Pragmatic Trial of Hospitalization Rate in Chronic Kidney Disease.

BACKGROUND: Despite the availability of effective therapies for patients with chronic kidney disease, type 2 diabetes, and hypertension (the kidney-dysfunction triad), the results of large-scale trials examining the implementation of guideline-directed therapy to reduce the risk of death and complications in this population are lacking. METHODS: In this open-label, cluster-randomized trial, we assigned 11,182 patients with the kidney-dysfunction triad who were being treated at 141 primary care clinics either to receive an intervention that used a personalized algorithm (based on the patient's electronic health record [EHR]) to identify patients and practice facilitators to assist providers in delivering guideline-based interventions or to receive usual care. The primary outcome was hospitalization for any cause at 1 year. Secondary outcomes included emergency department visits, readmissions, cardiovascular events, dialysis, and death. RESULTS: We assigned 71 practices (enrolling 5690 patients) to the intervention group and 70 practices (enrolling 5492 patients) to the usual-care group. The hospitalization rate at 1 year was 20.7% (95% confidence interval [CI], 19.7 to 21.8) in the intervention group and 21.1% (95% CI, 20.1 to 22.2) in the usual-care group (between-group difference, 0.4 percentage points; P = 0.58). The risks of emergency department visits, readmissions, cardiovascular events, dialysis, or death from any cause were similar in the two groups. The risk of adverse events was also similar in the trial groups, except for acute kidney injury, which was observed in more patients in the intervention group (12.7% vs. 11.3%). CONCLUSIONS: In this pragmatic trial involving patients with the triad of chronic kidney disease, type 2 diabetes, and hypertension, the use of an EHR-based algorithm and practice facilitators embedded in primary care clinics did not translate into reduced hospitalization at 1 year. (Funded by the National Institutes of Health and others; ICD-Pieces ClinicalTrials.gov number, NCT02587936.).

Applying Lean Six Sigma to Improve Depression Screening and Follow-Up in Oncology Clinics.

ABSTRACT: Depression is a common and serious illness that impairs the health of individuals and societies globally. It is associated with a significant economic burden, with productivity losses exceeding $40 billion dollars annually in the United States (U.S.) alone. This project focused on the use of a systematic, data-driven approach to improve the screening rate for depression in an academic, metropolitan cancer center located in North Texas. A multidisciplinary team collaboratively applied Lean Six Sigma education, methods, and tools within oncology and psychiatry clinics to address the increased risk of depression among oncology patients. Improving the standardization of screening and follow-up processes, resulted in a 44% sustained increase in the depression screening and follow-up performance rate. This improvement was verified to be statistically significant through the use of control charts toward the end of the project.

Development of the Thalassaemia Adult Life Index (ThALI).

BACKGROUND: Beta Thalassaemia Major (ßTM) is a chronic genetic illness whereby the challenges faced by patients exposes them to increased risk of psychosocial issues. Despite this, a disease-specific tool to measure the impact of this illness on adult patients has yet to be developed. METHODS: In collaboration with ßTM adult patients, this study aimed to develop a comprehensive, disease-specific, easy to use psychometrically sound tool to measure the impact of chelation and transfusion dependent ßTM in a cross-cultural patient group in England.The Thalassaemia Life Index (ThALI) was developed in two stages - item generation and pre-testing and item reduction - in collaboration with service users. Recruited adult patients shaped the design of the instrument including its statements and subscales. Standard item reduction techniques were used to develop the instrument. RESULTS: The final version of the ThALI encompasses 35 statements and five sub-scales - general physical health, coping, body image, appearance and confidence, social relationships and autonomy. This endorses the multidimensionality of quality of life (QoL). The factor structure of the ThALI is highly stable and its internal consistency is high (alpha = 0.87 for the overall scale; 0.83-0.94 for its subscales). The ThALI has sound scaling assumptions, acceptability and score variability. Content validity was confirmed by experts and service user interviewees. The loadings for the items retained were adequate and the item discriminant validity sound. CONCLUSIONS: The ThALI covers the impact of ßTM in adult patients. Preliminary testing shows its multidimensionality to be reliable and valid. The national authentication of the tool with patients treated in Centres of Excellence will aim to provide further evidence regarding the ThALI's psychometric properties. Once authenticated, the ThALI may be utilised in research and in clinical settings to assess the effects of new therapies and/or interventions from the patients' perspective to inform practice and/or to identify areas of concern.

