CHARACTERIZING, ASSESSING AND IMPROVING HEALTHCARE REFERRAL COMMUNICATION

Similar to other health care processes, referrals are susceptible to breakdowns. These breakdowns in the referral process can lead to poor continuity of care, slow diagnostic processes, delays and repetition of tests, patient and provider dissatisfaction, and can lead to a loss of confidence in providers. These facts and the necessity for a deeper understanding of referrals in healthcare served as the motivation to conduct a comprehensive study of referrals. The research began with the real problem and need to understand referral communication as a mean to improve patient care. Despite previous efforts to explain referrals and the dynamics and interrelations of the variables that influence referrals there is not a common, contemporary, and accepted definition of what a referral is in the health care context. The research agenda was guided by the need to explore referrals as an abstract concept by: 1) developing a conceptual definition of referrals, and 2) developing a model of referrals, to finally propose a 3) comprehensive research framework. This dissertation has resulted in a standard conceptual definition of referrals and a model of referrals. In addition a mixed-method framework to evaluate referrals was proposed, and finally a data driven model was developed to predict whether a referral would be approved or denied by a specialty service. The three manuscripts included in this dissertation present the basis for studying and assessing referrals using a common framework that should allow an easier comparative research agenda to improve referrals taking into account the context where referrals occur.

Persuasive email messages for patient communication.

To improve health and reduce costs, we need to encourage patients to make better health care decisions. Since email is widely available, it may be useful for patient-directed interventions. However, we know little about how the contents of an email message can influence a health-related decision. We propose a model to understand how patients may process persuasive email messages.

CATCH across Texas: Building a model for the diffusion of effective school-based health promotion programs

The impact of health promotion programs is related to both program effectiveness and the extent to which the program is implemented among the target population. The purpose of this dissertation was to describe the development and evaluation of a school-based program diffusion intervention designed to increase the rate of dissemination and adoption of the Child and Adolescent Trial for Cardiovascular Health, or CATCH program (recently renamed the Coordinated Approach to Child Health). ^ The first study described the process by which schools across the state of Texas spontaneously began to adopt the CATCH program after it was tested and proven effective in a multi-site randomized efficacy trial. A survey of teachers and administrator representatives of all schools on record that purchased the CATCH program, but were not involved in the efficacy trial, was used to find out who brought CATCH into the schools, how they garnered support for its adoption, why they decided to adopt the program, and what was involved in deciding to adopt. ^ The second study described how the Intervention Mapping framework guided the planning, development and implementation of a program for the diffusion of CATCH. An iterative process was used to integrate theory, literature, the experience of project staff and data from the target population into a meaningful set of program determinants and performance objectives. Proximal program objectives were specified and translated into both media and interpersonal communication strategies for program diffusion. ^ The third study assessed the effectiveness of the diffusion program in a case-comparison design. Three of the twenty Education Service Center regions in Texas were chosen, selected based on similar demographic criteria, and were followed for adoption of the CATCH curriculum. One of these regions received the full media and interpersonal channel intervention; a second received a reduced media-only intervention, and a third received no intervention. Results suggested the use of the interpersonal channels with media follow-up is an effective means to facilitate program dissemination and adoption. The media-alone condition was not effective in facilitating program adoption. ^

Family stress, coping, communication, and adaptation in unintended adolescent pregnancy

