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2015 NAPCRG Annual Meeting

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To What Extent do Organizational Characteristics of Primary Healthcare Practices Explain the Association Between Practices’ Size and Patients’ Experience of Care, Unmet Needs and Preventive Services?

Raynald Pineault, MD, PhD; Roxane Borges Da Silva, PhD; Mylaine Breton, PhD; Audrey Couture, MSc; Michel Fournier; Jean-Frederic Levesque, PhD, MD; Sylvie Provost; Alexandre Prud'homme; Pierre Tousignant


Context: The relationship between size of primary healthcare (PHC) practices and provision of care remains unclear. Furthermore, size is often used as a proxy for organizational characteristics. Objective: To identify PHC practices’ organizational characteristics and to determine the extent to which they mediate the relationship between PHC practices’ size and patients’ experience of care, preventive services and unmet needs. Design: We conducted a population-based telephone survey and a PHC practices’ mail survey in the two most populated regions of the province of Quebec in 2010. The surveys were linked through identification of the regular source of PHC by the population survey’s respondents. Associations between size, other organizational characteristics and patients’ outcomes were examined by applying multilevel regression analyses. Participants: Population survey involved 9180 randomly selected individuals (18 or older). The sample was non-proportionately stratified by 23 territories in the two regions. PHC practices survey involved all practices in the two regions (N=606). Measures of experience of care are adapted from PCAT and PCAS. Results: Overall, the larger a practice, the more resources (ex. information technologies) and desirable structural features (ex. collaborations with hospital) it had. Size was also associated with patients’ outcomes. Patients of smallest practices were less likely to report unmet needs (p<.001); and they had a lower score of accessibility (p<.001) but higher scores of continuity, comprehensiveness, responsiveness, perceived outcomes and preventive services (p<.001). These associations faded away when introducing organizational variables in the analysis model. Conclusion: These results support the hypothesized mediating effect of organizational characteristics on the relationship between practices’ size and patients’ experience of care, preventive services and unmet needs. Size does not add much information when organizational characteristics are already available. Furthermore, using practice size as a proxy for organizational characteristics can be misleading because its relationships with different outcomes are highly variable.

Primary Care Providers’ Responses to Standardized Patient Instructor-Delivered Training in Self-Efficacy Enhancing Interviewing Techniques: Results from a RCT


Context: Brief primary care provider (PCP) training in self-efficacy enhancing interviewing techniques (SEE IT), delivered by standardized patient instructors (SPIs), can improve interviewing behaviors and, subsequently, patient psychological factors that influence behavior. Whether PCPs are likely to embrace such training is unclear. Objective: To examine PCPs’ responses to SEE IT training. Design: Randomized controlled trial. Setting: Twelve primary care offices from two Northern California health systems. Participants: Fifty practicing family physicians and general internists. Interventions: Experimental arm providers (N=27) received SEE IT training during three SPI visits over 1 month. Control providers (N=23) viewed a video on diabetes treatments during a single SPI visit. SPI visits were timed to last

PR2 Setting the PaCE: NAPCRG’s Patient and Clinician Engagement Initiative

John Westfall, MD, MPH; Maret Felzien; Ned Norman

10/24/15 8:00 AM - 5:00 PM Coral Island 1

The PaCE (Patient and Clinician Engagement) Project is a NAPCRG special project funded by the Patient-Centered Outcomes Research Institute (PCORI) under the Eugene Washington Engagement Award Program. The purpose of PaCE is to develop a robust community of patients and primary care providers working together as dyads with knowledge and understanding of the unique features of patient-centered outcomes research related to primary care. The PaCE MX Preconference is a 1-day immersion for primary care providers, researchers, and community members to broaden their understanding and capacity around the: • Current state of primary care and primary care research • Advocacy for primary care and patient engagement within the research world • Importance of patient-centered outcomes research • Patient-Centered Outcomes Research Institute (PCORI) and the need for patient and clinician involvement in its Merit Review process • Opportunities for patient- and clinician-engaged research: the PCORI Pipeline-to-Proposal development and application writing Participants are encouraged to come as dyad teams—a researcher or primary care provider along with a patient s/he knows well. Together these teams will learn the skills needed to get started in advocacy and patient-centered outcomes research, begin to navigate the engagement process and join an engaged community of other dyad teams.

