Cost as a Feature of Medication Management Communication in Medical Visits

Little is known about how patients and physicians discuss medication costs in medical visits, if such discussions impact decision making, and if patients are more satisfied with their medications if they discuss cost. The predominance of medication therapy, the need for continuous treatment, and the variation in medication costs make it especially important to examine the extent to which rheumatoid arthritis (RA) patients discuss issues related to medication costs, how they manage their medications with their physicians, and how this relates to patient-reported medication satisfaction. This is a cross-sectional secondary analysis of survey and clinic visit audiotape data that were collected in North Carolina from 2003 to 2005 from 8 rheumatologists and 200 of their adult patients with RA. Qualitative analyses were conducted to examine the content of communication about medication costs and management in routine rheumatology clinic visits. Quantitative analyses employing multivariable models were conducted to examine the influence of patient, physician, and medication characteristics on visit communication about medication costs, management, and satisfaction. Results revealed that 34% of medical visits contained medication cost communication and the content centered on insurance coverage and strategies to reduce patient out-of-pocket medication expenses. Quantitative results revealed that patients identifying as White/Caucasian and those with no prescription drug coverage were significantly more likely to discuss medication costs. Results revealed that medication cost communication and disclosure of patient-initiated regimen changes were significantly, positively associated with one another. In over 20% of visits, patients disclosed self-initiated changes to their medication regimens and the communication demonstrated that patients were active managers of their medications. Patients disclosed taking more, less, and substituting medications for those prescribed. Almost unanimously, the regimen changes reduced their total RA medication cost burden. However, neither communication about medication costs nor patient medication management significantly predicted medication regimen changes in the medical visit and no factors reliably predicted patient-reported medication satisfaction. These findings have implications for conceptualizing medical visit communication about medication costs and management. Better understanding of these topics provides guidance for the development of conceptual frameworks and interventions to improve communication, and thereby improve care

Addysg Gymraeg ail iaith mewn Ysgolion cyfrwng-Saesneg Astudiaeth i archwilio i ba raddau y mae amodau dysgu’r rhaglen Gymraeg ail iaith yng Nghyfnodau Allweddol 2 a 3 yn gymwys i gynhyrchu siaradwyr yr iaith

Diben yr astudiaeth hon oedd ymchwilio’r ddarpariaeth iaith Gymraeg mewn ysgolion cynradd ac uwchradd cyfrwng-Saesneg, Cyfnodau Allweddol 2 a 3 er mwyn dirnad i ba raddau y gall gynhyrchu siaradwyr Cymraeg. Agenda ieithyddol Llywodraeth Cymru ar gyfer creu Cymru ddwyieithog a ysgogodd y gwaith ymchwil hwn. Ymhellach, rhydd pwyslais y Cwricwlwm Cenedlaethol ar sgiliau llafaredd, ynghyd ag argymhelliad parhaus Estyn a Llywodraeth Cymru i ddatblygu sgiliau cyfathrebol y disgyblion gyd-destun i’r astudiaeth. Gosodwyd y gwaith ymchwil o fewn fframwaith cysyniadol yn seiliedig ar egwyddorion dysgu ac addysgu ail iaith y Cyrchddull Cyfathrebol cyfredol. Cyfraniad gwreiddiol y gwaith ymchwil hwn i’r maes dysgu ac addysgu Cymraeg ail iaith yw dangos bod y ddarpariaeth Gymraeg yn yr ysgolion a gyfranogodd yn pwyso’r glorian ar ochr dulliau addysgu ail iaith traddodiadol; dulliau sydd yn arwain at anghyseinedd ymarferol ac, o ganlyniad, wedi tanseilio ffydd yn eu cymhwysedd i ddatblygu siaradwyr. Arsylwyd mewnbwn ieithyddol a oedd wedi’i gyfyngu i eirfa a strwythurau iaith ynysedig ac a oedd, ar y cyfan, yn camgynrychioli natur yr iaith darged. Tueddai ymarferion llafar ddatblygu o ymarferion mecanyddol i gyfnewidiau trafodaethol gyda diffyg pwyslais ar ddefnydd iaith at ddibenion ystyrlon. Dadleuir nad oedd y mewnbwn ieithyddol, y deunyddiau dosbarth na’r gweithgareddau yn cyfrannu at ddatblygu hunaniaeth ddiwylliannol na sgiliau cyfathrebol y disgyblion. Cynigia’r gwaith ymchwil hwn fewnwelediad gwerthfawr i wersi Cymraeg drwy astudiaeth feintiol fanwl o nodweddion yr addysgeg a fabwysiedir i addysgu’r Gymraeg mewn ysgolion cyfrwng-Saesneg. Yn sgil adolygiad Dyfodol Llwyddiannus Donaldson (LlC, 2015a) o’r Cwricwlwm Cenedlaethol, ac er mwyn gwireddu gweledigaeth Llywodraeth Cymru o Gymru ddwyieithog, gall canlyniadau’r ymchwil hwn gyfrannu at sicrhau nad yw’r un addysgeg Gymraeg ail iaith yn parhau o dan gyfundrefn ‘ddiwygiedig’

