Increased Adherence to Prenatal Group B Streptococcal Screening Guidelines Through a Paired Electronic Reminder and Education Intervention

The 2010 Centers for Disease Control and Prevention (CDC) update on perinatal group B streptococcal (GBS) prevention advises universal vaginal–rectal GBS screening of pregnant women in the 35th through 37th week of gestation. Because GBS colonization is transient, a test performed more than 5 weeks before delivery may not have sufficient negative predictive value to be clinically useful. Our objective was to increase rates of quality-improved, CDC-adherent GBS screening and decrease repeat screening. A reminder for maternal vaginal–rectal GBS testing was added to the physicians’ electronic ordering screen, and family medicine physicians and residents were educated about screening guidelines through standardized, in-person presentations. Retrospective chart review was performed before and after these interventions. Univariate or bivariate analysis was performed for demographic factors, timing of first screen, rates of CDC-adherent screening (the newly defined quality-improved screen and the usual screen), and rates of repeat and unnecessary screens. Multivariate analysis was performed with quality-improved and usual screening as dependent variables. Bivariate analysis showed that post-intervention rates of quality-improved screening increased from 30 to 62 % (P < .001), usual screening increased from 69 to 84 % (P = .005), and repeat GBS screening decreased from 20 to 8 % (P = .007). Multivariate analysis showed increased post-intervention odds of quality-improved screening [odds ratio (OR) 3.59; 95 % CI 2.07–6.34] and usual screening (OR 2.67; 95 % CI 1.40–5.25). Low-cost, reproducible quality improvement interventions (electronic order reminder, educational sessions) have the potential to increase guideline adherence for GBS screening in pregnant women and decrease repeat screening.     

Using Reminder Letters to Improve Adherence to Routine Hemoglobin A1C Testing in Adults with Diabetes

The American Diabetes Association (ADA) recommends hemoglobin A1C (A1C) goals of < 7% for most non-pregnant adults and < 8% for adult patients with extensive or life-limiting comorbidities. A1C testing is indicated every 3-months for patients not meeting goals to assess glycemic control, adjust medications, suggest lifestyle changes, and offer counseling. However, many patients do not adhere to routine testing. A clinic-wide quality improvement (QI) pilot project was implemented using mailed reminder letters to improve patient adherence to routine A1C testing in patients with hemoglobin A1C . 8%. Sixty-eight patients were identified for this letter intervention. Of these, 14 patients (20%) were historically adherent to 3-month interval testing, 31 patients (46%) were historically non-adherent, and 23 (34%) had historical A1C test intervals of less than 3-months because of provider orders. The primary outcome was improvement in A1C testing adherence rates of those who were previously non-adherent. There was a 58% increase overall and a 103% increase in testing rates among women. Statistical significance was not observed at the P = .05 level. However, improvement in adherence rates among women reached the P = .10 significance level. Mailed reminder letters may be useful in improving adherence to routine A1C testing in patients with diabetes. Further study of this intervention in larger groups is needed to provide timely data for the management of diabetes care.     

Cost and Cost Effectiveness of a Pilot m-Health Intervention Targeting Parents of School-Aged Children to Improve the Nutritional Quality of Foods Packed in the Lunchbox

The SWAP IT program aims to improve the nutritional quality of school lunchboxes via a multicomponent m-health intervention, involving: weekly support messages to parents; physical resources; school nutrition guidelines and lunchbox lessons. SWAP IT has been reported to be effective. This study aims to determine the cost and cost effectiveness of the SWAP IT m-health intervention. The retrospective trial-based economic evaluation was conducted in 12 Catholic primary schools in New South Wales, Australia. Schools were randomised to intervention or usual care. The costs (AUD, 2019) were evaluated from societal perspectives. The direct cost to uptake the intervention and the incremental cost-effectiveness ratios (ICER) were calculated. ICERS were calculated for two outcomes: reduction in total kJ and reduction in discretionary kJ from the lunchbox. The total cost was calculated to be AUD 55, 467. The mean incremental cost per student to receive the intervention was calculated to be AUD 31/student. The cost per reduction in total lunchbox energy was AUD 0.54. The ICER for the reduction in energy from discretionary foods in the lunchbox was AUD 0.24. These findings suggest that this m-health intervention has potential to be cost effective in reducing the kilojoules from discretionary foods packed in school lunchboxes.     

