Important health information including disease prevention and chronic disease self-management is increasingly packaged for digital use. The purpose of this sequential explanatory mixed methods study was to describe the extent of computer ownership, Internet access, and digital health information use in an ethnically diverse sample of older adults, comparing ownership, access, and use of digital health information (DHI) across ethnic groups and identifying the factors associated with them quantitatively. Significant differences in computer ownership, Internet access, and DHI use were found across ethnic groups (African American, Afro-Caribbean, Hispanic American, and European American). Logistic regression identified older age, less education, lower income, and minority group membership as significant predictors of limited DHI use. Older African Americans were one-fifth as likely to own a computer than were European Americans; Hispanic Americans were one-half as likely to have access to the Internet. We then conducted a series of focus groups which highlighted differences across ethnic groups. Participants in the African American/Afro-Caribbean group expressed frustration with lack of access to DHI but appreciation for alternative sources of information. Hispanic Americans critiqued information received from providers and drug inserts, some suggesting that a positive attitude and trust in God also contributed to getting well. European American participants evaluated various DHI websites, looking to providers for help in applying information to their personal situation. As the development and use of DHI continue, parallel efforts to increase access to DHI among economically disadvantaged and minority older adults are critical to prevent further disfranchisement.

Background. Long-term continuous adherence to biennial screening mammograms as guidelines recommend remains low. Limited evidence suggests that reminder calls may increase short-term adherence as much as telephone counseling, but research is needed comparing the long-term effects of these two approaches. Purpose. To compare the impacts of two telephone outreach interventions and mailed reminders on 4-year continuous mammography adherence. Method. A cohort of 3,215 women, age 50 to 81 years, was selected from 30,160 women from a 4-year randomized trial of three interventions to promote biennial mammography: reminder letter only (LO), letter plus reminder call (RC), and two letters plus educational material and a counseling call (CC). Women selected remained eligible for the trial all 4 years and received annual interventions as needed. The proportion with a mammogram in the last 24 months was determined at baseline and four annual time points. Results. Continuous adherence at all four time points was higher in the RC (78.8%) and CC arms (78.8%) than in the LO arm (75.1%; p < .001). Multivariable analysis confirmed this finding: CC (odds ratio = 1.27; 95% confidence interval = [1.01, 1.61]) and RC (odds ratio = 1.23; 95% confidence interval = [0.98, 1.56]). Only 27.8% of women eligible for an initial counseling call actually received counseling. Conclusions. Compared with letters alone, outreach calls can modestly increase continuous mammography adherence among insured women with consistent primary care. Telephone counseling was no more effective than a reminder call, possibly due to limited acceptance of counseling calls by women who may find them unwelcome or unnecessary.

As population health has become a focus of health care payers and providers, interest has grown in mail, phone, and other forms of outreach for improving population rates of cancer screening. Translational research is needed to compare the effectiveness and cost of low- and high-intensity behavioral outreach interventions for promoting cancer screening. The purpose of the article is to compare the effectiveness in promoting biannual mammograms of three interventions delivered over 4 years to a primary care population with a high baseline mammography adherence of 83.3%. We randomized women aged 40-84 to reminder letter only (LO arm), letter + reminder call (RC arm), and two letters + counseling call (CC arm) involving tailored education and motivational interviewing. Mammography adherence (≥1 mammogram in the previous 24 months) at four time points was determined from insurance claims records. Over 4 years, 30,162 women were randomized. At the end of 4 years, adherence was highest in the RC arm (83.0%) compared with CC (80.8%) and LO (80.8%) arms (p = .03). Only 23.5% of women in the CC arm were reached and accepted full counseling. The incremental cost per additional mammogram for RC arm women was $30.45 over the LO arm cost. A simple reminder call can increase screening mammogram adherence even when baseline adherence is high. Some more complex behavioral interventions delivered by mail and phone as in this study may be less effective, due to limited participation of patients, a focus on ambivalence, lack of follow-up, and other factors.

