The Changing Roles of Community Health Workers

Community Health Workers (CHWs) have been gaining attention from policymakers because of their unique role in addressing health disparities and socioeconomic drivers of disease, and because of their potential integration into the health care delivery system. To date, there has been limited research specifically describing the variation in CHWs’ roles and relationships, and how that variation relates to management, to financing, to health system integration, and to the competencies CHWs should have in different contexts. This report provides a snapshot of the varied landscape of CHW programs to better understand how CHWs are integrating with the health system both in terms of the structural elements of these programs, and the relational elements of CHW-health system interaction that make integrated models succeed. Authors suggest that there is no blueprint for success; rather, there are certain unifying structural elements of various integration types, and certain useful mechanisms that enable the preservation of the CHW concept

The Associations Between Children's and Adolescents’ Suicidal and Self-Harming Behaviors, and Related Behaviors Within Their Social Networks: A Systematic Review

© 2017, Copyright © International Academy for Suicide Research.Social influences—including the suicidal and self-harming behaviors of others—have been highlighted as a risk factor for suicidal and self-harming behavior in young people, but synthesis of the evidence is lacking. A systematic review of 86 relevant papers was conducted. Considerable published evidence was obtained for positive associations between young people's suicidal and self-harming behavior and that of people they know, with those reporting knowing people who had engaged in suicidal or self-harming behaviors more likely to report engaging in similar behaviors themselves. Findings are discussed in relation to a number of methodological and measurement issues—including the role of normative perceptions—and implications for the prevention of suicidal and self-harming behavior are considered

Patients' ratings of genetic conditions validate a taxonomy to simplify decisions about preconception carrier screening via genome sequencing

Advances in genome sequencing and gene discovery have created opportunities to efficiently assess more genetic conditions than ever before. Given the large number of conditions that can be screened, the implementation of expanded carrier screening using genome sequencing will require practical methods of simplifying decisions about the conditions for which patients want to be screened. One method to simplify decision making is to generate a taxonomy based on expert judgment. However, expert perceptions of condition attributes used to classify these conditions may differ from those used by patients. To understand whether expert and patient perceptions differ, we asked women who had received preconception genetic carrier screening in the last 3 years to fill out a survey to rate the attributes (predictability, controllability, visibility, and severity) of several autosomal recessive or X-linked genetic conditions. These conditions were classified into one of five taxonomy categories developed by subject experts (significantly shortened lifespan, serious medical problems, mild medical problems, unpredictable medical outcomes, and adult-onset conditions). A total of 193 women provided 739 usable ratings across 20 conditions. The mean ratings and correlations demonstrated that participants made distinctions across both attributes and categories. Aggregated mean attribute ratings across categories demonstrated logical consistency between the key features of each attribute and category, although participants perceived little difference between the mild and serious categories. This study provides empirical evidence for the validity of our proposed taxonomy, which will simplify patient decisions for results they would like to receive from preconception carrier screening via genome sequencing

Generating a taxonomy for genetic conditions relevant to reproductive planning

As genome or exome sequencing (hereafter genome-scale sequencing) becomes more integrated into standard care, carrier testing is an important possible application. Carrier testing using genome-scale sequencing can identify a large number of conditions, but choosing which conditions/genes to evaluate as well as which results to disclose can be complicated. Carrier testing generally occurs in the context of reproductive decision-making and involves patient values in a way that other types of genetic testing may not. The Kaiser Permanente Clinical Sequencing Exploratory Research program is conducting a randomized clinical trial of preconception carrier testing that allows participants to select their preferences for results from among broad descriptive categories rather than selecting individual conditions. This paper describes 1) the criteria developed by the research team, the return of results committee (RORC), and stakeholders for defining the categories; 2) the process of refining the categories based on input from patient focus groups and validation through a patient survey; and, 3) how the RORC then assigned specific gene-condition pairs to taxonomy categories being piloted in the trial. The development of four categories (serious, moderate/mild, unpredictable, late onset) for sharing results allows patients to select results based on their values without separately deciding their interest in knowing their carrier status for hundreds of conditions. A fifth category, lifespan limiting, was always shared. The lessons learned may be applicable in other results disclosure situations, such as incidental findings

BOB CAT: a Large-Scale Review and Delphi Consensus for Management of Barrett’s Esophagus With No Dysplasia, Indefinite for, or Low-Grade Dysplasia

OBJECTIVES: Barrett’s esophagus (BE) is a common premalignant lesion for which surveillance is recommended. This strategy is limited by considerable variations in clinical practice. We conducted an international, multidisciplinary, systematic search and evidence-based review of BE and provided consensus recommendations for clinical use in patients with nondysplastic, indefinite, and low-grade dysplasia (LGD). METHODS: We defined the scope, proposed statements, and searched electronic databases, yielding 20,558 publications that were screened, selected online, and formed the evidence base. We used a Delphi consensus process, with an 80% agreement threshold, using GRADE (Grading of Recommendations Assessment, Development and Evaluation) to categorize the quality of evidence and strength of recommendations. RESULTS: In total, 80% of respondents agreed with 55 of 127 statements in the final voting rounds. Population endoscopic screening is not recommended and screening should target only very high-risk cases of males aged over 60 years with chronic uncontrolled reflux. A new international definition of BE was agreed upon. For any degree of dysplasia, at least two specialist gastrointestinal (GI) pathologists are required. Risk factors for cancer include male gender, length of BE, and central obesity. Endoscopic resection should be used for visible, nodular areas. Surveillance is not recommended for <5 years of life expectancy. Management strategies for indefinite dysplasia (IND) and LGD were identified, including a de-escalation strategy for lower-risk patients and escalation to intervention with follow-up for higher-risk patients. CONCLUSIONS: In this uniquely large consensus process in gastroenterology, we made key clinical recommendations for the escalation/de-escalation of BE in clinical practice. We made strong recommendations for the prioritization of future research

