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2.
J Gen Intern Med ; 2019 Oct 23.
Artigo em Inglês | MEDLINE | ID: mdl-31646455

RESUMO

BACKGROUND: Shared decision-making (SDM) is widely recognized as a core strategy to improve patient-centered care. However, the implementation of SDM in routine care settings has been slow and its impact mixed. OBJECTIVE: We examine the temporal association of patient activation and patients' experience with the SDM process to assess the dominant directionality of this relationship. DESIGN: Patient activation, or a patients' knowledge, skills, and confidence in self-management, was assessed using the 13-item Patient Activation Measure (PAM). Patient-reported assessment of the SDM process was assessed using the 3-item CollaboRATE measure. Patients at 16 adult primary care practices were surveyed in 2015 and 2016 on PAM (α = 0.92), CollaboRATE (α = 0.90), and demographics. The relationship between PAM and CollaboRATE was estimated using a cross-lagged panel model with clustered robust standard errors and practice fixed effects, controlling for patient characteristics. PARTICIPANTS: 1222 adult patients with diabetes and/or cardiovascular disease with survey responses at baseline (51% response rate) and a 1-year follow-up (73% response rate). RESULTS: PAM (mean 3.27 vs 3.28 on a range of 1 to 4; p = 0.082) and CollaboRATE (mean 3.62 vs 3.63 on a range of 1 to 5; p = 0.14) did not change significantly over time. In adjusted analyses, the path from baseline PAM to follow-up CollaboRATE (ß = 0.35; p < 0.0001) was stronger than the path from baseline CollaboRATE to follow-up PAM (ß = 0.04; p = 0.001). CONCLUSIONS: The relationship between patient activation and patients' experiences of the SDM process is bidirectional, but dominated by baseline patient activation. Rather than promoting the use of SDM for all patients, healthcare organizations should prioritize interventions to promote patient activation and engage patients with relatively high activation in SDM interventions.

3.
Med Care ; 57(9): 710-717, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31295167

RESUMO

BACKGROUND: The State Innovation Models (SIM) Initiative invested $254 million in 6 states in Round 1 to accelerate delivery system and payment reforms. OBJECTIVE: The objective of this study was to examine the association of early SIM implementation and diagnosed diabetes prevalence among adults and hospitalization rates among diagnosed adults. RESEARCH DESIGN: Quasi-experimental design compares diagnosed diabetes prevalence and hospitalization rates before SIM (2010-2013) and during early implementation (2014) in 6 SIM states versus 6 comparison states. County-level, difference-in-differences regression models were estimated. SUBJECTS: The annual average of 4.5 million adults aged 20+ diagnosed with diabetes with 1.4 million hospitalizations in 583 counties across 12 states. MEASURES: Diagnosed diabetes prevalence among adults and hospitalization rates per 1000 diagnosed adults. RESULTS: Compared with the pre-SIM period, diagnosed diabetes prevalence increased in SIM counties by 0.65 percentage points (from 10.22% to 10.87%) versus only 0.10 percentage points (from 9.64% to 9.74%) in comparison counties, a difference-in-differences of 0.55 percentage points. The difference-in-differences regression estimates ranged from 0.49 to 0.53 percentage points (P<0.01). Regression results for ambulatory care-sensitive condition and all-cause hospitalization rates were inconsistent across models with difference-in-differences estimates ranging from -5.34 to -0.37 and from -13.16 to 0.92, respectively. CONCLUSIONS: SIM Round 1 was associated with higher diagnosed diabetes prevalence among adults after a year of implementation, likely because of SIM's emphasis on detection and care management. SIM was not associated with lower hospitalization rates among adults diagnosed with diabetes, but the SIM's long-term impact on hospitalizations should be assessed.