Repressive coping and cardiovascular reactivity to novel and recurrent stress.

BACKGROUND AND OBJECTIVES: Repressors tend to report less negative emotion and to describe challenges as less stressful, yet tend to exhibit higher rates of cardiovascular disease. While repressive coping has been shown to be associated with exaggerated physiological reactivity to novel stress, we sought to establish if elevated responses persisted across repeated exposure. DESIGN AND METHODS: In a sample of 86 healthy female adults, a verbal-autonomic response dissociation index of repressive coping was computed. Participants were exposed to two consecutive stress tasks, with analyses based on comparisons of consecutive stress responses. RESULTS: Analysis of covariance demonstrated significant differences across the study on diastolic blood pressure and cardiac output, as a function of repressive coping. Repressors showed elevated reactions to both stress tasks; however, cardiac output responses to the second task were more muted indicating that repressive coping was associated with successful adaptation to recurrent stress. Nevertheless, repressive copers maintained an exaggerated cardiovascular responses to recurrent stress. CONCLUSIONS: The present study identifies that repressive coping may be associated with increased risk of cardiovascular disease development through elevated cardiovascular reactions to both novel and recurrent stress.

A longitudinal investigation of repressive coping and ageing.

OBJECTIVES: Two studies investigated the possibility that repressive coping is more prevalent in older adults and that this represents a developmental progression rather than a cohort effect. Study 1 examined repressive coping and mental health cross-sectionally in young and old adults. Study 2 examined whether there was a developmental progression of repressive coping prevalence rates in a longitudinal sample of older adults. METHOD: Study 1 compared younger adults (mean age 27.6 years) with older adults (mean age 74.2 years) on inventories of mental health and well-being and examined the prevalence of repressive coping in both samples. Study 2 re-tested a sample of older adults previously reported following an interval of 7 years. RESULTS AND CONCLUSION: Study 1 - in line with previous research older adults demonstrated greater psychological well-being and had a higher prevalence of repressive coping than younger adults (at 30% vs. 12% respectively). Study 2 - the data indicated that the prevalence of repressive coping rose from 41% at the first time of testing (2002) to 56.4% at the second testing interval (2009). These results suggest that repressive coping may increase across the lifespan in certain individuals and continue to increase throughout older adulthood. Furthermore, this increase in repressive coping with age appears to result in better well-being in those older adults who become repressive copers.

The relationship between two types of impaired emotion processing: repressive coping and alexithymia.

The constructs of repressive coping and alexithymia are both related to impaired emotion processing, yet individuals with a repressive coping style (repressors) score lower than controls on standard self-report measures of alexithymia. A large body of evidence indicates that repressors avoid negative affect. Therefore, the current study examined the relationship between repressive coping and alexithymia by using independently-rated interviews with the aim of bypassing repressors' tendency of avoiding negative affect. Results showed that repressors scored high on alexithymia, similar to anxious individuals on the independently-rated interview, but scored low on alexithymia on a questionnaire measure. Our findings confirm a link between alexithymia and repressive coping and stress the need for non-standard measures in exploring the nature of the relationship between repressive coping and alexithymia.

Changing smokers' risk perceptions--for better or worse?

This study investigated the effect of a smoking health message on smokers' comparative optimism. Two groups watched an anti-smoking scenario, with one group imagining being part of the scenario. Participants, including controls, completed comparative optimism ratings for four smoking-related illnesses. The intervention had negative consequences with both intervention groups reporting significantly higher comparative optimism versus the control group for all four smoking-related illnesses. It is concluded that media health messages can be powerful tools in changing comparative optimism but are influenced by peoples' prior perceptions. Health messages need to be systematically assessed to understand prior beliefs of the target audience.

Determinants of personal protective equipment (PPE) use in UK motorcyclists: exploratory research applying an extended theory of planned behaviour.

