Nina R. Sperber

Influence of parent characteristics and disease outcome framing on HPV vaccine acceptability among rural, Southern women

ObjectiveA new prophylactic vaccine protects against infection with HPV types that cause many cervical cancers and genital warts. This study explored the impact of framing the vaccine’s benefits, with respect to the disease outcome being prevented, on women’s HPV vaccination intentions for themselves and for an adolescent daughter.MethodsA cross-sectional study was conducted in a rural North Carolina area with a high cervical cancer mortality rate. A questionnaire was administered among female attendees of a low-income public clinic and a private OB/GYN office. Data were analyzed using a generalized estimable model.ResultsWomen reported high intentions to vaccinate against HPV. Women reported higher intentions to vaccinate adolescent daughters than themselves, and this relationship varied by how the HPV vaccine was framed (preventing HPV, cervical cancer, or genital warts). Older women reported lower vaccination intentions than younger women.ConclusionsRural women, especially those who are younger, may be more accepting of the HPV vaccine when it is framed as a cervical cancer vaccine. Messages to mothers about the HPV vaccine for their daughters might be made more effective by framing the vaccine in terms of cancer and sexually transmitted disease prevention.

Patient and provider interventions for managing osteoarthritis in primary care: protocols for two randomized controlled trials.

BackgroundOsteoarthritis (OA) of the hip and knee are among the most common chronic conditions, resulting in substantial pain and functional limitations. Adequate management of OA requires a combination of medical and behavioral strategies. However, some recommended therapies are under-utilized in clinical settings, and the majority of patients with hip and knee OA are overweight and physically inactive. Consequently, interventions at the provider-level and patient-level both have potential for improving outcomes. This manuscript describes two ongoing randomized clinical trials being conducted in two different health care systems, examining patient-based and provider-based interventions for managing hip and knee OA in primary care.Methods / DesignOne study is being conducted within the Department of Veterans Affairs (VA) health care system and will compare a Combined Patient and Provider intervention relative to usual care among n = 300 patients (10 from each of 30 primary care providers). Another study is being conducted within the Duke Primary Care Research Consortium and will compare Patient Only, Provider Only, and Combined (Patient + Provider) interventions relative to usual care among n = 560 patients across 10 clinics. Participants in these studies have clinical and / or radiographic evidence of hip or knee osteoarthritis, are overweight, and do not meet current physical activity guidelines. The 12-month, telephone-based patient intervention focuses on physical activity, weight management, and cognitive behavioral pain management. The provider intervention involves provision of patient-specific recommendations for care (e.g., referral to physical therapy, knee brace, joint injection), based on evidence-based guidelines. Outcomes are collected at baseline, 6-months, and 12-months. The primary outcome is the Western Ontario and McMasters Universities Osteoarthritis Index (self-reported pain, stiffness, and function), and secondary outcomes are the Short Physical Performance Test Protocol (objective physical function) and the Patient Health Questionnaire-8 (depressive symptoms). Cost effectiveness of the interventions will also be assessed.DiscussionResults of these two studies will further our understanding of the most effective strategies for improving hip and knee OA outcomes in primary care settings.Trial registrationNCT01130740 (VA); NCT 01435109 (NIH)

The Role of Symptoms and Self-Efficacy in Predicting Physical Activity Change Among Older Adults With Arthritis

BACKGROUND Physical and psychological symptoms limit physical activity for people with arthritis. This study examined if self-efficacy mediated a relationship between symptom and physical activity (PA) frequency change. METHODS This was a secondary analysis of older adults with arthritis and joint pain in a trial of a lifestyle PA program (n = 339). Measures were depressive symptoms, pain, fatigue, arthritis self-efficacy, PA self-efficacy, and PA frequency. A panel model was used to analyze relationships at baseline and changes at 20 weeks. RESULTS The mean age was 68.8 years. At baseline, depression and fatigue were associated with arthritis self-efficacy (β = -.34 and -.24) and, in turn, PA self-efficacy (β = .63); PA self-efficacy was associated with PA (β = .15). Pain and depression changes were associated with arthritis self-efficacy change (β = -.20 and -.21) and, in turn, PA self-efficacy (β = .32) change; PA self-efficacy change was associated with PA change (β = .36). CONCLUSION Change in symptom severity affected change in PA frequency. These relationships appeared to operate through self-efficacy. Over time, pain appeared to have a stronger relationship than fatigue with self-efficacy and PA. These findings support strategies to help people with arthritis strengthen their confidence for symptom coping and PA participation.