4.
ACS Nano ; 13(6): 7223-7230, 2019 Jun 25.
Artigo em Inglês | MEDLINE | ID: mdl-31194513

RESUMO

Laser tweezers afford quantum dot (QD) manipulation for use as localized emitters. Here, we demonstrate fluorescence by radiative energy transfer from optically trapped colloidal QDs (donors) to fluorescent dyes (acceptors). To this end, we synthesized silica-coated QDs of different compositions and triggered their luminescence by simultaneous trapping and two-photon excitation in a microfluidic chamber filled with dyes. This strategy produces a near-field light source with great spatial maneuverability, which can be exploited to scan nanostructures. In this regard, we demonstrate induced photoluminescence of dye-labeled cells via optically trapped silica-coated colloidal QDs placed at their vicinity. Allocating nanoscale donors at controlled distances from a cell is an attractive concept in fluorescence microscopy because it dramatically reduces the number of excited dyes, which improves resolution by preventing interferences from the whole sample, while prolonging dye luminescence lifetime due to the lower power absorbed from the QDs.

5.
Sci Rep ; 9(1): 8974, 2019 Jun 20.
Artigo em Inglês | MEDLINE | ID: mdl-31221992

RESUMO

Our knowledge regarding microbiota associated with the swim bladder of physostomous, fish with the swim bladder connected to the esophagus via the pneumatic duct, remains largely unknown. The goal of this study was to conduct the first in-depth characterization of the swim bladder-associated microbiota using high-throughput sequencing of the V4 region of the 16 S rRNA gene in rainbow trout (Oncorhynchus mykiss). We observed major differences in bacterial communities composition between swim bladder-associated microbiota and distal intestine digesta microbiota in fish. Whilst bacteria genera, such as Cohnella, Lactococcus and Mycoplasma were more abundant in swim bladder-associated microbiota, Citrobacter, Rhodobacter and Clavibacter were more abundant in distal intestine digesta microbiota. The presumptive metabolic function analysis (PICRUSt) revealed several metabolic pathways to be more abundant in the swim bladder-associated microbiota, including metabolism of carbohydrates, nucleotides and lipoic acid as well as oxidative phosphorylation, cell growth, translation, replication and repair. Distal intestine digesta microbiota showed greater abundance of nitrogen metabolism, amino acid metabolism, biosynthesis of unsaturated fatty acids and bacterial secretion system. We demonstrated swim bladder harbors a unique microbiota, which composition and metabolic function differ from microbiota associated with the gut in fish.

6.
Milbank Q ; 97(3): 692-735, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31206824

RESUMO

Policy Points Accountable care organizations (ACOs) have incentives to promote the adoption of patient engagement strategies such as shared decision making and self-management support programs to improve patient outcomes and contain health care costs. High adoption of patient engagement strategies among ACO-affiliated practices did not improve patient-reported outcomes (PROs) of physical, emotional, and social function among adult patients with diabetes and/or cardiovascular disease over a one-year time frame, likely because implementing these strategies requires extensive clinician and staff training, workflow redesign, and patient participation over time. A dominant focus on improving clinical measures to meet external requirements may crowd out time needed for care team members to address other outcomes that matter to patients, including PROs. Payers and policy-makers should explicitly incentivize the collection and use of PROs when contracting with ACOs. CONTEXT: Adult primary care practices of accountable care organizations (ACOs) are adopting a range of patient engagement strategies, but little is known about how these strategies are related to patient-reported outcomes (PROs) and how relational coordination among team members aids implementation. METHODS: We used a mixed-methods cohort study design integrating administrative and clinical data with two data collection waves (2014-2015 and 2016-2017) of clinician and staff surveys (n = 764), surveys of adult patients with diabetes and/or cardiovascular disease (CVD) (n = 1,276), and key informant interviews of clinicians, staff, and administrators (n = 103). Multivariable linear regression estimated the relationship of practice adoption of patient engagement strategies, relational coordination, and PROs of physical, social, and emotional function. The mediating role of patient activation was examined using cross-lagged panel models. Key informant interviews assessed how relational coordination influences the implementation of patient engagement strategies. FINDINGS: There were no differential improvements in PROs among patients of practices with high vs. low adoption of patient engagement strategies or among patients of practices with high vs. low relational coordination. The Patient Activation Measure (PAM) is strongly related to better physical, emotional, and social PROs over time. Relational coordination facilitated the implementation of patient engagement strategies, but key informants indicated that resources and systems to systematically track treatment preferences and goals beyond clinical indicators were needed to support effective implementation. CONCLUSIONS: Adult patients with diabetes and/or CVD of ACO-affiliated practices with high adoption of patient engagement strategies do not have improved PROs of physical, emotional, and social function over a one-year time frame. Implementing patient engagement strategies increases task interdependence among primary care team members, which needs to be carefully managed. ACOs may need to make greater investment in collecting, monitoring, and analyzing PRO data to ensure that practice adoption and implementation of patient engagement strategies leads to improved physical, emotional, and social function among patients.

