A globally relevant change taxonomy and evidence-based change framework for land monitoring.

A globally relevant and standardized taxonomy and framework for consistently describing land cover change based on evidence is presented, which makes use of structured land cover taxonomies and is underpinned by the Driver-Pressure-State-Impact-Response (DPSIR) framework. The Global Change Taxonomy currently lists 246 classes based on the notation 'impact (pressure)', with this encompassing the consequence of observed change and associated reason(s), and uses scale-independent terms that factor in time. Evidence for different impacts is gathered through temporal comparison (e.g., days, decades apart) of land cover classes constructed and described from Environmental Descriptors (EDs; state indicators) with pre-defined measurement units (e.g., m, %) or categories (e.g., species type). Evidence for pressures, whether abiotic, biotic or human-influenced, is similarly accumulated, but EDs often differ from those used to determine impacts. Each impact and pressure term is defined separately, allowing flexible combination into 'impact (pressure)' categories, and all are listed in an openly accessible glossary to ensure consistent use and common understanding. The taxonomy and framework are globally relevant and can reference EDs quantified on the ground, retrieved/classified remotely (from ground-based, airborne or spaceborne sensors) or predicted through modelling. By providing capacity to more consistently describe change processes-including land degradation, desertification and ecosystem restoration-the overall framework addresses a wide and diverse range of local to international needs including those relevant to policy, socioeconomics and land management. Actions in response to impacts and pressures and monitoring towards targets are also supported to assist future planning, including impact mitigation actions.

Feasibility of a Video-Based Advance Care Planning Website to Facilitate Group Visits among Diverse Adults from a Safety-Net Health System.

BACKGROUND: Primary care providers in safety-net settings often do not have time to discuss advance care planning (ACP). Group visits (GV) may be an efficient means to provide ACP education. OBJECTIVES: To assess the feasibility and impact of a video-based website to facilitate GVs to engage diverse adults in ACP. DESIGN: Feasibility pilot among patients who were ≥55 years of age from two primary care clinics in a Northern California safety-net setting. Participants attended two 90-minute GVs and viewed the five steps of the movie version of the PREPARE website ( www.prepareforyourcare.org ) concerning surrogates, values, and discussing wishes in video format. Two clinician facilitators were available to encourage participation. MEASUREMENTS: We assessed pre-to-post ACP knowledge, whether participants designated a surrogate or completed an advance directive (AD), and acceptability of GVs and PREPARE materials. RESULTS: We conducted two GVs with 22 participants. Mean age was 64 years (±7), 55% were women, 73% nonwhite, and 55% had limited literacy. Knowledge improved about surrogate designation (46% correct pre vs. 85% post, p = 0.01) and discussing decisions with others (59% vs. 90%, p = 0.01). Surrogate designation increased (48% vs. 85%, p = 0.01) and there was a trend toward AD completion (9% vs. 24%, p = 0.21). Participants rated the GVs and PREPARE materials a mean of 8 (±3.1) on a 10-point acceptability scale. CONCLUSIONS: Using the PREPARE movie to facilitate ACP GVs for diverse adults in safety net, primary care settings is feasible and shows potential for increasing ACP engagement.

Designing and Implementing an Electronic Patient Registry to Improve Warfarin Monitoring in the Ambulatory Setting.

BACKGROUND: Warfarin requires individualized dosing and monitoring in the ambulatory setting for protection against thromboembolic disease. Yet in multiple settings, patients spend upwards of 30% of time outside the therapeutic range, subjecting them to an increased risk of adverse events. At an urban, publicly funded clinic, the electronic health record (EHR) would not support integration with extant warfarin management software, which led to the creation and implementation of an electronic patient registry and a complementary team-based work flow to provide real-time health-system-level data for warfarin patients. METHODS: Creation of the registry, which began in August 2014, entailed use of an existing platform, which could interface with the outpatient EHR. The registry was designed to help ensure regular testing and monitoring of patients while enabling identification of patients and subpopulations with suboptimal management. The work flow used for the clinic's warfarin patients was also redesigned. An assessment indicated that the registry identified 341 (96%) of 357 patients actively seen in the clinic. RESULTS: For the cohort of the 357 patients in the registry, the no-show rate decreased from 31% (preimplementation, August 2014-December 2014) to 21% (postimplementation, January 2015-November 2015). The ratio of visits to no-shows increased from 2.3 to 4.0 visits. CONCLUSION: Design and implementation of an electronic registry in conjunction with a complementary work flow established an active tracking system that improved treatment monitoring for patients on anticoagulation therapy. Registry creation also facilitated assessment of the quality of care and laid the groundwork for ongoing evaluation and quality improvement efforts.

