Study protocol: improving the transition of care from a non-network hospital back to the patient's medical home.

BACKGROUND: The process of transitioning Veterans to primary care following a non-Veterans Affairs (VA) hospitalization can be challenging. Poor transitions result in medical complications and increased hospital readmissions. The goal of this transition of care quality improvement (QI) project is to identify gaps in the current transition process and implement an intervention that bridges the gap and improves the current transition of care process within the Eastern Colorado Health Care System (ECHCS). METHODS: We will employ qualitative methods to understand the current transition of care process back to VA primary care for Veterans who received care in a non-VA hospital in ECHCS. We will conduct in-depth semi-structured interviews with Veterans hospitalized in 2015 in non-VA hospitals as well as both VA and non-VA providers, staff, and administrators involved in the current care transition process. Participants will be recruited using convenience and snowball sampling. Qualitative data analysis will be guided by conventional content analysis and Lean Six Sigma process improvement tools. We will use VA claim data to identify the top ten non-VA hospitals serving rural and urban Veterans by volume and Veterans that received inpatient services at non-VA hospitals. Informed by both qualitative and quantitative data, we will then develop a transitions care coordinator led intervention to improve the transitions process. We will test the transition of care coordinator intervention using repeated improvement cycles incorporating salient factors in value stream mapping that are important for an efficient and effective transition process. Furthermore, we will complete a value stream map of the transition process at two other VA Medical Centers and test whether an implementation strategy of audit and feedback (the value stream map of the current transition process with the Transition of Care Dashboard) versus audit and feedback with Transition Nurse facilitation of the process using the Resource Guide and Transition of Care Dashboard improves the transition process, continuity of care, patient satisfaction and clinical outcomes. DISCUSSION: Our current transition of care process has shortcomings. An intervention utilizing a transition care coordinator has the potential to improve this process. Transitioning Veterans to primary care following a non-VA hospitalization is a crucial step for improving care coordination for Veterans.

Integrating Motivational Interviewing Into a Home Telehealth Program for Veterans With Posttraumatic Stress Disorder Who Smoke: A Randomized Controlled Trial.

OBJECTIVE: We evaluated integrating a motivational interviewing (MI)-based smoking cessation curricula and MI counseling into a posttraumatic stress disorder (PTSD) home telehealth care management program to determine if smoking behaviors improved. METHOD: We randomized 178 Veterans with PTSD to a 90-session MI-based home telehealth program or to usual care. Outcome measures included self-reported 24-hour quit attempts, seven-day point prevalence abstinence, progression along the stages of change, and mental health symptoms. RESULTS: Favorable smoking cessation rates were observed in both groups. There was no statistical difference in self-reported 24-hour quit attempts, seven-day point prevalence smoking abstinence or progression along the stages of change. The intervention group showed improved depression and PTSD symptoms. CONCLUSION: Integrating MI-based smoking cessation treatment into PTSD home telehealth is an effective method to help Veterans with PTSD quit smoking. Further research is needed to understand how to optimize MI integration into home telehealth to achieve sustained smoking cessation rates.

Smoking cessation and care management for veterans with posttraumatic stress disorder: a study protocol for a randomized controlled trial.

BACKGROUND: Smoking remains the leading cause of preventable illness and mortality in the United States. Individuals with Posttraumatic Stress Disorder (PTSD) have smoking rates higher than that of others and fewer individuals with PTSD have quit smoking. This randomized controlled trial was designed to test the effectiveness of integrating telehealth care management and smoking cessation with motivational interviewing for Veterans with PTSD. METHODS/DESIGN: All smokers with PTSD, regardless of their desire to quit, were invited to participate. Enrollment occurred between November 2009 and April 2013. Target enrollment was 120 participants. Enrolled participants were randomized to either the control group, receiving usual care including a telehealth PTSD program, with a device that delivered PTSD information and in-home care management, or the intervention group, which included (1) a telehealth PTSD program, (2) motivational interviewing-based smoking cessation curricula via the telehealth device, and (3) weekly motivational interviewing counseling phone calls. Outcomes are self-reported 24-hour quit attempts, progression along the stages of change and 7-day point prevalence quit smoking rates for the intervention group compared to usual care alone. Secondary outcomes include participants' perception of care coordination, patient satisfaction with motivational interviewing, PTSD symptoms, pain, depression and quality of life. DISCUSSION: Motivational interviewing has been shown to increase readiness for change and smoking cessation care has been shown to be more successful when incorporated into in-person mental health care. Our study builds on previous studies. It integrates a written smoking cessation curriculum and phone-based motivational interviewing counseling into an established PTSD home telehealth care coordination program. This paper describes the design and methods of our randomized control trial. TRIAL REGISTRATION: ClinicalTrials.gov, NCT00908882, May 22, 2009.