7.
Arch. méd. Camaguey ; 23(2): 279-292, mar.-abr. 2019. tab, graf
Artigo em Espanhol | LILACS-Express | ID: biblio-1001238

RESUMO

RESUMEN Fundamento: el cáncer de páncreas presenta una alta mortalidad, producto que la mayoría de las veces se diagnóstica en etapa avanzada. El tratamiento de elección es la resección quirúrgica, la cual debida a su complejidad está acompañada de una morbimortalidad importante, cuando no se realiza en centros de alto volumen. Dentro de las complicaciones, la fístula pancreática postoperatoria, es de aparición frecuente. Objetivo: realizar una revisión sistemática actualizada acerca del concepto y clasificación de la fístula pancreática postoperatoria. Métodos: se realizó una revisión sistemática de la literatura con la base de datos SCOPUS bajo los criterios que establecen sus revisores, se utillizaron las siguientes palabras claves: pancreatic fistula, pancreatic surgery, complications, mortality, Whipple procedure. Se incluyeron todas las publicaciones en inglés y español. El método de análisis y síntesis se utilizó para la interpretación de la bibliografía. Resultados: se revisaron 175 artículos, de los cuales, se escogieron 55, que cumplían con los criterios de selección. Entre ellos, cuatro metanálisis, ocho artículos de revisión y 33 artículos originales. Conclusiones: el concepto y clasificación de la fístula pancreática postoperatoria constituye una herramienta válida para la comparación de resultados quirúrgicos entre instituciones. La centralización de la atención en centros de alto volumen constituye la principal medida para disminuir esta complicación.


ABSTRACT Background: pancreatic cancer presents a high mortality, a product that most of the time is diagnosed in advanced stage. The treatment of choice is surgical resection, which due to its complexity is accompanied by significant morbidity and mortality when it is not performed in high-volume centers. Among the complications, the postoperative pancreatic fistula is of frequent appearance. Objective: to carry out an updated systematic review about the concept and classification of postoperative pancreatic fistula. Methods: a systematic review of the literature was carried out using the SCOPUS database under the criteria established by its reviewers, using the following keywords: pancreatic fistula, pancreatic surgery, complications, mortality, Whipple procedure. All publications in English and Spanish were included. The method of analysis and synthesis was used for the interpretation of the bibliography. Results: 175 articles were reviewed, of which 55 were chosen that met the selection criteria. Among them, 4 meta-analyzes, 8 review articles and 33 original articles. Conclusions: the concept and classification of postoperative pancreatic fistula constitutes a valid tool for the comparison of surgical results between institutions. The centralization of care in high-volume centers is the main measure to reduce this complication.

8.
Artigo em Inglês | MEDLINE | ID: mdl-30908316

RESUMO

BACKGROUND: Teamwork is a central aspect of integrated care delivery and increasingly critical to primary care practices of accountable care organizations. Although the importance of leadership facilitation in implementing organizational change is well documented, less is known about the extent to which strong leadership facilitation can positively influence relational coordination among primary care team members. PURPOSE: The aim of this study was to examine the association of leadership facilitation of change and relational coordination among primary care teams of accountable care organization-affiliated practices and explore the role of team participation and solidarity culture as mediators of the relationship between leadership facilitation and relational coordination among team members. METHODOLOGY/APPROACH: Survey responses of primary care clinicians and staff (n = 764) were analyzed. Multilevel linear regression estimated the relationships among leadership facilitation, team participation, group solidarity, and relational coordination controlling for age, time, occupation, gender, team tenure, and team size. Models included practice site random effects to account for the clustering of respondents within practices. RESULTS: Leadership facilitation (ß = 0.19, p < .001) and team participation (ß = 0.18, p < .001) were positively associated with relational coordination, but solidarity culture was not associated. The association of leadership facilitation and relational coordination was only partially mediated (9%) by team participation. CONCLUSIONS: Leadership facilitation of change is positively associated with relational coordination of primary care team members. The relationship is only partially explained by better team participation, indicating that leadership facilitation has a strong direct effect on relational coordination. Greater solidarity was not associated with better relational coordination and may not contribute to better team task coordination. PRACTICE IMPLICATIONS: Leadership facilitation of change may have a positive and direct impact on high relational coordination among primary care team members.