Launch Vehicle Abort Analysis for Failures Leading to Loss of Control

Launch vehicle ascent is a time of high risk for an onboard crew. There is a large fraction of possible failures for which time is of the essence and a successful abort is possible if the detection and action happens quickly enough. This paper focuses on abort determination based on data already available from the Guidance, Navigation, and Control system. This work is the result of failure analysis efforts performed during the Ares I launch vehicle development program. The two primary areas of focus are the derivation of abort triggers to ensure that abort occurs as quickly as possible when needed, but that false aborts are avoided, and evaluation of success in aborting off the failing launch vehicle

Exploring Community-Based Nutrition Education Programs on Children’s Knowledge of Effective Budgeting and Nutritional Analysis

Children from low-income areas, ages 5-18, are at high risk for obesity and other related nutritional issues, partially due to lack of knowledge about effective budgeting and nutritional content analysis. Little information is known about the education provided by current community programs in Hampton Roads for teaching children to 1) shop smart, 2) read nutrition labels, and 3) the importance of eating healthier. We propose a longitudinal (12-week) observational study to determine what community-based education is provided to children on how and why to shop smart and read nutritional content; and to determine whether or not the education is effective. The data will be collected via researcher-developed questionnaires on nutritional education and attendance at community programs, then analyzed using the Pearson’s product-moment correlation technique

The use of patient-reported outcome measures to guide referral for hip and knee replacement. Part 1: the development of an evidence based model linking pre-operative score to the probability of gaining benefit from surgery

Aims To calculate how the likelihood of obtaining measurable benefit from hip or knee arthroplasty varies with preoperative patient-reported scores. Methods Existing UK data from 222,933 knee and 209,760 hip arthroplasty patients were used to model an individual’s probability of gaining meaningful improvement after surgery based on their preoperative Oxford Knee or Hip Score (OKS/OHS). A clinically meaningful improvement after arthroplasty was defined as ≥ 8 point improvement in OHS, and ≥ 7 in OKS. Results The upper preoperative score threshold, above which patients are unlikely to achieve any meaningful improvement from surgery, is 41 for knees and 40 for hips. At lower scores, the probability of improvement increased towards a maximum of 88% (knee) and 95% for (hips). Conclusion By our definition of meaningful improvement, patients with preoperative scores above 41 (OKS) and 40 (OHS) should not be routinely referred to secondary care for possible arthroplasty. Using lower thresholds would incrementally increase the probability of meaningful benefit for those referred but will exclude some patients with potential to benefit. The findings are useful to support the complex shared decision-making process in primary care for referral to secondary care; and in secondary care for experienced clinicians counselling patients considering knee or hip arthroplasty, but should not be used in isolation

Protocol for expansion of an existing national monthly survey of smoking behaviour and alcohol use in England to Scotland and Wales:The Smoking and Alcohol Toolkit Study

