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Purpose To assess the impact of providing healthcare professionals with feedback on patient-reported outcome measures (PROMs). Methods This is a systematic review including controlled studies investigating the effectiveness of PROMs feedback, specifically examining the impact at a group-level and a patient-level. Results Only one study provided feedback at a group-level as a measure of professional performance, which found no intervention effect. At a patient-level, sixteen studies were identified and only one study found an overall significant difference in the PROM score. However, an additional six studies found a significant result favouring the intervention group for a particular subgroup or domain. The studies which demonstrated the greatest impact primarily used PROMs as a management tool in an outpatient setting on a specialised patient population. In contrast, there was weak evidence supporting with the use of PROMs as a screening tool. The studies which found a positive effect had a lower quality score on average. Conclusions The effectiveness of PROMs feedback seems to be related to the function of the PROM. However, the evidence regarding the impact of PROMs feedback on patient outcomes is weak, and methodological issues with studies are frequent. The use of PROMs as a performance measure is not well investigated. Future research should focus on the appropriate application of PROMs by testing specific hypothesis related to cause and effect. Qualitative research is required to provide a deeper understanding of the practical issues surrounding the implementation of PROMs and the methodological issues associated with the effective use of the information.

Background The use of patient-reported outcome measures (PROMs) to provide healthcare professionals with peer benchmarked feedback is growing. However, there is little evidence on the opinions of professionals on the value of this information in practice. The purpose of this research is to explore surgeon’s experiences of receiving peer benchmarked PROMs feedback and to examine whether this information led to changes in their practice. Methods This qualitative research employed a Framework approach. Semi-structured interviews were undertaken with surgeons who received peer benchmarked PROMs feedback. The participants included eleven consultant orthopaedic surgeons in the Republic of Ireland. Results Five themes were identified: conceptual, methodological, practical, attitudinal, and impact. A typology was developed based on the attitudinal and impact themes from which three distinct groups emerged. ‘Advocates’ had positive attitudes towards PROMs and confirmed that the information promoted a self-reflective process. ‘Converts’ were uncertain about the value of PROMs, which reduced their inclination to use the data. ‘Sceptics’ had negative attitudes towards PROMs and claimed that the information had no impact on their behaviour. The conceptual, methodological and practical factors were linked to the typology. Conclusion Surgeons had mixed opinions on the value of peer benchmarked PROMs data. Many appreciated the feedback as it reassured them that their practice was similar to their peers. However, PROMs information alone was considered insufficient to help identify opportunities for quality improvements. The reasons for the observed reluctance of participants to embrace PROMs can be categorised into conceptual, methodological, and practical factors. Policy makers and researchers need to increase professionals’ awareness of the numerous purposes and benefits of using PROMs, challenge the current methods to measure performance using PROMs, and reduce the burden of data collection and information dissemination on routine practice.

To test whether providing surgeons with peer benchmarked feedback about patient-reported outcomes is effective in improving patient outcomes. Cluster randomised controlled trial. Secondary care--Ireland. Surgeons were recruited through the Irish Institute of Trauma and Orthopaedic Surgery, and patients were recruited in hospitals prior to surgery. We randomly allocated 21 surgeons and 550 patients. Surgeons in the intervention group received peer benchmarked patient-reported outcome measures (PROMs) feedback and education. Postoperative Oxford Hip Score (OHS). Primary outcome data were available for 11 intervention surgeons with responsibility for 230 patients and 10 control surgeons with responsibility for 228 patients. The mean postoperative OHS for the intervention group was 40.8 (95% CI 39.8 to 41.7) and for the control group was 41.9 (95% CI 41.1 to 42.7). The adjusted effect estimate was -1.1 (95% CI -2.4 to 0.2, p=0.09). Secondary outcomes were the Hip Osteoarthritis Outcome Score (HOOS), EQ-5D and the proportion of patients reporting a problem after surgery. The mean postoperative HOOS for the intervention group was 36.2 and for the control group was 37.1. The adjusted effect estimate was -1.1 (95% CI -2.4 to 0.3, p=0.1). The mean postoperative EQ-5D for the intervention group was 0.85 and for the control group was 0.87. The adjusted effect estimate was -0.02 (95% CI -0.05 to 0.008, p=0.2). 27% of intervention patients and 24% of control patients reported at least one complication after surgery (adjusted OR=1.2, 95% CI 0.6 to 2.3, p=0.6). Outcomes for patients operated on by surgeons who had received peer benchmarked PROMs data were not statistically different from the outcomes of patients operated on by surgeons who did not receive feedback. PROMs information alone seems to be insufficient to identify opportunities for quality improvement. ISRCTN 69032522.