9.
Healthc (Amst) ; 7(2): 10-15, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30765317

RESUMO

BACKGROUND: The Veterans Health Administration (VA) primary care is organized as a Patient Centered Medical Home (PCMH) that is based on continuity management of patient panels by interdisciplinary "teamlets" consisting of primary care providers, nurses, and clerical associates. While the teamlets are envisioned as interdisciplinary in this model, teamlet members may continue to report separately to middle management supervisors within their respective disciplines. Little is known about the role of middle managers in medical home implementation; therefore, the study purpose is to examine and characterize teamlet members' perceptions of middle managers' role in primary care operations and teamlet functioning in an outpatient setting. METHODS: This study applied a formal qualitative data collection method and analysis based on semi-structured interviews of 79 frontline interdisciplinary staff (primary care providers, nurses, and clerical associates) in VA Patient Aligned Care Teams (PACT) teamlets. Interviews were analyzed using a method of constant comparison. RESULTS: Teamlet members recognize that their supervising middle managers are essential to daily functioning of PACT teamlets in terms of clarifying roles and responsibilities, setting expectations, providing coverage strategies, supporting conflict resolution, and facilitating teamlet-initiated innovation. Teamlet members identified challenges when middle manager involvement was lacking. CONCLUSION: Within a multilevel system, frontline interdisciplinary staff continue to perceive the need for leadership by middle managers from their own professional disciplines for solving interdisciplinary problems, setting role-specific schedules and expectations, and fostering innovation. As such, greater focus on the structure and training of middle managers for participation in PCMH models is needed.

10.
Am J Manag Care ; 25(1): e21-e25, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30667614

RESUMO

OBJECTIVES: The adoption of advanced health information technology (HIT) capabilities, such as predictive analytic functions and patient access to records, remains variable among healthcare systems across the United States. This study is the first to identify characteristics that may drive this variability among health systems. STUDY DESIGN: Responses from the 2017/2018 National Survey of Healthcare Organizations and Systems were used to assess the extent to which healthcare system organizational structure, electronic health record (EHR) standardization, and resource allocation practices were associated with use of 5 advanced HIT capabilities. Of 732 systems surveyed, 446 responded (60.9%), 425 (58.1%) met sample inclusion criteria, and 389 (53.1%) reported consistent EHR use. METHODS: Measures of adoption, resource allocation, and organizational structure were developed based on survey responses. Multivariate linear regression with control variables estimated the relationships. RESULTS: Adoption of advanced HIT capabilities is low and variable, with a mean of 2.4 capabilities adopted and only 8.4% of systems reporting widespread adoption of all 5 capabilities. In adjusted analyses, EHR standardization (ß = 0.76; P = .001) was the strongest predictor of the number of advanced capabilities adopted, and ownership and management of medical groups (ß = 0.32; P = .04) was also a significant predictor. CONCLUSIONS: Health systems that standardize their EHRs and that own and manage hospitals and medical groups have higher rates of advanced HIT adoption and use. System leaders looking to increase the use of advanced HIT capabilities should consider ways to better standardize their EHRs across organizations.

