Remote Implementation of a School-Based Health Promotion and Health Coaching Program in Low-Income Urban and Rural Sites: Program Impact during the COVID-19 Pandemic.

BACKGROUND: Adapting existing health programs for synchronous remote implementation has the potential to support vulnerable youth during the COVID 19 pandemic and beyond. METHODS: The Stanford Youth Diabetes Coaches Program (SYDCP), a school-based health promotion and coaching skills program, was adapted for remote implementation and offered to adolescents from low-income communities in the US: an urban site in San Jose, CA and rural sites in Lawrence County, MO, and Central Valley, CA. Participants completed online pre- and post- surveys. Analysis included paired T-tests, linear regression, and qualitative coding. RESULTS: Of 156 enrolled students, 100 completed pre- and post-surveys. Of those: 84% female; 40% Hispanic; 37% White; 28% Asian; 3% African American; 30% other race. With T-tests and regression models, the following measures showed statistically significant improvements after program participation: health knowledge, patient activation, health understanding and communication, consumption of fruits and vegetables, psychosocial assets of self-esteem, self-efficacy, problem-solving, and ability to reduce stress. Technology barriers were frequently reported at Lawrence County site. 96% participants reported making a lifestyle change after program participation. CONCLUSIONS: Remote implementation of health promotion programs for vulnerable youth in diverse settings has potential to support adoption of healthy behaviors, enhance patient activation levels, and improve psychosocial assets.

Individual-Level and Neighborhood-Level Factors Associated with Longitudinal Changes in Cardiometabolic Measures in Participants of a Clinic-Based Care Coordination Program: A Secondary Data Analysis.

Background: Identifying individual and neighborhood-level factors associated with worsening cardiometabolic risks despite clinic-based care coordination may help identify candidates for supplementary team-based care. Methods: Secondary data analysis of data from a two-year nurse-led care coordination program cohort of Medicare, Medicaid, dual-eligible adults, Leveraging Information Technology to Guide High Tech, High Touch Care (LIGHT2), from ten Midwestern primary care clinics in the U.S. Outcome Measures: Hemoglobin A1C, low-density-lipoprotein (LDL) cholesterol, and blood pressure. Multivariable generalized linear regression models assessed individual and neighborhood-level factors associated with changes in outcome measures from before to after completion of the LIGHT2 program. Results: 6378 participants had pre-and post-intervention levels reported for at least one outcome measure. In adjusted models, higher pre-intervention cardiometabolic measures were associated with worsening of all cardiometabolic measures. Women had worsening LDL-cholesterol compared with men. Women with pre-intervention HbA1c > 6.8% and systolic blood pressure > 131 mm of Hg had worse post-intervention HbA1c and systolic blood pressure compared with men. Adding individual's neighborhood-level risks did not change effect sizes significantly. Conclusions: Increased cardiometabolic risks and gender were associated with worsening cardiometabolic outcomes. Understanding unresolved gender-specific needs and preferences of patients with increased cardiometabolic risks may aid in tailoring clinic-community-linked care planning.

Effect of Stanford Youth Diabetes Coaches' Program on Youth and Adults in Diverse Communities.

The Stanford Youth Diabetes Coaches' Program (SYDCP) trains high school students to become diabetes coaches for friends and adult family members. The objective of this study was to assess effects of SYDCP participation on youth and adults from a rural and urban underserved high school community. We used a mixed-methods approach. Patient-Reported Outcomes Measurement Information System (PROMIS) measures for Pediatric Sense of Meaning and Purpose were measured in high school students. PROMIS Adult Global Health and Self-Efficacy was measured in coached adults. Paired t tests compared pre- and postintervention and 6-month follow-up scores. Thematic analysis was used to analyze focus group discussion of adults. Twenty-five students participated, 15 students coached adults with diabetes or prediabetes. Students' sense of meaning and purpose significantly improved postintervention compared to preintervention. Diet and physical activity behaviors improved. Adolescent-adult relationships mediated participation benefits. Our study showed SYDCP improved adolescents' sense of meaning and purpose. In addition, youth and adult relatedness led to improved health behaviors. These findings have important implications, as a sense of purpose and youth-adult connectedness are associated with health behaviors and psychological well-being. Further larger studies of health education programs that engage related youth-adult dyads and assess long-term behaviors and health outcomes are needed.