Hair follicles modulate skin barrier function.

Our skin provides a protective barrier that shields us from our environment. Barrier function is typically associated with the interfollicular epidermis; however, whether hair follicles influence this process remains unclear. Here, we utilize a potent genetic tool to probe barrier function by conditionally ablating a quintessential epidermal barrier gene, Abca12, which is mutated in the most severe skin barrier disease, harlequin ichthyosis. With this tool, we deduced 4 ways by which hair follicles modulate skin barrier function. First, the upper hair follicle (uHF) forms a functioning barrier. Second, barrier disruption in the uHF elicits non-cell-autonomous responses in the epidermis. Third, deleting Abca12 in the uHF impairs desquamation and blocks sebum release. Finally, barrier perturbation causes uHF cells to move into the epidermis. Neutralizing IL-17a, whose expression is enriched in the uHF, partially alleviated some disease phenotypes. Altogether, our findings implicate hair follicles as multi-faceted regulators of skin barrier function.

Hair follicles modulate skin barrier function.

Our skin provides a protective barrier that shields us from our environment. Barrier function is typically associated with interfollicular epidermis; however, whether hair follicles influence this process remains unclear. Here, we utilize a potent genetic tool to probe barrier function by conditionally ablating a quintessential epidermal barrier gene, Abca12, which is mutated in the most severe skin barrier disease, harlequin ichthyosis. With this tool, we deduced 4 ways by which hair follicles modulate skin barrier function. First, the upper hair follicle (uHF) forms a functioning barrier. Second, barrier disruption in the uHF elicits non-cell autonomous responses in the epidermis. Third, deleting Abca12 in the uHF impairs desquamation and blocks sebum release. Finally, barrier perturbation causes uHF cells to move into the epidermis. Neutralizing Il17a, whose expression is enriched in the uHF, partially alleviated some disease phenotypes. Altogether, our findings implicate hair follicles as multi-faceted regulators of skin barrier function.

Headless, hungry, and unhealthy: a video content analysis of obese persons portrayed in online news.

The news media has substantial influence on public perceptions of social and health issues. This study conducted a video content analysis to examine portrayals of obese persons in online news reports about obesity. The authors downloaded online news videos about obesity (N = 371) from 5 major news websites and systematically coded visual portrayals of obese and nonobese adults and youth in these videos. The authors found that 65% of overweight/obese adults and 77% of overweight/obese youth were portrayed in a negative, stigmatizing manner across multiple obesity-related topics covered in online news videos. In particular, overweight/obese individuals were significantly more likely than were nonoverweight individuals to be portrayed as headless, with an unflattering emphasis on isolated body parts, from an unflattering rear view of their excess weight, eating unhealthy foods, engaging in sedentary behavior, and dressed in inappropriately fitting clothing. Nonoverweight individuals were significantly more likely to be portrayed positively. In conclusion, obese children and adults are frequently stigmatized in online news videos about obesity. These findings have important implications for public perceptions of obesity and obese persons and may reinforce negative societal weight bias.

Strategies to address weight-based victimization: youths' preferred support interventions from classmates, teachers, and parents.