11.
Health Serv Res ; 54 Suppl 1: 217-225, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30613953

RESUMO

OBJECTIVE: To examine the relationship between food swamps and hospitalization rates among adults with diabetes. DATA SOURCES: Blue Cross Blue Shield Association Community Health Management Hub® 2014, AHRQ Health Care Cost and Utilization Project state inpatient databases 2014, and HHS Area Health Resources File 2010-2014. STUDY DESIGN: Cross-sectional analysis of 784 counties across 15 states. Food swamps were measured using a ratio of fast food outlets to grocers. Multivariate linear regression estimated the association of food swamp severity and hospitalization rates. Population-weighted models were controlled for comorbidities; Medicaid; emergency room utilization; percentage of population that is female, Black, Hispanic, and over age 65; and state fixed effects. Analyses were stratified by rural-urban category. PRINCIPAL FINDINGS: Adults with diabetes residing in more severe food swamps had higher hospitalization rates. In adjusted analyses, a one unit higher food swamp score was significantly associated with 49.79 (95 percent confidence interval (CI) = 19.28, 80.29) additional all-cause hospitalizations and 19.12 (95 percent CI = 11.09, 27.15) additional ambulatory care-sensitive hospitalizations per 1000 adults with diabetes. The food swamp/all-cause hospitalization rate relationship was stronger in rural counties than urban counties. CONCLUSIONS: Food swamps are significantly associated with higher hospitalization rates among adults with diabetes. Improving the local food environment may help reduce this disparity.

12.
PLoS One ; 13(10): e0205405, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30379937

RESUMO

STUDY DESIGN: Randomized, single-blinded, multi-center, parallel-group trial. OBJECTIVES: To compare the effects of adding electrical dry needling into a program of manual therapy, exercise and ultrasound on pain, function and related-disability in individuals with plantar fasciitis (PF). BACKGROUND: The isolated application of electrical dry needling, manual therapy, exercise, and ultrasound has been found to be effective for PF. However, no previous study has investigated the combined effect of these interventions in this population. METHODS: One hundred and eleven participants (n = 111) with plantar fasciitis were randomized to receive electrical dry needling, manual therapy, exercise and ultrasound (n = 58) or manual therapy, exercise and ultrasound (n = 53). The primary outcome was first-step pain in the morning as measured by the Numeric Pain Rating Scale (NPRS). Secondary outcomes included resting foot pain (NPRS), pain during activity (NPRS), the Lower Extremity Functional Scale (LEFS), the Foot Functional Index (FFI), medication intake, and the Global Rating of Change (GROC). The treatment period was 4 weeks with follow-up assessments at 1 week, 4 weeks, and 3 months after the first treatment session. Both groups received 6 sessions of impairment-based manual therapy directed to the lower limb, self-stretching of the plantar fascia and the Achilles tendon, strengthening exercises for the intrinsic muscles of the foot, and therapeutic ultrasound. In addition, the dry needling group also received 6 sessions of electrical dry needling using a standardized 8-point protocol for 20 minutes. The primary aim was examined with a 2-way mixed-model analysis of covariance (ANCOVA) with treatment group as the between-subjects variable and time as the within-subjects variable after adjusting for baseline outcomes. RESULTS: The 2X4 ANCOVA revealed that individuals with PF who received electrical dry needling, manual therapy, exercise and ultrasound experienced significantly greater improvements in first-step morning pain (F = 22.021; P<0.001), resting foot pain (F = 23.931; P<0.001), pain during activity (F = 7.629; P = 0.007), LEFS (F = 13.081; P<0.001), FFI Pain Subscale (F = 13.547; P<0.001), FFI Disability Subscale (F = 8.746; P = 0.004), and FFI Total Score (F = 10.65; P<0.001) than those who received manual therapy, exercise and ultrasound at 3 months. No differences in FFI Activity Limitation Subscale (F = 2.687; P = 0.104) were observed. Significantly (X2 = 9.512; P = 0.023) more patients in the electrical dry needling group completely stopped taking medication for their pain compared to the manual therapy, exercise and ultrasound group at 3 months. Based on the cutoff score of ≥+5 on the GROC, significantly (X2 = 45.582; P<0.001) more patients within the electrical dry needling group (n = 45, 78%) achieved a successful outcome compared to the manual therapy, exercise and ultrasound group (n = 11, 21%). Effect sizes ranged from medium to large (0.53

