of patient deterioration. It was anticipated that the services would support early discharge, reducing pressure on beds. This study is an evaluation of the impact of the CVW services on hospital activity.MethodsUsing retrospective patient-level hospital admissions data, we built multivariate models to analyze the relationship between the implementation of CVW services and hospital activity outcomes: length of COVID-19 related stays and subsequent COVID-19 readmissions within 28 days. We used data from more than 98% of recorded COVID-19 hospital stays in England, where the patient was discharged alive between mid-August 2020 and late February 2021.FindingsWe found a longer length of stay for COVID-19 patients discharged from hospitals where a CVW was available, when compared to patients discharged from hospitals where there was no CVW (adjusted IRR 1·05, 95% CI 1·01 to 1·09). We found no evidence of a relationship between the availability of CVW and subsequent rates of readmission for COVID-19 (adjusted OR 0.97, 95% CI 0.91 to 1·03).InterpretationWe found no evidence of early discharges or changes in readmissions associated with the roll out of COVID Virtual Wards across England. Our analysis made pragmatic use of national-scale hospital data, but it is possible that a lack of specific data (for example, on which patients were enrolled and on potentially important confounders) may have meant that true impacts, especially at a local level, were not ultimately discernible. It is important that future research is able to make use of better quality - preferably linked - data, from multiple sites.FundingThis is independent research funded by the National Institute for Health Research, Health Services & Delivery Research program (RSET Project no. 16/138/17; BRACE Project no. 16/138/31) and NHSE&I. NJF is an NIHR Senior Investigator.

Terrie Fox Wetle Award (2021): Advancing multidisciplinary health services science: Developments in a Dementia-Focused Program of Research

The Terrie Fox Wetle Rising Star Award in health Services and Aging Research is an award named in honor of Fox Wetle, PhD, who is internationally recognized for her contributions to aging, public health, and health care research. The award recognizes health services researchers in early or middle-career phases who have made significant contributions that embody the value of multidisciplinary health services science and are likely to have a sustained, high impact on practice and research. This aware lecture will be presented by the 2021 Award Recipient, Andrea Gilmore-Bykovskyi, PhD, RN, and will highlight emergent findings and foci in her dementia-focused health services research program. In particular, the award lecture will discuss progress in investigating social and behavioral communication patterns among individuals with moderate to advanced dementia; and the role of temporally situated observational measures and inclusion of persons with dementia and their caregivers in this line of research. The lecture will conclude with a discussion of next steps for this area of investigation surrounding assessment of episodes of lucidity in advanced dementia; and considerations for strengthening progress in outcome evaluation among persons living with dementia through multidisciplinary and community-informed health services research.

MP40-13 WHEN IS A SEMINOMA NOT A SEMINOMA? THE INCIDENCE, RISK FACTORS AND MANAGEMENT OF PATIENTS WITH TESTICULAR SEMINOMA WITH DISCORDANT ELEVATED SERUM ALPHA-FETOPROTEIN