Challenges and strategies for implementing genomic services in diverse settings: experiences from the Implementing GeNomics In pracTicE (IGNITE) network

BackgroundTo realize potential public health benefits from genetic and genomic innovations, understanding how best to implement the innovations into clinical care is important. The objective of this study was to synthesize data on challenges identified by six diverse projects that are part of a National Human Genome Research Institute (NHGRI)-funded network focused on implementing genomics into practice and strategies to overcome these challenges.MethodsWe used a multiple-case study approach with each project considered as a case and qualitative methods to elicit and describe themes related to implementation challenges and strategies. We describe challenges and strategies in an implementation framework and typology to enable consistent definitions and cross-case comparisons. Strategies were linked to challenges based on expert review and shared themes.ResultsThree challenges were identified by all six projects, and strategies to address these challenges varied across the projects. One common challenge was to increase the relative priority of integrating genomics within the health system electronic health record (EHR). Four projects used data warehousing techniques to accomplish the integration. The second common challenge was to strengthen clinicians’ knowledge and beliefs about genomic medicine. To overcome this challenge, all projects developed educational materials and conducted meetings and outreach focused on genomic education for clinicians. The third challenge was engaging patients in the genomic medicine projects. Strategies to overcome this challenge included use of mass media to spread the word, actively involving patients in implementation (e.g., a patient advisory board), and preparing patients to be active participants in their healthcare decisions.ConclusionsThis is the first collaborative evaluation focusing on the description of genomic medicine innovations implemented in multiple real-world clinical settings. Findings suggest that strategies to facilitate integration of genomic data within existing EHRs and educate stakeholders about the value of genomic services are considered important for effective implementation. Future work could build on these findings to evaluate which strategies are optimal under what conditions. This information will be useful for guiding translation of discoveries to clinical care, which, in turn, can provide data to inform continual improvement of genomic innovations and their applications.

Differences in osteoarthritis self-management support intervention outcomes according to race and health literacy

We explored whether the effects of a telephone-based osteoarthritis (OA) self-management support intervention differed by race and health literacy. Participants included 515 veterans with hip and/or knee OA. Linear mixed models assessed differential effects of the intervention compared with health education (HE) and usual care (UC) on pain (Arthritis Impact Measurement Scales-2 [AIMS2] and Visual Analogue Scale), function (AIMS2 mobility and walking/bending), affect (AIMS2) and arthritis self-efficacy by: (i) race (white/non-white), (ii) health literacy (high/low) and (iii) race by health literacy. AIMS2 mobility improved more among non-whites than whites in the intervention compared with HE and UC (P = 0.02 and 0.008). AIMS2 pain improved more among participants with low than high literacy in the intervention compared with HE (P = 0.05). However, we found a differential effect of the intervention on AIMS2 pain compared with UC according to the combination of race and health literacy (P = 0.05); non-whites with low literacy in the intervention had the greatest improvement in pain. This telephone-based OA intervention may be particularly beneficial for patients with OA who are racial/ethnic minorities and have low health literacy. These results warrant further research designed specifically to assess whether this type of intervention can reduce OA disparities.

Spousal support in a behavior change intervention for cholesterol management

OBJECTIVE To evaluate spousal involvement in a nurse-led intervention for patients with high cholesterol in which patients set health goals and spouses learned support strategies. METHODS Qualitative interviews were conducted with 29 patients and 26 spouses who received the intervention during a trial. Interviews were stratified by patient LDL-C change (better, same, worse). Coded text was content analyzed, and organized into thematic matrices, with columns indicating individuals (spouse or patient) and rows indicating dyads. RESULTS Patients and spouses reported no drawbacks to spousal involvement; some patients whose LDL-C did not improve wanted more focus on spouse health. Spouses said that the nurses expertise and interest were helpful and they were better able to communicate with patients about health. Although the program helped couples work together, spouses with better or same LDL-C talked more about functioning as a unit, whereas those whose partners had worse LDL-C talked more about functioning as individuals. CONCLUSION Although the spousal role was accepted, there were variations in level of involvement. More active spousal involvement might relate to better patient outcomes. For less involved spouses, more focus on their health may improve commitment or involvement. PRACTICE IMPLICATIONS These findings can inform ways to generate spousal support in future trials.

Implementation of new clinical programs in the VHA healthcare system: the importance of early collaboration between clinical leadership and research.

ABSTRACTCollaboration between policy, research, and clinical partners is crucial to achieving proven quality care. The Veterans Health Administration has expended great efforts towards fostering such collaborations. Through this, we have learned that an ideal collaboration involves partnership from the very beginning of a new clinical program, so that the program is designed in a way that ensures quality, validity, and puts into place the infrastructure necessary for a reliable evaluation. This paper will give an example of one such project, the Lung Cancer Screening Demonstration Project (LCSDP). We will outline the ways that clinical, policy, and research partners collaborated in design, planning, and implementation in order to create a sustainable model that could be rigorously evaluated for efficacy and fidelity. We will describe the use of the Donabedian quality matrix to determine the necessary characteristics of a quality program and the importance of the linkage with engineering, information technology, and clinical paradigms to connect the development of an on-the-ground clinical program with the evaluation goal of a learning healthcare organization. While the LCSDP is the example given here, these partnerships and suggestions are salient to any healthcare organization seeking to implement new scientifically proven care in a useful and reliable way.