PURPOSE We wanted to evaluate novel decision aids designed to help patients trust and accept the controversial, evidence-based, US Preventive Services Task Force recommendations about prostate cancer screening (from 2012) and mammography screening for women aged 40 to 49 years (from 2009). METHODS We created recorded vignettes of physician-patient discussions about prostate cancer screening and mammography, accompanied by illustrative slides, based on principles derived from preceding qualitative work and behavioral science literature. We conducted a randomized crossover study with repeated measures with 27 men aged 50 to 74 years and 35 women aged 40 to 49 years. All participants saw a video intervention and a more traditional, paper-based decision aid intervention in random order. At entry and after seeing each intervention, they were surveyed about screening intentions, perceptions of benefits and harm, and decisional conflict. RESULTS Changes in screening intentions were analyzed without regard to order of intervention after an initial analyses showed no evidence of an order effect. At baseline, 69% of men and 86% of women reported wanting screening, with 31% and 6%, respectively, unsure. Mean change on a 3-point, yes, unsure, no scale was −0.93 (P = <.001) for men and −0.50 (P = <.001) for women after seeing the video interventions vs 0.0 and −0.06 (P = .75) after seeing the print interventions. At the study end, 33% of men and 49% of women wanted screening, and 11% and 20%, respectively, were unsure. CONCLUSIONS Our novel, persuasive video interventions significantly changed the screening intentions of substantial proportions of viewers. Our approach needs further testing but may provide a model for helping patients to consider and accept evidence-based, counterintuitive recommendations.

Purpose: Sepsis is the leading noncardiac cause of intensive care unit (ICU) death. Pre-ICU admission site may be associated with mortality of ICU patients with sepsis. This study quantifies mortality differences among patients with sepsis admitted to an ICU from a hospital ward, emergency department (ED), or an operating room (OR). Methods: We conducted a retrospective cohort study of 1762 adults with sepsis using ICU record data obtained from a clinical database of an academic medical center. Survival analysis provided crude and adjusted hazard rate ratio (HRR) estimates comparing hospital mortality among patients from hospital wards, EDs, and ORs, adjusted for age, sex, and severity of illness. Results: Mortality of patients with sepsis differed based on the pre-ICU admission site. Compared to patients admitted from an ED, patients admitted from hospital wards had higher mortality (HRR: 1.35; 95% confidence interval [CI]: 1.09-1.68) and those admitted from an OR had lower mortality (HRR: 0.37; 95% CI: 0.23-0.58). Conclusion: Patients with sepsis admitted to an ICU from a hospital ward experienced greater mortality than patients with sepsis admitted to an ICU from an ED. These findings indicate that there may be systematic differences in the selection of patient care locations, recognition, and management of patients with sepsis that warrant further investigation.

The optimal form of outreach to promote repeated, on time screening mammograms in primary care has not been established. The purpose of this study is to assess the implementation process and process outcomes for three interventions for promoting biannual screening mammography in a randomized trial. In a large urban primary care practice over a 4-year period, we randomized women aged 40-85 and eligible for mammograms to three interventions: reminder letter only (LO), reminder letter + reminder call (RC), and reminder letter + counseling call (CC). We tracked information system development, staff training, patient and provider recruitment, reach, dose delivered and received, fidelity, and context measures. Ninety-three of 95 providers approved participation by 80% (23,999) of age-eligible patients, of whom only 207 (0.9%) opted not to receive any intervention. Of 9161 initial reminder letters mailed to women coming due or overdue for mammograms, 0.8% were undeliverable. Of women in the RC and CC arms unresponsive to the first reminder letter (n = 3982), 71.4% were called and reached, and of those, 49.1% scheduled a mammogram. Only 33.4% of women reached in the CC arm received full counseling, and women in the CC arm were less likely to schedule a mammogram than those in the RC arm. Implementing mail and telephone mammography reminders is feasible and acceptable in a large urban practice and reaches a majority of patients. Many schedule a mammogram when reached. A reminder letter followed by a simple reminder call if needed may be the optimal approach to promoting screening mammograms.