You have accessJournal of UrologyPenile & Testicular Cancer I (MP40)1 Sep 2021MP40-13 WHEN IS A SEMINOMA NOT A SEMINOMA? THE INCIDENCE, RISK FACTORS AND MANAGEMENT OF PATIENTS WITH TESTICULAR SEMINOMA WITH DISCORDANT ELEVATED SERUM ALPHA-FETOPROTEIN Katherine E. Fero, Patrick Lec, Vidit Sharma, Andrew Lenis, Josiah Low, Mark Litwin, Michael Leapman, and Karim Chamie Katherine E. FeroKatherine E. Fero More articles by this author , Patrick LecPatrick Lec More articles by this author , Vidit SharmaVidit Sharma More articles by this author , Andrew LenisAndrew Lenis More articles by this author , Josiah LowJosiah Low More articles by this author , Mark LitwinMark Litwin More articles by this author , Michael LeapmanMichael Leapman More articles by this author , and Karim ChamieKarim Chamie More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002055.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The detection of elevated serum alpha-fetoprotein (AFP) in patients with pure seminoma testicular germ cell tumors (GCT) is a discordant finding that implies the presence of occult non-seminomatous GCT (NSGCT) elements. The histologic misclassification of a NSGCT as a pure seminoma has considerable therapeutic implications, as the two vary in the appropriateness of utilization of adjuvant treatments, or active surveillance. The incidence and management patterns of pure seminoma histology with elevated AFP remains understudied; thus, we aimed to described the incidence, clinical and demographic factors, and treatment patterns associated with discordant elevated AFP findings in patients with pure seminomatous histology. METHODS: We queried the National Cancer Database to identify patients with testicular GCT diagnosed between 2011 through 2015. We grouped patients based on histologic diagnosis and pre-operative serum AFP level and defined an outcome variable for type of adjuvant therapy patients received after orchiectomy, if any. RESULTS: Of 18,616 patients diagnosed with testicular GCT, 53% (N=9849) had pure seminomatous histology and 8.3% (N=821) had an elevated serum AFP pre-operatively. Non-white patients with seminoma were more likely to have a pre-op elevation of AFP (OR 1.42; 95% CI: 1.10–1.83); patients treated at higher volume centers were less likely to have a pre-op elevation AFP (0.66, 95% CI: 0.53–0.83). Patients with stage I seminoma with elevated AFP underwent adjuvant radiation more frequently than those with NSGCT (15% vs 0.2%, p<0.01) and less frequently received retroperitoneal lymph node dissection (RPLND) (1.9% vs 11.1% p<0.01). More patients with stage II seminoma with elevated AFP underwent adjuvant radiation than those with NSGCT (21.9% vs 0.1%, p<0.01) and fewer underwent adjuvant chemotherapy (54.4 vs 75%, p<0.01) or RPLND (8.8% vs 17.4%, p<0.01) (Figure 1). CONCLUSIONS: In this national study, approximately 8% of patients with pure seminomatous GCTs had diagnostically discordant elevated pre-operative AFP levels. Despite recommendations to manage these patients as NSGCT, patients with seminoma and elevated AFP were managed in a fashion comparable to those with seminoma and normal AFP levels. Source of Funding: KEF is supported by H&H Lee UCLA Surgical Scholars Program and Urology Care Foundation resident research award.Veterans Affairs Health Services Research program supports author V. Sharma © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e719-e719 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Katherine E. Fero More articles by this author Patrick Lec More articles by this author Vidit Sharma More articles by this author Andrew Lenis More articles by this author Josiah Low More articles by this author Mark Litwin More articles by this author Michael Leapman More articles by this author Karim Chamie More articles by this author Expand All Advertisement Loading ...

Reply by Authors.

