Adaptation and Implementation of the STarT Back Risk Stratification Strategy in a US Health Care Organization: A Process Evaluation.

OBJECTIVE: To support implementation of effective treatments for back pain that can be delivered to a range of people, we summarize learnings from our process evaluation of the MATCH trial's implementation of an adaptation of the STarT Back risk-stratified care model. DESIGN: Our logic model-driven evaluation focused primarily on qualitative data sources. SETTING: This study took place in a US-based health care delivery system that had adapted and implemented the STarT Back stratified care approach. This was the first formal test of the strategy in a US setting. METHODS: Data collection included observation of implementation activities, staff/provider interviews, and post-training evaluation questionnaires. Data were analyzed using thematic analysis of qualitative data and descriptive statistics for questionnaire data. RESULTS: We found that both primary care teams and physical therapists at intervention clinics gave the training high scores on evaluation questionnaires and reported in the interviews that they found the training engaging and useful. However, there was significant variation in the extent to which the risk stratification strategy was incorporated into care. Some primary care providers reported that the intervention changed their conversations with patients and increased their confidence in working with patients with back pain. Providers using the STarT Back tool did not change referral rates for recommended matched treatments. CONCLUSIONS: These insights provide guidance for future efforts to adapt and implement the STarT Back strategy and other complex practice change interventions. They emphasize the need for primary care-based interventions to minimize complexity and the need for ongoing monitoring and feedback.

Effect of Low Back Pain Risk-Stratification Strategy on Patient Outcomes and Care Processes: the MATCH Randomized Trial in Primary Care.

BACKGROUND: The STarT Back strategy for categorizing and treating patients with low back pain (LBP) improved patients' function while reducing costs in England. OBJECTIVE: This trial evaluated the effect of implementing an adaptation of this approach in a US setting. DESIGN: The Matching Appropriate Treatments to Consumer Healthcare needs (MATCH) trial was a pragmatic cluster randomized trial with a pre-intervention baseline period. Six primary care clinics were pair randomized, three to training in the STarT Back strategy and three to serve as controls. PARTICIPANTS: Adults receiving primary care for non-specific LBP were invited to provide data 2 weeks after their primary care visit and follow-up data 2 and 6 months (primary endpoint) later. INTERVENTIONS: The STarT Back risk-stratification strategy matches treatments for LBP to physical and psychosocial obstacles to recovery using patient-reported data (the STarT Back Tool) to categorize patients' risk of persistent disabling pain. Primary care clinicians in the intervention clinics attended six didactic sessions to improve their understanding LBP management and received in-person training in the use of the tool that had been incorporated into the electronic health record (EHR). Physical therapists received 5 days of intensive training. Control clinics received no training. MAIN MEASURES: Primary outcomes were back-related physical function and pain severity. Intervention effects were estimated by comparing mean changes in patient outcomes after 2 and 6 months between intervention and control clinics. Differences in change scores by trial arm and time period were estimated using linear mixed effect models. Secondary outcomes included healthcare utilization. KEY RESULTS: Although clinicians used the tool for about half of their patients, they did not change the treatments they recommended. The intervention had no significant effect on patient outcomes or healthcare use. CONCLUSIONS: A resource-intensive intervention to support stratified care for LBP in a US healthcare setting had no effect on patient outcomes or healthcare use. TRIAL REGISTRATION: National Clinical Trial Number NCT02286141.

Evaluation of a risk-stratification strategy to improve primary care for low back pain: the MATCH cluster randomized trial protocol.

BACKGROUND: Despite numerous options for treating back pain and the increasing healthcare resources devoted to this problem, the prevalence and impact of back pain-related disability has not improved. It is now recognized that psychosocial factors, as well as physical factors, are important predictors of poor outcomes for back pain. A promising new approach that matches treatments to the physical and psychosocial obstacles to recovery, the STarT Back risk stratification approach, improved patients' physical function while reducing costs of care in the United Kingdom (UK). This trial evaluates implementation of this strategy in a United States (US) healthcare setting. METHODS: Six large primary care clinics in an integrated healthcare system in Washington State were block-randomized, three to receive an intensive quality improvement intervention for back pain and three to serve as controls for secular trends. The intervention included 6 one-hour training sessions for physicians, 5 days of training for physical therapists, individualized and group coaching of clinicians, and integration of the STarT Back tool into the electronic health record. This prognostic tool uses 9 questions to categorize patients at low, medium or high risk of persistent disabling pain with recommendations about evidence-based treatment options appropriate for each subgroup. Patients at least 18 years of age, receiving primary care for non-specific low back pain, were invited to provide data 1-3 weeks after their primary care visit and follow-up data 2 months and 6 months (primary endpoint) later. The primary outcomes are back-related physical function and pain severity. Using an intention to treat approach, intervention effects on patient outcomes will be estimated by comparing mean changes at the 2 and 6 month follow-up between the pre- and post-implementation periods. The inclusion of control clinics permits adjustment for secular trends. Differences in change scores by intervention group and time period will be estimated using linear mixed models with random effects. Secondary outcomes include healthcare utilization and adherence to clinical guidelines. DISCUSSION: This trial will provide the first randomized trial evidence of the clinical effectiveness of implementing risk stratification with matched treatment options for low back pain in a United States health care delivery system. TRIAL REGISTRATION: NCT02286141. Registered November 5, 2014.

