Guiding Transformation: How Medical Practices Can Become Patient-Centered Medical Homes

Describes in detail eight change concepts as a guide to transforming a practice into a patient-centered medical home, including engaged leadership, quality improvement strategy, continuous and team-based healing relationships, and enhanced access

Minimally invasive scoliosis surgery: an innovative technique in patients with adolescent idiopathic scoliosis

Minimally invasive spine surgery is becoming more common in the treatment of adult lumbar degenerative disorders. Minimally invasive techniques have been utilized for multilevel pathology, including adult lumbar degenerative scoliosis. The next logical step is to apply minimally invasive surgical techniques to the treatment of adolescent idiopathic scoliosis (AIS). However, there are significant technical challenges of performing minimally invasive surgery on this patient population. For more than two years, we have been utilizing minimally invasive spine surgery techniques in patients with adolescent idiopathic scoliosis. We have developed the present technique to allow for utilization of all standard reduction maneuvers through three small midline skin incisions. Our technique allows easy passage of contoured rods, placement of pedicle screws without image guidance, and allows adequate facet osteotomy to enable fusion. There are multiple potential advantages of this technique, including: less blood loss, shorter hospital stay, earlier mobilization, and relatively less pain and need for pain medication. The operative time needed to complete this surgery is longer. We feel that a minimally invasive approach, although technically challenging, is a feasible option in patients with adolescent idiopathic scoliosis. Although there are multiple perceived benefits, long term data is needed before it can be recommended for routine use

Can user testing of a clinical trial patient information sheet make it fit-for-purpose? - a randomized controlled trial

Background: The participant information sheet (PIS) provided to potential trial participants is a critical part of the process of valid consent. However, there is long-standing concern that these lengthy and complex documents are not fit-for-purpose. This has been supported recently through the application of a performance-based approach to testing and improving readability called user testing. This method is now widely used to improve patient medicine leaflets - determining whether people can find and understand key facts. This study applied for the first time a controlled design to determine whether a PIS developed through user testing had improved readability over the original, using a sheet from a UK trial in acute myeloid leukemia (AML16). Methods: In the first phase the performance of the original PIS was tested on people in the target group for the trial. There were three rounds of testing including 50 people in total - with the information revised according to its performance after each of the first 2 rounds. In the second phase, the revised PIS was compared with the original in a parallel groups randomised controlled trial (RCT) A total of 123 participants were recruited and randomly allocated to read one version of the PIS to find and show understanding of 21 key facts. Results: The first, developmental phase produced a revised PIS significantly altered in its wording and layout. In the second, trial phase 66% of participants who read the revised PIS were able to show understanding of all aspects of the trial, compared with 15% of those reading the original version (Odds Ratio 11.2; Chi-square = 31.5 p < .001). When asked to state a preference, 87.1% participants chose the revised PIS (Sign test p < .001). Conclusions: The original PIS for the AML16 trial may not have enabled valid consent. Combining performance-based user testing with expertise in writing for patients and information design led to a significantly improved and preferred information sheet. User testing is an efficient method for indicating strengths and weaknesses in trial information, and Research Ethics Committees and Institutional Review Boards should consider requesting such testing, to ensure that PIS are fit-for-purpose

Closing the osteoporosis care gap – Increased osteoporosis awareness among geriatrics and rehabilitation teams

<p>Abstract</p> <p>Background</p> <p>A care gap exists between recommendations and practice regarding the diagnosis and treatment of osteoporosis in fracture patients. The current study was designed to determine rates and predictors of in-hospital diagnosis and treatment of osteoporosis in patients admitted with fragility hip fractures, and to assess differences in these rates since the outset of the multipronged "Fracture? Think Osteoporosis" (FTOP) Program, which includes education of geriatrics and rehabilitation teams.</p> <p>Methods</p> <p>This is a retrospective cohort study conducted with data from two Hamilton, Ontario, university-based tertiary-care hospitals, and represents a follow-up to a previous study conducted 8 years earlier. Data pertaining to all 354 patients, age >/= 50, admitted between March 2003 and April 2004, inclusive, with a diagnosis of fragility hip fracture were evaluated. Twelve patients were excluded leaving 342 patients for analysis, with 75% female, mean age 81.</p> <p>Outcomes included: Primary – In-hospital diagnosis of osteoporosis and/or initiation of anti-resorptive treatment ("new osteoporosis diagnosis/treatment"). Secondary – In-hospital mortality, BMD referrals, pre-admission osteoporosis diagnosis and treatment.</p> <p>Results</p> <p>At admission, 27.8% of patients had a pre-existing diagnosis of osteoporosis and/or were taking anti-resorptive treatment. Among patients with no previous osteoporosis diagnosis/treatment: 35.7% received a new diagnosis of osteoporosis, 21% were initiated on anti-resorptive treatment, and 14.3% received a BMD referral. The greatest predictor of new osteoporosis diagnosis/treatment was transfer to a rehabilitation or geriatrics unit: 79.5% of rehabilitation/geriatrics versus 18.5% of patients receiving only orthopedics care met this outcome (p < 0.001).</p> <p>Conclusion</p> <p>New diagnosis of osteoporosis among patients admitted with hip fracture has improved from 1.8% in the mid 1990's to 35.7%. Initiation of bisphosphonate therapy has likewise improved from 0% to 21%. Although multiple factors have likely contributed, the differential response between rehabilitation/geriatrics versus orthopedics patients suggests that education of the geriatric and rehabilitation teams, including one-on-one and group-based sessions, implemented as part of the FTOP Program, has played a role in this improvement. A significant care gap still exists for patients discharged directly from orthopedic units. The application of targeted inpatient and post-discharge initiatives, such as those that comprise the entire FTOP Program, may be of particular value in this setting.</p