Despite evident protective value of motorcycle personal protective equipment (PPE), no research has assessed considerations behind its uptake in UK riders. A cross-sectional online questionnaire design was employed, with riders (n=268) recruited from online motorcycle forums. Principal component analysis found four PPE behavioural outcomes. Theoretical factors of intentions, attitudes, injunctive and descriptive subjective norms, risk perceptions, anticipated regret, benefits and habit were also identified for further analysis. High motorcycle jacket, trousers and boots wear, middling high-visibility wear and low non-Personal Protective Equipment wear were found. Greater intentions, anticipated regret and perceived benefits were significantly associated with increased motorcycle jacket, trousers and boots wear, with habit presence and scooter use significantly associated with increased high-visibility wear. Lower intentions, anticipated regret and risk perceptions, being female, not holding a car licence and urban riding were significantly associated with increased non-PPE wear. A need for freedom of choice and mixed attitudes towards PPE use were evident in additional comments. PPE determinants in this sample provide a preliminary basis for future uptake interventions. Larger scale and qualitative research is needed to further investigate relevant constructs.

Do media messages change people's risk perceptions for binge drinking?

AIMS: The current study investigated the effect of a media health message for drinking on risk perception estimates (comparative optimism). METHODS: Sixty-five young adults who regularly drink alcohol watched an anti-drinking scenario (having an accident due to drinking). There were two intervention conditions: 30 participants 'imagined' they were part of the scenario, and 35 'watched' the scenario. They then completed four comparative optimism estimates comparing themselves to those the same age and gender with similar drinking habits. The four comparisons were of their likelihood of being involved in an accident due to drinking; having unprotected sex, when under the influence of alcohol; having a car accident due to drinking (drivers only) and developing cirrhosis. There was also a control group (n = 59) who just completed the questionnaires. RESULTS: Both intervention groups reported significantly lower comparative optimism for accident, unprotected sex and car accident than the control group. The 'imagine' group reported significantly lower comparative optimism than the 'watch' group for accidents. CONCLUSIONS: These results highlighted that media messages can successfully change people's risk perception, and also that imagination can be a powerful tool in changing risk perceptions associated with binge drinking.

Determinants of adults' intention to vaccinate against pandemic swine flu.

BACKGROUND: Vaccination is one of the cornerstones of controlling an influenza pandemic. To optimise vaccination rates in the general population, ways of identifying determinants that influence decisions to have or not to have a vaccination need to be understood. Therefore, this study aimed to predict intention to have a swine influenza vaccination in an adult population in the UK. An extension of the Theory of Planned Behaviour provided the theoretical framework for the study. METHODS: Three hundred and sixty two adults from the UK, who were not in vaccination priority groups, completed either an online (n = 306) or pen and paper (n = 56) questionnaire. Data were collected from 30th October 2009, just after swine flu vaccination became available in the UK, and concluded on 31st December 2009. The main outcome of interest was future swine flu vaccination intentions. RESULTS: The extended Theory of Planned Behaviour predicted 60% of adults' intention to have a swine flu vaccination with attitude, subjective norm, perceived control, anticipating feelings of regret (the impact of missing a vaccination opportunity), intention to have a seasonal vaccine this year, one perceived barrier: "I cannot be bothered to get a swine flu vaccination" and two perceived benefits: "vaccination decreases my chance of getting swine flu or its complications" and "if I get vaccinated for swine flu, I will decrease the frequency of having to consult my doctor," being significant predictors of intention. Black British were less likely to intend to have a vaccination compared to Asian or White respondents. CONCLUSIONS: Theoretical frameworks which identify determinants that influence decisions to have a pandemic influenza vaccination are useful. The implications of this research are discussed with a view to maximising any future pandemic influenza vaccination uptake using theoretically-driven applications.

Initial psychological responses to swine flu.