Immune infiltration in invasive lobular breast cancer

Background: Invasive lobular breast cancer (ILC) is the second most common histological subtype of breast cancer after invasive ductal cancer (IDC). Here, we aimed at evaluating the prevalence, levels and composition of tumor infiltrating lymphocytes (TIL) and their association with clinico-pathological, and outcome variables in ILC, and to compare it with IDC. Methods: We considered two patient series with TIL data: a multi-centric retrospective series (n=614) and the BIG 02-98 study (n=149 ILC and 807 IDC). We compared immune subsets identified by immuno-histochemistry in the ILC (n=159) and IDC (n=468) patients from the Nottingham series, as well as the CIBERSORT immune profiling of the ILC (n=98) and IDC (n=388) METABRIC and TCGA patients. All ILC/IDC comparisons were done in ER-positive/HER2-negative tumors. All statistical tests were two-sided. Results: TIL levels were statistically significantly lower in ILC compared to IDC (fold change =0.79; 95%CI: 0.70-0.88, P<.001). In ILC, high TIL levels were associated with young age, lymph node involvement, and high proliferative tumors. In the univariable analysis, high TIL levels were associated with worse prognosis in the retrospective and BIG 02-98 lobular series, although it did not reach statistical significance in the latter. The Nottingham series revealed that the levels of intra-tumoral but not total CD8+ were statistically significantly lower in ILC compared to IDC. Comparison of the CIBERSORT profiles highlighted statistically significant differences in terms of immune composition. Conclusion: This study shows differences between the immune infiltrates of ER-positive/HER2-negative ILC and IDC in terms of prevalence, levels, localization, composition, and clinical associations

Building a New Measure of Underservice to Assess How Far Physicians in Maryland’s State Visa Waiver and Loan Repayment Programs are Serving Medicare’s Underserved

The United States has a widely acknowledged problem of medical “underservice”, responses to which include programs that provide incentives for physicians to practice in “underserved areas”. This research study investigates the impact of these programs while viewing underservice as a complex and ill-defined phenomenon. Lack of definition of underservice inhibits the alignment of incentive programs with wider strategies for improving healthcare systems and outcomes. The study focuses on state programs, where the bulk of incentive program capacity is administered, where greater flexibility in how participating physicians are deployed can be exercised than in the National Health Service Corps’ federal program, and where much of the strategic effort to overcome problems in healthcare delivery is taking place. Recognizing that states have limited resources to monitor incentive program impact in order to align the programs more closely with wider state health policies, the study seeks to facilitate better alignment by developing a new measure of underservice, the Medicare Index of Service to the Underserved, that enables program impact to be monitored more accurately and efficiently than at present. Based on the case mix of individual primary care physicians, the new measure departs from traditional reliance on data aggregated across geographic areas. It expands beyond the traditional HPSA concept by incorporating, in addition to the rural/urban location that weighs heavily in the HPSA designation, measures of medical risk and socioeconomic status of Medicare patients treated that are derived from Medicare data. In the main analysis of this study the new index is used to assess the impact of Maryland’s physician loan repayment and visa waiver programs, using program participation data supplied under a Data Transfer and Use Agreement with Maryland Department of Health’s Office of Population Health Improvement. This data, extending from 2002 through 2017, permits long-term as well as short-term impact to be assessed. Utilizing both difference-in-means and difference-in-difference methods to quantify, understand and describe program impact, the study finds that primary care physicians participating in visa waiver and loan repayment programs are significantly and substantially more active in providing care to underserved populations than other primary care physicians in the state, but that the nature of this service varies between programs and through time. Specific findings include: • a greater tendency of waiver than loan repayment physicians to serve populations with high medical need; • a greater tendency of loan repayment physicians to remain working in rural areas; • high career mobility among waiver physicians, with substantial loss of waiver program participants to non-primary care specialties and/or to other states; • low career mobility among loan repayment physicians, resulting in longer-term commitment to underserved populations but with uncertainty about whether that commitment might have been in place even absent participation in the program. The study concludes with recommendations for research and for policy that would, firstly, address important data limitations identified during the study, and, secondly, assist in improving alignment between state physician incentive programs and wider policies for improving healthcare systems and outcomes

A Comparative Analysis of Windowing Approaches in Dense Sensing Environments

Windowing is an established technique employed within dense sensing environments to extract relevant features from sensor data streams. Among the established approaches of Explicit, Time-based and Sensor-Event based windowing, Dynamic windowing approaches are beginning to emerge. These dynamic approaches claim to address the inherent shortcomings of the aforementioned established approaches by determining the appropriate window length for live sensor data streams in real-time, thereby offering the potential to optimize and increase the recognition of these sensor represented activities. Beyond these potential benefits, dynamic approaches can also support anomaly detection by actively uncovering new, unknown window patterns within a trained model. This paper presents findings from a study which utilizes data from a single source dataset, towards benchmarking and comparing more traditional windowing approaches against a dynamic windowing approach. The experiments conducted on a real-world smart home dataset suggest Time-based windowing is the best approach. Through evaluation of results, Dynamic windowing approaches may benefit from carefully annotated datasets