DOES THE MESSAGE MATTER? ENHANCING PATIENT ADHERENCE THROUGH PERSUASIVE MESSAGES

To improve health and reduce costs, we need to encourage patients to make better healthcare decisions. Many informatics interventions are aimed at improving health outcomes by influencing patient behavior. However, we know little about how the content of a message in these interventions can influence a health-related decision. In this research we formulate a conceptual model to help explain and guide the design of “persuasive messages”, those which can change and influence patient behavior. We apply the conceptual model to design persuasive appointment reminder messages using humancentered design principles. Finally, we empirically test our hypotheses in a randomized controlled trial in order to determine the effectiveness of persuasive appointment reminders to reduce the number of missed appointments in a sample of 1016 subjects in a community health center. The results of the study confirm that reminder messages are effective in reducing missed appointment compared with no reminders (p=0.028). Further, reminder messages that incorporate heuristic cues such as authority, commitment, liking, and scarcity are more effective than reminder messages without such cues (p=0.006). However, the addition of systematic arguments or reasons for attending appointments have no effect on appointment adherence (p=0.646). The results of this research suggest that the content of reminder messages may be an important factor in helping to reduce missed appointments.

Clinical decisions related to CBC screening of asymptomatic full-term infants at risk for group B streptococcus disease

Objective. Although complete blood count (CBC) changes occur with the development of clinical sepsis in newborns, the CBC has not been reported to be a sensitive predictor of sepsis in asymptomatic full-term newborn infants, nor has it been reported to be related to risk factors for sepsis or clinical decisions. The objective of this study was to evaluate the relationship between the WBC/I:T (immature:total neutrophil) ratio and maternal group B streptococcal (GBS) risk factors (rupture of membranes ≥18 hours, maternal temperature ≥100.4°F, maternal age ≤20 years, previous infant with invasive GBS disease, maternal GBS bacteriuria, and black ethnicity); and to evaluate the relationship between the WBC/I:T ratios and providers' clinical decisions (observe versus repeat the CBC or complete sepsis evaluation) in the asymptomatic full-term newborn at risk for early-onset GBS sepsis. ^ Methods. Medical records of infants admitted to the well baby nursery at a tertiary care teaching hospital in Houston, TX between 1/1/99 and 12/31/00 whose gestational ages were ≥35 weeks; who had mothers with GBS positive or unknown culture status and inadequate intrapartum antibiotic prophylaxis; and who had screening CBCs performed in the first 30 hours of life because of GBS risk were reviewed (n = 412). Demographic information, maternal GBS risk factors, CBC results, clinical decisions, and rationales for clinical decisions were collected. ^ Results. With the exception of black ethnicity (p = .0000, odds ratio = 0.213), no statistically significant differences in risk factors between infants with normal and abnormal WBC counts or normal and abnormal I:T ratios were found. Infants with abnormal WBCs had a significantly higher likelihood of having a CBC repeated (p = 0.002 for WBC). Providers documented the CBC result in the rationale for clinical decisions in 62% of the cases. ^ Conclusion. The CBC results were not related to maternal risk factors for GBS except for ethnicity. Black infants had significantly lower WBC levels than infants of other ethnicities, although this difference was clinically insignificant. Infants with abnormal WBCs had a significantly higher likelihood of undergoing repeat CBCs but not sepsis evaluations. Provider rationale was difficult to evaluate due to insufficient documentation. The screening CBC result did not impact the clinicians' decisions to initiate sepsis evaluations in this population. ^

Genetic variations in the PI3K-AKT-mTOR pathway and bladder cancer susceptibility and clinical outcomes