No AccessJournal of UrologyAdult Urology1 Sep 2021Reply by Authorsis a reply to letterEditorial Comment Vidit Sharma, Tanner S. Miest, Tristan S. Juvet, Amir Toussi, Vignesh Packiam, Karim Chamie, Surena F. Matin, Stephen A. Boorjian, R. Houston Thompson, Igor Frank, Matthew K. Tollefson, and Aaron M. Potretzke Vidit SharmaVidit Sharma Department of Urology, Mayo Clinic, Rochester, Minnesota Department of Urology, University of California, Los Angeles, California Greater Los Angeles VA, Health Services Research and Development Program, Los Angeles, California Financial and/or other relationship with Cold Genesys. More articles by this author , Tanner S. MiestTanner S. Miest Department of Urology, MD Anderson Cancer Center, Houston, Texas More articles by this author , Tristan S. JuvetTristan S. Juvet Department of Urology, Mayo Clinic, Rochester, Minnesota More articles by this author , Amir ToussiAmir Toussi Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania More articles by this author , Vignesh PackiamVignesh Packiam Department of Urology, University of Iowa Medical Center, Iowa City, Iowa More articles by this author , Karim ChamieKarim Chamie Department of Urology, University of California, Los Angeles, California More articles by this author , Surena F. MatinSurena F. Matin Department of Urology, MD Anderson Cancer Center, Houston, Texas Financial and/or other relationship with Urogen and Ology Education. More articles by this author , Stephen A. BoorjianStephen A. Boorjian Department of Urology, Mayo Clinic, Rochester, Minnesota Financial and/or other relationship with Ferring, ArTara and FerGene. More articles by this author , R. Houston ThompsonR. Houston Thompson Department of Urology, Mayo Clinic, Rochester, Minnesota More articles by this author , Igor FrankIgor Frank Department of Urology, Mayo Clinic, Rochester, Minnesota More articles by this author , Matthew K. TollefsonMatthew K. Tollefson Department of Urology, Mayo Clinic, Rochester, Minnesota More articles by this author , and Aaron M. PotretzkeAaron M. Potretzke §Correspondence: Department of Urology, Mayo Clinic, 200 1st St. SW, Rochester, Minnesota 55905 telephone: 507-284-3983; FAX: 507-284-4951; E-mail Address: [email protected] Department of Urology, Mayo Clinic, Rochester, Minnesota More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001834.02AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Reply by Authors." The Journal of Urology, 206(3), p. 567 Reference 1. : The impact of ureteroscopy following computerized tomography urography in the management of upper tract urothelial carcinoma. J Urol 2021; 205: 392. Link, Google Scholar © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of UrologyJun 14, 2021, 12:00:00 AMEditorial Comment Volume 206Issue 3September 2021Page: 567-567 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Vidit Sharma Department of Urology, Mayo Clinic, Rochester, Minnesota Department of Urology, University of California, Los Angeles, California Greater Los Angeles VA, Health Services Research and Development Program, Los Angeles, California Financial and/or other relationship with Cold Genesys. More articles by this author Tanner S. Miest Department of Urology, MD Anderson Cancer Center, Houston, Texas More articles by this author Tristan S. Juvet Department of Urology, Mayo Clinic, Rochester, Minnesota More articles by this author Amir Toussi Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania More articles by this author Vignesh Packiam Department of Urology, University of Iowa Medical Center, Iowa City, Iowa More articles by this author Karim Chamie Department of Urology, University of California, Los Angeles, California More articles by this author Surena F. Matin Department of Urology, MD Anderson Cancer Center, Houston, Texas Financial and/or other relationship with Urogen and Ology Education. More articles by this author Stephen A. Boorjian Department of Urology, Mayo Clinic, Rochester, Minnesota Financial and/or other relationship with Ferring, ArTara and FerGene. More articles by this author R. Houston Thompson Department of Urology, Mayo Clinic, Rochester, Minnesota More articles by this author Igor Frank Department of Urology, Mayo Clinic, Rochester, Minnesota More articles by this author Matthew K. Tollefson Department of Urology, Mayo Clinic, Rochester, Minnesota More articles by this author Aaron M. Potretzke Department of Urology, Mayo Clinic, Rochester, Minnesota §Correspondence: Department of Urology, Mayo Clinic, 200 1st St. SW, Rochester, Minnesota 55905 telephone: 507-284-3983; FAX: 507-284-4951; E-mail Address: [email protected] More articles by this author Expand All Advertisement PDF DownloadLoading ...

A call for mandatory planetary health education in public health and health services research programs

The effects of global climate and environmental change endanger health, health systems, and public health infrastructure. As future public health and health services professionals, researchers, and clinicians, we will be tasked with protecting and promoting the health of communities in the face of these realities. However, there is limited integration of the environment-health nexus into the curricula of public health and health services research programs. Planetary health, an integrative paradigm linking the complex dynamics between the health of people to the natural systems on which we depend, offers an inroad to equipping emerging health system leaders with the skills and knowledge to protect people and the planet. We call on our institutions to follow other health disciplines, such as medicine, and embed planetary health and environmentally sustainable healthcare practices into core educational offerings.

Preparing Graduate Students for Community Engagement in Health Services Research.

The purpose of this paper is to shed light on the importance of didactic and experiential training in community engagement for students conducting Health Services Research (HSR) in pharmacy. The incorporation of community-based learning (CBL) courses can be beneficial for graduate students because they provide an opportunity to gain important skills in stakeholder engagement and developing sustainable research partnerships. Early exposure and mentorship of graduate students through CBL courses could minimize the risk of students entering communities in their future careers with harmful tactics such as stereotypes and implicit biases. In this paper, we draw upon previous research to identify an educational gap in community preparedness. Accordingly, we developed a community-engagement course for masters and doctoral graduate students in the HSR program at the University of Wisconsin-Madison School of Pharmacy. This paper provides an example of how other graduate programs may incorporate training in community engagement within their curriculum. In addition, we summarize how CBL courses can help address foundational graduate student knowledge gaps and offer suggestions for the formation of a CBL course.

Younger cancer survivors are more likely to face financial strain.