13.
BMJ Open ; 8(10): e023068, 2018 Oct 31.
Artigo em Inglês | MEDLINE | ID: mdl-30385443

RESUMO

OBJECTIVE: If patient engagement is the new 'blockbuster drug' why are we not seeing spectacular effects? Studies have shown that activated patients have improved health outcomes, and patient engagement has become an integral component of value-based payment and delivery models, including accountable care organisations (ACO). Yet the extent to which clinicians and managers at ACOs understand and reliably execute patient engagement in clinical encounters remains unknown. We assessed the use and understanding of patient engagement approaches among frontline clinicians and managers at ACO-affiliated practices. DESIGN: Qualitative study; 103 in-depth, semi-structured interviews. PARTICIPANTS: Sixty clinicians and eight managers were interviewed at two established ACOs. APPROACH: We interviewed healthcare professionals about their awareness, attitudes, understanding and experiences of implementing three key approaches to patient engagement and activation: 1) goal-setting, 2) motivational interviewing and 3) shared decision making. Of the 60 clinicians, 33 were interviewed twice leading to 93 clinician interviews. Of the 8 managers, 2 were interviewed twice leading to 10 manager interviews. We used a thematic analysis approach to the data. KEY RESULTS: Interviewees recognised the term 'patient activation and engagement' and had favourable attitudes about the utility of the associated skills. However, in-depth probing revealed that although interviewees reported that they used these patient activation and engagement approaches, they have limited understanding of these approaches. CONCLUSIONS: Without understanding the concept of patient activation and the associated approaches of shared decision making and motivational interviewing, effective implementation in routine care seems like a distant goal. Clinical teams in the ACO model would benefit from specificity defining key terms pertaining to the principles of patient activation and engagement. Measuring the degree of understanding with reward that are better-aligned for behaviour change will minimise the notion that these techniques are already being used and help fulfil the potential of patient-centred care.

14.
BMC Health Serv Res ; 18(1): 875, 2018 Nov 20.
Artigo em Inglês | MEDLINE | ID: mdl-30458778

RESUMO

OBJECTIVE: To compare the impact of implementing team-based diabetes care management involving community health workers (CHWs) vs. medical assistants (MA) in community health centers (CHCs) on diabetes care processes, intermediate outcomes, and patients' experiences of chronic care. DATA SOURCES: Clinical and administrative data (n = 6111) and patient surveys (n = 698) pre-intervention and post-intervention. Surveys (n = 285) and key informant interviews (n = 48) of CHC staff assessed barriers and facilitators of implementation. STUDY DESIGN: A three-arm cluster-randomized trial of CHC sites integrating MAs (n = 3) or CHWs (n = 3) for diabetes care management compared control CHC sites (n = 10). Difference-in-difference multivariate regression with exact matching of patients estimated intervention effects. PRINCIPAL FINDINGS: Patients in the CHW intervention arm had improved annual glycated hemoglobin testing (18.5%, p < 0.001), while patients in the MA intervention arm had improved low-density lipoprotein cholesterol control (8.4%, p < 0.05) and reported better chronic care experiences over time (ß=7.5, p < 0.001). Except for chronic care experiences (p < 0.05) for patients in the MA intervention group, difference-in-difference estimates were not statistically significant because control group patients also improved over time. Some diabetes care processes improved significantly more for control group patients than intervention group patients. Key informant interviews revealed that immediate patient care issues sometimes crowded out diabetes care management activities, especially for MAs. CONCLUSIONS: Diabetes care improved in CHCs integrating CHWs and MAs onto primary care teams, but the improvements were no different than improvements observed among matched control group patients. Greater improvement using CHW and MA team-based approaches may be possible if practice leaders minimize use of these personnel to cover shortages that often arise in busy primary care practices.