"Choosing wisely" in an academic department of medicine.

The "Choosing Wisely" campaign seeks to reduce unnecessary care in the United States through self-published recommendations by professional societies. The research team sought to identify factors related to low-value care in the Department of Medicine at the University of California San Francisco, using a subset of clinical scenarios published by the American College of Physicians. The team further explored respondents' values on cost consciousness. A notable minority disagreed with the identified low-value tests. In 6 of 8 scenarios, faculty were more likely to rate the scenarios as representing low-value testing (P < .05). Level of training was the only predictor of attitudes toward unnecessary care after linear regression analysis (coefficient 3.14, P < .001). Increased postgraduate education about cost of care is recommended.

Nutrition and neurodevelopment in children: focus on NUTRIMENTHE project.

There is growing evidence that early nutrition affects later cognitive performance. The idea that the diet of mothers, infants, and children could affect later mental performance has major implications for public health practice and policy development and for our understanding of human biology as well as for food product development, economic progress, and future wealth creation. To date, however, much of the evidence is from animal, retrospective studies and short-term nutritional intervention studies in humans. The positive effect of micronutrients on health, especially of pregnant women eating well to maximise their child's cognitive and behavioural outcomes, is commonly acknowledged. The current evidence of an association between gestational nutrition and brain development in healthy children is more credible for folate, n-3 fatty acids, and iron. Recent findings highlight the fact that single-nutrient supplementation is less adequate than supplementation with more complex formulae. However, the optimal content of micronutrient supplementation and whether there is a long-term impact on child's neurodevelopment needs to be investigated further. Moreover, it is also evident that future studies should take into account genetic heterogeneity when evaluating nutritional effects and also nutritional recommendations. The objective of the present review is to provide a background and update on the current knowledge linking nutrition to cognition and behaviour in children, and to show how the large collaborative European Project NUTRIMENTHE is working towards this aim.

Points for improvement: performance measurement for glycemic control in diabetes patients in a safety-net population.

BACKGROUND: Diabetes complications account for significant worldwide morbidity and mortality. Improving glycemic control decreases microvascular complications, particularly among patients with the worst control. Current performance measures fail to prioritize such individuals. The categorization of glycemic control within a safety-net clinic population was compared using a common performance measure against one derived from a metric accounting for change in glycated hemoglobin (A1c) over time. METHODS: Retrospective cohort analysis of all patients in a safety-net primary care clinic population quality registry with confirmed diabetes mellitus who had at least two A1c values between 2007 through 2011. Patients were stratified into five groups' on the basis of maximum and earliest A1c level (< 7%, 7% to < 8%, 8% to < 9%, 9% to < 10%, and > 10%). The change in Alc was assessed over time and compared with standard healthcare effectiveness data and information set (HEDIS) performance measures. RESULTS: Some 1122 patients were included in the analysis, with mean A1c of 7.9%. There was a modest annual decrease in the average A1c, and > 19% of patients improved by 1% or more during each of the previous three years. For patients who had maximum A1c values > or = 10%, there was a significantly greater reduction in A1c (p < .01), which was not reflected in the standard performance measure. CONCLUSIONS: It is feasible for safety-net clinics to analyze their patients with diabetes by level of disease control on the basis of change in A1c over time. Patients with the worst glycemic control tend to have the greatest improvement but are often overlooked by conventional performance measures. Improved performance measures should focus on longitudinal diabetes control and emphasize reducing risk of complications among patients at highest risk.

Nutrition and mental performance in children - The NUTRIMENTHE project.

The Nutrition And Mental Performance In Children project of the European Union (NUTRIMENTHE) has added to the evidence that maternal diet influences mental performance in childhood. The biological mechanisms have been shown to be complex and to involve genetic variation, as indicated by the work linking genetic variation in the fatty acid desaturase gene cluster to the processing of fatty acids. The role played by a child's diet also needs to be considered and this question is being addressed through the inclusion of post-natal intervention studies in the NUTRIMENTHE project's research plan. This paper summarises progress.

The bridge clinic.