Purpose: Sepsis treatment protocols emphasize source control with empiric antibiotics and fluid resuscitation. Previous reviews have examined the impact of infection site and specific pathogens on mortality from sepsis; however, no recent review has addressed the infection site. This review focuses on the impact of infection site on hospital mortality among patients with sepsis. Methods: The PubMed database was searched for articles from 2001 to 2014. Studies were eligible if they included (1) one or more statistical models with hospital mortality as the outcome and considered infection site for inclusion in the model and (2) adult patients with sepsis, severe sepsis, or septic shock. Data abstracted included stage of sepsis, infection site, and raw and adjusted effect estimates. Nineteen studies were included. Infection sites most studied included respiratory (n = 19), abdominal (n = 19), genitourinary (n = 18), and skin and soft tissue infections (n = 11). Several studies found a statistically significant lower mortality risk for genitourinary infections on hospital mortality when compared to respiratory infections. Conclusion: Based on studies included in this review, the impact of infection site in patients with sepsis on hospital mortality could not be reliably estimated. Misclassification among infections and disease states remains a serious possibility in studies on this topic.

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness I1 Apr 2015MP16-20 CHANGES IN PRIMARY CARE PROVIDER PRACTICE PATTERNS SINCE 2012: IMPACT OF THE USPSTF GUIDELINE STATEMENT Jennifer Yates, Mitchell Sokoloff, Achankeng Afiadata, Jennifer Fantasia, David Frendl, Mara Epstein, and Roger Luckmann Jennifer YatesJennifer Yates More articles by this author , Mitchell SokoloffMitchell Sokoloff More articles by this author , Achankeng AfiadataAchankeng Afiadata More articles by this author , Jennifer FantasiaJennifer Fantasia More articles by this author , David FrendlDavid Frendl More articles by this author , Mara EpsteinMara Epstein More articles by this author , and Roger LuckmannRoger Luckmann More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.827AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Prostate specific antigen (PSA) utilization in prostate cancer (CaP) screening has undergone significant changes since the 2012 release of the United States Preventive Services Task Force (USPSTF) guideline statement. The effect on primary care provider (PCP) practice patterns is still not well-characterized. The objective of this survey was to describe the impact of the USPSTF statement on CaP screening by PCPs. METHODS A survey composed of 25 questions was mailed electronically to approximately 350 PCP's within a single academic health care system. Providers included both hospital-employed and hospital-affiliated PCPs. The responses could not be traced to the respondent. The results of the survey were recorded. RESULTS A total of 73 PCP's responded to the survey (21%), including 51% female providers and 49% male providers. The majority of respondents (75.2%) were in practice for 11 years or greater, and 96% were MD/DO providers. Regarding familiarity with the 2012 USPSTF statement, 97% were somewhat or very familiar with the statement. Table 1 lists the responses of the survey participants to select questions. Of note, the majority of respondents (80%) believe routine PSA screening offers more harm than benefit to patients, and 75% of respondents have changed their PSA practice patterns based on the USPSTF statement. Fifty percent of respondents still offer PSA to patients older than 70 years of age. Forty-two percent were not at all concerned about the medicolegal consequences of a missed diagnosis of CaP, while the remainder were at least somewhat concerned about this possibility. The majority of respondents believe that the USPSTF addressed digital rectal exam (DRE), and as a result 36% have changed their practice to perform FEWER DREs. CONCLUSIONS The survey, while limited to single large academic center, describes the impact of the USPSTF 2012 statement on practice patterns. This defines the need for more educational opportunities for PCP's in regards to the USPSTF statement, AUA guidelines, and identifying patients appropriate for PSA screening. In particular, PCP's may benefit from information regarding the AUA guidelines, role of DRE in CaP screening, and the patients most likely to benefit from screening. Responses to selection survey questions Question Response Which of the following statements about the USPSTF statement on prostate cancer screening from May 2012 is true (Check ALL that apply) Advises against all routine PSA screening (52.24%) Advises against the use of PSA testing for following patients with known prostate cancer (treated or untreated). (0) Recommends that providers engage men of the appropriate age in shared decision making about PSA screening, and that that they order a PSA test for men who request one after engaging in shared decision making. (64.18%) PSA mortality has decreased over the past two decades. To what extent do you believe that this can be explained by PSA screening? PSA screening is at least partially responsible for this decrease (35.82%) PSA screening likely played no role in this decrease (32.84%) Not sure (31.34%) Is the following statement true? ‘The USPSTF statement specifically recommends against digital rectal exam (DRE) in asymptomatic men for prostate cancer screening.’ Yes (40.3%) No (40.3%) Not sure (19.4%) The USPSTF statement claims that based on existing evidence, the routine use of screening PSA may impart more harm than benefit to the patient. To what extent do you agree or disagree with this claim? Strongly disagree (1.49%) Disagree (11.94%) No opinion (16.42%) Agree (50.75%) Strongly Agree (19.4%) How did your practice change? (Check all that apply) (∗after the 2012 USPSTF Statement) I went from routinely recommending PSA screening to recommending against PSA screening (11.32%) I went from a neutral stance on PSA screening (neither for or against) to recommending against PSA screening (15.09%) I went from routinely recommending PSA screening to engaging patients in a shared decision making process and allowing patients to decide (60.38%) I went from routinely discussing PSA testing with my patients to discussing it ONLY if the patient brings it up (13.21%) Which of the following statements describe your current approach to PSA screening in our practice? (Check all that apply) Let appropriate patients know PSA screening is an option and engage them in shared decision making discussion (42.59%) Recommend against PSA testing as part of shared decision making or if a patient asks about PSA testing (24.07%) Support patients in getting PSA screening if they have weighed the benefits and risks and choose to be tested (64.81%) Routinely recommend PSA screening to men of the appropriate age and health status (3.7%) Do not routinely bring up PSA screening (9.26%) How concerned are you that NOT routinely recommending PSA screening to patients of appropriate age could lead to future litigation regarding failure to diagnosis early prostate cancer Responses on continuum from 1 to 5): 1. Not at all concerned (13.43%) ---2. (28.36%) --- 3. (37.31%) ---4. 14.93% --- 5. Very concerned (5.97%) How concerned are you that routinely recommending PSA screening to patients of appropriate age could lead to future litigation regarding OVERdiagnosis early prostate cancer? (Responses on continuum from 1 to 5): 1. Not at all concerned (33.33%) ---2. (34.85%) --- 3. (25.76%) ---4. (1.52%) --- 5. Very concerned (4.55%) Do you routinely recommend a periodic digital rectal exam (DRE) of the prostate to asymptomatic patients that you consider of the appropriate age for prostate cancer screening? Yes 42.42% No 57.58% Has the USPSTF statement on prostate cancer screening in 2012 changed your practice of recommending DRE? Yes, I recommend DRE more often (1.49%) Yes, I recommend DRE less often (35.82%) No, I have not changed my practice (62.69%) © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e175 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jennifer Yates More articles by this author Mitchell Sokoloff More articles by this author Achankeng Afiadata More articles by this author Jennifer Fantasia More articles by this author David Frendl More articles by this author Mara Epstein More articles by this author Roger Luckmann More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