PR1 Preconference Workshop for Methods for Primary Care Research

Gillian Bartlett, PhD; Christopher Morley, PhD; Cristina Longo, MSc; Justin Gagnon, MA, BSC; Isabelle Vedel, MD, PhD; Jamie DeMore; Christopher Meaney, MSc; Tibor Schuster; L. Miriam Dickinson, PhD

10/24/15 9:00 AM - 5:00 PM Coral Garden 3

Objectives of CASFM Research Methods Working Group: The objective of this CASFM (Committee on Advancing the Science of Family Medicine) working group is to bring together NAPCRG researchers and methodologists to disseminate and promote introductory and advanced methods for primary care research. The goal is to share methodological approaches and develop creative solutions to methodological issues that arise in the context of primary care research. This pre-conference course is being offered in response to the demand highlighted through previous methodological workshops and webinars offered by the CASFM Methods Working Group. Many primary care researchers are interested in gaining more experience in diverse methodologies that are necessary to address the complexity of primary care research so we anticipate a high attendance at these courses. Objectives of Pre-conference Course: To provide instruction in basic and advanced methods in qualitative, quantitative and mixed methods research relevant for primary care. Content: The course will be offered in three concurrent streams with topics in the morning and afternoon: Stream 1 Qualitative Research Methods: Introduction to Qualitative Methods (am) Basics of Mixed Methods (pm) Stream 2 Basic Quantitative Research Methods: Introduction to Statistics & Interpretation (am) Dealing with Missing Data in Statistical Analysis (pm) Stream 3 Advanced Quantitative Research Methods: Step Wedge Trial Design (am)  Log Linear Modelling (pm) Method: Each course topic will be offered over 3 hours and will follow an active learning model where participants will not only be provided with the substantive material but will also be actively participating in the course through engagement exercises and in-class activities. This method has been shown to promote retention of the material and minimize the time burden for the participants. In-class evaluation will be included in order to provide participants with a certificate of completion. The sessions are set up so that participants can pick and choose which two sessions of the six sessions offered in the one-day course that they would like to attend. Prerequisite Knowledge: Quantitative and/or qualitative methods knowledge and experience in practice-based research will be helpful but is not required.

P101 Health Disparities and Comorbid Behavioral Health and Chronic Disease: Findings From Employer-Sponsored Claims Data

Lynn VanderWielen, PhD, MPH; Benjamin Miller, PsyD; Molly Nowels, MA

10/25/15 9:30 AM - 10:40 AM Grand Coral Foyer

Context: Disparate outcomes of care for historically underserved populations have been widely documented in the literature. However, few studies have utilized nationally representative employee-sponsored healthcare plan data to examine disparities for individuals experiencing behavioral health conditions comorbid with chronic conditions. Objective: Examine outcomes of care as associated with socioeconomic patient characteristics among patients with comorbid behavioral health and chronic conditions. Design: This case control methodology will include several multivariate regression analyses to examine utilization patters including ED visits, hospitalizations, primary care visits, behavioral health visits, and ambulatory care sensitive conditions and total cost of care. Setting: Patients enrolled in employer-sponsored healthcare plans from 2009 to 2013 from the Health Care Cost Institute’s data repository which includes over 100 million covered lives from 2009 to 2013. Patients: Individuals enrolled in employer-sponsored health plans in the United States. Results: We anticipate that several health disparities associated with socioeconomic characteristics of patients experiencing behavioral health and chronic conditions including factors associated with race, ethnicity, income, and educational status. Conclusion: Findings from this work, positive or negative, will provide policy makers with evidence to provide focused attention on healthcare for underserved populations. Additionally, findings will create an opportunity for dialogue around health disparities and quality of care for underserved populations among front-line providers who serve such communities.

P102 Healthcare Utilization Patterns and Costs of Care: A Longitudinal Analysis of the Implications of the Mental Health Parity Act for Those With Comorbid Diabetes and Depression Diagnoses

Molly Nowels, MA; Lynn VanderWielen, PhD, MPH; Benjamin Miller, PsyD

10/25/15 9:30 AM - 10:40 AM Grand Coral Foyer

Context: Rates of depression in individuals with diabetes are twice that of the general population in the United States. Depression is associated with non-adherence to diabetes self-care, which results in worse clinical outcomes. Managing both the behavioral health and medical aspects of comorbid diabetes and depression necessitates attending to all symptoms, and may result in optimal patient outcomes and lower healthcare costs. Objective: The current study will examine healthcare utilization patterns and cost of care among individuals with diabetes with and without comorbid depression pre- and post- Affordable Care Act and Mental Health Parity implementation. Setting: We will use claims data for individuals enrolled in employer-sponsored plans in states with over 30% coverage penetration by Health Care Cost Institute (HCCI) plans: Colorado, Ohio, Missouri, New Jersey, the District of Columbia, Texas, Florida, Connecticut, Maryland, Minnesota, and Oregon. Patients: Individuals continuously enrolled in the HCCI dataset (approximately 7.8 million unique patients) from 2009 to 2013. Design: We will employ a longitudinal multilevel modeling analysis for to determine changes over time for individuals with diabetes with and without comorbid depression. Outcome Measures: Outcome measures will include utilization measures such as ED visits, hospitalizations, primary care visits, behavioral health visits, and overall costs of care. Results: We anticipate finding a significant difference in utilization and cost of care when comparing patients with diabetes with and without comorbid depression. Conclusion: Findings may provide policy makers with evidence for potential legislation around improving behavioral health and primary care.

