Eighty-four prenatally depressed women were randomly assigned to yoga, massage therapy or standard prenatal care control groups to determine the relative effects of yoga and massage therapy on prenatal depression and neonatal outcomes. Following 12 weeks of twice weekly yoga or massage therapy sessions (20 min each) both therapy groups versus the control group had a greater decrease on depression, anxiety and back and leg pain scales and a greater increase on a relationship scale. In addition, the yoga and massage therapy groups did not differ on neonatal outcomes including gestational age and birthweight, and those groups, in turn, had greater gestational age and birthweight than the control group.

This paper is a review of studies published during the last several years on exercise effects on overweight, growth, chronic illnesses, depression and anxiety in children and adolescents. Although the lion's share of the research involves aerobic exercise, studies on yoga and tai chi are also reviewed. Following exercise, body mass index and lipid profiles have improved in overweight children, and those with asthma, diabetes and depression have also benefited from exercise. The yoga studies reviewed here focused on ADHD and anxiety, and the tai chi studies involved children with ADHD and asthma. A potential underlying mechanism for the positive effects of exercise, yoga and tai chi may be the stimulation of pressure receptors leading to increased vagal activity, decreased stress hormones and increased production of anti-pain and antidepressant neurotransmitters such as serotonin. Further studies are needed using convergent behavioral, physiological and biochemical measures. Nonetheless, the current literature highlights the importance of adding exercise programs to clinics, schools and families for the physical and psychological well-being of children and adolescents.

OBJECTIVES To describe factors predictive of nursing home (NH) adherence to a clinical trial intervention. DESIGN Post hoc analysis of a cluster randomized trial (CRT) evaluating a structured communication intervention to improve nurse-physician telephone communication in NHs. SETTING NH. PARTICIPANTS All eligible licensed nursing staff in all participating NHs. MEASUREMENTS Adherence was defined as active participation for at least 3 months of the 12-month trial. NH characteristics hypothesized to affect trial outcomes (profit status, bed size, nursing staff time, NH quality, and leadership turnover) were measured a priori. The association between intervention adherence, NH characteristics and preintervention questionnaire response rate was examined. RESULTS Of 13 intervention NHs, seven adhered to the intervention. Three factors differentiated adherent from nonadherent NHs: director of nursing turnover (nonadherent NHs 50% vs adherent NHs 0%, P = .03); Centers for Medicare and Medicaid Services (CMS) nurse staffing rating (range: 1-5)(nonadherent NHs mean 3.7 ± 0.5 vs adherent NHs mean 4.3 ± 0.5), P = .048); and questionnaire response rate (nonadherent NHs 15.6 ± 10.0% vs adherent NHs 34.2 ± 12.1%, P = .02). Profit status, bed size, and number of NH deficiencies on state surveys were not significantly associated with intervention adherence. CONCLUSION CMS nurse staffing rating, leadership turnover, and questionnaire response rate are associated with adherence to a CRT intervention. Pretrial evaluation of NH staffing rating by CMS and of response to a questionnaire can help investigators improve trial efficiency by screening for NHs likely to adhere to a CRT intervention.

Background/Aims Initiative to improve the quality and safety of pharmaceutical care have lead to the development of quality of care measures including standards for the appropriate monitoring of high-risk medications (defined as medications commonly implicated in adverse drug events or with narrow therapeutic window). While low rates of laboratory monitoring of high-risk medications might indicate poor physician performance, it is unclear how much patient non-adherence to physician-ordered tests contribute to undermeasruement of physician quality. The study aim is to determine, for Health Employer Data Information Set (HEDIS) quality of care, high-risk medication laboratory monitoring measures: the prevalence of completion of recommended monitoring tests; and the proportion of incomplete testing attributable to lack of clinician test ordering relative to patient non-adherence to ordered tests. Methods and Results We measured the ordering and completion of laboratory tests for HEDIS-based high-risk medications (ACE inhibitors, ARBs, digoxin and diuretics, and anticonvulants) in a large multispecialty group practice between January 1, 2008 and July 31, 2008. Laboratory test completion for HEDIS cardiovascular drugs was higher than for anticonvulsants. Each cardiovascular drug had a completion rate of > 85%, while the completion rate for anticonvulsants ranged from 30-75%. The lowest test completion rate was for phenobarbital levels to monitor phenobarbital (30%). For all cardiovascular and anticonvulsant drugs, the proportion of recommended tests not ordered by the clinician ranged from 5% to 60%. The lowest test order prevalence was for phenobarbital level for phenobarbital use (35%), followed by valproic acid level for valproate use(48%), and carbamazepine level for carbamazepine use (60%). Rates of patient noncompletion of ordered tests for all drugs was generally <10%. Conclusion Completion of laboratory monitoring tests for high-risk cardiovascular medications was higher than for high-risk anticonvulsants according to HEDIS guidelines. Clinician ordering behavior exhibited more variation than patient adherence to test orders. Underestimation of HEDIS quality of care monitoring due to patient non-adherence is minimal for cardiovascular medications, but higher for anticonvulsants.