Weight-Based Victimization is a frequent experience for adolescents who are overweight or obese, and is associated with numerous psychosocial and physical consequences for those who are targets of victimization. Assessing targets` preferences for different types of support and intervention has been absent in the context of weight-based victimization, but is needed to help inform potential interventions, motivate action, and identify strategies to help adolescents cope with experiences of weight-related teasing or bullying. Adolescents (14-18 years, N = 361, 40 % female, 71 % Caucasian) enrolled in national weight-loss camps completed an on-line survey. Participants who reported previous experiences of weight-based victimization were surveyed about their preferred interventions from peers, friends, teachers, Physical Education (PE) teachers/coaches, and parents. Participants indicated their preferences for specific strategies pertaining to target support, bullying intervention and prevention (e.g., inclusion in peer activities, confronting the bully, telling an adult, and improving anti-bullying policies). Friends (66 %) and peers (58 %) were the most highly preferred intervention agents followed by teachers (55 %), PE teachers/coaches (44 %), and parents (43 %). Participants who experienced more weight-based victimization expressed increased desire for intervention. The frequency of victimization, social support from friends and family, and perceived likelihood and helpfulness of intervention significantly influenced participant preferences for certain types of intervention, although preferences were generally consistent across participants' characteristics. The current study is the first to document youth's preferences for interventions in response to weight-based victimization. The findings have important implications for encouraging appropriate intervention and informing bystanders, which may help to reduce the prevalence, recurrence, and consequences for youth who are targets of weight-based teasing or bullying.

Basal cell carcinomas acquire secondary mutations to overcome dormancy and progress from microscopic to macroscopic disease.

Basal cell carcinomas (BCCs) frequently possess immense mutational burdens; however, the functional significance of most of these mutations remains unclear. Here, we report that loss of Ptch1, the most common mutation that activates upstream Hedgehog (Hh) signaling, initiates the formation of nascent BCC-like tumors that eventually enter into a dormant state. However, rare tumors that overcome dormancy acquire the ability to hyperactivate downstream Hh signaling through a variety of mechanisms, including amplification of Gli1/2 and upregulation of Mycn. Furthermore, we demonstrate that MYCN overexpression promotes the progression of tumors induced by loss of Ptch1. These findings suggest that canonical mutations that activate upstream Hh signaling are necessary, but not sufficient, for BCC to fully progress. Rather, tumors likely acquire secondary mutations that further hyperactivate downstream Hh signaling in order to escape dormancy and enter a trajectory of uncontrolled expansion.

Deafness in an auditory specialist, the big brown bat (Eptesicus fuscus).

Bats are long-lived animals that show presumed resistance to noise-induced and age-related hearing loss, which has been attributed to their dependence on sound processing for survival. Echolocation and basic auditory functions have been studied extensively in the big brown bat (Eptesicus fuscus), an insectivorous microchiropteran species. We conducted hearing tests and analysis of cochlear sensory cells in a group of big brown bats that exhibited anomalies in behavioral sonar tracking experiments and/or lacked neural responses to acoustic stimulation in subcortical auditory nuclei. We show for the first time the presence of profound deafness and extensive cochlear damage in an echolocating bat species. Auditory brainstem responses were abnormal or absent in these bats, and histological analyses of their cochleae revealed extensive loss of hair cells, supporting cells, and spiral ganglion neurons. The underlying cause of deafness is unknown.

Creating and testing regulatory focus messages to enhance medication adherence.

OBJECTIVES: Strategies were explored to improve patient adherence to cardioprotective medications by borrowing from a motivational framework used in psychology, regulatory focus theory. The current study is part of a larger randomized control trial and was aimed at understanding what written educational messages, based on patients' regulatory focus tendency, resonated with each individual as a potential reminder to take medications. This study was also aimed at understanding why messages resonated with the patients. METHODS: Twenty veterans were tested for regulatory fitand presented with messages dependent on focus tendency. In-person semi-structured interviews were conducted to collect feedback of messages. An iterative analysis drawing primarily on matrix and reflexive team analyses was conducted. RESULT: Six promotion and six prevention messages emerged, such as "team up with your provider to create a combination of medications to prevent illness" and "Live your best life - Take your medications". Five themes related to types of health messages that spoke to patients' regulatory fit were discovered: relatability; empowerment and control; philosophy on life; relationship with provider and medications; and vocabulary effect on the impact of messages. DISCUSSION: Motivational messages based on regulatory fit may be useful in improving patient medication adherence, leading to improved cardiovascular outcomes.