Objective. This study examines post-crisis family stress, coping, communication, and adaptation using the Double ABC-X Model of Family Adaptation in families with a pregnant or postpartum adolescent living at home. ^ Methods. Ninety-eight pregnant and parenting adolescents between ages 14 and 18 years (Group 1 at 20 or more weeks gestation; Group 2 at delivery and 8 weeks postpartum) and their parent(s) completed instruments congruent with the model to measure family stress, coping, communication, and adaptation. Descriptive family data was obtained. Mother-daughter data was analyzed for differences between subjects and within subjects using paired t-tests. Correlational analysis was used to examine relationships among variables. ^ Results. More than 90% of families were Hispanic. There were no significant differences between mother and daughter mean scores for family stress or communication. Adolescent coping was not significantly correlated to family coping at any interval. Adolescent family adaptation scores were significantly lower than mothers' scores at delivery and 8 weeks postpartum. Mean individual ratings of family variables did not differ significantly between delivery and 8 weeks postpartum. Simultaneous multiple regression analysis showed that stress, coping, and communication significantly influenced adaptation for mothers and daughters at all three intervals. The relative contributions of the three independent variables exhibited different patterns for mothers and daughters. Parent-adolescent communication accounted for most of the variability in adaptation for daughters at all three intervals. Daughters' family stress ratings were significant for adaptability (p = .01) during the pregnancy and for cohesion (p = .03) at delivery. Adolescent coping (p = .03) was significant for cohesion at 8 weeks postpartum. Family stress was a significant influence at all three intervals for mothers' ratings of family adaptation. Parent-adolescent communication was significant for mother's perception of both family cohesion (p < .001) and adaptability (p < .001) at delivery and 8 weeks, but not during pregnancy. ^ Conclusions. Mothers' and daughters' ratings of family processes were similar regarding family stress and communication, but were significantly different for family adaptation. Adolescent coping may not reflect family coping. Family communication is a powerful component in family functioning and may be an important focus for interventions with adolescents and parents. ^

ROLE OF MIR-19A RELEASED BY INFLAMMATORY BREAST CANCER CELLS IN THE REGULATION OF DENDRITIC CELL FUNCTIONS: IN VITRO MODEL OF CROSSTALK IN THE TUMOR MICROENVIRONMENT OF INFLAMMATORY BREAST CANCER

Inflammatory breast cancer (IBC) is a rare but very aggressive form of locally advanced breast cancer (1-6% of total breast cancer patients in United States), with a 5-year overall survival rate of only 40.5%, compared with 85% of the non-IBC patients. So far, a unique molecular signature for IBC able to explain the dramatic differences in the tumor biology between IBC and non-IBC has not been identified. As immune cells in the tumor microenvironment plays an important role in regulating tumor progression, we hypothesized that tumor-associated dendritic cells (TADC) may be responsible for regulating the development of the aggressive characteristics of IBC. MiRNAs can be released into the extracellular space and mediate the intercellular communication by regulating target gene expression beyond their cells of origin. We hypothesized that miRNAs released by IBC cells can induce an increased activation status, secretion of pro-inflammatory cytokines and migration ability of TADC. In an in vitro model of IBC tumor microenvironment, we found that the co-cultured of the IBC cell line SUM-149 with immature dendritic cells (iDCSUM-149) induced a higher degree of activation and maturation of iDCSUM-149 upon stimulation with lipopolysaccharide (LPS) compared with iDCs co-cultured with the non-IBC cell line SUM-159 (iDCSUM-159), resulting in: increased expression of the costimulatory and activation markers; higher production of pro-inflammatory cytokines (TNF-a, IL-6); and 3) higher migratory ability. These differences were due to the exosome-mediated transfer of miR-19a and miR-146a from SUM-149 and SUM-159, respectively, to iDCs, causing the downregulation of the miR-19a target genes PTEN, SOCS-1 and the miR-146a target genes IRAK1, TRAF6. PTEN, SOCS-1 and IRAK1, TRAF6 are important negative and positive regulator of cytokine- and TLR-mediated activation/maturation signaling pathway in DCs. Increased levels of IL-6 induced the upregulation of miR-19a synthesis in SUM-149 cells that was associated with the induction of CD44+CD24-ALDH1+ cancer stem cells (CSCs) with epithelial-to-mesenchymal transition (EMT) characteristics. In conclusion, in IBC tumor microenvironment IL-6/miR-19a axis can represent a self-sustaining loop able to maintain a pro-inflammatory status of DCs, leading to the development of tumor cells with high metastatic potential (EMT CSCs) responsible of the poor prognosis in IBC patients.