Nutrition and physical activity in child care centers: the impact of a wellness policy initiative on environment and policy assessment and observation outcomes, 2011.

INTRODUCTION: The child care environment has emerged as an ideal setting in which to implement policies that promote healthy body weight of children. The purpose of this study was to assess the effect of a wellness policy and training program on the physical activity and nutrition environment in 24 child care centers in Georgia. METHODS: We used the Environment and Policy Assessment and Observation instrument to identify changes to foods served, staff behaviors, and physical activity opportunities. Observations were performed over 1 day, beginning with breakfast and concluding when the program ended for the day. Observations were conducted from February 2010 through April 2011 for a total of 2 observations in each center. Changes to nutrition and physical activity in centers were assessed on the basis of changes in scores related to the physical activity and nutrition environment documented in the observations. Paired t test analyses were performed to determine significance of changes. RESULTS: Significant improvements to total nutrition (P < .001) and physical activity scores (P < .001) were observed. Results indicate that centers significantly improved the physical activity environments of centers by enhancing active play (P = .02), the sedentary environment (P = .005), the portable environment (P = .002), staff behavior (P = .004), and physical activity training and education (P < .001). Significant improvements were found for the nutrition environment (P < .001), and nutrition training and education (P < .001). CONCLUSION: Findings from this study suggest that implementing wellness policies and training caregivers in best practices for physical activity and nutrition can promote healthy weight for young children in child care settings.

Sometimes Your Heart Says 'I Don't Know': Insights From Parents of Undervaccinated Children.

STUDY OBJECTIVE: To explore drivers of suboptimal vaccination rates by understanding why parents without strong antivaccine beliefs do not fully vaccinate their children. METHODS: Four focus groups were conducted in Washington state with 41 parents of children aged 24 to 48 months who delayed, declined, or missed some but not all vaccines. During the focus groups, parents were asked about reasons their child was undervaccinated, information that might address their concerns, and additional support they needed. Transcripts were analyzed using template analysis with deductive and inductive codes. RESULTS: Focus groups identified multiple reasons for parents deciding to delay or decline vaccines for their children, including issues of individualism and control. The groups emphasized the impact of personal circumstances, such as changes in insurance, on whether children were vaccinated. Our data also shed light on the reasons that parents do vaccinate their children, including school vaccination requirements, negative experiences with vaccine-preventable diseases, and a family tradition of vaccinating. Focus group participants offered suggestions for improving vaccine communication with parents such as having more parent/patient-friendly vaccine information, providing forums to discuss their concerns, and offering vaccination information in advance of well-child appointments. CONCLUSIONS: To achieve the full benefit of vaccines on individual and community health, we need better ways to address vaccine hesitancy and decrease barriers. We suggest that many hesitant parents would benefit from more dialog with health care providers about vaccines, more approachable educational materials, and enforcement of existing policies requiring vaccines in schools and childcare facilities.

Decision-making among adolescents prescribed antipsychotic medications: Interviews to gain perspectives of youth without psychosis or mania.

OBJECTIVES: This study aimed to understand the experiences of youth who had been prescribed antipsychotics but did not have psychosis, mania, autism spectrum disorder, or developmental disability. METHODS: Twenty-three qualitative telephone interviews were conducted with youth aged 11-18 who had been prescribed an antipsychotic medication but did not have a diagnosis of psychotic disorder, bipolar disorder, autism spectrum disorder, or developmental disability. Participants were recruited from four U.S. healthcare systems participating in the pragmatic trial Safer Use of Antipsychotics in Youth (SUAY). Interviews were recorded, transcribed and analyzed using template analysis techniques. RESULTS: Prior to initiating an antipsychotic medication, most participants experienced behavioral health crises; many felt that they had no options other than to start the medication. Other core themes included: (1) antipsychotics had both positive psychosocial outcomes, such as improvement of family life, and adverse effects, such as drowsiness or weight gain, (2) antipsychotics were only one part of a broader treatment plan, (3) efforts were made to maximize benefits and minimize side effects through careful titration, (4) feedback from friends and family was important in the decision to continue. CONCLUSIONS: The findings provide valuable insights into how to engage youth in conversations around the use of antipsychotics.

