Seasonal variation in blood pressure control across US health systems.

OBJECTIVE: We aimed to characterize seasonal variation in US population-based blood pressure (BP) control and BP-related metrics and evaluate the association between outdoor temperature and BP control variation. METHODS: We queried electronic health records (EHRs) from 26 health systems, representing 21 states, to summarize BP metrics by quarters of 12-month periods from January 2017 to March 2020. Patients with at least one ambulatory visit during the measurement period and a hypertension diagnosis during the first 6 months or prior to the measurement period were included. Changes in BP control, BP improvement, medication intensification, average SBP reduction after medication intensification across quarters and association with outdoor temperature were analyzed using weighted generalized linear models with repeated measures. RESULTS: Among 1 818 041 people with hypertension, the majority were more than 65 years of age (52.2%), female (52.1%), white non-Hispanic (69.8%) and had stage 1/2 hypertension (64.8%). Overall, BP control and process metrics were highest in quarters 2 and 3, and lowest in quarters 1 and 4. Quarter 2 had the highest percentage of improved BP (31.95 ±â€Š0.90%) and average SBP reduction after medication intensification (16 ±â€Š0.23 mmHg). Quarter 3 had the highest percentage of BP controlled (62.25 ±â€Š2.55%) and lowest with medication intensification (9.73 ±â€Š0.60%). Results were largely consistent in adjusted models. Average temperature was associated with BP control metrics in unadjusted models, but associations were attenuated following adjustment. CONCLUSION: In this large, national, EHR-based study, BP control and BP-related process metrics improved during spring/summer months, but outdoor temperature was not associated with performance following adjustment for potential confounders.

Improvement in Blood Pressure Control in Safety Net Clinics Receiving 2 Versions of a Scalable Quality Improvement Intervention: BP MAP A Pragmatic Cluster Randomized Trial.

Background Uncontrolled blood pressure (BP) remains a leading cause of death in the United States. The American Medical Association developed a quality improvement program to improve BP control, but it is unclear how to efficiently implement this program at scale across multiple health systems. Methods and Results We conducted BP MAP (Blood Pressure Measure Accurately, Act Rapidly, and Partner With Patients), a comparative effectiveness trial with clinic-level randomization to compare 2 scalable versions of the quality improvement program: Full Support (with support from quality improvement expert) and Self-Guided (using only online materials). Outcomes were clinic-level BP control (<140/90 mm Hg) and other BP-related process metrics calculated using electronic health record data. Difference-in-differences were used to compare changes in outcomes from baseline to 6 months, between intervention arms, and to a nonrandomized Usual Care arm composed of 18 health systems. A total of 24 safety-net clinics in 9 different health systems underwent randomization and then simultaneous implementation. BP control increased from 56.7% to 59.1% in the Full Support arm, and 62.0% to 63.1% in the Self-Guided arm, whereas BP control dropped slightly from 61.3% to 60.9% in the Usual Care arm. The between-group differences-in-differences were not statistically significant (Full Support versus Self-Guided=+1.2% [95% CI, -3.2% to 5.6%], P=0.59; Full Support versus Usual Care=+3.2% [-0.5% to 6.9%], P=0.09; Self-Guided versus Usual Care=+2.0% [-0.4% to 4.5%], P=0.10). Conclusions In this randomized trial, 2 methods of implementing a quality improvement intervention in 24 safety net clinics led to modest improvements in BP control that were not statistically significant. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03818659.

A multi-step education model for advancing competencies in geriatrics and interprofessional collaboration for health students.

At a time when the older adult population is increasing exponentially and health care agencies are fraught with crisis-level short-handedness and burnout, addressing the Quadruple Aim of enhancing patient experience, improving population health, reducing costs, and improving the work life of health care providers is more crucial than ever. A multi-step education model was designed to advance competencies in geriatrics and Interprofessional Collaborative Practice (IPCP) for health profession students focused on each element of the Quadruple Aim. The goals of this education were to equip students with knowledge and experience to provide team-based care for older adults and achieve satisfaction with the education program. The education steps consisted of online didactics, team icebreaker, skills practice, professional huddles, and interprofessional simulation with debriefing. Over 2,300 students and 87 facilitators from 16 professions completed the training over three years. A positive statistically significant increase was found between pre- and post-measures of IPCP competency, knowledge, and attitudes. Additionally, high satisfaction with the education was reported by students and facilitators. By providing positive geriatric education and experiences for health students to work in interprofessional teams, it can translate into future improvements in older adult population health, health care provider job satisfaction, and reduced health care costs.