Paying for daily living necessities such as food, housing, and other monthly bills puts a more significant strain on younger cancer survivors, even years after their diagnosis, according to findings published in the March 2020 issue of the Journal of the National Comprehensive Cancer Network.1 Among survivors of cancer who are aged 18 to 39 years, the study found that approximately 20.4% expressed high levels of worry about paying their monthly bills compared with 12.9% of individuals who did not have a history of cancer. Furthermore, approximately 6.3% of survivors in that same age group noted that they were unable to afford balanced meals compared with 3.4% of respondents without a cancer history. Older survivors aged 40 to 64 years reported less consistent findings, and the disparities were not noted to be present among participants aged 65 years and older. According to the study's lead researcher Zhiyuan “Jason” Zheng, PhD, a health economist and principal scientist in the Surveillance and Health Services Research program at the American Cancer Society, in Atlanta, Georgia, one possible reason for the disparity could be that younger cancer survivors' health conditions may cause them to lose their jobs and health insurance coverage. Child-rearing demands, mortgage obligations, student loans, low rates of savings, and significantly increasing costs of cancer care likely compound the problem further, he adds. Dr. Zheng and his colleagues used the 2013 to 2017 National Health Interview Survey, a cross-sectional household survey from the Centers for Disease Control and Prevention. It included more than 12,000 cancer survivors, excluding survivors of nonmelanoma skin cancer, who were aged 18 to 65 years and older. Financial concerns were sorted into categories related to retirement, the standard of living, monthly bills, and housing costs. The investigators assigned a point system based on concerns ranging from “very worried” to “not worried at all.” The analysis found that approximately 26.4% of cancer survivors aged 18 to 39 years reported severe financial worry, whereas 12.6% reported severe food insecurity. The results among survivors aged 40 to 64 years demonstrated approximately 22.2% reporting severe financial worry compared with 6.8% reporting severe food insecurity. In the survivor cohort aged 65 years and older, approximately 6.9% reported severe financial worry whereas 2.3% reported severe food insecurity. Dr. Zheng emphasizes the importance of addressing the needs of younger, low-income cancer survivors with higher numbers of comorbid conditions through clinical and health policy interventions that help to minimize their financial burdens and food insecurity. He points to promising developments, such as The Deferment for Active Cancer Treatment Act, passed by Congress in 2018, which allows patients with cancer to postpone payments on public student loans while they are actively receiving cancer treatment. At the same time, the Centers for Medicare and Medicaid Services has expanded coverage for young people with disabilities to include healthy groceries, rides to medical appointments, and home-delivered meals. The authors call for future research evaluating the impact of various financial hardships on outcomes among long-term cancer survivors.

Accelerating implementation of research in Learning Health Systems: Lessons learned from VA Health Services Research and NCATS Clinical Science Translation Award programs.

Translation of research to practice is challenging. In addition to the scientific challenges, there are additional hurdles in navigating the rapidly changing US health care system. There is a need for innovative health interventions that can be adopted in "real-world" settings. Barriers to translation involve misaligned timing of research funding and health system decision-making, lack of research questions aligned with health system and community priorities, and limited incentives in academia for health system and community-based research. We describe new programs from the US Department of Veterans Affairs Health Services Research and Development (HSR&D) and the National Center for Advancing Translational Sciences (NCATS) Clinical and Translational Science Award (CTSA) Programs that are building capacity for Learning Health System research. These programs help to incentivize adopting and adapting Learning Health System principles to ensure that, primarily in implementation science within academic/veterans affairs health systems, there is alignment of the research with the health system and community needs. Both HSR&D and NCATS CTSA Program encourage researchers to develop problem-focused research innovations in partnership with health systems and communities to ultimately facilitate design treatments that are feasible in "real-world" practice.

Cataract Surgery Quality and Capacity.

Cataract surgery is the most common operation performed in most developed countries, including Canada. Nuanced, evidence-driven policies are needed to ensure appropriate access to this sight-saving operation while maintaining the highest standards in quality of care. The Vision Health Services Research Program at Queen's University, in partnership with members of the Ontario Provincial Vision Task Force, has developed evidence to inform policies aimed at optimizing both access and quality across the eye care spectrum.

