Discussing uncertainty and risk in primary care: recommendations of a multi-disciplinary panel regarding communication around prostate cancer screening.

BackgroundShared decision making improves value-concordant decision-making around prostate cancer screening (PrCS). Yet, PrCS discussions remain complex, challenging and often emotional for physicians and average-risk men.ObjectiveIn July 2011, the Centers for Disease Control and Prevention convened a multidisciplinary expert panel to identify priorities for funding agencies and development groups to promote evidence-based, value-concordant decisions between men at average risk for prostate cancer and their physicians.DesignTwo-day multidisciplinary expert panel in Atlanta, Georgia, with structured discussions and formal consensus processes.ParticipantsSixteen panelists represented diverse specialties (primary care, medical oncology, urology), disciplines (sociology, communication, medical education, clinical epidemiology) and market sectors (patient advocacy groups, Federal funding agencies, guideline-development organizations).Main measuresPanelists used guiding interactional and evaluation models to identify and rate strategies that might improve PrCS discussions and decisions for physicians, patients and health systems/society. Efficacy was defined as the likelihood of each strategy to impact outcomes. Effort was defined as the relative amount of effort to develop, implement and sustain the strategy. Each strategy was rated (1-7 scale; 7 = maximum) using group process software (ThinkTank(TM)). For each group, intervention strategies were grouped as financial/regulatory, educational, communication or attitudinal levers. For each strategy, barriers were identified.Key resultsHighly ranked strategies to improve value-concordant shared decision-making (SDM) included: changing outpatient clinic visit reimbursement to reward SDM; development of evidence-based, technology-assisted, point-of-service tools for physicians and patients; reframing confusing prostate cancer screening messages; providing pre-visit decision support interventions; utilizing electronic health records to promote benchmarking/best practices; providing additional training for physicians around value-concordant decision-making; and using re-accreditation to promote training.ConclusionsConference outcomes present an expert consensus of strategies likely to improve value-concordant prostate cancer screening decisions. In addition, the methodology used to obtain agreement provides a model of successful collaboration around this and future controversial cancer screening issues, which may be of interest to funding agencies, educators and policy makers

Conceptualizing Cognitive-Behavioral Therapy as a Supportive-Educative Nursing System for Patients with Insomnia

Difficulty initiating and maintaining sleep is one of the most common health complaints of the general population. Approximately 35-50% of people experience occasional insomnia symptoms (Walsh et al., 2011) while 12-20% have insomnia disorder (Morin, et al., 2011; Roth et al., 2011). An effective treatment is cognitive behavioral therapy for insomnia (CBT-I; Schutte-Rodin, Broch, Buysse, Dorsey, & Sateia, 2008), a nonpharmacological, evidence-based intervention aimed at changing sleep behaviors. The purpose of this paper is to frame CBT-I as a nursing intervention for insomnia within the context of Orem’s self-care deficit nursing theory (Orem, 2001). Orem’s theory provides a framework from which to view the process of improving patients’ sleep using CBT-I as a supportive-educative nursing system. Through the therapies of CBT-I, patients develop the power components of selfcare agency resulting in behavior change, which is consistent with Orem’s notion of deliberate action and self-care. Because holistic patient care, support, and patient teaching are fundamental aspects of nursing care to which nurses are acculturated, nurses are ideally suited to provide CBT-I

State Strategies to Improve Quality and Efficiency: Making the Most of Opportunities in National Health Reform

Examines ten states' initiatives to address key components of quality and efficiency improvement, including data collection, aggregation, and standardization; public reporting; payment reform; consumer engagement; and provider engagement

Potential applications of conditional cash transfers for prevention of sexually transmitted infections and HIV in Sub-Saharan Africa

A growing number of developing countries have introduced conditional cash transfer programs that provide money to poor families with certain contingencies attached - such as requiring school attendance or regular immunization and health check-ups. As the popularity of conditional cash transfer programs has grown, experimentation with potential applications in other areas of health, such as sexual and reproductive health, and HIV prevention, in particular, has also increased. Evaluations of conditional cash transfer programs have focused almost exclusively on uptake of health and educational services, which make relatively low demands of participants compared with more complex interventions, which require the cessation of risky behaviors, such as smoking, obesity, and substance abuse. The literature on contingency management - based on the principle that behavioral change occurs when appropriate behaviors are reinforced and rewarded - provides a richer picture of the complexity of the use of conditionality to encourage healthy behavioral change. This paper examines developing countries'experiences with conditional cash transfer programs and the results of trials in clinical settings on the efficacy of contingency management, and addresses their relevance for designing conditional cash transfer programs to address risky sexual behavior and promote the prevention of sexually transmitted infections and HIV in Sub-Saharan Africa.Health Monitoring&Evaluation,Population Policies,Adolescent Health,Disease Control&Prevention,HIV AIDS

Designing Primary Prevention for People Living with HIV

Today, there are new reasons for a sharper focus on prevention for people living with HIV. Growing numbers of people with the disease are living more healthy, sexual lives. Recent evidence suggests that risk taking among both HIV-positive and negative people is increasing. After nearly two decades of life in the shadow of AIDS, communities are growing weary of traditional prevention messages and many people are openly grappling with difficult questions of intimacy and sex. Increasingly, people living with HIV also face multiple complex economic and substance abuse challenges that complicate prevention efforts.There is an urgent need -- and sufficient expertise -- to move forward with prevention campaigns focused on helping people living with HIV and AIDS avoid passing their infection along to others. Numerous innovative interventions for people with HIV show promise, including:a social marketing campaign for gay men and a five-session group intervention for women living with HIV in Massachusetts,a chat line for positives and a group session program for Latinas/Latinos in Los Angeles,Internet chat room interventions in Atlanta,a group session for gay Asian American-Pacific Islander Americans living with HIV in San Francisco, andPrevention Case Management programs newly funded by the Centers for Disease Control

State of Health Equity Movement, 2011 Update Part C: Compendium of Recommendations DRA Project Report No. 11-03

State of Health Equity Movement, 2011 Update Part C: Compendium of Recommendations DRA Project Report No. 11-0