P103 Health Coaching to Effect Lifestyle Behaviour Change: A Clinical Trial of Individuals With Pre-Disease

Marshall Godwin, MD, FCFP; Kris Aubrey-Bassler, MSc, MD; Shirley Solberg; Andrea Pike, MSc; Farah McCrate, MSc; Alice Gaudine; Veeresh Gadag; Heather Pitcher, RN, NP, BN; Sandra Lefort; Holly Etchegary; Shabnam Asghari, MD, MPH, PhD; Krystal Pike

10/25/15 9:30 AM - 10:40 AM Grand Coral Foyer

Context: Cardiovascular disease (CVD) is the leading cause of death in Canada. Newfoundland and Labrador (NL) has the highest prevalence of CVD in the country; many of the risk factors for CVD are also highly prevalent in this province including type 2 diabetes, hypertension. Targeting the risk factors for CVD can help decrease the likelihood (or delay the onset) of developing overt CVD. Objective: To determine if a six-month health coaching intervention in those with pre-disease (pre-hypertension or pre-diabetes) but without pre-existing CVD, is an effective strategy to change lifestyle behavior and prevent or delay onset of frank diabetes, hypertension, and CVD. Design: RCT Setting: St. John’s, NL Participants: Adults aged 40-60 years who have pre-diabetes and/or pre-hypertension (fasting blood glucose between 6.0-6.9mmol/L and/or blood pressure between 130-139 mmHG systolic and/or 85-89 mmHG diastolic). Intervention: This is a six month intervention. Participants will meet with a nurse trained in health coaching once/month. The first and last meetings will be completed in groups of 20; the four other meetings are one-on-one. Follow-up assessments will be conducted at 6 and 12 months for both groups. Outcome Measures: Simple Lifestyle Indicator Questionnaire (SLIQ) – is the primary outcome measure. Secondary outcome measures include: self-efficacy , global cardiovascular risk, fasting blood glucose, HbA1c, lipids, and blood pressure, progression to overt disease, health related quality of life. A qualitative assessment will be conducted after the final group session of each round to learn more about participants’ perspectives. Results: Recruitment and enrollment is finished and follow-up is nearly done. Final results are expected by October 2015. Conclusions: NL has a high prevalence of CVD and is an ideal context in which to investigate the potential benefits of a lifestyle intervention aimed at reducing the risk of CVD. Identifying, targeting, and intervening with pre-diseased patients early in primary prevention may help decrease the likelihood of developing CVD.

P105 Engaging the Community in Identifying and Prioritizing Outcomes for Integrated Primary Care Behavioral Health

Nancy Pandhi, MD, PhD; Nora Jacobson; Natalie DeCheck; Zaher Karp; Elizabeth Zeidler-Schreiter; Armando Hernandez; Neftali Serrano

10/25/15 9:30 AM - 10:40 AM Grand Coral Foyer

Context: Models that integrate behavioral health into primary care are increasing in popularity. However, little is known about the public perception of these models and desired outcomes from this care. As patient-centered care is a core value of family medicine, this knowledge is critical information for effective practice. Objective: To determine perceived benefits, concerns and desired outcomes from the Primary Care Behavioral Health (PCBH) Consultation Model. Then, to determine outcome priorities. Design: Video-vignette survey distributed online and in-person. The survey asked three open-ended questions about what was liked, disliked and desired from this model. Responses were independently coded by two researchers who then reconciled these themes. A third researcher read all data and verified coding. Next, statements were written that corresponded to the desired outcomes. These are being brought to focus groups where prioritization is occurring using a nominal group technique. Setting: Community (farmers markets, community center, social service agencies), online, and clinics (Academic Health center, FQHC and HMO) Patients: 381 patients completed the survey. 35% identified as low-income, 28% non-white and 44% as having a mental health diagnosis. Six focus groups of 6-9 participants, all who have received care through the PCBH model, are underway. Results: Benefits, concerns and desired outcomes were identified in four major domains: overall well-being, dignity, access/services, and care team experience. For example, most liked the model’s holistic approach, but some worried about mental health concerns displacing focus on physical health. Most appreciated the convenience and immediate access the model provided. A few worried the consultation length would not allow root causes to be uncovered. Having strategies to deal with daily problems was the highest ranked overall well-being outcome. Further outcomes are in process of being ranked. Conclusions: Public opinions can inform the evaluation of models that integrate behavioral health into primary care.

