Systematic Review of Practice Facilitation and Evaluation of a Chronic Illness Care Management Tailored Outreach Facilitation Intervention for Rural Primary Care Physicians

Nearly two decades of research on translating evidence-based care guidelines into practice has resulted in a considerable body of primary and secondary evidence about guideline implementation strategies and the individual, organizational and environmental challenges associated with closing the evidence to practice gap in primary care. Interventions to improve professional performance are complex and a disentangling of the various independent, intervening and constraining variables is required in order to be able to design and implement interventions that can improve primary care practice performance. The PRECEDE-PROCEED planning model (Green & Kreuter, 1999) provides a step-wise theoretical framework for understanding the complexity of causal relationships among the variables that affect the adoption of evidence-based practice and may assist in the design and implementation of practice-based interventions. Knowledge of an evidence-based practice guideline is important, but a consensus has emerged that having knowledge is rarely sufficient to change practice behaviour. Didactic education or passive dissemination strategies are ineffective, whereas interactive education, reminder systems and multifaceted interventions tailored to the needs of the practice are effective. Outreach or practice facilitation is a proven effective multifaceted approach that involves skilled individuals who enable others, through a range of tailored interventions, to address the challenges in implementing evidence-based care guidelines within the primary care setting. The challenges to implementing evidence-based chronic illness care practice guidelines are thought to be similar to the other contextual, organizational and individual behavioural challenges associated with the uptake of research findings into practice. A multifaceted guideline implementation strategy such as practice facilitation may be well-suited to improving the adoption of these guidelines within rural primary care settings. However, research has not systematically reviewed, through meta-analysis, the published practice facilitation trials to determine overall effects and an implementation research study of practice facilitation that has considered fidelity of implementation within the rural Ontario setting for a complex practice guideline such as chronic illness management has not been done. The systematic review in the thesis incorporated an exploratory meta-analysis of randomized and non-randomized controlled trials of interventions targeted towards implementing evidence-based practice guidelines through practice facilitation, and was conducted to gain an understanding of the overall effect of practice facilitation and the factors that moderate implementation success. The results were the identification of an improvement overtime in the methodological rigour of practice facilitation implementation research based on a critical appraisal of methods, a significant moderate overall effect size of 0.54 (95% CI 0.43 – 0.65) for 19 good quality practice facilitation intervention studies and several significant effect size modifiers; notably, tailoring to the needs of the practice, using multiple intervention components, extending duration, and increasing the intensity of practice facilitation were associated with larger effect sizes. As more practices were assigned to the practice facilitator, the effect diminished. A significant positive association between the number of PRECEDE predisposing, enabling and reinforcing strategies employed by the facilitator and the effect size was detected. The implementation research study utilized mixed methods for data collection as part of an embedded case study of four rural primary care practices to determine the implementation fidelity of the practice facilitation of chronic illness care planning and the factors that impeded and contributed to implementation success. The feasibility of and potential cost savings of practice facilitation via videoconferencing was also implemented for two of the practices. For those practices that successfully implemented care planning, fidelity was achieved for the implementation of care plans. On the other hand, the dosage, duration, component delivery of the practice facilitation intervention was low in comparison to other published studies, and tailoring of the intervention to the practice was inconsistent. Based on the qualitative analysis of physician interviews, the moderating factors for successful implementation were categorized into the broad themes of pessimism and tempered optimism. Pessimistic physicians were unsuccessful at implementation, lacked a willingness to engage and were uncomfortable with the patient-centred approach to chronic illness care. Optimists were positive about the psychosocial, patient-centred assessment aspects of the chronic illness care protocol and provided anecdotes of success in resolving patient problems. However, this was tempered as both pessimists and optimists reflected on the time intensive aspect of the protocol and the unlikelihood of widespread implementation without additional supports. Participating physicians were satisfied with the facilitator and the videoconferencing experience, and the intervention cost analysis revealed opportunities for cost saving via the use of videoconferenced facilitation. Improvements to the intervention suggested by participants included integrating chronic illness management with medical information systems, involving other health disciplines, and forming networks of community health resources and support services for health providers and patients. This work has demonstrated that although practice facilitation can successfully result in moderate significant improvements in practice behaviour, it is not necessarily singularly effective in all contexts or for all targeted behaviours. A complex practice guideline such as the chronic illness care management model is unlikely to be adopted in the current context of primary care in rural Ontario and as a consequence to have any impact on the health of chronically ill patients without further intervention supports, adaptation, and implementation research undertaken to demonstrate successful execution of chronic illness care management. Alternative care delivery models are required to address barriers and improve the delivery of chronic illness care management

Using a collaborative research approach to develop an interdisciplinary research agenda for the study of mobile health interventions for older adults.