Cost Effectiveness of Home Health Care as an Alternative to Inpatient Care

This study of a sample of patients discharged from the Visiting Nurse Association of Greater St. Louis (VNA) focused on the extent to which VNA services were used as an alternative to institutional care. Based on physician estimates, patients averaged 18 fewer days in the hospital due to home care, saving more than $3,300 per patient. Utilization patterns are discussed for patients grouped by age, diagnosis, payment source and disposition upon discharge. Variations observed suggest valuable avenues for additional investigation into the types of patients for whom home care is most likely to be an appropriate alternative to hospital care.     

Cost and Cost Effectiveness of Venous and Pressure Ulcer Protocols of Care

Background

To meet the challenge of an aging population, providers andpayors must optimize chronic wound care outcomes and contain costs.

Objective

To explore the costs, outcomes, and effects of outcomes on costs of pressure and venous ulcer woundcare protocols.

Design

Modeling study using outcomes from a literature review.

Methods

The cost of 12 weeks of wound care was modeled for a hypothetical managed-care plan. This included 100 000 covered lives and used a peer-validated wound care protocol. Only modalities with a pooled evidence base of at least 100 wounds were used to populate the model. Costs excluded supportive treatments.

Results

26 studies of three pressure ulcer protocols (n = 519) and three venous ulcer protocols (n = 883) qualified for inclusion in the models. After 12 weeks, the weighted average proportion of ulcers healed, and cost per ulcer healed, ranged from 48 to 61% and from $US910 to $US2179 (2000 values) for pressure ulcers, and from 39 to 51% and $US1873 to $US15 053 for venous ulcers. For a hypothetical managed-care plan, the difference between the least and most cost-effective modalities was $US1.9 million for pressure ulcers and $US5.8 million for venous ulcers. Observed differences were generally attributable to variances in outcomes and cost differences related to frequency of dressing changes. Pressure ulcer care takes place in inpatient care settings; venous ulcers are managed on an outpatient basis. Physician visit frequencies are once every four weeks for pressure ulcers and once each week for venous ulcers. Wound sizes ranged from 2.5cm² to 5.6cm² for pressure ulcers and 5.4cm² to 10cm² for venous ulcers. All patients with pressure ulcers required pressure relief, nutritional support and incontinence management; venous ulcers required gradient compression. Costs per patient healed were lowest for pressure ulcers with hydrocolloids and highest with saline gauze (this is a manpower issue). Costs to heal venous ulcers were highest with human skin construct and lowest for 12-week management with hydrocolloid.

Conclusions

Despite the limitations of the models (as a result of incomplete study data), this analysis confirms that defining wound care costs solely as cost of products used is inaccurate and can be expensive.

     

Comparative Cost‐Effectiveness of Interventions to Improve Medication Adherence after Myocardial Infarction

Objective

To evaluate the comparative cost-effectiveness of interventions to improve adherence to evidence-based medications among postmyocardial infarction (MI) patients.

Data Sources/Study Setting

Cost-effectiveness analysis.

Study Design

We developed a Markov model simulating a hypothetical cohort of 65-year-old post-MI patients who were prescribed secondary prevention medications. We evaluated mailed education, disease management, polypill use, and combinations of these interventions. The analysis was performed from a societal perspective over a lifetime horizon. The main outcome was an incremental cost-effectiveness ratio (ICER) as measured by cost per quality-adjusted life year (QALY) gained.

Data Collection/Extraction Methods

Model inputs were extracted from published literature.

Principal Findings

Compared with usual care, only mailed education had both improved health outcomes and reduced spending. Mailed education plus disease management, disease management, polypill use, polypill use plus mailed education, and polypill use plus disease management cost were $74,600, $69,200, $133,000, $113,000, and $142,900 per QALY gained, respectively. In an incremental analysis, only mailed education had an ICER of less than $100,000 per QALY and was therefore the optimal strategy. Polypill use, particularly when combined with mailed education, could be cost effective, and potentially cost saving if its price decreased to less than $100 per month.

Conclusions

Mailed education and a polypill, once available, may be the cost-saving strategies for improving post-MI medication adherence.     