15.
JMIR Diabetes ; 3(4): e15, 2018 Oct 30.
Artigo em Inglês | MEDLINE | ID: mdl-30377141

RESUMO

BACKGROUND: Diabetes is a major contributor to global death and disability. Text-messaging interventions hold promise for improving diabetes outcomes through better knowledge and self-management. OBJECTIVE: The aim of this study was to examine the implementation and impact of a diabetes text-messaging program targeted primarily for low-income Latino patients receiving care at 2 federally qualified health centers (FQHCs). METHODS: A mixed-methods, quasi-experimental research design was employed for this pilot study. A total of 50 Spanish or English-speaking adult patients with diabetes attending 2 FQHC sites in Los Angeles from September 2015 to February 2016 were enrolled in a 12-week, bidirectional text-messaging program. A comparison group (n=160) was constructed from unexposed, eligible patients. Demographic data and pre/post clinical indicators were compared for both the groups. Propensity score weighting was used to reduce selection bias, and over-time differences in clinical outcomes between groups were estimated using individual fixed-effects regression models. Population-averaged linear models were estimated to assess differential effects of patient engagement on each clinical indicator among the intervention participants. A sample of intervention patients (n=11) and all implementing staff (n=8) were interviewed about their experiences with the program. Qualitative data were transcribed, translated, and analyzed to identify common themes. RESULTS: The intervention group had a mean glycated hemoglobin (HbA1c) reduction of 0.4 points at follow-up, relative to the comparison group (P=.06). Patients who were more highly engaged with the program (response rate ≥median of 64.5%) experienced a 2.2 point reduction in HbA1c, relative to patients who were less engaged, controlling for demographic characteristics (P<.001). Qualitative analyses revealed that many participants felt supported, as though "someone was worrying about [their] health." Participants also cited learning new information, setting new goals, and receiving helpful reminders. Staff and patients highlighted strategies to improve the program, including incorporating patient responses into in-person clinical care and tailoring the messages to patient knowledge. CONCLUSIONS: A diabetes text-messaging program provided instrumental and emotional support for participants and may have contributed to clinically meaningful improvements in HbA1c. Patients who were more engaged demonstrated greater improvement. Program improvements, such as linkages to clinical care, hold potential for improving patient engagement and ultimately, improving clinical outcomes.

16.
Artigo em Inglês | MEDLINE | ID: mdl-30460533

RESUMO

Tannin acyl hydrolases, also known as tannases, are a group of enzymes critical for the transformation of tannins. The study of these enzymes, which initially evolved in different organisms to detoxify and/or use these plant metabolites, has nowadays become relevant in microbial enzymology research due to their relevant role in food tannin transformation. Microorganisms, particularly bacteria, are major sources of tannase. Cloning and heterologous expression of bacterial tannase genes and structural studies have been performed in the last few years. However, a systematic compilation of the information related to all recombinant tannases, their classification, and characteristics is missing. In this review, we explore the diversity of heterologously produced bacterial tannases, describing their substrate specificity and biochemical characterization. Moreover, a new classification based on sequence similarity analysis is proposed. Finally, putative tannases have been identified in silico for each group of tannases taking advantage of the use of the "tannase" distinctive features previously proposed.

17.
Artigo em Inglês | MEDLINE | ID: mdl-30299381

RESUMO

BACKGROUND: Electronic health records (EHRs) have potential to improve quality, health outcomes, and efficiency, but little is known about the mechanisms through which these improvements occur. PURPOSE: One potential mechanism could be that EHRs improve care team communication and coordination, leading to better outcomes. To test this hypothesis, we examine whether ease of EHR use is associated with better relational coordination (RC), a measure of team communication and coordination, among primary care team members. METHODOLOGY: Surveys of adult primary care team members (n = 304) of 16 practices of two accountable care organizations in Chicago and Los Angeles were analyzed. The survey included a validated measure of RC and a measure of ease of EHR use from a national survey. Linear regression models estimated the association of ease of EHR use and RC, controlling for care site and patient demographics and accounting for cluster-robust standard errors. An interaction term tested a differential association of ease of EHR use and RC for primary care providers (PCPs) versus non-PCPs. RESULTS: Ease of EHR use (mean = 3.5, SD = 0.6, range: 0-4) and RC were high (mean = 4.0, SD = 0.7, range: 0-5) but differed by occupation. In regression analyses, a 1-point increase in ease of EHR use was associated with a 0.36 point higher RC score (p = .001). The association of ease of EHR and RC use was stronger for non-PCPs than PCPs. CONCLUSION: Ease of EHR use is associated with better RC among primary care team members, and the benefits accrue more to non-PCPs than to PCPs. PRACTICE IMPLICATIONS: Ensuring that clinicians and staff experience EHRs as easy to use for accessing and integrating data and for communication may produce gains in efficiency and outcomes through high RC. Future studies should examine whether interventions to improve EHR usability can lead to improved RC and patient outcomes.