Licensed under Creative Commons Attribution cc-by 2.0Background: Seniors with chronic diseases are often called on to self-manage their conditions. Mobile health (mHealth) tools may be a useful strategy to help seniors access health information at the point of decision-making, receive real-time feedback and coaching, and monitor health conditions. However, developing successful mHealth interventions for seniors presents many challenges. One of the key challenges is to ensure the scope of possible research questions includes the diverse views of seniors, experts and the stakeholder groups who support seniors as they manage chronic disease. Objective: Our primary objective was to present a case-study of a collaborative research approach to the development of an interdisciplinary research agenda. Our secondary objectives were to report on the results of a nominal group technique (NGT) approach used generate research questions and to assess the success of including non-academic researchers to enrich the scope, priority, and total number of possible research questions. Methods: We invited researchers and stakeholders to participate in a full day meeting that included rapid-style presentations by researchers, health care professionals, technology experts, patients and community groups followed by group discussions. An NGT was used to establish group consensus on the following question: In your opinion, what research needs to be done to better understand the effectiveness, usability and design of mobile health apps and devices for older adults? Results: Overall, the collaborative approach was a very successful strategy to bring together a diverse group of participants with the same end goal. The 32 participants generated 119 items in total. The top three research questions that emerged from the NGT were related to adoption, the need for high quality tools and the digital divide. Strong sub-themes included privacy and security, engagement and design. The NGT also helped us include the perspectives information from non-academic researchers that would not have been captured if the process had been limited to the research team. Conclusions: Developing ways for patients and other stakeholders to have a voice when it comes to developing patient awareness as related to mHealth may guide future research into engagement, ownership, usability and design. It is our intention that our paper be used and adapted by other researchers to engage small or vulnerable populations often excluded from mHealth research and design.None Declare

Effect of a Mobile Phone Intervention on Quitting Smoking in a Young Adult Population of Smokers: Randomized Controlled Trial

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mhealth and uhealth, is properly cited. The complete bibliographic information, a link to the original publication on http://mhealth.jmir.org/, as well as this copyright and license information must be included.Background: Digital mobile technology presents a promising medium for reaching young adults with smoking cessation interventions because they are the heaviest users of this technology. Objective: The aim of this study was to determine the efficacy of an evidence-informed smartphone app for smoking cessation, Crush the Crave (CTC), on reducing smoking prevalence among young adult smokers in comparison with an evidence-informed self-help guide, On the Road to Quitting (OnRQ). Methods: A parallel, double-blind, randomized controlled trial with 2 arms was conducted in Canada to evaluate CTC. In total, 1599 young adult smokers (aged 19 to 29 years) intending to quit smoking in the next 30 days were recruited online and randomized to receive CTC or the control condition OnRQ for a period of 6 months. The primary outcome measure was self-reported continuous abstinence at the 6-month follow-up. Results: Overall follow-up rates were 57.41% (918/1599) and 60.48% (967/1599) at 3 and 6 months, respectively. Moreover, 45.34% (725/1599) of participants completed baseline, 3-, and 6-month follow-up. Intention-to-treat analysis (last observation carried forward) showed that continuous abstinence (N=1599) at 6 months was not significantly different at 7.8% (64/820) for CTC versus 9.2% (72/779) for OnRQ (odds ratio; OR 0.83, 95% CI 0.59-1.18). Similarly, 30-day point prevalence abstinence at 6 months was not significantly different at 14.4% (118/820) and 16.9% (132/779) for CTC and OnRQ, respectively (OR 0.82, 95% CI 0.63-1.08). However, these rates of abstinence were favorable compared with unassisted 30-day quit rates of 11.5% among young adults. Secondary measures of quit attempts and the number of cigarettes smoked per day at 6-month follow-up did not reveal any significant differences between groups. For those who completed the 6-month follow-up, 85.1% (359/422) of young adult smokers downloaded CTC as compared with 81.8% (346/423) of OnRQ, χ21(N=845)=1.6, P=.23. Furthermore, OnRQ participants reported significantly higher levels of overall satisfaction (mean 3.3 [SD 1.1] vs mean 2.6 [SD 1.3]; t644=6.87, P<.001), perceived helpfulness (mean 5.8 [SD 2.4] vs mean 4.3 [SD 2.6], t657=8.0, P<.001), and frequency of use (mean 3.6 [SD 1.2] vs mean 3.2 [SD 1.1], t683=5.7, P<.001) compared with CTC participants. Conclusions: CTC was feasible for delivering cessation support but was not superior to a self-help guide in helping motivated young adults to quit smoking. CTC will benefit from further formative research to address satisfaction and usage. As smartphone apps may not serve as useful alternatives to printed self-help guides, there is a need to conduct further research to understand how digital mobile technology smoking cessation interventions for smoking cessation can be improved. Trial Registration: ClinicalTrials.gov NCT01983150; http://clinicaltrials.gov/ct2/show/NCT01983150 (Archived by WebCite at http://www.webcitation.org/6VGyc0W0i)This work was supported by a grant from Health Canada, Federal Tobacco Control Strategy (Agreement #: 6549-15-2011/8300125) and a grant from the Canadian Institutes of Health Research (Grant #: MOP-130303). NBB received salary support from the Canadian Cancer Society Research Institute (Grant #: 2011-701019 & Grant# 2017-704507)

Inhibition of Pediatric Glioblastoma Tumor Growth by the Anti-Cancer Agent OKN-007 in Orthotopic Mouse Xenografts