Home blood pressure data visualization for the management of hypertension: using human factors and design principles.

BACKGROUND: Home blood pressure measurements have equal or even greater predictive value than clinic blood pressure measurements regarding cardiovascular outcomes. With advances in home blood pressure monitors, we face an imminent flood of home measurements, but current electronic health record systems lack the functionality to allow us to use this data to its fullest. We designed a data visualization display for blood pressure measurements to be used for shared decision making around hypertension. METHODS: We used an iterative, rapid-prototyping, user-centred design approach to determine the most appropriate designs for this data display. We relied on visual cognition and human factors principles when designing our display. Feedback was provided by expert members of our multidisciplinary research team and through a series of end-user focus groups, comprised of either hypertensive patients or their healthcare providers required from eight academic, community-based practices in the Midwest of the United States. RESULTS: A total of 40 participants were recruited to participate in patient (N = 16) and provider (N = 24) focus groups. We describe the conceptualization and development of data display for shared decision making around hypertension. We designed and received feedback from both patients and healthcare providers on a number of design elements that were reported to be helpful in understanding blood pressure measurements. CONCLUSIONS: We developed a data display for substantial amounts of blood pressure measurements that is both simple to understand for patients, but powerful enough to inform clinical decision making. The display used a line graph format for ease of understanding, a LOWESS function for smoothing data to reduce the weight users placed on outlier measurements, colored goal range bands to allow users to quickly determine if measurements were in range, a medication timeline to help link recorded blood pressure measurements with the medications a patient was taking. A data display such as this, specifically designed to encourage shared decision making between hypertensive patients and their healthcare providers, could help us overcome the clinical inertia that often results in a lack of treatment intensification, leading to better care for the 35 million Americans with uncontrolled hypertension.

Home blood pressure data visualization for the management of hypertension: designing for patient and physician information needs.

BACKGROUND: Nearly half of US adults with diagnosed hypertension have uncontrolled blood pressure. Clinical inertia may contribute, including patient-physician uncertainty about how variability in blood pressures impacts overall control. Better information display may support clinician-patient hypertension decision making through reduced cognitive load and improved situational awareness. METHODS: A multidisciplinary team employed iterative user-centered design to create a blood pressure visualization EHR prototype that included patient-generated blood pressure data. An attitude and behavior survey and 10 focus groups with patients (N = 16) and physicians (N = 24) guided iterative design and confirmation phases. Thematic analysis of qualitative data yielded insights into patient and physician needs for hypertension management. RESULTS: Most patients indicated measuring home blood pressure, only half share data with physicians. When receiving home blood pressure data, 88% of physicians indicated entering gestalt averages as text into clinical notes. Qualitative findings suggest that including a data visualization that included home blood pressures brought this valued data into physician workflow and decision-making processes. Data visualization helps both patients and physicians to have a fuller understanding of the blood pressure 'story' and ultimately promotes the activated engaged patient and prepared proactive physician central to the Chronic Care Model. Both patients and physicians expressed concerns about workflow for entering and using home blood pressure data for clinical care. CONCLUSIONS: Our user-centered design process with physicians and patients produced a well-received blood pressure visualization prototype that includes home blood pressures and addresses patient-physician information needs. Next steps include evaluating a recent EHR visualization implementation, designing annotation functions aligned with users' needs, and addressing additional stakeholders' needs (nurses, care managers, caregivers). This significant innovation has potential to improve quality of care for hypertension through better patient-physician understanding of control and goals. It also has the potential to enable remote monitoring of patient blood pressure, a newly reimbursed activity, and is a strong addition to telehealth efforts.

Using the RE-AIM framework to evaluate internal and external validity of mobile phone-based interventions in diabetes self-management education and support.