Broadening the research gaze in complementary and integrative medicine: towards a critical public health and health services research program

Broadening the research gaze in complementary and integrative medicine: towards a critical public health and health services research program

Study protocol: a hybrid effectiveness-implementation trial of Moral Reconation Therapy in the US Veterans Health Administration

BackgroundMoral Reconation Therapy (MRT) is a cognitive-behavioral intervention aimed at reducing risk for criminal recidivism by restructuring antisocial attitudes and cognitions (i.e., “criminogenic thinking”). MRT has empirical support for reducing risk for criminal recidivism among civilian offenders. Recently, a version of MRT was developed for military veterans; however, no randomized controlled trials (RCT) have been conducted with the veteran-specific protocol, and the effectiveness and implementation potential of MRT outside of correctional settings has not been established.MethodsUsing a Hybrid Type 1 RCT design, this study will test the effectiveness of MRT to reduce risk for criminal recidivism and improve health-related outcomes among justice-involved veterans entering mental health residential treatment at three US Veterans Health Administration (VHA) Medical Centers. Upon admission to the treatment program, justice-involved veterans will complete a baseline assessment, be randomized to usual care (UC) or UC + MRT, and be followed 6 and 12 months post-baseline. A process evaluation will also be conducted to identify barriers and facilitators to implementation of MRT in residential treatment.DiscussionThe primary aim of this study is to evaluate the effectiveness of MRT with justice-involved veterans. If MRT proves effective in this trial, the findings can provide large healthcare systems that serve veterans with an evidence-based intervention for addressing criminogenic thinking among justice-involved adults, as well as guidance on how to facilitate future implementation of MRT in non-correctional settings.Trial registrationThis trial is funded by the VA Health Services Research & Development Program (IIR 14–081) and is registered with ClinicalTrials.gov (ID: NCT02524171).

Androgen deprivation with or without radiation therapy for clinically node-positive prostate cancer. Lin CC, Gray PJ, Jemal A, Efstathiou JA, Surveillance and Health Services Research Program, Intramural Research, American Cancer Society, Atlanta, GA (CCL, AJ); Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (PJG, JAE); e-mail: jefstathiou@partners.org. J Natl Cancer Inst. 2015 May 9;107(7). pii: djv119.

BackgroundClinically lymph node-positive (cN+) prostate cancer (PCa) is an often-fatal disease. Its optimal management remains largely undefined given a lack of prospective, randomized data to inform practice. We sought to describe modern practice patterns in the management of cN+PCa and assess the effect of adding radiation therapy (RT) to androgen deprivation therapy (ADT) on survival using the National Cancer Data Base. MethodsPatients with cN+PCa and without distant metastases diagnosed between 2004 and 2011 were included. Five-year overall survival for patients diagnosed between 2004 and 2006 and treated with ADT alone or ADT+RT were compared. Propensity score (PS) matching was used to balance baseline characteristics, and Cox multivariate regression analysis was used to estimate hazard ratios (HRs) for all-cause mortality. ResultsOf 3,540 total patients, 32.2% were treated with ADT alone and 51.4% received ADT+RT. Compared with ADT alone, patients treated with ADT+RT were younger and more likely to have private insurance, lower comorbidity scores, higher Gleason scores, and lower PSA values. After PS matching, 318 patients remained in each group. Compared with ADT alone, ADT+RT was associated with a 50% decreased risk of five-year all-cause mortality (HR = 0.50, 95% CI: 0.37–0.67, two-sided P<0.001; crude OS rate: 71.5% vs. 53.2%). ConclusionsUsing a large national database, we have identified a statistically significant survival benefit for patients with cN+PCa treated with ADT+RT. These data, if appropriately validated by randomized trials, suggest that a substantial proportion of such patients at high risk for prostate cancer death may be undertreated, warranting a reevaluation of current practice guidelines.

Improving Nursing Home Care through Feedback On PerfoRMance Data (INFORM): Protocol for a cluster-randomized trial

BackgroundAudit and feedback is effective in improving the quality of care. However, methods and results of international studies are heterogeneous, and studies have been criticized for a lack of systematic use of theory. In TREC (Translating Research in Elder Care), a longitudinal health services research program, we collect comprehensive data from care providers and residents in Canadian nursing homes to improve quality of care and life of residents, and quality of worklife of caregivers. The study aims are to a) systematically feed back TREC research data to nursing home care units, and b) compare the effectiveness of three different theory-based feedback strategies in improving performance within care units.MethodsINFORM (Improving Nursing Home Care through Feedback On PerfoRMance Data) is a 3.5-year pragmatic, three-arm, parallel, cluster-randomized trial. We will randomize 67 Western Canadian nursing homes with 203 care units to the three study arms, a standard feedback strategy and two assisted and goal-directed feedback strategies. Interventions will target care unit managerial teams. They are based on theory and evidence related to audit and feedback, goal setting, complex adaptive systems, and empirical work on feeding back research results. The primary outcome is the increased number of formal interactions (e.g., resident rounds or family conferences) involving care aides – non-registered caregivers providing up to 80% of direct care. Secondary outcomes are a) other modifiable features of care unit context (improved feedback, social capital, slack time) b) care aides’ quality of worklife (improved psychological empowerment, job satisfaction), c) more use of best practices, and d) resident outcomes based on the Resident Assessment Instrument – Minimum Data Set 2.0. Outcomes will be assessed at baseline, immediately after the 12-month intervention period, and 18 months post intervention.DiscussionINFORM is the first study to systematically assess the effectiveness of different strategies to feed back research data to nursing home care units in order to improve their performance. Results of this study will enable development of a practical, sustainable, effective, and cost-effective feedback strategy for routine use by managers, policy makers and researchers. The results may also be generalizable to care settings other than nursing homes.Trial registrationClinicalTrials.gov Identifier: NCT02695836. Date of registration: 24 February 2016