P106 Impact of Problem Gambling on Family Functioning

Irasema Rodriguez-Rodriguez, MD, FP; Celina Gomez-Gomez, MD, PhD; Eduardo Mendez-Espinosa; Hector R. Riquelme- Heras, MD, FP; Magda M Sánchez López, MD

10/25/15 9:30 AM - 10:40 AM Grand Coral Foyer

Context: Pathological gambling is an addiction socially accepted and it is difficult to know the extent of the problem and its implications. The gambler´s family may also be affected, because the functionality is altered, a factor related to maintaining health and solution to the crisis. Objective: To demonstrate the association between pathological gambling and family functioning. Design: Cross-sectional comparative convenience sample. Setting: General community. Participants: A convenience sample of 20 active gamblers, older than 18 years, with an established diagnosis of pathological gambling according to DSM-IV-R and no addictions or mental illness in the family were interviewed at casinos: Other comparative group the same size apparently healthy without family mental illness history were interviewed at home. Study endorsed by an institutional ethic committee. Main outcome measure: The Questionnaire South Oaks for pathological gambling was applied as well as the Evaluation of Domestic Relations Scale to assess family attachment and support, difficulties and expression. Descriptive statistics and Fisher test were used for statistical analysis (p <.05). Results: 95.0% of the gamblers showed a low level of attachment, while any one of the comparison group did (95% vs 0.0%; p <.001); for expression of thoughts and feelings the whole group of gamblers presented a low level in the comparison to the other group (100.0%vs.0.0%; p <.001). Higher level of difficulty was found in gamblers than the apparently healthy comparative group (100% vs.10.0%; p <.001). Conclusions: The three dimensions of functionality as scored by the scale used are highly affected in families of gamblers. It is essential to know how gambling affect families to intervene earlier before entering in frank dysfunctionality.

P108 Beyond Health Behavior Change: Meeting the Mental Health Needs of Primary Care Patients Referred for Health Coaching

Kaile Ross, MA; Shandra Brown Levey, PhD; Lacey Clement, MA; Corey Lyon, DO; Kevin Masters

10/25/15 9:30 AM - 10:40 AM Grand Coral Foyer

Context: Many primary care patients meet criteria for one or more psychiatric diagnoses. Patients may be reticent to discuss mental health issues yet feel more comfortable working on issues such as weight gain or insomnia with a health coach. Often patients feel comfortable working with health coaches for health behavior change and through this work also discuss related mental health concerns, some of which can be quite serious and distressing and may even require immediate safety planning and intervention. Objective: To assess the potential level of mental health care need among patients referred for health coaching by examining the frequency of psychiatric diagnoses and the frequency at which psychological concerns are addressed during health coaching sessions. Design: Cross-sectional, observational, quality improvement initiative. Setting: Level 3 PCMH. Patients or Other Participants: 118 patients referred by their PCP to the in-clinic health coaching program. Patients were referred for behavioral issues including weight loss, smoking cessation, sleep management, etc. Health coaching was provided by two graduate students in a PhD Clinical Health Psychology program. Main and Secondary Outcome Measures: Percentage of referred patients with a documented psychiatric diagnosis in their EMR problem list, percentage of patients indicating depression symptoms on the PHQ-9, and the percentage of health coaching sessions coded as addressing both behavioral and psychological patient issues. Results: Many patients (33.1%) referred to health coaching had at least one EMR documented psychiatric diagnosis, 7.6% had two or more, and 20.3% indicated experiencing depression symptoms. Of the 61 completed initial health coaching sessions, 14.8% were coded as including aspects of both psychological and behavioral health intervention. Conclusions: Many patients referred to health coaching have mental health needs, which may arise during health coaching and impact the patient’s ability to make progress on their health behavior goals. To provide appropriate support of patients referred for health coaching, health coaches may need mental health training and/or need to be part of an integrated behavioral health system.

P109 Perceptions of Primary Care Among Breast Cancer Survivors: The Effects of Weight Status

Allison Christian, EdD; Shawna Hudson, PhD; Suzanne Miller, PhD; Alicja Bator, MPH; Pamela Ohman-Strickland, PhD; Robert Somer, MD; Jeanne Ferrante, MPH, MD

10/25/15 9:30 AM - 10:40 AM Grand Coral Foyer

Context. Obese breast cancer survivors (BCS) are impacted by diminished quality of life (QOL), multiple comorbid conditions and poor disease outcomes. Despite national guidelines recommending a healthy weight to improve QOL and outcomes post- treatment, support and education are not routinely provided to BCS in primary care. Objective. We assessed perceptions of primary care received among BCS by weight status. Design. This is a secondary analysis of data collected from a cross-sectional survey of 325 early-stage breast and prostate cancer survivors. Setting. Data was collected from two cancer centers that were part of the Rutgers Cancer Institute of New Jersey’s Network of affiliated hospitals. Participants. A total of 188 early stage (I or II), >=2 years post-active cancer treatment (excluding hormonal maintenance therapies), English speaking BCS were recruited from May 2012-June 2013 and included in this analysis. Patients were approached about the study at the time of a follow-up visit or through identification from an onsite patient registry. Main and Secondary Outcome Measures. Socio-demographics, height, weight, medical history, and functional health status were assessed. The Patient Satisfaction Questionnaire Short-Form (PSQ-18) was utilized to asses seven aspects of satisfaction with PCP care with no reference to a specific time frame or visit. To evaluate PCP involvement in follow-up care, items from the Follow-Up Care Use among Survivors (FOCUS) survey were used. The Components of Primary Care Instrument assessed BCS’ perceptions of their receipt of patient-centered medical home constructs (comprehensive care, coordination of care, and personal relationship over time). Results. 82% of overweight BCS and 30% of obese BCS reported not being told by their doctor that they were overweight or obese, despite these conditions being highly prevalent (35% and 35%, respectively). Obese BCS were significantly more likely than healthy weight BCS to be African American and have a higher comorbidity score, poorer functional health status (physical and mental component score) and greater satisfaction with their PCP. Conclusions. PCPs play an integral role in providing comprehensive survivorship care to BCS, particularly to those who are obese or struggling with multiple comorbid conditions. The PCP-patient encounter may represent an opportunity to correct misperceptions and promote weight reduction efforts, thus improving QOL and disease outcomes among BCS.