OBJECTIVE: We evaluated the extent to which studies that tested short message service (SMS)- and application (app)-based interventions for diabetes self-management education and support (DSMES) report on factors that inform both internal and external validity as measured by the RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance) framework. MATERIALS AND METHODS: We systematically searched PubMed, Embase, Web of Science, CINAHL (Cumulative Index of Nursing and Allied Health Literature), and IEEE Xplore Digital Library for articles from January 1, 2009, to February 28, 2019. We carried out a multistage screening process followed by email communications with study authors for missing or discrepant information. Two independent coders coded eligible articles using a 23-item validated data extraction tool based on the RE-AIM framework. RESULTS: Twenty studies (21 articles) were included in the analysis. The comprehensiveness of reporting on the RE-AIM criteria across the SMS- and app-based DSMES studies was low. With respect to internal validity, most interventions were well described and primary clinical or behavioral outcomes were measured and reported. However, gaps exist in areas of attrition, measures of potential negative outcomes, the extent to which the protocol was delivered as intended, and description on delivery agents. Likewise, we found limited information on external validity indicators across adoption, implementation, and maintenance domains. CONCLUSIONS: Reporting gaps were found in internal validity but more so in external validity in the current SMS- and app-based DSMES literature. Because most studies in this review were efficacy studies, the generalizability of these interventions cannot be determined. Future research should adopt the RE-AIM dimensions to improve the quality of reporting and enhance the likelihood of translating research to practice.

Home Blood Pressure Monitoring in Cases of Clinical Uncertainty to Differentiate Appropriate Inaction From Therapeutic Inertia.

PURPOSE: Conventional clinic blood pressure (BP) measurements are routinely used for hypertension management and physician performance measures. We aimed to check home BP measurements after elevated conventional clinic BP measurements for which physicians did not intensify treatment, to differentiate therapeutic inertia from appropriate inaction. METHODS: We conducted a pre and post study of home BP monitoring for patients with uncontrolled hypertension as determined by conventional clinic BP measurements for which physicians did not intensify hypertension management. Physicians were notified of average home BP 2-4 weeks after the initial clinic visit. Outcome measures were the proportion of patients with controlled hypertension using average home BP measurements, changes in hypertension management by physicians, changes in physicians' hypertension metrics, and factors associated with home-clinic BP differences. RESULTS: Of 90 recruited patients who had elevated conventional clinic BP recordings, 65.6% had average home BP measurements that were <140/90 mm Hg. Physicians changed treatment plans for 61% of patients with average home BP readings of ≥140/90 mm Hg, whereas decisions to not change treatment for the remaining patients were based on contextual factors. Substituting average home BP for conventional clinic BP for 4% of patients from 2 physicians' hypertension registries improved the physicians' hypertension control rates by 3% to 5%. Greater body mass index and increased number of BP medications were associated with home BP measurement ≥140/90 mm Hg. Clinic BP levels did not estimate normal home BP levels. CONCLUSIONS: Documented home BP in cases of clinical uncertainty helped differentiate therapeutic inertia from appropriate inaction and improved physicians' hypertension metrics.

Lay Advisor Interventions in Rural Populations: A Systematic Review and Meta-analysis.

CONTEXT: Age-adjusted death rates for heart disease are higher in rural areas than in urban areas. Lay advisors could potentially facilitate improvement in cardiovascular health outcomes. The aim of this systematic review and meta-analysis is to estimate lay advisor intervention effects on cardiovascular health metrics in rural populations. EVIDENCE ACQUISITION: Searches of databases including MEDLINE, CINAHL, and Scopus from 1975 through October 2017 retrieved 323 citations, of which 272 abstracts were reviewed. Two authors independently abstracted data from eligible studies. Analysis was conducted in March 2018. EVIDENCE SYNTHESIS: Of 21 articles included in the systematic review, eight were RCTs and 13 were pre- and post-intervention studies. Of the RCTs, three took place in the U.S. Only two studies had low risk of bias. Using a random effects model, meta-analysis of six RCTs (1,641 participants) showed that lay advisor interventions in rural residents were associated with improvement in HbA1c of 0.4% (95% CI=0.13, 0.66, p=0.004, I2=60.65%). From four RCTs (873 participants), lay advisor interventions significantly improved BMI with pooled effect of 2.18 (95% CI=1.13, 3.24, p<0.001, I2=0.00%). Most studies had normal baseline blood pressure and cholesterol levels before intervention, and no significant effects were noted for these outcomes. Diverse types of measures used for diet, physical activity, and smoking precluded statistical synthesis. CONCLUSIONS: Lay advisor interventions had significant positive effects on glycemic control and BMI for rural residents; however, further rigorous studies are needed in U.S. rural populations, and elements of effective lay advisor interventions require further investigation.

