Tag: 2018

Principal investigator Dr. Ruanne Barnabas (Global Health) and co-investigator Dr. Adam Szpiro (Biostatistics) have received funding from the National Institutes of Health for "Leveraging routing science to optimize ART delivery for efficient scale-up, high ART coverage, and viral suppression in South Africa."

Abstract:

Globally, half of the world’s 37 million people living with HIV are on antiretroviral therapy (ART) representing immense and encouraging success with access to HIV care. ART prevents disease, death and HIV transmission and HIV-positive persons can expect to live as long as their HIV-negative peers. However, the burden of supplying ART is enormous. In South Africa alone, seven million HIV-positive persons will require ART for life and only 3.3 million are currently on ART. Prescription refills consume 70% of current pharmacy load, contributing to the overcrowding of clinics. Further, over four years, a third of HIV-positive persons are lost from care due to barriers of collecting ART at clinic pharmacies including long waits and inconvenient hours. To address this resupply gap, efforts are underway to support medication refills outside the clinic, including private pharmacy pick-up, but in rural communities without pharmacies and a formal address
system, this has been challenging. How ART delivery will be scaled up and distributed for life to millions of people is a critical question for sustainable HIV treatment.

Decentralized ART delivery, i.e. ART resupply outside the clinic, can increase the number of persons receiving safe ART resupply and monitoring. Specifically, community-based mobile vans are increasingly being tested as a venue for ART resupply and monitoring. Tools are needed to determine where mobile vans should be stationed, the optimal delivery time, and the number clients served. Amazon.com is the largest internet-based retailer in the world with experience delivering goods on time to persons in diverse settings, including rural areas. We will collaborate with Amazon’s routing science scientists and adapt their algorithms to optimize delivery to efficiently meet ART demand. Further, for participants who are willing to pay a delivery fee, home ART delivery can simplify their resupply (the Amazon Prime model). A fee for home delivery of ART could increase engagement in care and offset costs of home delivery. Data driven ART delivery algorithms have the potential to sustain 90% viral suppression among persons on ART.

Working closely with Amazon, we propose to develop and test a software application (Deliver Health) that uses spatial GPS data on where HIV-positive clients live, distance from mobile van potential locations, street maps, and client needs and preferences to inform an objective algorithm. The Deliver Health algorithm uses these data to maximizes the number of clients served by the mobile van location at a specific time. We will compare algorithm and study coordinator determined mobile van placement for ART delivery in a cluster randomized study (N=600). Separately, we will test a fee for home delivery service in a randomized pilot study (N=120) compared to mobile van ART resupply and monitoring. The study outcomes are the proportion of HIV-positive persons virally
suppressed and the number of missed ART refills. We will also assess costs and conduct participatory research to support implementation of decentralized strategies for ART resupply.

Sponsor Award Number: 1R21MH115770-01A1

Funding has been awarded to principal investigator Dr. J. Randall Curtis by the NIH National Institute of Nursing Research for "Evaluating Effectiveness of a Communication Facilitator to Reduce Distress and Improve Goal Concordant Care for Critically Ill Patients and Their Families".

Abstract:

The impact of critical illness is increasing due to our aging population as well as advances in effectiveness and availability of critical care. Critically ill patients and their families suffer a high burden of symptoms of depression, anxiety, and post-traumatic stress due, in part, to fragmented medical care that is often poorly aligned with their goals. Fragmented care includes numerous transitions for patients and families across clinicians and across settings, starting in the ICU and extending to acute care, skilled nursing facilities, or home. As illness progresses, patients and families struggle to navigate the spectrum of goals of care, to match their values and goals with treatments, to communicate their goals to their clinicians, and to make difficult medical decisions without letting unmet emotional needs interfere. Poor communication exacerbated by these transitions compounds an already stressful experience, causing distress to patients and their families. Taken together, these issues lead to ineffective communication during and after the ICU which can often result in high intensity “default” care that may be unwanted.

Using a randomized trial, this application proposes to evaluate an innovative model of care in which ICU nurse facilitators support, model, and teach communication strategies that enable patients and families to secure care in line with their goals over an illness trajectory, beginning in the ICU and continuing into the community. Facilitators will use communication skills, attachment theory, and mediation to improve: 1) patients' and families' self-efficacy to communicate with clinicians within and across settings; 2) patients' and families' outcome expectation that communication with clinicians can improve their care; and 3) patients' and families' behavioral capability through skill building to resolve barriers to effective communication and mediate conflict.