Niche-Specific Factors Dynamically Regulate Sebaceous Gland Stem Cells in the Skin.

Oil-secreting sebaceous glands (SGs) are critical for proper skin function; however, it remains unclear how different factors act together to modulate SG stem cells. Here, we provide functional evidence that each SG lobe is serviced by its own dedicated stem cell population. Upon ablating Notch signaling in different skin subcompartments, we find that this pathway exerts dual counteracting effects on SGs. Suppressing Notch in SG progenitors traps them in a hybrid state where stem and differentiation features become intermingled. In contrast, ablating Notch outside of the SG stem cell compartment indirectly drives SG expansion. Finally, we report that a K14:K5→K14:K79 keratin shift occurs during SG differentiation. Deleting K79 destabilizes K14 in sebocytes, and attenuates SGs and eyelid meibomian glands, leading to corneal ulceration. Altogether, our findings demonstrate that SGs integrate diverse signals from different niches and suggest that mutations incurred within one stem cell compartment can indirectly influence another.

Perspectives on a Home Telehealth Care Management Program for Veterans With Posttraumatic Stress Disorder Who Smoke.

BACKGROUND: Individuals with posttraumatic stress disorder (PTSD) have high rates of smoking and low quit rates. We conducted a qualitative evaluation of an integrated smoking cessation randomized controlled trial (RCT) that used home telehealth and motivational interviewing (MI) to change smoking behaviors among individuals with PTSD. METHOD: Using a convenience sample sourced from the original RCT, intervention and control group participants were invited to participate in a qualitative evaluation. Semistructured interview guides were used to assess the effectiveness of study components, make recommendations for future interventions, and identify facilitators/barriers to smoking cessation. We analyzed these data using an inductive and deductive, team-based content analysis approach. RESULTS: We interviewed 32 study participants (intervention: n = 15, control: n = 17) who completed the original RCT within the previous 6 months. Respondents were highly satisfied with home telehealth and MI counseling. The intervention group respondents found MI counseling to be supportive, nonjudgmental, and informative. Control group respondents felt that they had received smoking cessation assistance. Respondents from both groups desired more information about PTSD and smoking, relied on smoking as a coping mechanism for PTSD, and believed that quitting was an individual choice. CONCLUSION: Respondents reported that home telehealth and MI were acceptable ways to provide smoking cessation assistance to individuals with PTSD. The support and increased awareness of smoking behaviors were perceived as helpful. Future investigations should focus on increasing support and information about stress management, smoking, PTSD, and the relationship between them for individuals with PTSD who smoke.

Development and Feasibility of a Structured Goals of Care Communication Guide.

BACKGROUND: Discussing goals of care and advance care planning is beneficial, yet how to best integrate goals of care communication into clinical care remains unclear. OBJECTIVE: To develop and determine the feasibility of a structured goals of care communication guide for nurses and social workers. DESIGN/SETTING/SUBJECTS: Developmental study with providers in an academic and Veterans Affairs (VA) health system (n = 42) and subsequent pilot testing with patients with chronic obstructive pulmonary disease or heart failure (n = 15) and informal caregivers (n = 4) in a VA health system. During pilot testing, the communication guide was administered, followed by semistructured, open-ended questions about the content and process of communication. Changes to the guide were made iteratively, and subsequent piloting occurred until no additional changes emerged. MEASUREMENTS: Provider and patient feedback to the communication guide. RESULTS: Iterative input resulted in the goals of care communication guide. The guide included questions to elicit patient understanding of and attitudes toward the future of illness, clarify values and goals, identify end-of-life preferences, and agree on a follow-up plan. Revisions to guide content and phrasing continued during development and pilot testing. In pilot testing, patients validated the importance of the topic; none said the goals of care discussion should not be conducted. Patients and informal caregivers liked the final guide length (∼30 minutes), felt it flowed well, and was clear. CONCLUSIONS: In this developmental and pilot study, a structured goals of care communication guide was iteratively designed, implemented by nurses and social workers, and was feasible based on administration time and acceptability by patients and providers.