Bladder cancer is the fourth most common cancer in men in the United States. There is compelling evidence supporting that genetic variations contribute to the risk and outcomes of bladder cancer. The PI3K-AKT-mTOR pathway is a major cellular pathway involved in proliferation, invasion, inflammation, tumorigenesis, and drug response. Somatic aberrations of PI3K-AKT-mTOR pathway are frequent events in several cancers including bladder cancer; however, no studies have investigated the role of germline genetic variations in this pathway in bladder cancer. In this project, we used a large case control study to evaluate the associations of a comprehensive catalogue of SNPs in this pathway with bladder cancer risk and outcomes. Three SNPs in RAPTOR were significantly associated with susceptibility: rs11653499 (OR: 1.79, 95%CI: 1.24–2.60), rs7211818 (OR: 2.13, 95%CI: 1.35–3.36), and rs7212142 (OR: 1.57, 95%CI: 1.19–2.07). Two haplotypes constructed from these 3 SNPs were also associated with bladder cancer risk. In combined analysis, a significant trend was observed for increased risk with an increase in the number of unfavorable genotypes (P for trend<0.001). Classification and regression tree analysis identified potential gene-environment interactions between RPS6KA5 rs11653499 and smoking. In superficial bladder cancer, we found that PTEN rs1234219 and rs11202600, TSC1 rs7040593, RAPTOR rs901065, and PIK3R1 rs251404 were significantly associated with recurrence in patients receiving BCG. In muscle invasive and metastatic bladder cancer, AKT2 rs3730050, PIK3R1 rs10515074, and RAPTOR rs9906827 were associated with survival. Survival tree analysis revealed potential gene-gene interactions: patients carrying the unfavorable genotypes of PTEN rs1234219 and TSC1 rs704059 exhibited a 5.24-fold (95% CI: 2.44–11.24) increased risk of recurrence. In combined analysis, with the increasing number of unfavorable genotypes, there was a significant trend of higher risk of recurrence and death (P for trend<0.001) in Cox proportional hazard regression analysis, and shorter event (recurrence and death) free survival in Kaplan-Meier estimates (P log rank<0.001). This study strongly suggests that genetic variations in PI3K-AKT-mTOR pathway play an important role in bladder cancer development. The identified SNPs, if validated in further studies, may become valuable biomarkers in assessing an individual's cancer risk, predicting prognosis and treatment response, and facilitating physicians to make individualized treatment decisions. ^

Bayesian generalized linear models for meta-analysis of diagnostic tests

With the recognition of the importance of evidence-based medicine, there is an emerging need for methods to systematically synthesize available data. Specifically, methods to provide accurate estimates of test characteristics for diagnostic tests are needed to help physicians make better clinical decisions. To provide more flexible approaches for meta-analysis of diagnostic tests, we developed three Bayesian generalized linear models. Two of these models, a bivariate normal and a binomial model, analyzed pairs of sensitivity and specificity values while incorporating the correlation between these two outcome variables. Noninformative independent uniform priors were used for the variance of sensitivity, specificity and correlation. We also applied an inverse Wishart prior to check the sensitivity of the results. The third model was a multinomial model where the test results were modeled as multinomial random variables. All three models can include specific imaging techniques as covariates in order to compare performance. Vague normal priors were assigned to the coefficients of the covariates. The computations were carried out using the 'Bayesian inference using Gibbs sampling' implementation of Markov chain Monte Carlo techniques. We investigated the properties of the three proposed models through extensive simulation studies. We also applied these models to a previously published meta-analysis dataset on cervical cancer as well as to an unpublished melanoma dataset. In general, our findings show that the point estimates of sensitivity and specificity were consistent among Bayesian and frequentist bivariate normal and binomial models. However, in the simulation studies, the estimates of the correlation coefficient from Bayesian bivariate models are not as good as those obtained from frequentist estimation regardless of which prior distribution was used for the covariance matrix. The Bayesian multinomial model consistently underestimated the sensitivity and specificity regardless of the sample size and correlation coefficient. In conclusion, the Bayesian bivariate binomial model provides the most flexible framework for future applications because of its following strengths: (1) it facilitates direct comparison between different tests; (2) it captures the variability in both sensitivity and specificity simultaneously as well as the intercorrelation between the two; and (3) it can be directly applied to sparse data without ad hoc correction. ^

Measuring value in cancer-related health care: A case study in head and neck cancer