Objectives To synthesise qualitative studies that investigated the experiences of healthcare professionals with using information from patient-reported outcome measures (PROMs) to improve the quality of care. Design A qualitative systematic review was conducted by searching PubMed, PsycINFO and CINAHL with no time restrictions. Hand searching was also performed. Eligible studies were evaluated using the Critical Appraisal Skills Programme toolkit for qualitative studies. A thematic synthesis identified common themes across studies. Study characteristics were examined to explain differences in findings. Setting All healthcare settings. Participants Healthcare professionals. Outcomes Professionals’ views of PROMs after receiving PROMs feedback about individual patients or groups of patients. Results Sixteen studies met the inclusion criteria. Barriers and facilitators to the use of PROMs emerged within four main themes: collecting and incorporating the data (practical), valuing the data (attitudinal), making sense of the data (methodological) and using the data to make changes to patient care (impact). Conclusions Professionals value PROMs when they are useful for the clinical decision-making process. Practical barriers to the routine use of PROMs are prominent when the correct infrastructure is not in place before commencing data collection and when their use is disruptive to normal work routines. Technology can play a greater role in processing the information in the most efficient manner. Improvements to the interpretability of PROMs should increase their use. Attitudes to the use of PROMs may be improved by engaging professionals in the planning stage of the intervention and by ensuring a high level of transparency around the rationale for data collection.

Translocation is an important management tool that has been used for >50 years in Arizona, USA, to increase bighorn sheep (Ovis canadensis) population densities and to restore herds to suitable habitat throughout their historical range. Yet, translocation can also alter the underlying genetic diversity and spatial structure of managed wildlife species in beneficial or detrimental ways. To evaluate the long-term effect of translocation actions on bighorn sheep, we characterized statewide genetic structure and diversity using microsatellite and mitochondrial DNA data in 16 indigenous and translocated (supplemented or reintroduced) Arizona populations sampled between 2005 and 2012. Populations that were recipients of translocated animals showed no reduction in genetic diversity with allelic richness and heterozygosity estimates equivalent to, and in some cases greater than, indigenous source populations. The indigenous population occupying the Silver Bell Mountains population displayed the lowest indices of genetic diversity but shared mitochondrial DNA haplotypes with the Mohawk Mountains, Sierra Pinta, and Cabeza Prieta populations, indicating past connectivity and potential opportunities for genetic management if warranted. Bayesian clustering on genetic similarity and genetic divergence estimates corroborated previous work differentiating Rocky Mountain bighorn sheep (O. c. canadensis) and 2 desert lineages corresponding with Nelson’s (O. c. nelsoni) and Mexican desert bighorn sheep (O. c. mexicana). In northern Arizona, assignment tests confirmed the presence of 2 indigenous metapopulations of Nelson’s desert bighorn sheep in the Black Mountains and Grand Canyon and indicated that gene flow from the Grand Canyon population has likely played a role in maintaining genetic diversity and mitigating founder effects among multiple translocated populations in the area. In southern Arizona, we detected genetic structure consistent with 2 metapopulations of Mexican desert bighorn sheep representing a departure from current management practices that consider this lineage to be a single genetic unit. Several lines of genetic evidence presented in this study suggest that the Bill Williams River area is the contemporary contact zone for the 2 desert lineages; however, the degree to which translocation has enhanced introgression is unknown. Despite relative isolation from other herds, the translocated Rocky Mountain bighorn sheep population in eastern Arizona had high levels of allelic richness and heterozygosity and a negative inbreeding coefficient, conceivably as a result of multiple translocation events from sources in Colorado and New Mexico, USA. Although translocation management has successfully contributed to the reestablishment of bighorn sheep populations in Arizona without diminishing genetic diversity, future translocation should proceed with caution to preserve the genetic integrity and potential local adaptation within the Nelson’s and Mexican desert bighorn sheep metapopulations identified in this study.