BACKGROUND: The emergence of influenza A ("swine flu") in early 2009 led to widespread public concern. However, little research has examined the factors that underlie initial worry about infection and subsequent behavioral responses to such worry. PURPOSE: This study seeks to model some key predictors of worry and behavioral responses in the early stages of the swine flu pandemic (WHO pandemic stage 5). METHOD: A cross-sectional internet questionnaire study (N = 186). RESULTS: Twenty-five percent of respondents rated themselves as worried about being a victim of swine flu, 40% that they were worried of a family member contracting the virus. Twenty percent had bought, or intended to buy, preparatory materials (e.g., face masks), 20% intended to delay or cancel air travel. In a structural equation model, conservation values and family or friends perception of risks predicted worry about infection, while worry correlated with the purchase of preparatory materials, a lesser willingness to travel by public transport, and difficulty in focusing on everyday activities. CONCLUSION: While previous research on pandemic risk perception has focused on cognitive risk judgments, our data suggests that initial "emotional" concerns about infection are also significant predictors of behavioral responses to pandemic threat. Such worry is likely to be influenced by a variety of individual factors, such as personal values, as well as normative pressures. Practitioners can use and expand on such models of pandemic response when tailoring health campaigns to meet newly emergent threats.

Understanding of stroke and coronary heart disease in the UK: an exploratory study.

It has been suggested by the UK's 2007 National Stroke strategy for England (NSSFE) that general population awareness is high for coronary heart disease (CHD) but low for stroke. This was investigated in the present study. One hundred eighty-two members of the general public completed a questionnaire about understanding of stroke/CHD. Data were analysed using ANOVA, t-tests and chi square. The main findings were that although members of the general public understood some of the main aspects of stroke and CHD, there was more awareness of general facts about CHD than stroke but symptoms of stroke were better identified compared to CHD. Therefore, our findings only partially supported the NSSFE view.

Mediation of personality influences on physical activity within the theory of planned behaviour.

This study estimated the effect of extraversion, conscientiousness and variables from a modified two-component Theory of Planned Behaviour (TPB) on prospective self-reported physical activity (N = 397). Mediation analysis using structural equation modelling with bootstrapping suggested that only conscientiousness had significant effects on intention and behaviour. Affective attitude and perceived behavioural control partially mediated the effect on intention. The effect on behaviour was significantly mediated by TPB variables consistent with partial or total mediation. The modified TPB mediates the effects of conscientiousness on intention and behaviour; it is unclear whether it is sufficient to mediate all of the effect on behaviour.

The importance of the repressive coping style: findings from 30 years of research.

During the last three decades there has been substantial research exploring the repressive coping style as defined by Weinberger, Schwartz, and Davidson. As "repressors," who score low on trait anxiety and high on defensiveness, account for up to 50% of certain populations, they are an essential group for psychologists to study. However, there are methodological issues in identifying repressors as well as considerable evidence that repressors avoid negative self-relevant information. Possible methods of addressing these difficulties are discussed in this review. Importantly, there is a body of evidence linking repressive coping and poor physical health, including heart disease and cancer. However, some preliminary findings suggest that repressors compared to non-repressors may be better at health behaviors that they perceive as under their personal control. This needs more extensive investigation as such behaviors are only one aspect of health and other factors may contribute to repressors' poor physical health. Possible future directions of research are discussed including: the need for systematic empirical research of a new theory of repressive coping--the Vigilance-Avoidance Theory--more longitudinal health studies, and an in-depth exploration of the physiological mechanisms which may underlie repressive coping.

Initial psychological responses to Influenza A, H1N1 ("Swine flu").