Patient-Centered Pain Care Using Artificial Intelligence and Mobile Health Tools: Protocol for a Randomized Study Funded by the US Department of Veterans Affairs Health Services Research and Development Program.

BackgroundCognitive behavioral therapy (CBT) is one of the most effective treatments for chronic low back pain. However, only half of Department of Veterans Affairs (VA) patients have access to trained CBT therapists, and program expansion is costly. CBT typically consists of 10 weekly hour-long sessions. However, some patients improve after the first few sessions while others need more extensive contact.ObjectiveWe are applying principles from “reinforcement learning” (a field of artificial intelligence or AI) to develop an evidence-based, personalized CBT pain management service that automatically adapts to each patient’s unique and changing needs (AI-CBT). AI-CBT uses feedback from patients about their progress in pain-related functioning measured daily via pedometer step counts to automatically personalize the intensity and type of patient support. The specific aims of the study are to (1) demonstrate that AI-CBT has pain-related outcomes equivalent to standard telephone CBT, (2) document that AI-CBT achieves these outcomes with more efficient use of clinician resources, and (3) demonstrate the intervention’s impact on proximal outcomes associated with treatment response, including program engagement, pain management skill acquisition, and patients’ likelihood of dropout.MethodsIn total, 320 patients with chronic low back pain will be recruited from 2 VA healthcare systems and randomized to a standard 10 sessions of telephone CBT versus AI-CBT. All patients will begin with weekly hour-long telephone counseling, but for patients in the AI-CBT group, those who demonstrate a significant treatment response will be stepped down through less resource-intensive alternatives including: (1) 15-minute contacts with a therapist, and (2) CBT clinician feedback provided via interactive voice response calls (IVR). The AI engine will learn what works best in terms of patients’ personally tailored treatment plans based on daily feedback via IVR about their pedometer-measured step counts, CBT skill practice, and physical functioning. Outcomes will be measured at 3 and 6 months post recruitment and will include pain-related interference, treatment satisfaction, and treatment dropout. Our primary hypothesis is that AI-CBT will result in pain-related functional outcomes that are at least as good as the standard approach, and that by scaling back the intensity of contact that is not associated with additional gains in pain control, the AI-CBT approach will be significantly less costly in terms of therapy time.ResultsThe trial is currently in the start-up phase. Patient enrollment will begin in the fall of 2016 and results of the trial will be available in the winter of 2019.ConclusionsThis study will evaluate an intervention that increases patients’ access to effective CBT pain management services while allowing health systems to maximize program expansion given constrained resources.

Evaluating the Productivity of VA, NIH, and AHRQ Health Services Research Career Development Awardees.

To evaluate the academic advancement and productivity of Department of Veterans Affairs Health Services Research and Development (HSR&D) Career Development Award (CDA) program recipients, National Institutes of Health (NIH) K awardees in health services research (HSR), and Agency for Healthcare Research and Quality (AHRQ) K awardees. In all, 219 HSR&D CDA recipients from fiscal year (FY) 1991 through FY2010; 154 NIH K01, K08, and K23 awardees FY1991-FY2010; and 69 AHRQ K01 and K08 awardees FY2000-FY2010 were included. Most data were obtained from curricula vitae. Academic advancement, publications, grants, recognition, and mentoring were compared after adjusting for years since award, and personal characteristics, training, and productivity prior to the award. No significant differences emerged in covariate-adjusted tenure-track academic rank, number of grants as primary investigator (PI), major journal articles as first/sole author, Hirsch h-index scores, likelihood of a journal editorship position or membership in a major granting review panel, or mentoring postgraduate researchers between the HSR&D CDA and NIH K awardees from FY1991-FY2010, or among the three groups of awardees from FY2000 or later. Among those who reported grant funding levels, HSR&D CDAs from FY1991-2010 had been PI on more grants of $100,000 than NIH K awardees. HSR&D CDAs had a higher mean number of major journal articles than NIH K awardees from FY1991-2010. Findings show that all three HSR career development programs are successfully selecting and mentoring awardees, ensuring additional HSR capacity to improve the quality and delivery of high-value care.