Fossil data are ambiguous regarding the evolutionary origin of contemporary desert bighorn sheep (Ovis canadensis subspecies). To address this uncertainty, we conducted phylogeographic and population genetic analyses on bighorn sheep subspecies found in southwestern North America. We analyzed 515 base pairs of mtDNA control region sequence and 39 microsatellites in 804 individuals from 58 locations. Phylogenetic analyses revealed 2 highly divergent clades concordant with Sierra Nevada (O. c. sierrae) and Rocky Mountain (O. c. canadensis) bighorn and showed that these 2 subspecies both diverged from desert bighorn prior to or during the Illinoian glaciation (~315–94 thousand years ago [kya]). Desert bighorn comprised several more recently diverged haplogroups concordant with the putative Nelson (O. c. nelsoni), Mexican (O. c. mexicana), and Peninsular (O. c. cremnobates) subspecies. Corresponding estimates of effective splitting times (~17–3 kya), and haplogroup ages (~85–72 kya) placed the most likely timeframe for divergence among desert bighorn subspecies somewhere within the last glacial maximum. Median-joining haplotype network and Bayesian skyline analyses both indicated that desert bighorn collectively comprised a historically large and haplotype-diverse population, which subsequently lost much of its diversity through demographic decline. Using microsatellite data, discriminant analysis of principle components (DAPC) and Bayesian clustering analyses both indicated genetic structure concordant with the geographic distribution of 3 desert subspecies. Likewise, microsatellite and mitochondrial-based F ST comparisons revealed significant fixation indices among the desert bighorn genetic clusters. We conclude these desert subspecies represent ancient lineages likely descended from separate Pleistocene refugial populations and should therefore be managed as distinct taxa to preserve maximal biodiversity. Los datos de fósiles sobre el origen evolutivo de las ovejas del desierto (Ovis canadensis subespecies) contemporáneas son ambiguos. Para dilucidar esta incertidumbre, llevamos a cabo análisis filogeográficos y de genética de poblaciones entre cinco subespecies de ovejas del suroccidente de Norteamérica. Analizamos 515 pb de secuencia de la región control del ADN mitocondrial y 39 microsatélites en 804 ovejas de 58 localidades. Los análisis filogenéticos revelaron 2 clados altamente divergentes concordantes con ovejas de la Sierra Nevada (O. c. sierrae) y de las Montañas Rocosas (O. c. canadensis), y demostraron que estas dos subespecies divergieron antes o durante la glaciación de Illinois (315,000–94,000 años). Las ovejas del desierto formaron varios haplogrupos recientemente derivados concordantes con las subespecies de Nelson (O. c. nelsoni), México (O. c. mexicana) y peninsular (O. c. cremnobates). Las estimaciones correspondientes al tiempo de separación efectiva (17,000–3,000 años) y edades de haplogrupos (85,000–72,000 años) son los plazos más probables para las divergencias entre subespecies de ovejas del desierto dentro de la última glaciación máxima. Análisis de redes de haplotipos de unión de medias y análisis bayesianos de líneas de horizonte indicaron que las ovejas del desierto formaron una población históricamente grande y diversa en términos de haplotipos, que luego perdieron gran parte de su diversidad a través de un descenso demográfico. Utilizando datos de microsatélites los análisis DAPC y TESS indicaron agrupamiento genético concordante con la distribución geográfica actual de las tres subespecies. Asimismo, comparaciones de F ST con datos de microsatélites y mitocondriales revelaron índices de fijación significativos entre los grupos genéticos de ovejas del desierto. Concluimos que estas subespecies de ovejas del desierto representan linajes antiguos que probablemente descienden de poblaciones de distintos refugios del Pleistoceno, y que por lo tanto deben ser manejadas como taxones distintos para preservar su biodiversidad máxima.