Patient Judgments About Hypertension Control: The Role of Variability, Trends, and Outliers in Visualized Blood Pressure Data.

BACKGROUND: Uncontrolled hypertension is a significant health problem in the United States, even though multiple drugs exist to effectively treat this chronic disease. OBJECTIVE: As part of a larger project developing data visualizations to support shared decision making about hypertension treatment, we conducted a series of studies to understand how perceptions of hypertension control were impacted by data variations inherent in the visualization of blood pressure (BP) data. METHODS: In 3 Web studies, participants (internet sample of patients with hypertension) reviewed a series of vignettes depicting patients with hypertension; each vignette included a graph of a patient's BP. We examined how data visualizations that varied by BP mean and SD (Study 1), the pattern of change over time (Study 2), and the presence of extreme values (Study 3) affected patients' judgments about hypertension control and the need for a medication change. RESULTS: Participants' judgments about hypertension control were significantly influenced by BP mean and SD (Study 1), data trends (whether BP was increasing or decreasing over time-Study 2), and extreme values (ie, outliers-Study 3). CONCLUSIONS: Patients' judgment about hypertension control is influenced both by factors that are important predictors of hypertension related-health outcomes (eg, BP mean) and factors that are not (eg, variability and outliers). This study highlights the importance of developing data visualizations that direct attention toward clinically meaningful information.

The role of home BP monitoring: Answers to 10 common questions.

How does home BP monitoring stack up against clinic and ambulatory measurements for the Dx and management of hypertension? Find out in this review.

Effect of peer support interventions on cardiovascular disease risk factors in adults with diabetes: a systematic review and meta-analysis.

BACKGROUND: Peer support by persons affected with diabetes improves peer supporter's diabetes self-management skills. Peer support interventions by individuals who have diabetes or are affected by diabetes have been shown to improve glycemic control; however, its effects on other cardiovascular disease risk factors in adults with diabetes are unknown. We aimed to estimate the effect of peer support interventions on cardiovascular disease risk factors other than glycemic control in adults with diabetes. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials comparing peer support interventions to a control condition in adults affected by diabetes that measured any cardiovascular disease risk factors [Body Mass Index, smoking, diet, physical activity, cholesterol level, glucose control and blood pressure]. Quality was assessed by Cochrane's risk of bias tool. We calculated standardized mean difference effect sizes using random effects models. RESULTS: We retrieved 438 citations from multiple databases including OVID MEDLINE, Cochrane database and Scopus, and author searches. Of 233 abstracts reviewed, 16 articles met inclusion criteria. A random effects model in a total of 3243 participants showed a positive effect of peer support interventions on systolic BP with a pooled effect size of 2.07 mmHg (CI 0.35 mmHg to 3.79 mmHg, p = 0.02); baseline pooled systolic blood pressure was 137 mmHg. There was a non-significant effect of peer support interventions on diastolic blood pressure, cholesterol, body mass index, diet and physical activity. Cardiovascular disease risk factors other than glycemic control outcomes were secondary outcomes in most studies and baseline values were normal or mildly elevated. Only one study reported smoking outcomes. CONCLUSIONS: We found a small (2 mmHg) positive effect of peer support interventions on systolic blood pressure in adults with diabetes whose baseline blood pressure was on average minimally elevated. Additional studies need to be conducted to further understand the effect of peer support interventions on high-risk cardiovascular disease risk factors in adults with diabetes.