OBJECTIVE:To determine the feasibility, acceptability, and outcomes of a telephone counseling intervention promoting colorectal cancer (CRC) screening when patients are referred for counseling by primary care providers (PCPs).STUDY DESIGN:Interventional cohort study with no formal control group.METHODS:PCPs in 3 practices were prompted to address CRC screening in patient encounters and, if appropriate, to recommend referral for telephone counseling. A telephone counselor called referred patients, made an appointment for a counseling call, and mailed an educational booklet to patients. Counseling included education about CRC and screening tests, motivational interviewing, barrier counseling, and facilitated referral for colonoscopy or mailing of a fecal occult blood testing kit. About 7 months following counseling, electronic records were searched for evidence of colonoscopy.RESULTS:PCPs addressed CRC screening with 1945 patients, most of whom were up-to-date with CRC testing, recommended counseling referral to 362, and of these 180 (49.7%) accepted the referral. A total of 140 (77.8%) of referred patients were contacted and 67 (37.2%) received counseling. After counseling 93.9% were planning on CRC screening compared with 54.6% at the beginning of the call. Of those planning a colonoscopy, 53.2% received one within 7 months.CONCLUSIONS:Referring patients for telephone counseling to promote CRC screening may be feasible and acceptable to PCPs and to some patients, and may increase CRC screening. Further evaluation of the intervention may be warranted to compare the rate of screening associated with the intervention to rates related to usual care and to other interventions.