Blood pressure checks and diagnosing hypertension (BP-CHECK): Design and methods of a randomized controlled diagnostic study comparing clinic, home, kiosk, and 24-hour ambulatory BP monitoring.

BACKGROUND: The US Preventive Services Task Force recommends out-of-office blood pressure (BPs) before making a new diagnosis of hypertension, using 24-h ambulatory (ABPM) or home BP monitoring (HBPM), however this is not common in routine clinical practice. Blood Pressure Checks and Diagnosing Hypertension (BP-CHECK) is a randomized controlled diagnostic study assessing the comparability and acceptability of clinic, home, and kiosk-based BP monitoring to ABPM for diagnosing hypertension. Stakeholders including patients, providers, policy makers, and researchers informed the study design and protocols. METHODS: Adults aged 18-85 without diagnosed hypertension and on no hypertension medication with elevated BPs in clinic and at the baseline research visit are randomized to one of 3 regimens for diagnosing hypertension: (1) clinic BPs, (2) home BPs, or (3) kiosk BPs; all participants subsequently complete ABPM. The primary outcomes are the comparability (with daytime ABPM mean systolic and diastolic BP as the reference standard) and acceptability (e.g., adherence to, patient-reported outcomes) of each method compared to ABPM. Longer-term outcomes are assessed at 6-months including: patient-reported outcomes, primary care providers' diagnosis of hypertension; and BP control. We report challenges experienced and our response to these. RESULTS: Enrollment began in May of 2017 with a target of randomizing 510 participants. BP thresholds for diagnosing hypertension in the US changed after the trial started. We discuss the stakeholder process used to assess and respond to these changes. CONCLUSION AND PUBLIC HEALTH IMPACT: BP-CHECK will inform which hypertension diagnostic methods are most accurate, acceptable, and feasible to implement in primary care.

Patient Perspectives on Communication with Primary Care Physicians about Chronic Low Back Pain.

OBJECTIVES: Chronic low back pain (CLBP) is a common health problem with challenges for providing satisfactory care. This study was undertaken to identify opportunities to improve key aspects of physicians' communications with CLBP-affected patients. METHODS: A series of 3 focus groups, each with 7 to 11 patients with CLBP, were recruited from primary care settings and grouped by risk level of reduced function resulting from back pain, to elicit perspectives about interactions with their primary care physicians. Analysis of focus group transcripts used an iterative process based on a thematic approach and a priori concepts. RESULTS: A total of 28 patients participated in the focus groups. Patient comments about communicating with physicians around CLBP fit into themes of listening and empathy, validating pain experiences, conducting effective CLBP assessment, providing clear diagnosis and information, and collaboratively working on treatment. Patients shared that physicians can foster positive interactions with CLBP-affected patients by sharing personal experiences of chronic pain, being truthful about not having all the answers and being clear about how patients can benefit from referrals, reviewing the patient's previous treatments before beginning conversations about treatment options, providing follow-up instructions, giving patients a diagnosis beyond "chronic pain," and explaining the role of imaging in their care. CONCLUSION: This study provides specific steps that physicians in the US can take to improve physician-patient interactions during primary care visits pertaining to CLBP. The findings could inform physician training, development of educational materials for patients, and future research.

Incorporating variations in pesticide catabolic activity into a GIS-based groundwater risk assessment.

The catabolic activity of incumbent microorganisms in soil samples of eleven dissimilar soil series was investigated, with respect to the herbicide isoproturon. Soils were collected from a 30x37 km area of river catchment to the north-west of London, England. Catabolic activity in each soil type during a 500 h assay was determined by 14C-radiorespirometry. Results showed four soils that exhibited high levels of catabolic activity (33-44% mineralisation) while the remaining seven soils showed lower levels of catabolic activity (12-16% mineralisation). There was evidence to suggest that soils exhibiting high catabolic activity had low (<22%) clay content and tended towards lower organic carbon content (<2.7%), but that these higher levels of catabolic activity were also related to pre-exposure to isoproturon. The 14C-radiorespirometric results were used to produce a GIS layer representing levels of catabolic activity for the dissimilar soils across the study area. This layer was combined with other GIS layers relating to pesticide attenuation, including soil organic carbon content, depth to groundwater and hydrogeology, to produce a map showing risk of groundwater contamination by isoproturon. The output from this approach was compared with output from an attenuation-only approach and differences appraised. Inclusion of the catabolism layer resulted in a lowering of risk in the model in 15% of the study area. Although there appears to be limited benefit in including pesticide catabolic activity in this regional-scale groundwater risk model, this type of addition could be useful in a site-specific risk assessment.