P110 Reduced Health Inequalities in Cervical Cancer Screening is Associated With Urbanity and Increased Share of Public Health Expenditure: Results From the World Health Survey

Naheed Lakhani, MD, MPH

10/25/15 9:30 AM - 10:40 AM Grand Coral Foyer

Background Cervical cancer is the leading cause of female cancer mortality in low- and middle-income countries (LMICs). The Papanicolaou (Pap) test is underutilized among LMIC women, despite being universally accepted as an effective screening tool. Public financing of healthcare can help overcome individual barriers to healthcare and thus reduces socioeconomic inequality in healthcare use. Objective This study tests the hypothesis that a higher country-level share of public health expenditure as a percentage of total health expenditure (%PHE) is inversely associated with the magnitude of inequality of receiving a Pap test in low- and middle-income countries. Design/Setting Nationally representative sample of adults aged 18 or older from 59 countries included in the World Health Survey 2002 Patients Women aged 18-69 years (N=107,086) Methods/Instrument Applying multi-level mixed-effects logistic regression with three cross-level interaction terms of %PHE and education, wealth, and urbanity, we obtained the marginal effect of %PHE on differentials in receipt of a Pap test among women with respect to each. The results indicated that increased %PHE is associated with reduced magnitude of socioeconomic inequalities in women’s receipt of a Pap test within the past three years. Analysis of country by level of urbanity and cervical cancer screening prevalence was also conducted. Outcome Measures For example, all else being fixed, in terms of urban inequality, %PHE decreases the likelihood of inequality of receiving a Pap test from 3.9 percentage points [95% CI: 2.7, 5.1] to 0.3 percentage points [95% CI:-0.8, 1.5] at %PHE of 10% and 70%, respectively (Figure 1). Countries with a larger urban population had increased rates of Pap testing (Figure 2). Conclusions Improving public health financing may be an effective strategy to reduce socioeconomic inequalities in cervical cancer screening. In the context of rurality, enhanced infrastructure and access can ameliorate disparities based on where women live.

P111 The Impact of State Vaccination Laws, Enforcement and Monitoring on Vaccine-Specific Exemptions From School Immunization Requirements Among Selected States in the US

Brittany Sprague; Christopher P. Morley, PhD; Jana Shaw, MD, MPH, MS

10/25/15 9:30 AM - 10:40 AM Grand Coral Foyer

Context: Previous studies have shown a positive relationship between the number of philosophical exemptions to school immunization laws permitted by states, and the rate of school immunization exemptions. With the continued changes in vaccination laws in several states, an updated evaluation of the difficulty for obtaining nonmedical exemptions through state legislative code and state Department of Health (DOH) regulations is needed. Objective: To determine the impact of state vaccination laws, regulations, and enforcement on school immunization and exemption rates in the United States. Design: Retrospective study using publicly available data from CDC’s state and national school vaccination assessment reports (SchoolVaxView) and the National Immunization Survey (NIS). Populations include 19-35 month old children, kindergarten aged children, and adolescents 13-17 year old, included in data reports from 2008-2014. Individual state legislative code and DOH regulations will be categorized by level of complexity of obtaining an exemption as well as listing of enforcement. Multivariable regression analysis will be used to evaluate relationships between state levels of school immunization and exemption rates and 1) a quantitative rating of complexity of obtaining an exemption in each state; 2) level and type of enforcement listed by state legislative code and/or DOH regulations, and 3) type of exemptions allowed. Main and secondary outcome measures: State immunization rate for each vaccine type, within each applicable age category; state exemption rate for each vaccine type, within each applicable age category. Results & conclusion: Results from this study may have important implications in guiding future interventions regarding state enforcement, regulations, and laws. As vaccination hesitancy and resistance is a core issue for primary care, analysis of the comparative effects of legal and regulatory exemption provisions on vaccine rates may inform, assist, and encourage vaccine-positive legislative advocacy by primary care providers.