Resource use, costs and quality of end-of-life care: observations in a cohort of elderly Australian cancer decedents.

BackgroundThe last year of life is one of the most resource-intensive periods for people with cancer. Very little population-based research has been conducted on end-of-life cancer care in the Australian health care setting. The objective of this program is to undertake a series of observational studies examining resource use, costs and quality of end-of-life care in a cohort of elderly cancer decedents using linked, routinely collected data.Methods/DesignThis study forms part of an ongoing cancer health services research program. The cohorts for the end-of-life research program comprise Australian Government Department of Veterans’ Affairs decedents with full health care entitlements, residing in NSW for the last 18 months of life and dying between 2005 and 2009. We used cancer and death registry data to identify our decedent cohorts and their causes of death. The study population includes 9,862 decedents with a cancer history and 15,483 decedents without a cancer history. The median age at death is 86 and 87 years in the cancer and non-cancer cohorts, respectively. We will examine resource use and associated costs in the last 6 months of life using linked claims data to report on health service use, hospitalizations, emergency department visits and medicines use. We will use best practice methods to examine the nature and extent of resource use, costs and quality of care based on previously published indicators. We will also examine factors associated with these outcomes.DiscussionThis will be the first Australian research program and among the first internationally to combine routinely collected data from primary care and hospital-based care to examine comprehensively end-of-life care in the elderly. The research program has high translational value, as there is limited evidence about the nature and quality of care in the Australian end-of-life setting.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-014-0148-2) contains supplementary material, which is available to authorized users.

Quality and Equity of Care in U.S. Hospitals

BackgroundNearly every U.S. hospital publicly reports its performance on quality measures for patients who are hospitalized for acute myocardial infarction, heart failure, or pneumonia. Because performance rates are not reported according to race or ethnic group, it is unclear whether improvements in equity of care have accompanied aggregate improvements in health care quality over time.MethodsWe assessed performance rates for quality measures covering three conditions (six measures for acute myocardial infarction, four for heart failure, and seven for pneumonia). These rates, adjusted for patient- and hospital-level covariates, were compared among non-Hispanic white, non-Hispanic black, and Hispanic patients who received care between 2005 and 2010 in acute care hospitals throughout the United States.ResultsAdjusted performance rates for the 17 quality measures improved by 3.4 to 57.6 percentage points between 2005 and 2010 for white, black, and Hispanic adults (P<0.001 for all comparisons). In 2005, as compared with adjusted performance rates for white patients, adjusted performance rates were more than 5 percentage points lower for black patients on 3 measures (range of differences, 12.3 to 14.2) and for Hispanic patients on 6 measures (5.6 to 14.5). Gaps decreased significantly on all 9 of these measures between 2005 and 2010, with adjusted changes for differences between white patients and black patients ranging from −8.5 to −11.8 percentage points and from −6.2 to −15.1 percentage points for differences between white patients and Hispanic patients. Decreasing differences according to race or ethnic group were attributable to more equitable care for white patients and minority patients treated in the same hospital, as well as to greater performance improvements among hospitals that disproportionately serve minority patients.ConclusionsImproved performance on quality measures for white, black, and Hispanic adults hospitalized for acute myocardial infarction, heart failure, or pneumonia was accompanied by increased racial and ethnic equity in performance rates both within and among U.S. hospitals. (Funded by the Centers for Medicare and Medicaid Services and the Veterans Affairs Health Services Research and Development Career Development Program.)