Pet ownership issues encountered by geriatric professionals: Preliminary findings from an interdisciplinary sample.

Pets often factor in older adults' health behaviors and decisions. However, the degree to which issues related to pet ownership are encountered or addressed by professionals working with this population remains unknown. The aim of this study was to identify specific issues stemming from pet ownership professionals had encountered in their work with older adults, people living with dementia, and care partners. An interdisciplinary (e.g., social services and healthcare) sample (N = 462, 89.13% female, M age = 53.02, SD age = 12.18) completed an online survey addressing pet ownership issues encountered in their work. Descriptive statistics, t-tests, and repeated measures ANOVAs were used to analyze quantitative data. A conventional content analysis was used to analyze open-ended responses to an item asking about "other" issues encountered in their work with these populations. The professionals estimated 46.29% of clients had been pet owners, 41.23% regularly asked about pets, and 79.22% had encountered issues related to pet ownership. Specific issues raised to the professionals varied by type of client. The professionals reported older adults most often raised getting pet items into the home and concerns about their pets' health. The issues most often raised by people living with dementia to the professionals were planning for the pet due to a housing transition and basic pet care. Care partners focused on basic pet care and planning for the pet due to a housing transition. The professionals themselves most often raised the issues of basic pet care, concerns about falling, and the pets' behavior. Professionals who entered clients' homes were more likely to raise issues stemming from pet ownership compared to those who reported they did not enter clients' homes in their current job, t(429.40) = 5.59, p < 0.00001. The eleven new issues identified by the content analysis (e.g., pets impeding care, people refusing care due to the pet) underscored how the health and wellbeing of people and their pets are linked. The results of this study provide strong evidence that professionals do encounter issues related to pet ownership. Including issues stemming from pet ownership into procedures, policies, and programs is likely to have positive impacts on those served by and working in the geriatric workforce.

Trauma-informed Collaborative Care for African American Primary Care Patients in Federally Qualified Health Centers: A Pilot Randomized Trial.

BACKGROUND: African Americans have nearly double the rate of posttraumatic stress disorder (PTSD) compared with other racial/ethnic groups. OBJECTIVE: To understand whether trauma-informed collaborative care (TICC) is effective for improving PTSD among African Americans in New Orleans who receive their care in Federally Qualified Health Centers (FQHCs). DESIGN AND METHOD: In this pilot randomized controlled trial, we assigned patients within a single site to either TICC or to enhanced usual care (EUC). We performed intent to treat analysis by nonparametric exact tests for small sample sizes. PARTICIPANTS: We enrolled 42 patients from October 12, 2018, through July 2, 2019. Patients were eligible if they considered the clinic their usual source of care, had no obvious physical or cognitive obstacles that would prevent participation, were age 18 or over, self-identified as African American, and had a provisional diagnosis of PTSD. MEASURES: Our primary outcome measures were PTSD measured as both a symptom score and a provisional diagnosis based on the PTSD Checklist for DSM-5 (PCL-5). KEY RESULTS: Nine months following baseline, both PTSD symptom scores and provisional PTSD diagnosis rates decreased substantially more for patients in TICC than in EUC. The decreases were by 26 points in EUC and 36 points in TICC for symptoms (P=0.08) and 33% in EUC and 57% in TICC for diagnosis rates (P=0.27). We found no effects for mediator variables. CONCLUSIONS: TICC shows promise for addressing PTSD in this population. A larger-scale trial is needed to fully assess the effectiveness of this approach in these settings.

Building Provider-Caregiver Partnerships: Curricula for Medical Students and Residents.