A nurse-led postdischarge clinic improves care transitions in a public hospital.

Signal and noise: applying a laboratory trigger tool to identify adverse drug events among primary care patients.

BACKGROUND: The extent of outpatient adverse drug events (ADEs) remains unclear. Trigger tools are used as a screening method to identify care episodes that may be ADEs, but their value in a population with high chronic-illness burden remains unclear. METHODS: The authors used six abnormal laboratory triggers for detecting ADEs among adults in outpatient care. Eligible patients were included if they were >18 years, sought primary or urgent care between November 2008 and November 2009 and were prescribed at least one medication. The authors then used the clinical / administrative database to identity patients with these triggers. Two physicians conducted in-depth chart review of any medical records with identified triggers. RESULTS: The authors reviewed 1342 triggers representing 622 unique episodes among 516 patients. The trigger tool identified 91 (15%) ADEs. Of the 91 ADEs included in the analysis, 49 (54%) occurred during medication monitoring, 41 (45%) during patient self-administration, and one could not be determined. 96% of abnormal international normalised ratio triggers were ADEs, followed by 12% of abnormal blood urea nitrogen triggers, 9% of abnormal alanine aminotransferase triggers, 8% of abnormal serum creatinine triggers and 3% of aspartate aminotransferase triggers. CONCLUSIONS: The findings imply that other tools such as text triggers or more complex automated screening rules, which combine data hierarchically are needed to effectively screen for ADEs in chronically ill adults seen in primary care.

Patient Follow-up in an Urban Resident Continuity Clinic: An Initiative to Improve Scheduling Practices.

INTRODUCTION: Failure to schedule timely follow-up appointments may impair continuity and quality of care, especially for patients with low health literacy and unstable living situations. Resident continuity clinics face particular challenges in scheduling patient follow-up because of residents' complex schedules and limited time in clinic. METHODS: As part of a structured quality-improvement curriculum, residents initiated discussions with clinical supervisors and clerical staff to evaluate and improve scheduling practices in an urban continuity clinic. The problem-solving process emphasized feasibility (rapid implementation/evaluation cycle, low time/resource burden) and measurable outcomes. These discussions led to design of a new scheduling form. We evaluated the short-term impact of awareness raising by comparing scheduling rates before (month 1) versus after (months 2-3) implementation, and of the form itself by randomly selecting 2 afternoon clinics to implement the new form, with a third serving as control. RESULTS: We analyzed all patient encounters over a 3-month period (n  =  910), excluding patients with a recommended follow-up interval of greater than 4 months. The proportion of appointments "never scheduled" (at 1 month after provider-requested follow-up date) declined from 18.8% (95% confidence interval [CI], 14.5%-23.9%) in month 1 to 11.4% (CI, 8.1%-15.5%) in month 3. This proportion was significantly higher before than after implementation of the form (multivariable relative risk, 1.49; 95% CI, 1.08-2.03; P  =  .02), both in clinics that used and did not use the form (P  =  .93 for difference). CONCLUSIONS: We describe a model resident-led, team-based intervention that addressed core competencies in graduate medical education while improving outpatient scheduling practices.

Advancing diabetes self-management in the Mexican American population: a community health worker model in a primary care setting.

PURPOSE: The purpose of this study was to pilot test the effectiveness of health promoters trained in the transtheoretical model of change to provide diabetes management education and support to Mexican Americans in a primary care setting. METHODS: The study site was an urban community health center in Oakland, California. This study reports on 142 patients who were enrolled for at least 1 year in the program. Community health workers acted as extenders of the medical staff to facilitate behavior change, using patient-centered counseling. This was a 1-group pretest/posttest pilot study. Descriptive statistics and the paired-sample t test were used to compare the change in clinical outcome measures from baseline to 6 months and 1 year. Statistically significant changes were correlated with frequency of community health worker contact. RESULTS: The paired-sample t test showed significant reduction in glycosylated hemoglobin (HbA1c) from baseline to 1 year (P < .004). Reductions were also seen in low-density lipoprotein cholesterol and blood pressure, but they were not statistically significant. When stratified by gender, women showed a greater reduction in HbA1c than men at 1 year. Patients with a higher frequency of community health worker contact showed a greater decline in HbA1c level. CONCLUSIONS: The pilot study demonstrates that community health workers, as an integral part of the health care team, are effective agents in providing self-management support to persons with diabetes.