Facilitators will work with seriously ill patients (n=376) and their families (n=564) beginning with a critical care unit stay and following them over the course of 3 months. The intervention's effectiveness will be measured with patient- and family-centered outcomes including symptoms of depression, anxiety, and post-traumatic stress, as well as quality of life and assessments of goal- concordant care, at 1, 3, and 6 months post-randomization. The primary outcome will be family members' burden of symptoms of depression over the 6 months. We will also evaluate whether the intervention improves the value of healthcare by reducing healthcare costs while improving patient and family outcomes. Finally, we will use qualitative methods to explore implementation factors (intervention, settings, individuals, processes) associated with improved implementation outcomes (acceptability, fidelity, penetration) to inform dissemination of this type of intervention to support patients and their families.

This application will address key knowledge gaps while evaluating a methodologically rigorous intervention to improve outcomes for patients with serious illness and their families across the trajectory of care and the spectrum of goals of care.

Sponsor Award Number: 1R01NR018161-01

Funding has been awarded to principal investigator Dr. Joana Cunha-Cruz by the NIH National Institute on Minority Health and Health Disparities for "OHEAL: Oral Health Equity in Alaska".

Abstract:

This R21 applicant did formative work on barriers to dental care and achieving good oral health for Alaska Native children (Grant No. UH2DE025488, PI J. Cunha-Cruz) in which it identified the absence of critical dental office-systems that providers need to implement evidence-based practices (EBP) proven to control dental caries (tooth decay). American Indian and Alaska Native (AIAN) children suffer from the poorest oral health of all population groups in the United States with 3 times higher rates of untreated caries than non- Hispanic white children. Despite great resilience, tribal nations face geographical isolation, dentist shortages and distrust in health care systems exacerbating disparities. The Oral Health Equity for Alaska (OHEAL) program initiated by the applicant in collaboration with a tribal healthcare organization (SouthEast Alaska Regional Health Consortium - SEARHC) and local tribal communities offers a unique opportunity to implement an evidence-based, culturally-appropriate and theory-informed program to disseminate EBPs to Alaska Native settings.

The purpose of this R21 is to adapt and test feasibility of an implementation strategy prior to larger-scale implementation and evaluation. The rationale is that tribal dental services want to increase dental caries control efforts for children in remote villages, but lack evidence-based tools adapted to the AIAN culture and environment that can be implemented and maintained effectively and efficiently. Our SPECIFIC AIMS are: 1) to collaboratively develop and culturally adapt the caries control tools and strategies; 2) to test the feasibility of the caries control tools and strategies; and 3) to investigate the acceptability and appropriateness of the caries control tools and strategies among provider, community and patient stakeholders.

METHODS: Workshops with tribal organization, patient and community stakeholders will be used to culturally adapt EBP guidelines and office-systems tools and strategies. Data from interviews and surveys with community, patient and organizational stakeholders, dental claims and administrative records will be used to assess acceptability, appropriateness and feasibility. A feasibility test of the program will be conducted. Guided by organizational and behavioral theory, triangulation of qualitative and quantitative findings will identify office-systems strategies likely to be used by AIAN and non-AIAN dental providers. We will learn which implementation strategies, provider behaviors, and contextual factors are likely to impact implementation and identify mechanisms essential for program success as well as aspects difficult to implement.

SIGNIFICANCE: The proposed R21 will lead to a R01 proposal for a larger-scale study. This preliminary research is significant and innovative because of its focus on 1) improving public health by increasing caries control for AIAN children and for its implications for greater adoption and replication by others serving minority, low income, rural communities, and 2) advancing knowledge of how and why adaption of implementation strategies for dissemination of EBPs is necessary.

Sponsor Award Number: 1R21MD012868-01

Doctoral student Rebecca Brander has received F31 funding from the National Institutes of Health for "Addressing adverse outcomes following acute illness among children in Sub-Saharan Africa: predicting risks and cost-effectiveness."
 