Background: With the impetus for healthcare reform and the imperative for healthcare organizations to improve efficiency and reduce waste, it is valuable to examine high-volume procedures and practices in order to identify potential overuse. At the same time, organizations must ensure that improved efficiency does not inadvertently reduce patient safety.Methods: We undertook a multicenter analysis of the use of adult cardiac telemetry outside of the intensive care unit or step-down units at 4 teaching hospitals to determine the percentage of monitoring days that were not justified by an accepted indication and the monetary costs associated with these nonindicated days. We also assessed the safety of eliminating monitoring on days when it was not justified by looking at the incidence of arrhythmias.Results: We found that in 35% of telemetry days, telemetry use was not supported by an accepted set of clinical indications. The incidence of arrhythmias on nonindicated days was low (3.1 per 100 days of monitoring per nonindicated day), and the arrhythmias detected were clinically insignificant. Eliminating monitoring on nonindicated days could save a minimum of $53 per patient per day. The average 400-bed hospital with a conservative estimate of 5000 nonindicated patient days per year could save $250,000 per year.Conclusion: Reducing the use of telemetry on nonindicated days may provide an opportunity for institutions to safely reduce cost as well as staff time and effort, while maintaining and potentially increasing patient safety.

BACKGROUND:Despite the demonstrated need to increase screening mammography utilization and strong evidence that mail and telephone outreach to women can increase screening, most managed care organizations have not adopted comprehensive outreach programs. The uncertainty about optimum strategies and cost effectiveness have retarded widespread acceptance. While 70% of women report getting a mammogram within the prior 2 years, repeat mammography rates are less than 50%. This 5-year study is conducted though a Central Massachusetts healthcare plan and affiliated clinic. All women have adequate health insurance to cover the test.METHODS/DESIGN:This randomized study compares 3 arms: reminder letter alone; reminder letter plus reminder call; reminder letter plus a second reminder and booklet plus a counselor call. All calls provide women with the opportunity to schedule a mammogram in a reasonable time. The invention period will span 4 years and include repeat attempts. The counselor arm is designed to educate, motivate and counsel women in an effort to alleviate PCP burden.All women who have been in the healthcare plan for 24 months and who have a current primary care provider (PCP) and who are aged 51-84 are randomized to 1 of 3 arms. Interventions are limited to women who become ≥ 18 months from a prior mammogram. Women and their physicians may opt out of the intervention study.Measurement of completed mammograms will use plan billing records and clinic electronic records. The primary outcome is the proportion of women continuously enrolled for ≥ 24 months who have had ≥ 1 mammogram in the last 24 months. Secondary outcomes include the number of women who need repeat interventions. The cost effectiveness analysis will measure all costs from the provider perspective.DISCUSSION:So far, 18,509 women aged 51-84 have been enrolled into our tracking database and were randomized into one of three arms. At baseline, 5,223 women were eligible for an intervention. We anticipate that the outcome will provide firm data about the maximal effectiveness as well as the cost effectiveness of the interventions both for increasing the mammography rate and the repeat mammography rate.TRIAL REGISTRATION:http://clinicaltrials.gov/NCT01332032.

ACP Journal Club18 January 2011Review: Prostate cancer screening using PSA does not decrease mortalityRoger Luckmann, MD, MPHRoger Luckmann, MD, MPHUniversity of Massachusetts Medical School, Worcester, Massachusetts, USA (R.L.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-154-2-201101180-02002 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Source CitationDjulbegovic M, Beyth RJ, Neuberger MM, et al. Screening for prostate cancer: systematic review and meta-analysis of randomised controlled trials. BMJ. 2010;341:c4543. https://pubmed.ncbi.nlm.nih.gov/20843937Clinical Impact RatingsGIM/FP/GP: References1 Hugosson J, Carlsson S, Aus G, et al. Mortality results from the Göteborg randomised population-based prostate-cancer screening trial. Lancet Oncol. 2010;11:725-32. [PMID: 20598634] Google Scholar2 Schröder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med. 2009;360:1320-8. [PMID: 19297566] Google Scholar Author, Article, and Disclosure InformationAffiliations: University of Massachusetts Medical School, Worcester, Massachusetts, USA (R.L.)This article was published at Annals.org on 4 January 2011. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 18 January 2011Volume 154, Issue 2Page: JC1-2KeywordsAge distributionAntigensCancer screeningProstate cancerRisk managementSystematic reviews ePublished: 18 January 2011 Issue Published: 18 January 2011 CopyrightCopyright © 2011 by American College of Physicians. All Rights Reserved.PDF DownloadLoading ...