PROBLEM: A disconnect exists between caregivers and health care providers, resulting in fragmented communication, which increases caregiver stress and compromises patient care. Although providers have a responsibility to recognize caregiver burden, they receive scant training on issues important to caregivers. APPROACH: From 2014 to 2017, as part of the Building Caregiver Partnerships Through Interprofessional Education project-a collaborative effort between Northeast Ohio Medical University and Summa Health-the authors developed curricula to foster effective partnerships between health care providers and caregivers by exposing medical students and residents to highly personal caregiving narratives. The curricula center on a short film featuring 4 families representing diverse caregiving experiences. The authors crafted several discussion guides, case-based learning exercises, structured clinical encounters, team-based simulations, and clinical cases as companion educational tools for the film. OUTCOMES: Medical students reported the educational tools piloted to be valuable in broadening their understanding of caregivers' needs, while residents reported the educational tools piloted to also be valuable in improving their communication and building partnerships with caregivers. Undergraduate and graduate faculty reported finding the pilots valuable. NEXT STEPS: Future goals include conducting an outcome evaluation, based on ACGME milestones, to identify and examine clinical outcomes to determine whether communication increases and quality of care improves as a result of the project. The authors would also like to include caregivers in the evaluation. Finally, because caregiving is best addressed from a team approach, the authors plan to pilot the project at other health professions programs.

Use of Film to Sensitize Medical Students to Issues of Family Caregiving.

BACKGROUND AND OBJECTIVE: Families are the backbone of our long-term care system, managing complicated illnesses, providing direct care, and assisting with the day-to-day functioning of elderly patients. Medical education, however, provides students with little, if any, exposure to the challenges faced by family caregivers or how best to communicate with them to optimize patient care. We assessed the value of an educational program combining film and discussion as a means of sensitizing third-year medical students to caregiver issues. During their family medicine clerkship, third-year medical students at Northeast Ohio Medical University view the film, No Roadmap: Caregiver Journeys and discuss issues of family caregiving. METHODS: A mixed-methods approach was used to evaluate the program, including a qualitative focus group with clerkship preceptors and ongoing quantitative student evaluations. RESULTS: Preceptors reported that students related to the film in highly personal ways, often recounting experiences within their own families, and gained a greater appreciation of caregivers. Three years of student evaluations (n=403) were used to validate preceptor comments. Students agreed that the program helped them establish a comfortable relationship with caregivers, increased their awareness of caregiver challenges and rewards, and provided valuable insights into caregiver experiences. CONCLUSIONS: Film depicting compelling narratives of caregiver journeys, coupled with guided discussion, is a valuable strategy for increasing student awareness of the important role of caregivers.

Popular Media Representations of Physical Activity Among Mothers.

PURPOSE: Many mothers fail to meet the recommended guidelines for physical activity. Popular media magazines targeting mothers provide information about physical activity and health, but little is known about the framing and content of physical activity messages within these sources. The aim of this content analysis was to analyze the framing and content (i.e., benefits, consequences, and sources of self-efficacy) of physical activity messages directed toward mothers in popular magazines. METHOD: Ten popular magazines were selected for data analysis and coded independently by two researchers in NVivo Version 10.0 for gain- or loss-framed messages, benefits and consequences of physical activity, and sources of self-efficacy. RESULTS: Most of the 164 articles encouraged physical activity by presenting benefits associated with physical activity. These benefits primarily focused on weight loss and fitness gains and few articles used self-efficacy messages to enhance confidence in physical activity participation. CONCLUSIONS: It is promising that popular media magazines used gain-framed messages about the benefits of physical activity for mothers. Future research should focus on finding ways of using popular media outlets to promote a more comprehensive set of physical activity benefits, enhance physical activity self-efficacy, and determine the impact of such messages on physical activity participation.

From Design to Dissemination: Implementing Community-Based Participatory Research in Postdisaster Communities.

OBJECTIVES: To review how disasters introduce unique challenges to conducting population-based research and community-based participatory research (CBPR). METHODS: From 2007-2009, we conducted the Head-off Environmental Asthma in Louisiana (HEAL) Study in the aftermath of Hurricane Katrina in a Gulf Coast community facing an unprecedented triple burden: Katrina's and other disasters' impact on the environment and health, historic health disparities, and persistent environmental health threats. RESULTS: The unique triple burden influenced every research component; still, most existing CBPR principles were applicable, even though full adherence was not always feasible and additional tailored principles govern postdisaster settings. CONCLUSIONS: Even in the most challenging postdisaster conditions, CBPR can be successfully designed, implemented, and disseminated while adhering to scientific rigor.

Antiretroviral Drug Resistance Among Children and Youth in the United States With Perinatal HIV.