Abstract:

The burden and consequences of infectious diseases are disproportionately high in children under age 5 in Sub-Saharan Africa. Following recovery from acute illness, children remain at high risk for adverse outcomes, including mortality and growth faltering (which can lead to irreversible stunting, which is associated with substantial health and developmental detriments). Targeted antibiotic interventions may be cost-effective strategies to improving long-term outcomes in settings of high infectious disease burden, due to their growth-promoting, anti-inflammatory, immunomodulatory, and/or prophylactic properties. However, identifying children who are most likely to benefit from targeted interventions and assessing cost-effectiveness of such interventions are needed to inform the development and implementation of such interventions. The proposed research will provide tools for predicting which children are at highest risk of adverse outcomes following acute illness, and for evaluating cost-effectiveness of targeted interventions.

First, we will utilize data on a large, multi-site cohort of children with moderate-to severe diarrhea, to predict children at presentation with diarrhea who are at high risk for experiencing growth faltering in the 50-90 days following the acute illness. We will also evaluate whether children whose diarrhea was treated with antibiotics, irrespective of whether a bacterial pathogen was isolated, were less likely to experience growth faltering in the follow up period. This will inform management strategies of children with diarrhea and identify children who may stand to benefit from targeted antibiotics to prevent growth faltering. Next, we will address several research questions necessary for evaluating intervention cost effectiveness. Quality, precise cost inputs are key for cost-effectiveness analyses but are difficult to ascertain in low-resource settings. We will identify optimal methods for ascertaining health outcome costs in resource limited settings by evaluating micro-costing methods in terms of results, reproducibility, and time investment. This will inform approaches to costing, ultimately improving economic evaluations in low-resource settings. Finally, ongoing clinical trials are evaluating targeted approaches to antibiotic administration to prevent child mortality, such as azithromycin given at discharge to recently hospitalized Kenyan children.

Other recent trials have found a mortality benefit of community-wide distribution of antibiotics, but the relative cost-effectiveness of these approaches is unknown. We will build a cost-effectiveness model to evaluate whether targeted antibiotic prophylaxis is more cost-effective than community-based distribution. Inputs in this model can be updated as new efficacy data becomes available.

This comparative cost-effectiveness model will allow for understanding the resource implications of implementing each strategy and therefore be a guide for policy development. Completion of these specific aims will provide tools that will be useful in developing and implementing interventions for improving long term outcomes following acute illness in children in SSA.

Sponsor Award Number: 1F31HD096776-01

Funding has been awarded to principal investigator Wendy Barrington by the NIH National Cancer Institute for "Implementation and Impact of Cancer Screening Navigation by Community Health Workers in Two National Screening Programs".

Abstract:

Significant disparities in breast, cervical, and colorectal cancer mortality persist among marginalized populations, partially attributable to lower guideline concordant screening. Patient navigation is an evidence-based practice to improve adherence to cancer screening guidelines among marginalized populations in order to reduce cancer disparities. Cancer screening navigation activities may be implemented using professional (e.g. nurse) or lay (e.g. community health worker, CHW) navigator models, the latter in clinical or community settings. Implementation of CHW-led cancer screening navigation is more feasible in low-resource settings compared to nurse-led cancer screening navigation and is associated with improved screening outcomes.

However, we lack a comprehensive understanding of how this is accomplished, both from the perspective of CHWs as well as from the perspective of the clients they serve. Furthermore, rigorous evaluation of CHW-led cancer screening activities in relation to screening outcomes is lacking. The purpose of this study is to characterize factors that affect implementation of cancer screening navigation activities by CHWs in the context of the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and the Colorectal Cancer Control Program (CRCCP), two federal screening programs established to provide vulnerable populations access to timely cancer screening and diagnostic services.

Using the Consolidated Framework for Implementation Research (CFIR), we will identify implementation domains that affect CHW-led cancer screening navigation including: outer setting (e.g. program policies), inner setting (e.g. CHW training), and individual characteristics (e.g. CHW social support) via key informant interviews with CHWs (n=25). We will compare domains across cancer- (i.e. breast, cervical, and colorectal) and community-type (i.e. urban and rural) to understand potential differences. We will also recruit program clients of CHWs (n=250) to study associations between the presence, type, intensity, and quality (e.g. client satisfaction) of CHW-led cancer screening navigation activities as well as subsequent screening outcomes over a one-year period. Finally, we will use community-based participatory research (CBPR) principles to engage program stakeholders at all stages of the research process which will culminate in a consensus conference to generate best practices for the implementation of CHW-led cancer screening navigation activities.