Evaluating the Effectiveness of a Multi-component Intervention to Improve Health in an Inner-city Havana Community

Abstract

The ecosystem approach to human health was applied to guide an evaluation of the effectiveness of a multi-component intervention to improve quality of life and health in an inner-city Havana community. A pre- versus post-intervention analysis was carried out in the study community of CayoHueso, and Colon, a concurrent comparison community. Ahousehold survey of 1,703 individuals was conducted in 30 neighborhoods, equally divided between the two areas. Greater improvements in housing, local infrastructure, and exposure to risk were perceived to have occurred in the targeted community, more so from the perspective of benefit to the community rather than with regard to the residents own households. Improvements in some lifestyle-related risk factors and self-rated health in the most vulnerable subgroups (elderly and adolescents) were also chieved. Overall, the Cayo Hueso Plan was considered highly successful in improving the quality of life amid difficult circumstances. Its lessons are being embraced by other communities.     

Effectiveness of a Motivational Nutritional Intervention through Social Networks 2.0 to Increase Adherence to the Mediterranean Diet and Improve Lung Function in Active Smokers: The DIET Study,a Randomized,Controlled and Parallel Clinical Trial in Primary Care

Background: Diet can help preserve lung function in smokers, as well as aid individuals who avoid smoking. This study aimed to evaluate the effectiveness of a nutritional intervention, using the Social Networks 2.0 tool, to increase adherence to the Mediterranean diet (MD) and improve lung function in smokers without prior respiratory disease. Methods: A randomized controlled parallel design was used. The participants were assigned to either the intervention or control group. Data from representative smokers without respiratory disease (n = 77) aged 18–70 years were analyzed. The participants completed a validated semi-quantitative food-frequency questionnaire, and their adherence to the diet was evaluated by using the questionnaire called the Mediterranean Diet Adherence Score (MEDAS, with 14 items), which considers ≥9 points to indicate high adherence. The lung function was assessed by spirometry. Associations among variables were determined by logistic regression. Results: A comparison of the variables at the end of the study between the control and intervention groups showed that the intervention significantly increased adherence to the MD based on the MEDAS questionnaire (0.69 (2.1) vs. 2.05 (2.03); p = 0.009). Specifically, the consumption of fruits was increased after two years in both groups; however, a more significant increase was detected in the intervention group (121 (178) vs. 12.7 (167) in the control group; p-value = 0.008). In the unadjusted analysis, the intervention only showed a statistical significant increase in the score of adherence to the MD (β: 1.36; 95% CI 0.35; 2.3; p = 0.009), and this increase was maintained after adjusting for age and sex (β: 1.15; 95% CI 0.05; 2.2; p = 0.040) and after adjusting for various sociodemographic, lifestyle and anthropometric variables (β: 1.17; 95% CI 0.02; 2.31; p = 0.046). The pulmonary function parameters improved more in the intervention group; however, no significant differences were observed between the two groups. Conclusions: A nutritional intervention based on a dietetic-nutritional education program resulted in a significant increase in adherence to the MD. However, some evidence suggests that an MD dietary intervention can improve lung function, but in our study, we were not able to demonstrate this. Further research is needed to obtain more robust data and confirm a possible benefit of the program before it can be extended to general practice.     

Effectiveness of a Brief Care Management Intervention for Reducing Psychiatric Hospitalization Readmissions

This study examines a recovery-focused care management bridging strategy implemented during time of inpatient stay with the goal to increase engagement in aftercare and reduce early psychiatric readmissions. The sample included 195 individuals who received care from a large psychiatric specialty hospital. Eighty-seven individuals were assigned to receive the intervention, while 108 individuals were assigned to the control group. Individuals in the intervention group received a brief interview prior to inpatient discharge plus usual care, and individuals in the control group received usual care. After controlling for age, living situation, and utilization, individuals in the control group were more likely to be readmitted within 30 days of an index readmission than individuals in the intervention group (OR?=?2.44, p?=?.02). Bridging strategies utilized prior to discharge for individuals at higher risk of early mental health inpatient readmission may be used as an effective alternative to more costly interventions.     

Using mHealth to Deliver a Home-Based Testing and Counseling Program to Improve Linkage to Care and ART Adherence in Rural South Africa

Prevention Science - Community-based HIV testing and counseling (HTC) programs have become an important part of the healthcare system in South Africa and other low- and middle-income countries with...     