Background The Smoking and Alcohol Toolkit Study (STS/ATS) in England has delivered timely insights to inform and evaluate strategies aimed at reducing tobacco smoking- and alcohol-related harm. From the end of 2020 until at least 2024 the STS/ATS is expanding to Scotland and Wales to include all constituent nations in Great Britain. Expanding data collection to Scotland and Wales will permit the evaluation of how smoking and alcohol related behaviours respond to divergent policy scenarios across the devolved nations. Methods The STS/ATS consists of monthly cross-sectional household interviews (computer or telephone assisted) of representative samples of adults in Great Britain aged 16+ years. Commencing in October 2020 each month a new sample of approximately 1700 adults in England, 450 adults in Scotland and 300 adults in Wales complete the survey (~n = 29,400 per year). The expansion of the survey to Scotland and Wales has been funded for the collection of at least 48 waves of data across four years. The data collected cover a broad range of smoking and alcohol-related parameters (including but not limited to smoking status, cigarette/nicotine dependence, route to quit smoking, prevalence and frequency of hazardous drinking, attempts and motivation to reduce alcohol consumption, help sought and motives for attempts to reduce alcohol intake) and socio-demographic characteristics (including but not limited to age, gender, region, socio-economic position) and will be reviewed monthly and refined in response to evolving policy needs and public interests. All data analyses will be pre-specified and available on a free online platform. A dedicated website will publish descriptive data on important trends each month. Discussion The Smoking and Alcohol Toolkit Study will provide timely monitoring of smoking and alcohol related behaviours to inform and evaluate national policies across Great Britain

Pittsboro, adult community members with disabilities, Chatham County, North Carolina : focusing on life with a disability in Pittsboro, NC : an action oriented community diagnosis : findings and next steps of action

This document is a qualitative report of the findings from an Action Oriented Community Diagnosis (AOCD) focused on persons with disabilities, 18 years and older residing in and/or using services in Pittsboro, North Carolina. AOCD is a process in which the strengths and needs of a community are assessed in order to gain an understanding of the community from the perspective of those that live or work there and then have them identify goals and action steps to move toward achievement of these goals. This AOCD began in October 2002 and was conducted by six graduate students from the University of North Carolina (UNC) School of Public Health under the direction of two preceptors from the North Carolina Office on Disability and Health (NCODH) and instructors from the Department of Health Behavior Health Education at the UNC School of Public Health. As part of the AOCD process, the team spoke with service providers, community members with disabilities, and community members without disabilities in Pittsboro as well as reviewed secondary data sources. The information gleaned from the interviews, focus groups and other data sources were analyzed and themes were identified. While conducting these interviews and focus groups, it became apparent that the team was speaking with people who had different points of view. The team referred to these points of view as “insider” and “outsider.” Insiders were community members with and without disabilities and the family members of persons with disabilities. The team looked to insiders to supply a perspective of someone familiar with Pittsboro’s history and inner workings. Outsiders were service providers who worked in Pittsboro, or who worked at an agency that served Pittsboro. Although the team realized that some of the outsiders were actually residents of Pittsboro, the team chose to interview these people for their expertise as professionals serving Pittsboro, and for information on how services are delivered; thus they were considered to supply an outsider point of view. The team felt that it was important to examine both the insider and outsider perspectives because, by looking at the experiences and interpretations of persons with different points of views, steps could be taken to begin action on areas where points of view were similar, and discussion could be encouraged in areas where points of view differed. Two categories of themes were identified from the AOCD findings: descriptive themes and active themes. The team noted two themes as being descriptive: strengths, and finance and income. Strengths was considered a descriptive theme because it represented potential resources for the Pittsboro community to tap into as they worked to achieve action steps in prioritized areas. Pittsboro’s overall strengths will be increased through progress in other areas. Finances and Income was also considered a descriptive theme but for slightly different reasons. While all services are affected by finances available, to a certain extent, finances are affected by less changeable forces such as the national economy and budget. The team wanted to ensure that concrete action steps could be developed that did not require an unrealistic influx of funds. Active themes are those where the power to take action lies within the community. Active themes include awareness, attitudes, support, accessibility, activities, housing and transportation. The team hosted a community forum May 1st in Pittsboro. During the forum the community members and services providers extensively discussed two of the active themes: attitudes and support. As a result of the discussions the community identified several action steps for each theme. To address attitudes, the community plans to work within existing committees and organizations to increase representation of community members with disabilities and to work with Pittsboro’s strong faith community to provide outreach and needs assessments for persons with disabilities. To increase support for persons with disabilities, the forum participants plan to investigate resources available to persons with disabilities and update and distribute a resource list of services to persons with disabilities. The support action steps were also directed at utilizing Pittsboro’s strong volunteer community to help persons with disabilities obtain jobs. Another result of the forum was that some of the service providers and community members who attended became better acquainted with one another. Building new partnerships between people will hopefully lead to future collaborative efforts to help Pittsboro better serve community members with disabilities.Master of Public Healt