18.
Inquiry ; 55: 46958018794542, 2018 Jan-Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30168364

RESUMO

Many strategies to improve health care quality focus on improving the structural capabilities of primary care practices, including quality infrastructure and registry use, which are critical to managing chronic diseases. However, improving structural capabilities requires practices to expend significant resources and can be especially disruptive to community health centers (CHCs) serving high proportions of socioeconomically vulnerable patients. We explore the relationship between the structural capabilities and workplace climate in CHCs. The final sample for this analysis includes 25 CHC sites that could be matched across CHC site director surveys of structural capabilities and CHC adult primary care clinicians and staff (n = 446). To estimate the association between structural capabilities and dimensions of workplace climate, we estimated multivariate linear regression models that included the climate scales as dependent variables and the 5 structural capability scales as the main independent variables, with the 3 clinic-level and 2 staff-level covariates. More manageable clinic workload was associated with lower electronic record functionality (ß = -0.47, P = .007), but positively associated with quality infrastructure (ß = 0.92, P = .007). Staff relationships and quality improvement orientation were positively associated with quality infrastructure (ß = 1.09, P = .006 and ß = 0.87, P = .005). Manager readiness was associated with more robust quality infrastructure (ß = 1.35, P = .016), but lower electronic record functionality (ß = -0.48, P = .015) and less proactive patient outreach (ß = -1.32, P = .025). Complex relationships between structural capabilities and workplace climate were found in CHCs. Further clarification of these complex connections may enable policy makers and practitioners to design and implement nuanced strategies to improve quality of care in CHCs.

19.
Sci Rep ; 8(1): 13575, 2018 Sep 11.
Artigo em Inglês | MEDLINE | ID: mdl-30206304

RESUMO

Catechins, including catechin (C) and epicatechin (E), are the main type of flavonoids in cacao seeds. They play important roles in plant defense and have been associated with human health benefits. Although flavonoid biosynthesis has been extensively studied using in vitro and in vivo models, the regulatory mechanisms controlling their accumulation under light/dark conditions remain poorly understood. To identify differences in flavonoid biosynthesis (particularly catechins) under different light treatments, we used cacao cell suspensions exposed to white-blue light and darkness during 14 days. RNA-Seq was applied to evaluate differential gene expression. Our results indicate that light can effectively regulate flavonoid profiles, inducing a faster accumulation of phenolic compounds and shifting E/C ratios, in particular as a response to switching from white to blue light. The results demonstrated that HY5, MYB12, ANR and LAR were differentially regulated under light/dark conditions and could be targeted by overexpression aiming to improve catechin synthesis in cell cultures. In conclusion, our RNA-Seq analysis of cacao cells cultured under different light conditions provides a platform to dissect key aspects into the genetic regulatory network of flavonoids. These light-responsive candidate genes can be used further to modulate the flavonoid production in in vitro systems with value-added characteristics.

20.
Artigo em Inglês | MEDLINE | ID: mdl-30109902

RESUMO

Primary care redesign for older adult patients is currently ongoing in countries with aging populations. One of the main challenges of this type of transformations is how to estimate implementation costs in different types of health care delivery organizations. This study compares start-up and incremental expenses of implementing a primary care redesign across 2 organization types: integrated group (n = 31) practices and independent practice association (IPA) sites (n = 213). Administrators involved with implementing the redesign completed a cost capture template to quantifying expenses. The potential impact of measurement error, recollection bias, and implementation models across sites and geographic regions was examined in sensitivity analyses. Marginal start-up and incremental expenses were higher for Group sites ($122-$328) compared to IPA sites ($31-$227). Group and IPA sites, however, implemented the redesign with different intensities. According to our analyses, if IPA sites implemented the redesign with the same intensity as Group sites, marginal costs would have been $5 to $13 higher for IPA sites than for Group sites. This study shows how a flexible approach to estimate the cost of a wellness care redesign is needed when the intensity of the transformation differs across 2 different types of health care organizations.

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