Rationale and study design of a patient-centered intervention to improve health status in chronic heart failure: The Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) randomized trial.

While contemporary heart failure management has led to some improvements in morbidity and mortality, patients continue to report poor health status (i.e., burdensome symptoms, impaired function, and poor quality of life). The Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) trial is a NIH-funded, three-site, randomized clinical trial that examines the effect of the CASA intervention compared to usual care on the primary outcome of patient-reported health status at 6months in patients with heart failure and poor health status. The CASA intervention involves a nurse who works with patients to treat symptoms (e.g., shortness of breath, fatigue, pain) using disease-specific and palliative approaches, and a social worker who provides psychosocial care targeting depression and adjustment to illness. The intervention uses a collaborative care team model of health care delivery and is structured and primarily phone-based to enhance reproducibility and scalability. This article describes the rationale and design of the CASA trial, including several decision points: (1) how to design a patient-centered intervention to improve health status; (2) how to structure the intervention so that it is reproducible and scalable; and (3) how to systematically identify outpatients with heart failure most likely to need and benefit from the intervention. The results should provide valuable information to providers and health systems about the use of team care to manage symptoms and provide psychosocial care in chronic illness.

The Veterans Health Administration's proposal for APRN full-practice authority.

The Veterans Health Administration (VHA) is proposing full-practice authority for advanced practice registered nurses (APRNs) to improve access, care delivery, and patient choice, as well as reduce costs. The authors performed a mixed-methods assessment to obtain the perspectives of administrators and APRNs on the characterization of the APRN workforce and their present practice in the VHA.

Public reactions to obesity-related health campaigns: a randomized controlled trial.

BACKGROUND: Despite numerous obesity-related health campaigns throughout the U.S., public perceptions of these campaigns have not been formally assessed. In addition, several recent publicized campaigns have come under criticism in the popular media for reinforcing stigmatization of obese people. Thus, research in this area is warranted. PURPOSE: To systematically assess public perceptions of recent obesity-related public health campaigns in the U.S. DESIGN: RCT. SETTING/PARTICIPANTS: The data were collected online in summer 2012 from a nationally representative sample of American adults (N=1085). INTERVENTION: Participants were randomly assigned to view 10 obesity-related health campaigns that were pretested and publicly criticized as being stigmatizing of obese people, or 10 campaigns that contained more-neutral content. MAIN OUTCOME MEASURES: Participants provided evaluations of each of the campaigns regarding the extent to which campaigns were rated to be stigmatizing of obese people, motivating for improving lifestyle behaviors, and promoting of self-efficacy for healthy behavior change. Participants additionally evaluated the appropriateness of the visual content depicted in each campaign. Analysis was completed in 2012. RESULTS: Stigmatizing campaigns were no more likely to instill motivation for improving lifestyle behaviors among participants than campaigns that were more neutral (OR=1.095, 95% CI=0.736, 1.630). Stigmatizing campaigns were also rated as inducing less self-efficacy (adjusted mean difference = -0.171 SD, 95% CI= -0.266, -0.076) and having less-appropriate visual content compared to less stigmatizing campaigns (adjusted difference in probability = -0.092, 95% CI= -0.124, -0.059). These findings remained consistent regardless of participants' body weight, and were generally consistent across sociodemographic predictors. CONCLUSIONS: This study highlights the need for careful selection of language and visual content used in obesity-related health campaigns, and provides support for efforts to portray obese people in a nonstigmatizing manner.

Weight-based victimization: bullying experiences of weight loss treatment-seeking youth.