P112 The Better Living Programme: Improving Cancer Care in Rural Settings

Meghan Matos; Robert Wedel, MD; Carmen Thompson; Neil Drummond, PhD

10/25/15 9:30 AM - 10:40 AM Grand Coral Foyer

Context: Rural cancer patients often find themselves isolated by virtue of the distances and travel involved in obtaining specialized treatment. These patients also tend to lose contact with their family doctor and primary care team. Objective: To evaluate the impact of a multidisciplinary program that institutes proactive surveillance and the development of an individualized complex care plan that addresses psycho-social, spiritual and medical needs. Design/Objective: Non-randomized, quasi-experimental research design evaluating the impact of the Better Living Programme on: 1) patient quality of life 2) caregiver quality of life 3) continuity of care 4) patient satisfaction 5) ER and acute care admissions. Participants/Setting: Patients with colon, breast, prostate, or lung cancer participating in the Better Living Programme through a primary care clinic in a rural community in Southern Alberta (estimated N=130). Comparison group recruited from a similar clinic in the same geographic area (estimated N = 130). Instruments: Evaluation of the Better Living Programme is undertaken with the Functional Assessment of Cancer Therapy – General (Fact-G) to assess patient’s health related quality of life. The Edmonton System Assessment System (ESAS) monitors common symptoms of cancer in patients. Caregiver wellness is measured with SF12v2 for quality of life and the Caregiver Reaction Assessment which evaluates for caregiver strain. Results: Chi-square and t-tests comparing the two clinics, with possible sub-analyses. Baseline Data: There are 28 total participants thus far from the experimental group with 51.9% (N=14) male and 48.1% (N=13) female. The majority were in remote survivorship (N=25) with 10.7% (N=3) in active treatment. Many (N=12, 42.9%) were diagnosed with breast cancer, followed by 32.1% with colon cancer (N=9), 21.4% with prostate (N=6) and one participant with lung cancer (3.6%). Conclusions: If supported, this new model of coordinated care will be more broadly implemented in a Primary Care Network in Southern Alberta.

P113 Feasibility and Acceptability of a Telephone Supported Self-Care Intervention for Cancer Survivors With Depressive Symptoms

Jane McCusker; Mark Yaffe, MD; Rosana Faria; Sylvie Lambert; Manon de Raad; Mona Magalhaes; Eric Belzile

10/25/15 9:30 AM - 10:40 AM Grand Coral Foyer

Context: There are limited psychosocial resources to treat cancer survivors who experience significant depressive symptoms. Objective: To assess feasibility and acceptability of a depression self-care intervention for cancer survivors. Design: Uncontrolled trial of a depression self-care intervention. Setting: Patients were recruited from primary care practices, community support groups, and cancer care clinics. Patients: Cancer survivors aged 18+, having completed primary cancer treatment, with no recurrence or metastasis, experiencing moderately severe depressive symptoms (PHQ - 9 score of 8-19), and capable of participating in a telephone-supported intervention (in English or French). Patients (n=30) will be followed for 2 months. Intervention: Enrolled participants receive a toolkit including written and audiovisual materials, and are called weekly for 2 months by a trained self-care coach. The toolkit was originally developed for primary care patients with chronic physical conditions, but adapted to cancer survivors following focus groups among patients and health professionals. Main outcome measures: 1) feasibility, assessed by recruitment and retention of the target population; 2) acceptability, assessed by patient satisfaction with the intervention; 3) responsiveness, assessed by PHQ-9 score improvement. Results: Of 45 screened by telephone, 30 were eligible (67%); 28 (93%) eligible patients have enrolled in the study. To date 17 have completed follow-up, 3 have dropped out (11% of those enrolled) and 1 suicidal patient was withdrawn. Recruitment and follow-up are ongoing. Among the completed participants the mean number of coach contacts was 6.9 (SD 1.3), with average call duration of 15.2 minutes (SD 5.4), and high levels of satisfaction. Results to date show a decrease of 5.5 (SD 3.4) in mean PHQ-9 score at 2 months, an effect size of 1.62. Conclusions: A telephone supported depression self-care intervention for cancer survivors is feasible and acceptable.

P114 Changes in the Prevalence of Dyslipidemia in Primary Care Settings in Newfoundland and Labrador: A Serial Cross-Sectional Analysis of Canadian Primary Care Sentinel Surveillance Network Data Between 2009 and 2014

Shabnam Asghari, MD, MPH, PhD; Erfan Aref-Eshghi; Oliver Hurley, M. Env.Sc.; Guang Sun; Alvin Simms; Marshall Godwin, MD, FCFP; Pauline Duke, MD, CCFP, FCFP