We thank the Peggy and Charles Stephenson Cancer Center at the University of Oklahoma, Oklahoma City, OK, for funding, who received an Institutional Development Award (IDeA) from the National Institute of General Medical Sciences of the National Institutes of Health under grant number P20 GM103639 for the use of the Histology and Immunohistochemistry Core for providing immunohistochemistry and photographic services. This work was also supported by Oklahoma State University, Center of Veterinary Health Science (Support Grant AE-1-50060 to P.C.S.), the Musella Foundation (R.A.T.), and the Childhood Brain Tumor Foundation (R.A.T.).Pediatric glioblastomas (pGBM), although rare, are one of the leading causes of cancer-related deaths in children, with tumors essentially refractory to existing treatments. Here, we describe the use of conventional and advanced in vivo magnetic resonance imaging (MRI) techniques to assess a novel orthotopic xenograft pGBM mouse (IC-3752GBM patient-derived culture) model, and to monitor the effects of the anti-cancer agent OKN-007 as an inhibitor of pGBM tumor growth. Immunohistochemistry support data is also presented for cell proliferation and tumor growth signaling. OKN-007 was found to significantly decrease tumor volumes (p<0.05) and increase animal survival (p<0.05) in all OKN-007-treated mice compared to untreated animals. In a responsive cohort of treated animals, OKN-007 was able to significantly decrease tumor volumes (p<0.0001), increase survival (p<0.001), and increase diffusion (p<0.01) and perfusion rates (p<0.05). OKN-007 also significantly reduced lipid tumor metabolism in responsive animals (Lip1.3 and Lip0.9)-to-creatine ratio (p<0.05), as well as significantly decrease tumor cell proliferation (p<0.05) and microvessel density (p<0.05). Furthermore, in relationship to the PDGFRα pathway, OKN-007 was able to significantly decrease SULF2 (p<0.05) and PDGFR-α (platelet-derived growth factor receptor-α) (p<0.05) immunoexpression, and significantly increase decorin expression (p<0.05) in responsive mice. This study indicates that OKN-007 may be an effective anti-cancer agent for some patients with pGBMs by inhibiting cell proliferation and angiogenesis, possibly via the PDGFRα pathway, and could be considered as an additional therapy for pediatric brain tumor patients.Yeshttp://www.plosone.org/static/editorial#pee

A comparison of adolescent smoking initiation measures on predicting future smoking behavior

Objectives: Evidence suggests that age at smoking initiation has implications for tobacco use, nicotine dependence, and resulting long-term health and chronic disease outcomes. The objective of the current study was to examine two different measures of smoking onset and to compare their validity in predicting future adolescent smoking survey. Methods: Data from grades 9–12 students who participated in the 2012/2013 Youth Smoking Survey, a nationally-generalizable Canadian survey, and who had ever tried a cigarette, even a few puffs (n = 8126) were used in a multivariable logistic regression analysis to examine the association between age at smoking onset and current smoking behavior. Results: Both “age at first puff” and “age at first whole cigarette” were significantly associated with current smoking status. Specifically, a delay of one year in the age at first puff was associated with lower odds of being a current smoker by 24% (AOR = 0.76, 95% CI = 0.73–0.79). Similarly, high school students who smoked their first whole cigarette at old age were less likely to report being a current smoker (AOR = 0.66, 95% CI = 0.62–0.71). Conclusion: Efforts to prevent smoking uptake among youth, especially younger youth, are especially important in tobacco control efforts

Smartphone Apps for Vaping Cessation: Quality Assessment and Content Analysis

BackgroundAs the prevalence of electronic cigarette (e-cigarette) use, or vaping, continues to grow, particularly among young people, so does the need for research and interventions to address vaping. ObjectiveThis study examines the quality of free vaping cessation apps, their contents and features, popularity among users, and adherence to evidence-based principles. MethodsA systematic search of existing apps for vaping cessation was conducted in December 2020. Eligible apps were free, in English, and included features specifically targeting vaping cessation. Each app included in the analysis was used daily for at least seven consecutive days, assessed using the Mobile App Rating Scale, and rated by at least two authors (AK, EL, or SS) based on adherence to evidence-based practices. Intraclass correlation coefficient (ICC) estimates were computed to assess interrater reliability (excellent agreement; ICC 0.92; 95% CI 0.78-0.98). ResultsA total of 8 apps were included in the quality assessment and content analysis: 3 were developed specifically for vaping cessation and 5 focused on smoking cessation while also claiming to address vaping cessation. The mean of app quality total scores was 3.66 out of 5. Existing vaping cessation apps employ similar approaches to smoking cessation apps. However, they are very low in number and have limited features developed specifically for vaping cessation. ConclusionsGiven the lack of vaping cessation interventions at a time when they are urgently needed, smartphone apps are potentially valuable tools. Therefore, it is recommended that these apps apply evidence-based practices and undergo rigorous evaluations that can assess their quality, contents and features, and popularity among users. Through this process, we can improve our understanding of how apps can be effective in helping users quit vaping