OBJECTIVE: Few studies have comprehensively examined weight-based victimization (WBV) in youth, despite its serious consequences for their psychosocial and physical health. Given that obese and treatment-seeking youth may be highly vulnerable to WBV and its negative consequences, the current study provides a comprehensive assessment of WBV in a weight loss treatment-seeking sample. METHODS: Adolescents (aged 14-18 years; N = 361) enrolled in 2 national weight loss camps were surveyed. An in-depth assessment of WBV was conducted by using an online survey, in which participants indicated the duration, typical locations, frequent perpetrators, and forms of WBV they had experienced. RESULTS: Findings indicate that 64% of the study participants reported WBV at school, and the risk of WBV increased with body weight. Most participants reported WBV enduring for 1 year (78%), and 36% were teased/bullied for 5 years. Peers (92%) and friends (70%) were the most commonly reported perpetrators, followed by adult perpetrators, including physical education teachers/sport coaches (42%), parents (37%), and teachers (27%). WBV was most frequently reported in the form of verbal teasing (75%-88%), relational victimization (74%-82%), cyberbullying (59%-61%), and physical aggression (33%-61%). WBV was commonly experienced in multiple locations at school. CONCLUSIONS: WBV is a prevalent experience for weight loss treatment-seeking youth, even when they are no longer overweight. Given the frequent reports of WBV from adult perpetrators in addition to peers, treatment providers and school personnel can play an important role in identifying and supporting youth who may be at risk for pervasive teasing and bullying.

Eating behaviors, victimization, and desire for supportive intervention among adolescents in weight-loss camps.

This study examined links between eating behaviors, weight-based victimization (WBV) and preferences for bullying intervention among adolescents. Adolescents enrolled in weight loss camps participated in an online survey (N = 361). Regression models examined relationships between key variables. Almost half of adolescents who experienced WBV engaged in unhealthy eating behaviors, which corresponded to less desire for supportive intervention. Unhealthy eating behaviors may offset adaptive coping strategies to deal with WBV, such as support from peers and family.

An experimental assessment of physical educators' expectations and attitudes: the importance of student weight and gender.

BACKGROUND: At school, physical education (PE) teachers and coaches may be key supports for physical activity. Unfortunately, PE teachers may endorse negative stereotypes and attitudes toward overweight youth. These biases may influence the amount of instruction physical educators provide to students and their participation in PE or other physical activity. METHODS: This study assessed physical educators' (N = 162) ability and performance expectations, attributions, and attitudes toward overweight and non-overweight students. RESULTS: Physical educators endorsed inferior ability expectations for overweight students compared to non-overweight students. Poorer performance expectations were limited to overweight female targets, but when controlling for participant characteristics, this effect became marginally significant for overweight male targets. There was a trend such that participants endorsed more external attributions for the abilities and performance of overweight female students, yet this effect was reduced to marginal significance when controlling for participant characteristics. Participants endorsed more negative attitudes for both overweight males and females compared to non-overweight youth. CONCLUSIONS: Findings indicate that physical educators' expectations, attributions, and attitudes regarding students may be negatively influenced by youth body weight, and differ by student gender. The potential effect of physical educators' weight bias on adolescent participation in physical activity and its implications for students' physical health, academic achievement, and social development are discussed.

Parental perceptions of weight terminology that providers use with youth.

OBJECTIVES: Little research has been performed to examine patient perceptions of weight-related language, especially related to childhood obesity. In this study we assessed parental perceptions of weight-based terminology used by health care providers to describe a child's excess weight and assessed perceived connotations associated with these terms including stigma, blame, and motivation to reduce weight. METHODS: A national sample of American parents with children aged 2 to 18 years (N = 445) completed an online survey to assess their perceptions of 10 common terms to describe excess body weight in youth (including "extremely obese," "high BMI," "weight problem," "unhealthy weight," "weight," "heavy," "obese," "overweight," "chubby," and "fat"). Parents were asked to use a 5-point rating scale to indicate how much they perceived each term to be desirable, stigmatizing, blaming, or motivating to lose weight. RESULTS: Regression models revealed that the terms "weight" and "unhealthy weight" were rated as most desirable, and "unhealthy weight" and "weight problem" were rated as the most motivating to lose weight. The terms "fat," "obese," and "extremely obese" were rated as the most undesirable, stigmatizing, blaming, and least motivating. Parents' ratings were consistent across sociodemographic variables, body weight, and child's body weight. CONCLUSIONS: The results of this study have important implications for the improvement of health care for youth with obesity; it may be advantageous for health care providers to use or avoid using specific weight-based language during discussions about body weight with families. Pediatricians play a key role in obesity prevention and treatment, but their efforts may be undermined by stigmatizing or offensive language that can hinder important discussions about children's health.