Among 234 US youths with perinatal human immunodeficiency virus, 75% had antiretroviral resistance, substantially higher than that of the reference laboratory overall (36%-44%). Resistance to newer antiretrovirals and to all antiretrovirals in a class was uncommon. The only factor independently associated with future resistance was a higher peak viral load.

Prevalence and Persistence of Varicella Antibodies in Previously Immunized Children and Youth With Perinatal HIV-1 Infection.

BACKGROUND: Two doses of live-attenuated varicella-zoster vaccine are recommended for human immunodeficiency virus 1 (HIV-1)-infected children with CD4% ≥ 15%. We determined the prevalence and persistence of antibody in immunized children with perinatal HIV (PHIV) and their association with number of vaccinations, combination antiretroviral therapy (cART), and HIV status. METHODS: The Adolescent Master Protocol is an observational study of children with PHIV and perinatally HIV-exposed but uninfected (PHEU) children conducted at 15 US sites. In a cross-sectional analysis, we tested participants' most recent stored sera for varicella antibody using whole-cell and glycoprotein enzyme-linked immunosorbent assay. Seropositivity predictors were identified using multivariable logistic regression models and C statistics. RESULTS: Samples were available for 432 children with PHIV and 221 PHEU children; 82% of children with PHIV and 97% of PHEU children were seropositive (P < .001). Seropositivity after 1 vaccine dose among children with PHIV and PHEU children was 100% at <3 years (both), 73% and 100% at 3-<7 years (P < .05), and 77% and 97% at ≥ 7 years (P < .01), respectively. Seropositivity among recipients of 2 vaccine doses was >94% at all intervals. Independent predictors of seropositivity among children with PHIV were receipt of 2 vaccine doses, receipt of 1 dose while on ≥ 3 months of cART, compared with none (adjusted odds ratio [aOR]: 14.0 and 2.8, respectively; P < .001 for overall dose effect), and in those vaccinated ≥ 3 years previously, duration of cART (aOR: 1.29 per year increase, P = .02). CONCLUSIONS: Humoral immune responses to varicella vaccine are best achieved when children with PHIV receive their first dose ≥ 3 months after cART initiation and maintained by completion of the 2-dose series and long-term cART use.

The Relationship Between Organizational Characteristics and Advance Care Planning Practices.

Organizational characteristics may impede the uniform adoption of advance care planning (ACP) best practices. We conducted telephone interviews with site directors of a Midwestern state's Medicaid waiver program administered by the Area Agencies on Aging and surveyed the 433 care managers (registered nurses and social workers) employed within these 9 agencies. Care managers at 2 agencies reported more frequent ACP discussions and higher levels of confidence. Both sites had ACP training programs, follow-up protocols, and informational packets available for consumers that were not consistently available at the other agencies. The findings point to the need for consistent educational programs and policies on ACP and more in depth examination of the values, beliefs, and resources that account for organizational differences in ACP.

The HEAL, Phase II Project: enhancing features of an electronic medical record system to improve adherence to asthma guidelines.

This article describes the implementation of an enhanced electronic medical record (EMR) system in three community health care centers in the Greater New Orleans area of Louisiana. This report may aid efforts directed at the implementation of enriched tools, such as decision support, in an EMR with the goal of improving pediatric asthma outcomes.

Factors associated with advance care planning discussions by area agency on aging care managers.

BACKGROUND: Initiating advance care planning (ACP) discussions in the home may prevent avoidable hospitalizations by elucidating goals of care. Area agencies on aging care managers (AAACMs) work in the home with high-risk consumers. PURPOSE: To determine which AAACM characteristics contribute to an increased frequency of ACP discussions. METHOD: Cross-sectional investigator-generated surveys administered to AAACMs at 3 AAAs in Ohio. RESULTS: Of 289 AAACMs, 182 (63%) responded. The more experience and comfort AAACMs felt with ACP discussions, the more likely they were to initiate ACP discussions. DISCUSSION: It may be necessary to build interactive educational experiences where, for example, AAACMs are asked to fill out their own advance directives and/or facilitate others in ACP discussions to improve experience and comfort with ACP discussions.

Disentangling consumer and provider predictors of advance care planning.