Scheduled telephone visits in the veterans health administration patient-centered medical home

BackgroundThe Veterans Health Administration (VHA) patient-centered medical home model, Patient Aligned Care Teams (PACT), includes telephone visits to improve care access and efficiency. Scheduled telephone visits can replace in-person care for some focused issues, and more information is needed to understand how this mode can best work for primary care. We conducted a study at the beginning of PACT implementation to elicit stakeholder views on this mode of healthcare delivery, including potential facilitators and barriers.MethodsWe conducted focus groups with primary care patients (n = 3 groups), providers (n = 2 groups) and staff (n = 2 groups). Questions were informed by Donabedian’s framework to evaluate and improve healthcare quality. Content analysis and theme matrix techniques were used to explore themes. Content was assigned a positive or negative valuation to indicate whether it was a facilitator or barrier. PACT principles were used as an organizing framework to present stakeholder responses within the context of the VHA patient-centered medical home program.ResultsScheduled telephone visits could potentially improve care quality and efficiency, but stakeholders were cautious. Themes were identified relating to the following PACT principles: comprehensiveness, patient-centeredness, and continuity of care. In sum, scheduled telephone visits were viewed as potentially beneficial for routine care not requiring physical examination, and patients and providers suggested using them to evaluate need for in-person care; however, visits would need to be individualized, with patients able to discontinue if not satisfied. Patients and staff asserted that providers would need to be kept in the loop for continuity of care. Additionally, providers and staff emphasized needing protected time for these calls.ConclusionThese findings inform development of scheduled telephone visits as part of patient-centered medical homes by providing evidence about areas that may be leveraged to most effectively implement this mode of care. Presenting this service as enhanced care, with ability to triage need for in-person clinic visits and consequently provide more frequent contact, may most adequately meet different stakeholder expectations. In this way, scheduled telephone visits may serve as both a substitute for in-person care for certain situations and a supplement to in-person interaction.

Implementation evaluation of the Telephone Lifestyle Coaching (TLC) program: organizational factors associated with successful implementation

The Telephone Lifestyle Coaching (TLC) program provided telephone-based coaching for six lifestyle behaviors to 5321 Veterans at 24 Veterans Health Administration (VHA) medical facilities. The purpose of the study was to conduct an evaluation of the TLC program to identify factors associated with successful implementation. A mixed-methods study design was used. Quantitative measures of organizational readiness for implementation and facility complexity were used to purposively select a subset of facilities for in-depth evaluation. Context assessments were conducted using interview transcripts. The Consolidated Framework for Implementation Research (CFIR) was used to guide qualitative data collection and analysis. Factors most strongly correlated with referral rates included having a skilled implementation leader who used effective multi-component strategies to engage primary care clinicians as well as general clinic structures that supported implementation. Evaluation findings pointed to recommendations for local and national leaders to help anticipate and mitigate potential barriers to successful implementation.

Innovation in a Learning Health Care System: Veteran-Directed Home- and Community-Based Services

A path‐breaking example of the interplay between geriatrics and learning healthcare systems is the Veterans Health Administrations (VHAs) planned roll‐out of a program for providing participant‐directed home‐ and community‐based services to veterans with cognitive and functional limitations. We describe the design of a large‐scale, stepped‐wedge, cluster‐randomized trial of the Veteran‐Directed Home‐ and Community‐Based Services (VD‐HCBS) program. From March 2017 through December 2019, up to 77 Veterans Affairs Medical Centers will be randomized to times to begin offering VD‐HCBS to veterans at risk of nursing home placement. Services will be provided to community‐dwelling participants with support from Aging and Disability Network Agencies. The VHA Partnered Evidence‐based Policy Resource Center (PEPReC) is coordinating the evaluation, which includes collaboration from operational stakeholders from the VHA and Administration for Community Living and interdisciplinary researchers from the Center of Innovation in Long‐Term Services and Supports and the Center for Health Services Research in Primary Care. For older veterans with functional limitations who are eligible for VD‐HCBS, we will evaluate health outcomes (hospitalizations, emergency department visits, nursing home admissions, days at home) and healthcare costs associated with VD‐HCBS availability. Learning healthcare systems facilitate diffusion of innovation while enabling rigorous evaluation of effects on patient outcomes. The VHAs randomized rollout of VD‐HCBS to veterans at risk of nursing home placement is an example of how to achieve these goals simultaneously. PEPReCs experience designing an evaluation with researchers and operations stakeholders may serve as a framework for others seeking to develop rapid, rigorous, large‐scale evaluations of delivery system innovations targeted to older adults.