Background Although investigations have begun to differentiate biological and neurobiological responses to a variety of adversities, studies considering both endocrine and immune function in the same datasets are limited. Methods Associations between proximal (family functioning, caregiver depression, and anxiety) and distal (SES-D; socioeconomic disadvantage) early-life adversities with salivary inflammatory biomarkers (IL-1β, IL-6, IL-8, and TNF-α) and hair HPA markers (cortisol, cortisone, and dehydroepiandrosterone) were examined in two samples of young U.S. children ( N  = 142; N  = 145). Results Children exposed to higher SES-D had higher levels of TNF-α ( B  = 0.13, p  = 0.011), IL-1β ( B  = 0.10, p  = 0.033), and DHEA ( B  = 0.16, p  = 0.011). Higher family dysfunction was associated with higher cortisol ( B  = 0.08, p  = 0.033) and cortisone ( B  = 0.05, p  = 0.003). An interaction between SES-D and family dysfunction was observed for cortisol levels ( p  = 0.020) whereby children exposed to lower/average levels of SES-D exhibited a positive association between family dysfunction and cortisol levels, whereas children exposed to high levels of SES-D did not. These findings were partially replicated in the second sample. Conclusions Our results indicate that these biological response systems may react differently to different forms of early-life adversity. Impact Different forms of early-life adversity have varied stress signatures, and investigations of early-life adversities with inflammation and HPA markers are lacking. Children with higher socioeconomic disadvantage had higher TNF-α, IL-1β, and DHEA. Higher family dysfunction was associated with higher hair cortisol and cortisone levels, and the association between family dysfunction and cortisol was moderated by socioeconomic disadvantage. Biological response systems (immune and endocrine) were differentially associated with distinct forms of early-life adversities.

The Ovarian Cancer Epidemiology, Healthcare Access and Disparities study aims to characterize healthcare access (HCA) across five specific dimensions—Availability, Affordability, Accessibility, Accommodation and Acceptability—among Black, Hispanic and White patients with ovarian cancer (OC) to evaluate the impact of HCA on quality of treatment, supportive care and survival, and explore biological mechanisms that may contribute to OC disparities. Currently, there are no validated instruments for empirically measuring all HCA dimensions. To characterize HCA among diverse cancer survivors, there is a need to develop reliable, content-relevant, and comprehensive measures that have cross-cultural applicability. Thus, the goal of the present study was to: (1) develop a comprehensive survey instrument for HCA, guided by the Penchansky and Thomas framework; and (2) evaluate the factor structure, reliability, and psychometric properties of two domains (Accommodation and Acceptability) that are only estimable from patient-reported survey data. There are no validated instruments for measuring healthcare access (HCA). This study aimed to develop a cohesive HCA instrument for cancer survivors and evaluate the factor structure, reliability, and psychometric properties of two HCA domains—Acceptability and Accommodation—that require patient-reported survey data. Methods: This study reports data from three general methodological approaches: (1) concept elicitation using focus groups with 32 cancer survivors (63% Black, 18% Hispanic) to inform the development of new HCA survey items; (2) refining the new survey items using cognitive interviews with seven ovarian cancer survivors (n = 3 Black, n = 1 Hispanic) and pilot testing with 54 ovarian cancer survivors (74% White, 14% Black); and (3) psychometric evaluation of the Acceptability and Accommodation items among 333 ovarian cancer survivors (82% White, 13% Black). Multiple model structures were assessed for each HCA dimension using confirmatory factor analysis methods, and composite reliability was estimated for selected models. Results: In focus group discussions, cancer survivors expressed challenges navigating cancer treatment across multiple HCA domains, with the Acceptability domain (quality of patient–provider interaction) being the most salient across all racial groups. Lack of empathy, compassion, and poor communication overshadowed positive aspects of providers’ specialty, experience, or reputation. Cognitive interviews and pilot testing of new HCA survey items helped to clarify the language of specific items and refine the recruitment and consent process for implementation of the survey. In psychometric evaluation, the Accommodation domain (convenience and organization of services) was best accounted for by a two-factor structure: satisfaction with care and access to support services (comparative fit index (CFI) = 0.99). For the Acceptability domain, all fit indices supported the retention of a five-factor higher-order model (CFI = 0.96). Composite reliability estimates were >0.80 for all latent factors in the two-factor Accommodation model and the higher-order Acceptability model. Conclusions: Empirical evidence supports the utility of standardized measures of Accommodation and Acceptability using self-reported survey items, which will contribute to the better characterization of HCA dimensions among diverse cancer survivors.