Abstract 4141: Access to medical or radiation oncology consultation in patients who died from cancer in the Sudbury-Manitoulin District of Northeastern Ontario, Canada

Abstract Sudbury-Manitoulin district is located in Northeastern Ontario, Canada, and resident cancer patients often receive care at the Northeast Cancer Centre (NECC), a Cancer Care Ontario regional cancer program located at Health Sciences North in Sudbury. In 2008, as part of enhancing services in this district, the NECC established an ambulatory Palliative Clinic. Presently, referral to this clinic occurs subsequent to a patient consultation with a medical or radiation oncology specialist. Using administrative data, the primary purpose of this population-based retrospective study was to estimate the percentage of patients who died from cancer without having had the opportunity to access this clinic through a prior documented medical or radiation oncology consultation during the interval of 2004-2008. A secondary purpose was to determine factors associated with never having received this specialized medical consult. Data was obtained through The Ontario Cancer Data Linkage Project (`cd-link') an initiative of the Ontario Institute for Cancer Research/Cancer Care Ontario Health Services Research Program. For each index case, we constructed a timeline (days) of all Ontario Health Insurance Plan (OHIP) billing codes and associated service dates, from primary cancer diagnosis through to cancer death. Our main outcome variable, consultation with a medical or radiation oncologist, was dichotomized as “ever” or “never”. A total of 6,683 individuals with a valid primary cancer diagnosis record died from any cancer cause in the Sudbury-Manitoulin District within the 5 year period from 2004-2008. Most (n=5988, 89.6%) had one primary cancer diagnoses. For this subgroup, and excluding those with a disease duration of 0 days (n=67), about 18.4% (n=1088/5921) never consulted a medical or radiation oncologist through their disease trajectory. Multivariable logistic regression identified three significant and independent predictors of having never received a consultation. Older age and rural residence were associated with increased risk of “never consultation”, with adjusted Odds Ratio (OR)s of 7.13 (95% Confidence Interval (CI) 3.68-13.81) and 1.77 (95% CI 1.51-2.06) for residents 80 years and older, or living in a rural residence, respectively. A longer duration of disease was associated with a decreased risk, with an OR of 0.99 (95% CI 0.99-0.99). While there are limitations to using administrative data, we estimate that 18.4% of the residents in this area did not benefit from a specialized consultation about their cancer care, which could also have included suitability and timing of referral to the palliative care clinic. Specific strategies directed towards older and rural patients may help to address this important access to care issue. Citation Format: Michael Conlon, Mark Hartman, Barbara Ballantyne, Mary Bewick, Margaret Meigs, Natalie Aubin, Andrew Knight. Access to medical or radiation oncology consultation in patients who died from cancer in the Sudbury-Manitoulin District of Northeastern Ontario, Canada. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 4141. doi:10.1158/1538-7445.AM2014-4141

Improving Aboriginal maternal and infant health services in the 'Top End' of Australia; synthesis of the findings of a health services research program aimed at engaging stakeholders, developing research capacity and embedding change.

BackgroundHealth services research is a well-articulated research methodology and can be a powerful vehicle to implement sustainable health service reform. This paper presents a summary of a five-year collaborative program between stakeholders and researchers that led to sustainable improvements in the maternity services for remote-dwelling Aboriginal women and their infants in the Top End (TE) of Australia.MethodsA mixed-methods health services research program of work was designed, using a participatory approach. The study area consisted of two large remote Aboriginal communities in the Top End of Australia and the hospital in the regional centre (RC) that provided birth and tertiary care for these communities. The stakeholders included consumers, midwives, doctors, nurses, Aboriginal Health Workers (AHW), managers, policy makers and support staff. Data were sourced from: hospital and health centre records; perinatal data sets and costing data sets; observations of maternal and infant health service delivery and parenting styles; formal and informal interviews with providers and women and focus groups. Studies examined: indicator sets that identify best care, the impact of quality of care and remoteness on health outcomes, discrepancies in the birth counts in a range of different data sets and ethnographic studies of ‘out of hospital’ or health centre birth and parenting. A new model of maternity care was introduced by the health service aiming to improve care following the findings of our research. Some of these improvements introduced during the five-year research program of research were evaluated.ResultsCost effective improvements were made to the acceptability, quality and outcomes of maternity care. However, our synthesis identified system-wide problems that still account for poor quality of infant services, specifically, unacceptable standards of infant care and parent support, no apparent relationship between volume and acuity of presentations and staff numbers with the required skills for providing care for infants, and an ‘outpatient’ model of care. Services were also characterised by absent Aboriginal leadership and inadequate coordination between remote and tertiary services that is essential to improve quality of care and reduce ‘system-introduced’ risk.ConclusionEvidence-informed redesign of maternity services and delivery of care has improved clinical effectiveness and quality for women. However, more work is needed to address substandard care provided for infants and their parents.