These findings will inform multi-level health service interventions to improve the effectiveness of cancer screening navigation using CHW models of delivery. The proposed career development in implementation science, leading practice-based research, and applying and evaluating CBPR processes will prepare the candidate to excel as an independent researcher focused on addressing cancer disparities in partnership with marginalized communities and health systems.

Sponsor Award Number: 1K01CA229996-01

Funding has been awarded to principal investigator and SMART Center postdoctoral fellow Stephanie Brewer by the NIH National Institute of Mental Health for "Integrating Implementation Science and Cultural Adaptation to Understand Intervention Modifications within School-Based Mental Health".

Abstract:

The goal of this Ruth L. Kirschstein National Research Service Award is to support the applicant in developing the specialized skills necessary to build an independent program of research with the goal of improving the implementation of contextually relevant and culturally responsive evidence-based treatments (EBTs) in schools, and thereby promoting equitable mental health services for historically underserved youth.

This F32 application proposes research to address NIMH strategic priority 4.1: Improve the efficiency and effectiveness of existing mental health services through research, specifically by contributing to the budding knowledgebase on the modifications made to EBTs in practice, and thereby optimizing the effective implementation of EBTs in real-world contexts. The research component of this F32 responds to a call to action by leaders of the NIH Implementation Science Team, who have advocated for the compilation of a comprehensive body of knowledge identifying the modifications that are made to EBTs in practice and explaining their impacts on relevant outcomes.

The proposed research will be conducted in two stages: Study 1 will develop a novel coding scheme that integrates theoretical models from implementation science and cultural adaptation, using modified Delphi procedures with an expert panel comprised of implementation science researchers and cultural adaptation researchers (Research Aim 1). Using this coding scheme, Study 2 will examine the modifications made to an EBT being implemented within schools, through the use of mixed quantitative and qualitative methods. Specifically, data will be collected from school-based mental health providers via quantitative measures and semi-structured interviews, and the coding scheme developed in Study 1 will be used to identify which modifications are being made to an EBT as it is implemented in schools, and why they are being made (Research Aim 2). Finally, a set of hypotheses will be tested in order to estimate the construct validity of the coding scheme developed in Study 1 by examining expected associations between types of EBT modifications and clinician- and school-level variables (Research Aim 3). In combination, these two studies will provide a strong foundation for a Career Development Award focused on the impact of EBT modifications on child/adolescent mental health outcomes.

In addition, by designing and engaging in a three-year progression of targeted training activities, the applicant will develop expertise in school-based mental health research, while gaining critical knowledge and skills in implementation science, cultural adaptation, and mixed methods research. Specific training goals to be achieved are to: 1) Build expertise in contextually relevant intervention research, with a particular emphasis on school-based mental health research; 2) Expand conceptual knowledge of the modifications made to EBTs in practice settings by integrating two pertinent, yet disparate, literatures — implementation science and cultural adaptation; 3) Develop experience and expertise in mixed methods research; and 4) Strengthen grant-writing and manuscript-writing skills.

Sponsor Award Number: 1F32MH116623-01A1

Funding has been awarded to principal investigator Dr. McKenna Claire Eastment by the NIH National Cancer Institute for a "Randomized Controlled Trial of an Implementation Science Tool to Increase Cervical Cancer Screening in Mombasa, Kenya".

Abstract:

This proposal supports a 4-year research and training program to allow Dr. Eastment to make substantial progress toward a career as an independent investigator and leader in the field of women’s health and cervical cancer screening implementation. She aims to quantify the cervical cancer screening care cascade and understand the correlates of appropriate screening. She will then conduct a cluster randomized trial to test an implementation science tool, the Systems Analysis and Improvement Approach (SAIA), to improve cervical cancer screening for both HIV-positive and HIV-negative women in Mombasa, Kenya. A budget impact analysis of SAIA will be performed for Mombasa County Department of Health (DOH).

Dr. Eastment’s expertise in coordinating studies in Kenya utilizing the same implementation science tool provides a strong foundation for this proposed plan. Her training program will include further instruction in study design, economic evaluations, analysis of correlated data, and implementation science from leaders in these fields, leveraging on the outstanding research and training environments at the University of Washington (UW), and the strength of long- term collaborations with Mombasa County. Her collection of mentors from the UW Departments of Medicine, Biostatistics, Epidemiology, and Global health, along with her collaborators from Mombasa County, are eager to mentor and support Dr. Eastment’s project and career development.