10/25/15 9:30 AM - 10:40 AM Grand Coral Foyer

Context: Studies have shown a higher prevalence of dyslipidemia among patients of primary care settings in Newfoundland and Labrador (NL) compared to the rest of Canada. During the past decade, changes in lifestyle along with medication therapy dramatically influenced the prevalence of dyslipidemia. To our knowledge, no study has assessed the changes in prevalence of dyslipidemia over time in this population. Objective: to examine the trends in the prevalence of dyslipidemia in NL’s primary care population during 2009-2014. Design: serial cross-sectional study. Setting: primary care setting. Patients: All non-pregnant adults, aged ≥ 20 years from NL with a serum lipid measurement from January 2009 to December 2014 in Canadian Primary Care Sentinel Surveillance Network Database (CPCSSN) were included in the study. Measures: Serum lipid levels of total cholesterol, HDL, LDL, and triglyceride were extracted. Canadian guidelines for the dyslipidemia management and diagnosis were used to identify patients with dyslipidemia. Prevalence of dyslipidemia in six consecutive years is compared using Cuzick's Test for trend. Using a post logit trend test, we adjusted for factors including age, gender, BMI, smoking, comorbidities, and lipid-modifying medication. An autoregressive integrated moving average (ARIMA) model is performed. Results: Prevalence of total cholesterol, HDL, LDL, triglyceride, and ratio dyslipidemia decreased steadily between 2009 and 2014 from 40% to 38% (p=0.01), 47% to 37% (p<0.0001), 32% to 28% (p<0.0001), 32% to 31% (p=0.01), 26% to 18% (p<0.0001), respectively. Similar trends were observed after adjustment for other factors. ARIMA modeling is in progress. Conclusion: Initial findings demonstrate a significant decrease in the prevalence of all types of dyslipidemia in primary care settings in NL. Our observation may suggest effective dyslipidemia management in primary care settings. Additional studies are required to confirm our findings and to reveal the factors associated with changes in dyslipidemia in NL.

P115 Meeting Halfway: Challenges and Opportunities of Conducting Collaborative Research With Healthcare Decision-Makers to Adapt and Implement a Community-Based Cardiovascular Health Awareness Program

Marie-Thérèse Lussier, MD, MSc; Emmanuelle Arpin; Magali Girard, PhD; Janusz Kaczorowski, PhD

10/25/15 9:30 AM - 10:40 AM Grand Coral Foyer

CONTEXT: Public funding agencies in Canada increasingly require greater involvement of decision-makers in the research process (e.g. Canadian Institutes of Health Research’s Integrated Knowledge Translation model), with the hope that research findings will more likely meet local stakeholders’ needs thus facilitating translation into programs, policies, and practice. The Community Health Awareness Program (CHAP) is currently being adapted, implemented and evaluated in Laval (Quebec, Canada), borrowing the IKT model. OBJECTIVE: To describe the collaboration process between CHAP researchers and Laval’s healthcare stakeholders, and how this collaboration is shaping the research process, including adaptation, implementation and evaluation of the CHAP. DESIGN: Collaborative research and stakeholders engagement. SETTING: Laval, Québec’s third largest city (Canada), is a large francophone region that ranges from semi-rural to suburban and urban. PARTICIPANTS: Key local decision-makers involved in the prevention and management of chronic disease. INTERVENTION/INSTRUMENT: Two organised consultation sessions with key local stakeholders, ongoing involvement of researchers on the development of Laval’s chronic disease prevention and management program, and collaboration with decision-makers to integrate CHAP into this new chronic disease program. RESULTS: Close collaboration with local decision-makers lead to a greater knowledge of local priorities, resources and needs by researchers, and greater transparency and trust between the two parties. So far, this collaborative research and the engagement of stakeholders in the research process have resulted in the adaptation of the CHAP model for new programs and settings. However, there remains a number of issues, namely in relation to the length of time to build such trust and to raise awareness of the role of research in facilitating health policy decision-making. Also, conflicting objectives, priorities, agendas and timelines need to be understood and negotiated throughout the collaboration. CONCLUSION: Engaging stakeholders in the co-production of knowledge, although time-consuming, facilitates the development of interventions that are closely tailored to local needs and realities.

P116 Using “Life’s Simple 7” to Assess Cardiovascular Health and Cumulative Burden of Disease in an Appalachian Adult Population

Sarah Singh; Stephanie Frisbee; Courtney Pilkerton; Adam Christian; Khumara Huseynova; Carl Shrader Jr, MD, PhD

10/25/15 9:30 AM - 10:40 AM Grand Coral Foyer

BACKGROUND: Cardiovascular disease, the leading cause of death in the U.S, is associated with significant socioeconomic and geographic disparities. OBJECTIVE: The objective of the current study was to assess the extent to which cardiovascular health, or the absence there of, was accompanied by one or several other health challenges, and the socioeconomic factors associated with disparities in these associations, in a cohort of rural adults. METHODS: We used the “Life’s Simple 7” approach recently developed by the American Heart Association, which incorporates behavioral and biological factors, to measure cardiovascular health in this population. We used data from both a clinical (primary care) source and a population (epidemiologic) cohort. The “Life’s Simple 7”as developed by the AHA was adapted to fit the data and questions available. In additional to cardiovascular health, we assessed the number of additional medical diagnoses and conditions present in individuals, either from self-report or medical records review, to determine burden of disease. RESULTS: Overall, only 9.6% of adults had ideal cardiovascular health (67.4% had intermediate cardiovascular health and 23.1% had poor cardiovascular health). Poor cardiovascular health was associated with increased risk for host of other health problems including: Alzheimer’s, asthma, chronic bronchitis, COPD, emphysema, fibromyalgia, liver disease, arthritis, Parkinson’s, thyroid disease, stroke, kidney disease, and cancer (p<0.05 for all). Multiple age- and gender based disparities were observed. For example, women with poor cardiovascular health were more than twice as likely as men with poor CVHI to also have asthma, chronic bronchitis, immune disease, arthritis, and thyroid disease (p<0.05). Men and women with poor cardiovascular had similar probability of developing liver disease, stroke and cancer. Older age groups, regardless of gender, were associated with decreasing cardiovascular. The probability of having multiple diagnoses increased with decreasing cardiovascular (p<0.05); these differences were not equal across gender and other socioeconomic variables, thus representing sources of health disparities. CONCLUSIONS: Results from this study suggest that cardiovascular health is strongly associated with multiple other health conditions and that these indices of poor health are clustering in lower socioeconomic strata.