Barriers and supports to implementing a nutrition and physical activity intervention in child care: directors' perspectives.

OBJECTIVE: To explore the experiences of child care centers implementing a nutrition and physical activity (PA) program and identify supports and barriers as reported by center directors. DESIGN: Semi-structured interviews with 20 child care center directors following program implementation. SETTING: Twenty-two child care centers serving low-income children in Georgia. PARTICIPANTS: Twenty child care center directors who led program implementation at their respective centers. INTERVENTION: The program focused on introducing wellness policies to centers and on providing training and technical assistance to support implementation. PHENOMENON OF INTEREST: Center directors' perceptions, attitudes, and reflections on the process of implementing changes to nutrition and PA practices. ANALYSIS: Qualitative analysis of interview transcripts was conducted using NVivo 9 software. Researchers employed 2 levels of coding; 4 predominant themes emerged. RESULTS: Directors' insights included the importance of hands-on activities and printable materials to engage children in nutrition and PA education and healthy behaviors; challenges and supports to engaging parents in child wellness; recognition that children readily accept nutrition and PA changes; and the need for program implementation efforts to prioritize the provision of support for directors and staff in modifying nutrition and PA practices. CONCLUSION AND IMPLICATIONS: Directors consider nutrition and PA policy changes to be beneficial to the child care environment. This study highlights important considerations for efforts to promote healthy weight environments in the early care setting.

Assessment of mealtime environments and nutrition practices in child care centers in Georgia.

BACKGROUND: The amount of time children spend in child care each week has increased in recent years. The aim of this cross-sectional study was to describe the nutritional quality of foods served and the mealtime environment in 24 child care centers in Georgia. METHODS: Data were collected between April 2010 and September 2010. Each child care center provided a sample 5-day menu (breakfast, lunch, and an afternoon snack) at baseline. Energy and nutrient contents of the menus were analyzed using NutriKids Menu Planning & Nutritional Analysis software (LunchByte Systems, Inc., Rochester, NY). Foods and beverages on the menus were compared to MyPlate food group standards for preschoolers. The child care environment was assessed in each center over 1 full day using the Environment and Policy Assessment and Observation instrument. RESULTS: Menus met one half to two thirds of the recommended levels for energy, carbohydrate, protein, and vitamins A and C. However, the menus were high in saturated fat and sodium content and did not meet the recommendations for iron or fiber. The majority of the centers did not meet the recommendations for MyPlate food group standards for preschoolers. On the day of the observation, seven centers did not serve a vegetable and more than half of the centers (n=13) did not serve any whole grains. Nineteen centers served high-sugar and/or high-fat foods and 11 did not have visible water indoors. CONCLUSIONS: This study identified determinants of the child care environment and nutritional characteristics of the combined meals and snacks offered to children. Findings from this study could inform child care centers how to provide healthier nutrition environments to preschool children.

Evaluating factors influencing groundwater vulnerability to nitrate pollution: developing the potential of GIS.

The 1991 EU Nitrate Directive was designed to reduce water pollution from agriculturally derived nitrates. England and Wales implemented this Directive by controlling agricultural activities within their most vulnerable areas termed Nitrate Vulnerable Zones. These were designated by identifying drinking water catchments (surface and groundwater), at risk from nitrate pollution. However, this method contravened the Nitrate Directive because it only protected drinking water and not all waters. In this paper, a GIS was used to identify all areas of groundwater vulnerable to nitrate pollution. This was achieved by constructing a model containing data on four characteristics: the quality of the water leaving the root zone of a piece of land; soil information; presence of low permeability superficial (drift) material; and aquifer properties. These were combined in a GIS and the various combinations converted into a measure of vulnerability using expert knowledge. Several model variants were produced using different estimates of the quality of the water leaving the root zone and contrasting methods of weighting the input data. When the final models were assessed all produced similar spatial patterns and, when verified by comparison with trend data derived from monitored nitrate concentrations, all the models were statistically significant predictors of groundwater nitrate concentrations. The best predictive model contained a model of nitrate leaching but no land use information, implying that changes in land use will not affect designations based upon this model. The relationship between nitrate levels and borehole intake depths was investigated since there was concern that the observed contrasts in nitrate levels between vulnerability categories might be reflecting differences in borehole intake depths and not actual vulnerability. However, this was not found to be statistically important. Our preferred model provides the basis for developing a new set of groundwater Nitrate Vulnerable Zones that should help England and Wales to comply with the EU Nitrate Directive.