BackgroundDecision aids educate patients about treatment options and outcomes. Communication aids include question lists, consultation summaries, and audio-recordings. In efficacy studies, decision aids increased patient knowledge, while communication aids increased patient question-asking and information recall. Starting in 2004, we trained successive cohorts of post-baccalaureate, pre-medical interns to coach patients in the use of decision and communication aids at our university-based breast cancer clinic.MethodsFrom July 2005 through June 2012, we used the RE-AIM framework to measure Reach, Effectiveness, Adoption, Implementation and Maintenance of our interventions.ResultsReach: Over the study period, our program sent a total of 5,153 decision aids and directly administered 2,004 communication aids. In the most recent program year (2012), out of 1,524 eligible patient appointments, we successfully contacted 1,212 (80 %); coached 1,110 (73 %) in the self-administered use of decision and communication aids; sent 958 (63 %) decision aids; and directly administered communication aids for 419 (27 %) patients. In a 2010 survey, coached patients reported self-administering one or more communication aids in 81 % of visitsEffectiveness: In our pre-post comparisons, decision aids were associated with increased patient knowledge and decreased decisional conflict. Communication aids were associated with increased self-efficacy and number of questions; and with high ratings of patient preparedness and satisfactionAdoption: Among visitors sent decision aids, 82 % of survey respondents reviewed some or all; among those administered communication aids, 86 % reviewed one or more after the visitImplementation: Through continuous quality adaptations, we increased the proportion of available staff time used for patient support (i.e. exploitation of workforce capacity) from 29 % in 2005 to 84 % in 2012Maintenance: The main barrier to sustainability was the cost of paid intern labor. We addressed this by testing a service learning model in which student interns work as program coaches in exchange for academic credit rather than salary. The feasibility test succeeded, and we are now expanding the use of unpaid interns.ConclusionWe have sustained a clinic-wide implementation of decision and communication aids through a novel staffing model that uses paid and unpaid student interns as coaches.
His Bundle pacing (HBP) restores electrical synchronization in left bundle branch block (LBBB), however, the underlying mechanisms are poorly understood. We examined the relationship between native QRS axis in LBBB, a potential indicator of the site of block, and QRS normalization in patients with LBBB. Data from patients (n=41) undergoing HBP at three sites were studied (68±13 years, 13 females). Study criteria included strictly defined complete LBBB, and successful implantation of a permanent HBP lead. Pre- and post-procedure electrocardiograms were reviewed independently by two blinded readers. QRS axis and duration were measured to the nearest 10° and 10ms, respectively. QRS narrowing or normalization was the primary endpoint. Of 29 patients meeting study criteria, 9 had frontal plane QRS axes between −60° and −80°, 10 from −40° to 0°, and 10 from +1° to +90°. QRS narrowing occurred in 24 patients (83%, 44±34ms, p<0.05). Percent QRS narrowing by axis were 26±19%, 29±25%, and 28±23%, respectively. No correlation between pre-pacing QRS axis and post-pacing narrowing was identified (r2 = 0.001, p = 0.9). In patients with or without QRS normalization following HBP, mean QRS duration were 155±21ms vs. 171±8ms, respectively, p=0.014). HBP induces significant QRS narrowing in most patients, and normalization in patients with shorter baseline QRS duration. In conclusion, the lack of correlation between native QRS axis and narrowing suggests that proximal His-Purkinje block causes most cases of LBBB, or that additional mechanisms underlie HBP efficacy. Further studies are needed to better understand how to predict those patients in whom HBP will normalize LBBB.
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