Research Plan: Cervical cancer is the most common cancer in women in sub-Saharan Africa, and the majority of cervical cancer mortality occur in low and middle income countries (LMICs). Many of the disparities between high and LMICs are attributed to differences in screening. Kenyan guidelines recommend screening with visual inspection methods followed by treatment of pre-cancerous lesions with cryotherapy and loop electrosurgical excision procedure (LEEP). Implementation of these are poor with only 14% of Kenyan women ever having been screened for cervical cancer as of 2014. To address this implementation gap, this application proposes three aims. In Aim 1, we will describe the cervical cancer screening care cascade, from identification of female clients age 21-65 years old, through referral for follow-up of clients with positive or suspicious screens, in family planning (FP) clinics in Mombasa County. Following characterization of this cascade, we will conduct an analysis of correlates of failure to screen for cervical cancer in FP clients seen over a one-year period in Mombasa County. Aim 2 will test whether SAIA increases cervical cancer screening compared to usual procedures in a cluster randomized trial in 20 FP clinics in Mombasa County. Finally, in Aim 3, we will determine the cost and budget impact of using SAIA to increase cervical cancer screening in FP clinics in Mombasa County.

The results of this study have the potential to improve cervical cancer screening, and inform policy in the Mombasa DOH for a fiscally responsible evidenced-based approach for cervical cancer screening. The long-term goal is to decrease cervical cancer mortality and improve women’s health.

Sponsor Award Number: 1K08CA228761-01A1

Funding has been awarded to Pat Areán by the National Institute of Mental Health for the "University of Washington ALACRITY Center for Psychosocial Interventions Research".

Abstract:

The UW ALACRITY Center purpose is to address critical problems in the implementation of evidence-based psychosocial interventions (EBPIs) for underserved communities as they are delivered in primary care medicine settings. Per a recent IOM report on psychosocial intervention standards, access to EBPIs is hampered by (1) poor clinician training, (2) intervention design complexity, and (3) insufficient support to sustain quality of care. We will attempt to solve these problems by creating a team of researchers from human centered design (Drs. Fogarty, Gonzalez, Munson, Popovic), education (Raue, Popovic), implementation science (Drs. Bennett and Lyon), psychosocial interventions (Drs. Aisenberg, Arean, Kaysen, Raue), health services research (Dr. Fortney, Ratzliff and Unutzer) and research methods (Dr. Atkins and Hoeft).

The Center represents a unique partnership between the School of Medicine’s Departments of Psychiatry/Behavioral Sciences and Family Medicine, the Department of Computer Science and Engineering, the Department of Communications, and the School of Social Work. The Center also bridges UW’s many resources: CoMotion (UW’s center for health technology innovation), the Institute for Translational Health Sciences (the UW CTSA), the AIMS Center (UW implementation and training center for collaborative care), and the WWAMI-region Practice Research Network (WPRN, a collaborative group of primary care practices through the states of Washington, Wyoming, Alaska, Montana and Idaho to facilitate innovative community- based research). The Administrative Core will serve as the communication hub between center cores, our two advisory boards, and will oversee the solicitation and selection of R03 level proof of concept studies. The Methods Core (MC) will provide research infrastructure to the projects. Each project will use our Discover, Design, Build and Test framework to address clinician capacity, intervention usability and intervention sustainability. The MC will also compile data from these projects to create a Typology of EBPI Targets and a Matrix of EBPI Modifications that will be shared with other researchers within and outside of UW through our online research community.

Research projects will collect a common core of outcomes to determine the impact of modifying EBPI targets on clinicians’ quality delivery of care and patient-reported outcomes. The first R34 project proposes to improve clinician EPBI capacity by designing and building an Intelligent Tutor System based on adaptive training. The second R34 project will partner with the WPRN to simplify problem-solving therapy (PST), using user-centered design principles. The third R34 project will partner with the Washington Behavioral Health Integration Program (BHIP) to develop an electronic health record-supported behavioral health module and registry to support sustained clinician skill in delivering PST in primary care. All three projects, and future R03s, will test the effects modification targets of implementation outcomes (time to training, clinician skill drift), system usability, EBPI system burden, system acceptability, and patient-reported outcomes.

Sponsor Award Number: 1P50MH115837-01