In the current climate of escalating health care costs, defining value and accurately measuring it are two critical issues affecting not only the future of cancer care in particular but also the future of health care in general. Specifically, measuring and improving value in cancer-related health care are critical for continued advancements in research, management, and overall delivery of care. However, in oncology, most of this research has focused on value as it relates to insurance industry and payment reform, with little attention paid to value as the output of clinical interventions that encompass integrated clinical teams focusing on the entire cycle of care and measuring objective outcomes that are most relevant to patients. ^ In this study, patient-centered value was defined as health outcomes achieved per dollar spent, and calculated using objective functional outcomes and total care costs. The analytic sample comprised patients diagnosed with three common head and neck cancers—cancer of the larynx, oral cavity, and oropharynx—who were treated in an integrated tertiary care center over an approximately 10-year period. The results of this study provide initial empirical data that can be used to assess and ultimately to help improve the quality and value of head and neck cancer care, and more importantly they can be used by patients and clinicians to make better-informed decisions about care, particularly what therapeutic services and outcomes matter the most to patients.^

Assessing the relationship between board composition and nonprofit hospital financial performance from a multi-theoretic perspective

This dissertation assesses the relationship between board composition and financial performance for the top 71 major nonprofit hospitals in the United States during the period 2004-2009. The underlying data were collected from copies of IRS Form 990 available at http://www.guidestar.org . The dissertation investigates five factors: board size, board independence (percentage of outsiders), number of MDs, CEO succession and CEO compensation. And it evaluates the results within a multi-theoretic framework drawing on agency theory, resource dependence theory, institutional theory and social network theory. Corporate governance literature suggests that board composition has an important impact on firm financial performance. This dissertation examines whether the same may be true for nonprofit hospitals. The results should help hospital executives make better governance decisions during trying economic times.^

HIV disclosure decisions and social support among African-American women in Houston, Texas

African Americans make up 12.3% of the population but account for over half of the new HIV cases and 39% of the AIDS cases in 2003 (Centers for Disease Control and Prevention [CDC], 2003). African American women in particular accounted for 64% of these cases of HIV and 60% of the AIDS cases (Leigh & Huff, 2003). This study contributed to the knowledge about the disclosure process of women living with HIV/AIDS by documenting the relationship between social support and the disclosure process in the African American HIV/AIDS population.^ The study aims were to: (1) discuss the participants' self concept of support; (2) describe the common characteristics of the disclosure process; and (3) evaluate the common characteristics of support sought in a potential disclosure source. The ethnographic qualitative methodology was utilized to elicit participant narratives of HIV disclosure and social support. The researcher utilized a key informant interview methodology building on existing social and organizational relationships (Krueger, 1994) to gain access to the population. ^ Semi-structured interviews are a widely used and accepted qualitative research method for use with hard to reach populations and sensitive topics. Ten participants completed a 45 to 60 minute, one on one semi-structured interview covering social support and disclosure variables. Inclusion and exclusion criteria included: (1) self identified as a person living with HIV/AIDS; (2) African American); (3) female; (4) age 18-64 years old, (5) residence in Houston or surrounding counties.^ Themes generated from the interviews were (1) nondisclosure, (2) experiences with disclosure, (3) timing, (4) disclosure sources, and (5) coping. The themes suggest African American women living with HIV/AIDS come from different lifestyles but share similar experiences. Women utilize different strategies such as deciphering whom to trust and determining how much information to divulge in order to protect themselves or others.^ Although the sample group was small for this study, the results inform us about the various experiences each woman goes through as it relates to social support and disclosure and that each woman has to customize her response to the type of support she is receiving and her personal attitude about her disease.^

Child Welfare Workers’ Perceptions of the Influence of the Organizational Environment on Permanency Decisions for Families

The findings of this study suggest that while child welfare workers are consistently distracted by competing priorities from unexpected events, most are committed, and to understand perspectives is more inclusive and may improve retention rates. Notably, while it is recognized that permanency decisions are not made in an intellectual, legal or clinical vacuum and certain traditional aspects of the bureaucratic structure do not impact decision making, this study advances the body of knowledge on child welfare decision making. Examined in this study are child welfare case workers’ perceptions of the extent to which the organizational environment influences the permanency decisions they make to reunify or terminate parental rights of children placed out-of-home. This study includes a sample of 95 child welfare social workers employed in three public child welfare agencies in the Baltimore and Washington, DC metropolitan area. It used a cross-sectional research design, employing a survey instrument to examine bureaucratic distraction, role conflict, and supervisory adequacy as contextual factors in the organizational environment's influence on permanency outcome decisions. Implications are made for child welfare policy, practice, and research.