Dynamic Electronic Health Record Note Prototype: Seeing More by Showing Less.

INTRODUCTION: Cluttered documentation may contribute adversely to physician readers' cognitive load, inadvertently obscuring high-value information with less valuable information. We test the hypothesis that a novel, collapsible assessment, plan, subjective, objective (APSO) note design would be faster, more accurate, and more satisfying to use than a conventional electronic health record (EHR) subjective, objective, assessment, plan (SOAP) note for finding information needed for ambulatory chronic disease care. METHODS: We iteratively developed physician clinic note prototypes with features designed to emphasize more important information and de-emphasize less clinically relevant information. Sixteen primary care physicians reviewed comparable clinic notes with the 4 note styles presented in random order to find key information in the notes during timed tasks. The 4 note styles were denoted A (traditional SOAP note), B (2-column APSO note), C (collapsible APSO note), and D (2-column collapsible APSO note). The 4 unique note styles were designed to have equal amounts of information in each section. We simulated their utility for clinical practice by imposing time limits and by interrupting 1 of the tasks with a typical clinical interruption. For each session, we recorded audio, computer-screen activity, eye tracking, and made field notes. We obtained usability ratings (System Usability Scale), new feature preference ratings, and performed semistructured post-task interviews with subsequent content analysis. We compared the effectiveness of the 4 note styles by measuring time on task, task success (accuracy), and effort as measured by NASA Task Load Index. RESULTS: Note styles C and D were significantly faster than A and B for the Review of Systems and Physical Examination tasks, as we expected. Notes B and C had the best success (finding requested data) scores. Users strongly endorsed all the new note features incorporated into the new note prototypes. Previously expressed concerns about temporarily hiding parts of the note (using the accordion display design pattern) were allayed. Usability ratings for note A were worst but comparably better for note styles B, C, and D. DISCUSSION: The new APSO note prototypes performed better than the traditional SOAP note format for speed, task success (accuracy), and usability for physician users acquiring information needed for a typical chronic disease visit in primary care. Moving Assessment and Plan to the top is 1 easily accomplished feature change. Innovative documentation displays of EHR data can safely improve information display without eliminating data from the record of the visit.

Peer Support Interventions for Adults With Diabetes: A Meta-Analysis of Hemoglobin A1c Outcomes.

PURPOSE: Peer support intervention trials have shown varying effects on glycemic control. We aimed to estimate the effect of peer support interventions delivered by people affected by diabetes (those with the disease or a caregiver) on hemoglobin A1c (HbA1c) levels in adults. METHODS: We searched multiple databases from 1960 to November 2015, including Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, CINAHL, and Scopus. We included randomized controlled trials (RCTs) of adults with diabetes receiving peer support interventions compared with otherwise similar care. Seventeen of 205 retrieved studies were eligible for inclusion. Quality was assessed with the Cochrane risk of bias tool. We calculated the standardized mean difference (SMD) of change in HbA1c level from baseline between groups using a random effects model. Subgroup analyses were predefined. RESULTS: Seventeen studies (3 cluster RCTs, 14 RCTs) with 4,715 participants showed an improvement in pooled HbA1c level with an SMD of 0.121 (95% CI, 0.026-0.217; P = .01; I2 = 60.66%) in the peer support intervention group compared with the control group; this difference translated to an improvement in HbA1c level of 0.24% (95% CI, 0.05%-0.43%). Peer support interventions showed an HbA1c improvement of 0.48% (95% CI, 0.25%-0.70%; P <.001; I2 = 17.12%) in the subset of studies with predominantly Hispanic participants and 0.53% (95% CI, 0.32%-0.73%; P <.001; I2 = 9.24%) in the subset of studies with predominantly minority participants; both were clinically relevant. In sensitivity analysis excluding cluster RCTs, the overall effect size changed little. CONCLUSIONS: Peer support interventions for diabetes overall achieved a statistically significant but minor improvement in HbA1c levels. These interventions may, however, be particularly effective in improving glycemic control for people from minority groups, especially those of Hispanic ethnicity.