Psychological resilience is critical to minimize the health effects of traumatic events. Trauma may induce a chronic state of hyperarousal, resulting in problems such as anxiety, insomnia, or posttraumatic stress disorder. Mind-body practices, such as relaxation breathing and mindfulness meditation, help to reduce arousal and may reduce the likelihood of such psychological distress. To better understand resilience-building practices, we are conducting the Biofeedback-Assisted Resilience Training (BART) study to evaluate whether the practice of slow, paced breathing with or without heart rate variability biofeedback can be effectively learned via a smartphone app to enhance psychological resilience. Our objective was to conduct a limited, interim review of user interactions and study data on use of the BART resilience training app and demonstrate analyses of real-time sensor-streaming data. We developed the BART app to provide paced breathing resilience training, with or without heart rate variability biofeedback, via a self-managed 6-week protocol. The app receives streaming data from a Bluetooth-linked heart rate sensor and displays heart rate variability biofeedback to indicate movement between calmer and stressful states. To evaluate the app, a population of military personnel, veterans, and civilian first responders used the app for 6 weeks of resilience training. We analyzed app usage and heart rate variability measures during rest, cognitive stress, and paced breathing. Currently released for the BART research study, the BART app is being used to collect self-reported survey and heart rate sensor data for comparative evaluation of paced breathing relaxation training with and without heart rate variability biofeedback. To date, we have analyzed the results of 328 participants who began using the BART app for 6 weeks of stress relaxation training via a self-managed protocol. Of these, 207 (63.1%) followed the app-directed procedures and completed the training regimen. Our review of adherence to protocol and app-calculated heart rate variability measures indicated that the BART app acquired high-quality data for evaluating self-managed stress relaxation training programs. The BART app acquired high-quality data for studying changes in psychophysiological stress according to mind-body activity states, including conditions of rest, cognitive stress, and slow, paced breathing.

We randomly assigned 95 patients with large esophageal varices (Grade 3 or 4) who had not previously had upper gastrointestinal tract bleeding to two groups: 49 received intravariceal sclerotherapy, and 46 were followed as controls. Over a mean follow-up of 13 months there was no difference between the sclerotherapy group and the control group in mortality (24.4 percent) or any significant difference in average hospital stay per month (3.0 vs. 2.6 days). Sclerotherapy was associated with significantly more episodes of upper gastrointestinal bleeding (26 vs. 10 episodes, P<0.05); 75 percent of deaths in the sclerotherapy group were related to bleeding, as compared with 18 percent in the control group. An additional 54 patients with cirrhosis who did not qualify for the study were also followed — 20 with small varices and 34 with none. Mortality was 20 and 15 percent, respectively; no deaths were due to bleeding. We conclude that prophylactic sclerotherapy does not provide clinical benefit to patients with large esophageal varices. (N Engl J Med 1988; 318:814–8.) CIRRHOSIS of the liver remains a major clinical problem, affecting about 2 million people in the United States, with excessive ingestion of alcohol as the chief etiologic factor. 1 Mortality is high among these patients; hepatic failure and hemorrhage account for two thirds of all deaths. 2 Programs employing long-term sclerotherapy to treat variceal hemorrhage have reduced the rate of subsequent hemorrhage, and in several studies resulted in improved long-term survival. 3 4 5 6 7 8 9 A logical extension of therapeutic sclerotherapy has been prophylactic variceal sclerosis for patients found to have esophageal varices that have not previously bled. 10 11 12 13 The earliest studies (from Germany) reported impressive results . . .