Embedding PbS Quantum Dots (QDs) in Pb-Halide Perovskite Matrices: QD Surface Chemistry and Antisolvent Effects on QD Dispersion and Confinement Properties

Hybrid materials of metal chalcogenide colloidal quantum dots (QDs) embedded in metal halide perovskites (MHPs) have led to composites with synergistic properties. Here, we investigate how QD size, surface chemistry, and MHP film formation methods affect the resulting optoelectronic properties of QD/MHP “dot-in-matrix” systems. We monitor the QD absorption and photoluminescence throughout synthesis, ligand exchange, and transfer into the MHP ink, and we characterize the final QD/MHP films via electron microscopy and transient absorption. In addition, we are the first to globally map how PbS QDs are distributed on the micrometer scale within these dot-in-matrix systems, using three-dimensional (3D) tomography time-of-flight secondary ion mass spectrometry. The surface chemistry imparted during synthesis directly affects the optical properties of the dot-in-matrix composites. Pb-halide passivation leads to QD/MHP dot-in-matrix samples with optical properties that are well-described by a theoretical model, based on a Type I finite-barrier heterostructure between the PbS QD and the MHP matrix. Samples without Pb-halide passivation show complicated size-dependent behavior, indicating a transition from a Type I heterostructure between the PbS QD wells and MHP barriers for small-sized QDs to PbS QDs that are electronically decoupled from the MHP matrix for larger QDs. Furthermore, the choice in perovskite antisolvent crystallization method leads to a difference in the spatial QD distribution within the perovskite matrix, differences in carrier lifetime, and photoluminescence shifts of up to 180 meV for PbS in methylammonium lead iodide. This work establishes an understanding of such emerging synergistic systems relevant for technologies such as photovoltaics, infrared emitters and detectors, and other unexplored technological applications

A unified multi-level model approach to assessing patient responsiveness including; return to normal, minimally important differences and minimal clinically important improvement for patient reported outcome measures

OBJECTIVE:This article reviews and compares four commonly used approaches to assess patient responsiveness with a treatment or therapy (return to normal (RTN), minimal important difference (MID), minimal clinically important improvement (MCII), OMERACT-OARSI [Outcome Measures in Rheumatology-Osteoarthris Reseach Society International] (OO)) and demonstrates how each of the methods can be formulated in a multilevel modelling (MLM) framework. DESIGN:Cohort study. SETTING:A cohort of patients undergoing total hip and knee replacement were recruited from a single UK National Health Service hospital. POPULATION:400 patients from the Arthroplasty Pain Experience cohort study undergoing total hip (n=210) and knee (n=190) replacement who completed the Intermittent and Constant Osteoarthritis Pain questionnaire prior to surgery and then at 3, 6 and 12 months after surgery. PRIMARY OUTCOMES:The primary outcome was defined as a response to treatment following total hip or knee replacement. We compared baseline scores, change scores and proportion of individuals defined as 'responders' using traditional and MLM approaches with patient responsiveness. RESULTS:Using existing approaches, baseline and change scores are underestimated, and the variance of baseline and change scores overestimated in comparison with MLM approaches. MLM increases the proportion of individuals defined as responding in RTN, MID and OO criteria compared with existing approaches. Using MLM with the MCII criteria reduces the number of individuals identified as responders. CONCLUSION:MLM improves the estimation of the SD of baseline and change scores by explicitly incorporating measurement error into the model and avoiding regression to the mean when making individual predictions. Using refined definitions of responsiveness may lead to a reduction in misclassification when attempting to predict who does and does not respond to an intervention and clarifies the similarities between existing methods