Factorial surveys were used to examine community-based long-term care providers' judgments about consumers' need for advance care planning (ACP) and comfort levels in discussing ACP. Providers (448 registered nurses and social workers) judged vignettes based on hypothetical consumers. Hierarchical linear models indicated providers judged consumers who were older, had end-stage diagnoses, multiple emergency department visits, and uninvolved caregivers as most in need of ACP. These variables explained 10% of the variance in judgments. Providers' beliefs about ACP predicted judgments of need for ACP and comfort level in discussing ACP. Provider characteristics explained more variance in comfort levels (44%) than in judgments of need (20%). This study demonstrates the need for tailored educational programs to increase comfort levels and address ACP misconceptions.

Addressing the "other" health literacy competencies--knowledge, dispositions, and oral/aural communication: development of TALKDOC, an intervention assessment tool.

Most health literacy assessments evaluate literacy skills including reading, writing; numeracy and interpretation of tables, graphs, diagrams and charts. Some assess understanding of health systems, and the ability to adequately apply one's skills to specific health-related tasks or demands in health situations. However, to achieve functional health literacy, the ability to "obtain, process, and understand basic health information and services needed to make appropriate health decisions," other health literacy dimensions should be assessed: a person's knowledge and attitudes about a health issue affects his or her ability to and interest in participating in his or her own care. In patient care settings, the abilities to listen, ask questions and check one's understanding are crucial to making appropriate decisions and carrying out instructions. Although literacy is a skill associated with educational attainment and therefore difficult to change in a short time, health education interventions can address health literacy domains such as knowledge, attitudes and oral communication skills. For this reason, an instrument that can assess these constructs is a valuable part of a health educator's toolbox. The authors describe the development and process and outcomes of testing a novel instrument targeted to assess HPV and cervical cancer health literacy competencies, TALKDOC, including its validation with the Health Activities Literacy Scale.

Managing in the trenches of consumer care: the challenges of understanding and initiating the advance care planning process.

To better understand how community-based long-term care providers define advance care planning and their role in the process, we conducted 8 focus groups with 62 care managers (social workers and registered nurses) providing care for Ohio's Medicaid waiver program. Care managers shared that most consumers had little understanding of advance care planning. The care managers defined it broadly, including legal documentation, social aspects, medical considerations, ongoing communication, and consumer education. Care managers saw their roles as information providers, healthcare team members, and educators/coaches. Better education, resources, and coordination are needed to ensure that consumer preferences are realized.

Parenting: the forgotten role of women living with systemic lupus erythematosus.

This study investigates parenting and the impact of symptoms, such as pain and fatigue, on the parenting abilities of mothers with systemic lupus erythematosus (SLE). Participants were 68 mothers with SLE who had children 18 years of age and younger. The mothers completed surveys consisting of a demographic questionnaire and self-report instruments such as the Parenting Disability Index (PDI), Health Assessment Questionnaire, Pain Visual Analog Scale, and Multidimensional Assessment of Fatigue Scale. Analysis of variance was used to compare parenting abilities for women with younger children (birth -5 years) and women with older children (6-18 years) and women with children in both age groups. There were no significant differences between the three groups. However, having more fatigue, functional disability, and less education resulted in higher PDI scores in all groups. Mothers with children younger than age 5 reported that having energy to talk/listen to a child was the most difficult parenting task. Mothers with children between 6 and 18 years of age reported the most difficulties with maintaining discipline, playing games, shopping, and doing household chores. Symptoms of lupus have a significant influence on mothering roles. In daily practice, health care providers may want to consider inquiring about the impact SLE may be having on their patients' parenting roles.

A 4-year integrated curriculum in palliative care for medical undergraduates.

In order to graduate physicians prepared to effectively address clinical issues in palliative medicine and to comply with LCME requirements, the Northeastern Ohio Universities Colleges of Medicine and Pharmacy (NEOUCOM) integrated a coordinated four-year palliative care (PC) curriculum. This report describes the development of the longitudinal curriculum and provides helpful resources and strategies to guide clinicians and administrators undertaking similar efforts. This is a retrospective, descriptive report based on data collected throughout development of the new curriculum. A Palliative Care Advisory Committee initiated development of curricula in PC. An Office of Palliative Care was established to assess and coordinate offerings. Curriculum transformation was based on best practices. Two cornerstone pieces are highlighted: a mandatory hospice experience and a case based small group discussion prior to graduation.