Adherence to a Vitamin D Supplement Intervention in Urban Schoolchildren

Vitamin D supplementation is an important strategy for preventing low levels of serum 25OHD and improving bone health and consequent associated health risks, especially in children at risk of deficiency. Although vitamin D supplements are recommended, there is limited research on the factors that influence adherence to taking them. In a cross-sectional sample of 256 child (aged 9 to 15 years) and parent pairs in the Boston, MA, area during January to March 2012, analysis of covariance was used to determine associations between health beliefs about vitamin D, parental vitamin D−containing supplement use, and the individual responsible for pill administration with supplement adherence measured by pill counts. Mean and median supplement pill count adherence over 3 months were 84% and 89%, respectively. Adherence was positively associated with parents’ use of vitamin D−containing supplements (7% higher, P=0.008) and with combined child and parent responsibility for administration of the supplement compared with child only (9% higher, P=0.03). Parents’ beliefs about vitamin D neither predicted their children’s beliefs nor positively influenced children’s adherence. Adherence was higher when parents took vitamin D−containing supplements and when parents and children shared responsibility for administering the supplement. Promoting child supplement use through parent involvement and role modeling may be a practical solution for registered dietitians who are aiming to improve vitamin D adherence in at-risk youth.     

Effectiveness of an Intervention Programme on Adherence to the Mediterranean Diet in a Preschool Child: A Randomised Controlled Trial

Background: The Mediterranean diet is considered one of the dietary patterns with the most accumulated scientific evidence on health benefits. In children, it has positive effects in the prevention of obesity and cardiovascular diseases, as well as in the prevention of diabetes. We aimed to evaluate the medium-term efficacy of an intervention programme, targeting adherence to the Mediterranean diet among preschool children. Methods: In a randomised, parallel trial of participants aged 3–5 years, a school garden was attended in the experimental group, and in the control group, the usual content on the human body and health were taught. Adherence to the Mediterranean diet was assessed using the KIDMED questionnaire, controlling for weight, height, body mass index (BMI) and socio-demographic variables. Results: A reduction in BMI was found in the experimental group after one year and at the end of the follow-up period. In the overall score obtained in the KIDMED survey, a statistical trend was found between the two groups (p = 0.076). In multivariate analysis, consumption of pulses more than once a week’ was predictive of improved diet quality, with an Odds Ratio (OR) in the experimental group of 1.382 (95% CI 1.126–1.695; p = 0.009). Conclusions: The experimental approach improved the quality of the participants’ diet, increasing adherence to the Mediterranean diet due to increased consumption of plant-based protein.     

Cost Effectiveness of Antibacterial Restriction Strategies in a Tertiary Care University Teaching Hospital

Objective

To compare various strategies for antibacterial administration in terms of patient outcomes, overall costs and quality of care provided.

Design

Prospective, nonblind, randomized, clinical study.

Setting

Tertiary care hospital in Greece from November 1995 to June 1996.

Patients and participants

458 patients admitted to the internal medicine department who received antibacterial therapy for infectious diseases.

Methods

Patients were randomized into 4 different antibacterial administration policies defined by various levels of restriction control. Efficacy and resource use data were obtained from clinical study case report forms, the hospital financial database and physician expert opinion. Outcomes included complete infection control, disease improvement, unchanged patient condition, infection needing surgical treatment, and death. Direct medical costs were estimated. The perspective adopted was that of the healthcare system (hospital budget; third-party payor). Cost-minimisation analysis was based on cost per patient treated.

Results

382 eligible patient records examined showed no significant difference in clinical outcomes among patient groups. Baseline analysis showed the strict antibacterial control policy to produce statistically significant differences (p < 0.05) in various resource parameters. Accordingly, compared with all other patient groups, total cost per patient for that strategy was reduced by 26 to 30%. Also, patients in that group received fewer drug doses and underwent fewer treatment days, and antibacterial treatment was modified in fewer cases for these patients.

Conclusion

Strict control of antibacterial administration in this hospital setting achieved lower direct medical costs with no harmful effect on patient outcomes or quality of care provided. Such a policy appears to be a useful option for both physicians and administrators.

     

Communication Strategies to Improve HIV Treatment Adherence

Although antiretroviral therapy has increased the survival of HIV-positive patients, traditional approaches to improving medication adherence have failed consistently. Acknowledging the role of communication in health behavior, we conducted a qualitative study to learn about patients' HIV treatment adherence experiences and to identify which communication strategies might influence adherence. Findings indicate that five constructs – cultural beliefs/language, stigma, cues to action, self-efficacy, and mood state – are potentially modifiable by improved communication. Results will be used to create a direct marketing campaign targeted to HIV-infected patients.     