The Somatic Genomic Landscape of Glioblastoma

We describe the landscape of somatic genomic alterations based on multi-dimensional and comprehensive characterization of more than 500 glioblastoma tumors (GBMs). We identify several novel mutated genes as well as complex rearrangements of signature receptors including EGFR and PDGFRA. TERT promoter mutations are shown to correlate with elevated mRNA expression, supporting a role in telomerase reactivation. Correlative analyses confirm that the survival advantage of the proneural subtype is conferred by the G-CIMP phenotype, and MGMT DNA methylation may be a predictive biomarker for treatment response only in classical subtype GBM. Integrative analysis of genomic and proteomic profiles challenges the notion of therapeutic inhibition of a pathway as an alternative to inhibition of the target itself. These data will facilitate the discovery of therapeutic and diagnostic target candidates, the validation of research and clinical observations and the generation of unanticipated hypotheses that can advance our molecular understanding of this lethal cancer

A Framework for Applying Global Learning to Improve Primary Health Care in the United States

Background and objectives: Lessons from global health have long informed efforts to improve primary health care (PHC) in the United States (US). Despite this history, no generalizable framework exists to guide US stakeholders in the identification and application of ideas from abroad related to the key PHC components of community engagement and service delivery. We sought to develop such a framework. Methods: We reviewed the experience of Global to Local, a community-based organization (CBO) founded with a mission to apply global health strategies to improve the health in vulnerable populations in the US, and examined the experience of care delivery organizations in the US that have successfully implemented global-to-local solutions. Based on that experience, and supported by the advice of an expert panel, we developed a framework for applying global learning to improve US PHC. Findings: The framework includes six change concepts under three broad categories. The first category focuses on the need to actively and intentionally incorporate a global perspective in organizational program design and improvement activities. The second category addresses approaches to identifying global solutions related to community engagement and to health service delivery. The third category focuses on adaptation and implementation of lessons from global health in domestic contexts by applying relevant insights from dissemination and implementation science and diffusion of innovation theory. Conclusions: In the absence of a robust literature providing implementation guidance to US health systems and CBOs open to adopting or adapting PHC strategies and practices from other countries, the proposed framework synthesizing the experience of organizations that have done so can inform efforts to apply lessons from global health to improve PHC in the US

The extent to which tobacco marketing and tobacco use in films contribute to children\u27s use of tobacco: a meta-analysis

OBJECTIVE: To quantify the effect of exposure on initiation of tobacco use among adolescents. DATA SOURCES: A systematic literature search of MEDLINE, PsychINFO, ABI/INFORM, and Business Source Premier through October/November 2005 was conducted. Unpublished studies were solicited from researchers. STUDY SELECTION: Of 401 citations initially identified, 51 (n = 141 949 participants) met the inclusion criteria: reporting on exposure and tobacco use outcomes and participants younger than 18 years. Included studies reported 146 effects; 89 were conceptually independent effects. Data were extracted independently by 3 of us using a standardized tool. Weighted averages were calculated using a linear mixed-effects model. Heterogeneity and publication bias were assessed. Main Exposures Exposures (tobacco advertising, promotions, and samples and pro-tobacco depictions in films, television, and videos) were categorized as low or high engagement based on the degree of psychological involvement required. MAIN OUTCOME MEASURES: Outcomes were categorized as cognitive (attitudes or intentions) or behavioral (initiation, tobacco use status, or progression of use). RESULTS: Exposure to pro-tobacco marketing and media increases the odds of youth holding positive attitudes toward tobacco use (odds ratio, 1.51; 95% confidence interval, 1.08-2.13) and more than doubles the odds of initiating tobacco use (odds ratio, 2.23; 95% confidence interval, 1.79-2.77). Highly engaging marketing and media are more effective at promoting use (odds ratio, 2.67; 95% confidence interval, 2.19-3.25). These effects are observed across time, in different countries, with different study designs and measures of exposure and outcome. CONCLUSIONS: Pro-tobacco marketing and media stimulate tobacco use among youth. A ban on all tobacco promotions is warranted to protect children