BACKGROUND: The outbreak of the pandemic flu, Influenza A H1N1 (Swine Flu) in early 2009, provided a major challenge to health services around the world. Previous pandemics have led to stockpiling of goods, the victimisation of particular population groups, and the cancellation of travel and the boycotting of particular foods (e.g. pork). We examined initial behavioural and attitudinal responses towards Influenza A, H1N1 ("Swine flu") in the six days following the WHO pandemic alert level 5, and regional differences in these responses. METHODS: 328 respondents completed a cross-sectional Internet or paper-based questionnaire study in Malaysia (N = 180) or Europe (N = 148). Measures assessed changes in transport usage, purchase of preparatory goods for a pandemic, perceived risk groups, indicators of anxiety, assessed estimated mortality rates for seasonal flu, effectiveness of seasonal flu vaccination, and changes in pork consumption RESULTS: 26% of the respondents were 'very concerned' about being a flu victim (42% Malaysians, 5% Europeans, p < .001). 36% reported reduced public transport use (48% Malaysia, 22% Europe, p < .001), 39% flight cancellations (56% Malaysia, 17% Europe, p < .001). 8% had purchased preparatory materials (e.g. face masks: 8% Malaysia, 7% Europe), 41% Malaysia (15% Europe) intended to do so (p < .001). 63% of Europeans, 19% of Malaysians had discussed the pandemic with friends (p < .001). Groups seen as at 'high risk' of infection included the immune compromised (mentioned by 87% respondents), pig farmers (70%), elderly (57%), prostitutes/highly sexually active (53%), and the homeless (53%). In data collected only in Europe, 64% greatly underestimated the mortality rates of seasonal flu, 26% believed seasonal flu vaccination gave protection against swine flu. 7% had reduced/stopped eating pork. 3% had purchased anti-viral drugs for use at home, while 32% intended to do so if the pandemic worsened. CONCLUSION: Initial responses to Influenza A show large regional differences in anxiety, with Malaysians more anxious and more likely to reduce travel and to buy masks and food. Discussions with family and friends may reinforce existing anxiety levels. Particular groups (homosexuals, prostitutes, the homeless) are perceived as at greater risk, potentially leading to increased prejudice during a pandemic. Europeans underestimated mortality of seasonal flu, and require more information about the protection given by seasonal flu inoculation.

An exploratory study investigating factors associated with adherence to chest physiotherapy and exercise in adults with cystic fibrosis.

This study explored the relationship between psychological and demographic variables relating to chest physiotherapy (CP) and exercise in adults with cystic fibrosis. The main results were that adherence to both treatments was low and analysis of variance indicated that severity and gender were associated with exercise adherence, importance and burden. These results suggest potential areas for interventions to improve exercise adherence.

The effects of age on psychopathology, well-being and repressive coping.

The present study was conducted to test the hypothesis that the increased psychological well-being and positivity effect in old age can be related to a high prevalence of repressive coping in healthy older adults. Both older (mean age 73) and younger (mean age 20) adults completed a range of indices measuring psychopathology and repressive coping. Results showed that older adults scored lower than younger adults on almost all indices of psychopathology, and were more likely to be classed as repressive copers than younger adults (41% versus 11%, respectively). Furthermore, when the repressive copers and borderline repressors were removed from both samples, age effects on several, but not all, measures of psychopathology disappeared, indicating that even older non-repressors showed better mental health than young non-repressors. Possible mechanisms of increased positivity, in terms of repressive coping and reductions in intrusive thoughts and rumination in old age, are discussed.

Adherence to chest physiotherapy in adults with cystic fibrosis.

Chest physiotherapy (CP) is seen as a cornerstone of Cystic Fibrosis (CF) treatment. However, previous studies have suggested that adherence to CP is low. This study of adults with CF (N = 563) investigated CP adherence and associated factors. Only 29.5 per cent reported undertaking daily CP. Predictors of adherence included problems with fitting CP into lifestyle, a perception that CP does not help, physical consequences of CP, doing exercises instead and doing CP as and when necessary. These variables accounted for 45 per cent of the variance in adherence. Content analysis revealed a number of themes related to adherence to CP. Future studies should explore the benefits of daily CP and attempt to devise simple interventions to maximize adherence to CP.

Social cognitive predictors of sun protection intention and behavior.

The authors investigated sunbathing behavior and intention prospectively using the Theory of Planned Behavior (TPB). Before summer, 85 young adults who intended to sunbathe completed a TPB questionnaire. After summer; 46 of them completed a second questionnaire about their summertime sunbathing behavior The proposed model was successful in predicting both behavior and intention to use sun protection, with 45% of the variance of self-reported sunscreen use and 32% of the variance in intention explained by the TPB. Items designed to measure self-efficacy and perceived control loaded onto different factors and demonstrated discriminant validity. Self-efficacy predicted both intention and behavior (after controlling for all other TPB variables), but perceived behavioral control did not. The authors discuss the implications of the findings for potential interventions to improve sun protection behavior