Effectiveness of Interventions to Increase Adherence to Statin Therapy

A number of large randomized controlled trials (RCTs) have documented the effectiveness of HMG-CoA reductase inhibitor (‘statin’) therapy for both primary and secondary prevention of coronary heart disease. Current international guidelines, therefore, recommend the use of statin therapy in patients with or at high risk for coronary heart disease. Unfortunately, patient adherence to statin therapy is unsatisfactory. In patients taking statins for secondary prevention, non-adherence ranges from 42% to 64%; for those taking these drugs for primary prevention, non-adherence is even higher (e.g. 75%). Interventions to increase patient adherence to statin therapy are therefore required. In this review, we summarize the existing evidence relating to interventions for increasing adherence to statin therapy. After searching MEDLINE, CINAHL, EMBASE, CENTRAL and the Health Technology Assessment databases using appropriate search terms, we found ten RCTs, one non-randomized controlled trial, and four ‘before-after’ trials. In four of the ten RCTs and in the non-randomized controlled trial, intervention was associated with a significant increase in the percentage of patients adhering to statin therapy compared with the control group. The remaining six RCTs found no significant difference in adherence between the intervention and control groups. All four before-after trials reported an increase in adherence to statin therapy after the intervention. However, this increase may also have been due to secular trends and changes in medical practice following the publication of the landmark statin trials. Given the inconsistency of the findings and the limitations of certain study designs, RCTs with a large sample size are needed to further investigate the effectiveness of adherence-increasing interventions in patients with statin therapy.     

药学服务干预对于慢性病患者用药疗效与用药依从性的影响

目的：探讨在慢性病患者的治疗过程中采用合适的药学服务干预方法对于患者用药疗效和用药依从性的影响。方法：本研究选取2011年10月-2013年5月本院收治的650例慢性疾病患者,按照随机数字表法将其分为观察组和对照组各325例。观察组采用相关措施对患者用药进行药学服务干预,对照组给予常规用药指导,观察比较两组患者的治疗效果和干预开始后半年内的用药依从性变化。结果：通过开展积极的药学服务干预措施,观察组6个月后的治疗总有效率83.1%明显高于对照组的61.2%（P〈0.05）,而干预后1~6个月的问卷调查显示,观察组各时期的用药依从性评分均明显高于对照组,差异均有统计学意义（P〈0.05）。结论：强化药学服务干预在慢性病患者的治疗过程中有积极的意义,可以显著提高患者的用药疗效和用药依从性,值得在临床上推广。     

Response and Adherence of Nursing Home Residents to a Nutrition/Exercise Intervention

ObjectivesInterindividual response variability to nutrition and exercise interventions is extensive in older adults. A group of nursing home (NH) residents participated in a combined intervention. The objective of this post-hoc analysis was to identify factors associated with intervention response measured by change in physical function and body composition.DesignPost-hoc analyses in the Older Person's Exercise and Nutrition study, a 2-arm randomized trial. The primary outcomes were 30-second Chair Stand Test and composite scores combining physical function and fat-free mass. A secondary outcome was intervention adherence. A 12-week intervention of sit-to-stand exercises and protein-rich nutritional supplements did not improve chair-stand capacity vs control on intention-to-treat basis.Setting and ParticipantsResidents ≥75 years of age from dementia and somatic units in eight NHs in Sweden.MethodsLogistic regressions were performed to define factors associated with response (maintenance/improvement) or nonresponse (deterioration) in 30-second Chair Stand Test, and with intervention adherence. Linear regressions were performed to explore factors associated with response in composite scores.ResultsMean age of participants (n = 52 intervention, n = 49 control) was 85.8 years. Sarcopenia was occurring in 74%. Sarcopenia at baseline (P = .005) and high adherence to nutritional supplements (P = .002) increased the odds of response. Higher independence in daily activities increased the odds of adherence to sit-to-stand exercises (P = .027) and the combined intervention (P = .020). Allocation to the intervention group and higher self-perceived health were associated with higher composite scores.Conclusions and ImplicationsNH residents with baseline sarcopenia, better self-perceived health, and high adherence to nutritional supplements benefitted most from a combined nutrition and exercise intervention regarding chair-stand capacity and composite scores of function and fat-free mass. Adherence was related to higher grade of independence. Understanding factors associated with response and adherence to an intervention will help target susceptible residents in most need of support and to optimize the outcome.