Documentation of Advance Directives and Code Status in Electronic Medical Records to Honor Goals of Care.

Advance care planning is a process that supports conversations about the values that matter most to patients and their family members. The documentation of advance directives and code status in a patient's electronic health record (EHR) is a critical step to ensure treatment preferences are honored in the medical care received. The current approach to advanced care planning documentation in electronic medical records often remains disparate within and across EHR systems. Without a standardized format for documentation or centralized location for documentation, advance directives and even code status content are often difficult to access within electronic medical records. This case report launched our palliative care team into partnership with the Information Technology team for implementation of a centralized, standardized, longitudinal, functional documentation of advance care planning and code status in the electronic medical record system.

A Micro-Costing Study of Screening for Lynch Syndrome-Associated Pathogenic Variants in an Unselected Endometrial Cancer Population: Cheap as NGS Chips?

Background: Lynch syndrome is the most common inherited cause of endometrial cancer. Identifying individuals affected by Lynch syndrome enables risk-reducing interventions including colorectal surveillance, and cascade testing of relatives. Methods: We conducted a micro-costing study of screening all women with endometrial cancer for Lynch syndrome using one of four diagnostic strategies combining tumor microsatellite instability testing (MSI), immunohistochemistry (IHC), and/or MLH1 methylation testing, and germline next generation sequencing (NGS). Resource use (consumables, capital equipment, and staff) was identified through direct observation and laboratory protocols. Published sources were used to identify unit costs to calculate a per-patient cost (£; 2017) of each testing strategy, assuming a National Health Service (NHS) perspective. Results: Tumor triage with MSI and reflex MLH1 methylation testing followed by germline NGS of women with likely Lynch syndrome was the cheapest strategy at £42.01 per case. Tumor triage with IHC and reflex MLH1 methylation testing of MLH1 protein-deficient cancers followed by NGS of women with likely Lynch syndrome cost £45.68. Tumor triage with MSI followed by NGS of all women found to have tumor microsatellite instability cost £78.95. Immediate germline NGS of all women with endometrial cancer cost £176.24. The cost of NGS was affected by the skills and time needed to interpret results (£44.55/patient). Conclusion: This study identified the cost of reflex screening all women with endometrial cancer for Lynch syndrome, which can be used in a model-based cost-effectiveness analysis to understand the added value of introducing reflex screening into clinical practice.

A church-based diabetes self-management education program for African Americans with type 2 diabetes.

INTRODUCTION: Diabetes self-management education interventions in community gathering places have been moderately effective, but very few studies of intervention effectiveness have been conducted among African Americans with type 2 diabetes. This paper describes a church-based diabetes self-management education intervention for African Americans, a randomized controlled trial to evaluate the intervention, and baseline characteristics of study participants. METHODS: A New DAWN: Diabetes Awareness & Wellness Network was conducted among 24 churches of varying size in North Carolina. Each church recruited congregants with type 2 diabetes and designated a diabetes advisor, or peer counselor, to be part of the intervention team. Participants were enrolled at each church and randomized as a unit to either the special intervention or the minimal intervention. The special intervention included one individual counseling visit, twelve group sessions, three postcard messages from the participant's diabetes care provider, and twelve monthly telephone calls from a diabetes advisor. Baseline data included measures of weight, hemoglobin A1c, blood pressure, physical activity, dietary and diabetes self-care practices, and psychosocial factors. The study to evaluate the intervention (from enrollment visit to last follow-up) began in February 2001 and ended in August 2003. RESULTS: Twenty-four churches (with 201 total participants) were randomized. Sixty-four percent of the participants were women. On average, the participants were aged 59 years and sedentary. They had an average of 12 years of education, had been diagnosed with diabetes for 9 years, had a body mass index of 35, had a hemoglobin A1c level of 7.8%, and had a reported dietary intake of 39% of calories from fat. CONCLUSION: A New DAWN is a culturally sensitive, church-based diabetes self-management education program for African Americans with type 2 diabetes that is being evaluated for effectiveness in a randomized controlled trial. The outcomes of A New DAWN will contribute to the literature on community-based interventions for minority populations and help to inform the selection of approaches to improve diabetes care in this population.

Evaluating nurses' implementation of an infant-feeding counseling protocol for HIV-infected mothers: The Ban Study in Lilongwe, Malawi.

A process evaluation of nurses' implementation of an infant-feeding counseling protocol was conducted for the Breastfeeding, Antiretroviral and Nutrition (BAN) Study, a prevention of mother-to-child transmission of HIV clinical trial in Lilongwe, Malawi. Six trained nurses counseled HIV-infected mothers to exclusively breastfeed for 24 weeks postpartum and to stop breastfeeding within an additional four weeks. Implementation data were collected via direct observations of 123 infant feeding counseling sessions (30 antenatal and 93 postnatal) and interviews with each nurse. Analysis included calculating a percent adherence to checklists and conducting a content analysis for the observation and interview data. Nurses were implementing the protocol at an average adherence level of 90% or above. Although not detailed in the protocol, nurses appropriately counseled mothers on their actual or intended formula milk usage after weaning. Results indicate that nurses implemented the protocol as designed. Results will help to interpret the BAN Study's outcomes.