P117 The Role of the Novel Oral Anticoagulants in Atrial Fibrillation Management

Katherine Kirley, MD; Goutham Rao, MD; Christopher Masi, MD, PhD; Victoria Bauer, BSC

10/25/15 9:30 AM - 10:40 AM Grand Coral Foyer

Context: Oral anticoagulants (OACs) decrease the risk of stroke in patients with atrial fibrillation (AF) by 60%. However, thirty to sixty percent of AF patients do not receive an OAC when it is indicated, an under-treatment problem that results in thousands of preventable strokes annually. The reasons for the AF under-treatment problem are complex and only partially understood. The introduction of three novel OACs to the U.S. market has complicated our understanding of this problem. Objective: To gather formative data regarding physicians’ knowledge, beliefs, experiences, and practices related to the management of patients with AF, focusing on the role of the novel OACs in AF management. This formative data will be used in the development of a new survey instrument to study the use of the novel OACs and to identify factors contributing to the AF under-treatment problem. Design: A qualitative approach employing the Framework Method to analyze semi-structured interviews of physicians. Setting: Multiple urban and suburban health care systems in and around Chicago. Participants: Primary care physicians (4) and cardiologists (3) practicing in above settings. Results: Initial analyses of physician interviews suggest the emergence of four broad themes: 1) Physicians’ prior experience with OACs, 2) Facilitators and barriers to OAC prescribing that are external to the physician, 3) Cost as a key driver of OAC prescribing, and 4) Clinical benefits and risks of OAC use. Conclusions: Physicians reported a wide range of experiences and factors that influence their AF management practices and use of OACs. Similarly, physicians expressed a wide range of opinions regarding the role of the novel OACs in AF management.

P118 Does Supplementing Vitamin D Improve Ambulatory Blood Pressure in African Americans: A Randomised Clinical Trial

Yuan-Xiang Meng, MD, PhD, FAAFP; David Martins; Naureen Tareen; Jae Eun Lee; Jan Morgan-Billingslea; Caroline Farodolu; Halima Garba

10/25/15 9:30 AM - 10:40 AM Grand Coral Foyer

Context: Both vitamin D deficiency and hypertension are highly prevalent among African Americans. Observational data suggest that vitamin D deficiency is associated with high blood pressure by multiple mechanisms, including direct regulation of the renin-angiotensin-aldosterone axis. However, randomized trials specifically designed to test the effect of vitamin D on blood pressure are scarce. Objectives: This study is desired to evaluate the effect of vitamin D3 supplementation on 24 hour ambulatory blood pressure monitoring (ABPM) in African Americans. Study design: A multi-site randomized double-blinded placebo-controlled clinical trial. Sample size and study participants: 130 adult overweight (or obese) and hypertensive African Americans with serum level of 25-hydroxyvitamin D (25(OH)D) between 10-25 ng/ml were enrolled. 75 of participants completed the ABPM. Participants received a monthly oral dose of 100,000 International Units (IU) of vitamin D3 or placebo for twelve weeks. The ABPM was performed at baseline visit (pre-intervention) and at week twelve follow up visit (post intervention). ABPM device was set up as 2 readings per hour (30 minute interval) for wake period (06:00-22:00) and 1 or 2 readings per hour for sleep periods (22:00 – 06:00). Statistical analysis: Paired t-test for absolute change in outcome measures and a generalized linear mixed model (GLIMMIX) was used. The difference of changed outcome between study groups was determined by an interaction term of time (baseline and week 12) and group (placebo and vitamin D). Results: There were no statistical significant differences of participants’ basic characteristics. There were no statistical significant differences of all day AMBP, nighttime AMBP, daytime AMBP, dipping (systolic or diastolic) blood pressure, and non-dipping pattern between baseline visit and week twelve follow up, and groups of vitamin D3 supplementing and placebo. Discussion: There was no significant effect on ambulatory blood pressure among high risk African Americans taking 3-month high dose vitamin D3 supplementation. The clinical trials with larger sample size, optimal vitamin D dosage and longer intervention period are needed.