Background/Aims Inadequate laboratory monitoring of high-risk medications is a medical error associated with preventable adverse drug events. Patient failure to complete ordered laboratory tests is not uncommon. We conducted in-depth interviews with patients who did not complete a recently ordered laboratory test to identify barriers to test completion. Methods The target population was patients in a large multispecialty group practice who failed to complete an ordered laboratory test. We conducted semi-structured interviews with 18 patients who did not complete a monitoring test order related to 1 of 7 high-risk medications (angiotensin converting enzyme inhibitors (ACE) inhibitors, angiotensin II receptor blockers (ARBs), digoxin, phenytoin, statins, thyroid replacement hormone, or valproic acid) between July 2008 and October 2010. For comparison, we also interviewed 5 patients who completed all ordered laboratory tests. The interviews occurred in person when possible (n=17) as well as by phone (n=6). All interviews were recorded and transcribed and analyzed using a grounded theory approach. Results The laboratory monitoring discussions included the following themes: physician communication about lab tests, patient comprehension of lab test purpose, patient attitude toward lab tests, and barriers to test completion. The most prominent barrier to test completion was forgetting. Patients often did not realize they had missed an ordered test. When patients did acknowledge missing an ordered test, they often noted that they did not encounter any barriers besides forgetting. Regarding potential interventions, patients reported that understanding the indication for the tests would not help reduce non-completion. Several patients understood the reason for the test, but still failed to complete it. While some thought it was important to understand the reason for the test, others trusted their physician and did not believe it was essential to understand. Some patients were using an online personal health portal system offered through the practice that included information about upcoming tests. Conclusions Forgetting was the most prominent theme for non-completion of ordered test. Patients felt that providing timely (near desired test completion date) patient reminders, either by phone or by e-mail, would likely improve completion rates of laboratory monitoring for high-risk medications, while providing more information about the test indication would not.

Background Parents of many children with cancer administer highly complex chemotherapy regimens at home which are error prone. One way to identify and repair potential error prone processes is with a Failure Mode and Effect Analysis (FMEA). An FMEA is a systematic, team-based approach to understanding the ways a process can fail and developing interventions; it has been used in hospitals for decades but has never, to our knowledge, been used with a team of parents. Methods The objective of this study was to identify aspects of the home medication use processes at risk for error and propose interventions using an FMEA with a group of parents. We recruited parents of children with cancer taking home medications. FMEA steps included: selection of a high-risk process; diagram the process; brainstorm potential failure modes; rate and prioritize failure modes; identify root causes; and redesign the process. The target high-risk process was parent/ caregiver administration of 6-mercaptopurine following a change in medication dose. Parents were trained in FMEA methodology using materials at a 6th grade reading level and a real-life example. Failure modes were prioritized using ratings for severity, frequency of occurrence, and detectability. Results The process diagram developed by the parent-team included 12 steps. The highest priority failure modes were: shared instructions by the parent who attended the clinic visit regarding change in dose are misunderstood by the other caregiver(s); administration of chemotherapy without realizing that another caregiver already administered it; parent misunderstanding of physician's instructions about the change in dose; and the parent who attended the clinic visit shares incorrect instructions regarding the change in dose with other caregivers. During the discussion of interventions, communication tools (e.g. written instructions from the physician, a home medication calendar with communication tools such as check boxes to indicate when a dose had been administered, and others) were high priority for parent participants. Conclusions Parents can understand and perform an FMEA. The parent-team identified modifiable failure modes, many communication-related, which could lead to significant patient injury in home medication use. Parents prioritized tools that could lead to system improvements and reduce errors.

Background Research suggests physician-patient discussions about colonoscopies may be brief or absent. We sought to investigate men and women's familiarity and experiences with colonoscopies, and perceived benefits and barriers. Methods In the context of the multi-site CRN study "Health Literacy and Cancer Prevention" adults aged 40 to 70 were interviewed about knowledge, attitudes and experiences related to colonoscopy screening. Results Of 1068 adults queried, 99% had heard of a colonoscopy, and 90% knew what type of cancer it tested for. 976 men and women had or intended to have a colonoscopy (accepters). The most common reasons cited for a colonoscopy were age appropriateness (59%), physician advice (56%), family history (16%), and colon-related symptoms (14%). 69 men and women had not had and did not intend to be tested (decliners). These participants cited lack of doctor recommendation (39%), age (16%), absence of family history (15%) and absence of colon-related issues (15%) as reasons. Most participants (92%) would find a normal result reassuring, and most (80%) believed having a colonoscopy would reduce their chances of dying from colon cancer. Overall, 41% would be nervous about what a colonoscopy might find and 69% agreed that having a colonoscopy is unpleasant. A statistically significant difference between accepters and decliners was found only on the latter belief, with 68% of decliners endorsing that a colonoscopy is unpleasant, compared to 82% of accepters (p<.05). There were no statistically significant differences between accepters and decliners on health literacy test scores, however those who did not know what sort of cancer a colonoscopy screened for scored lower than those who did (p<.05). Overall, 14% of participants had read or been given conflicting information about a colonoscopy; those who had were more likely to report mixed feelings about having a colonoscopy (p<.05). Conclusions Almost all participants in this study were familiar with colonoscopy screening, and a large majority knew what type of cancer it screened for. While many participants were aware of age as a factor in screening appropriateness, not surprisingly physicians' advice (or its absence) also appeared to be influential.

Background Prostate cancer screening is controversial; treatment of early stage cancer has uncertain benefits, and complications are likely. Physician-patient discussions about PSA testing may be brief or absent. We investigated men's familiarity and experiences with PSA testing, and perceived benefits and barriers. Methods In the context of the multi-site CRN study "Health Literacy and Cancer Prevention" men aged 40-70 were interviewed about knowledge, attitudes and experiences related to PSA testing. Results: Of 437 men queried, 69% had heard of a PSA test, and 51% knew what type of cancer it tested for. 246 men had/intended PSA screening (PSA-accepters). The most common reasons cited for screening were physician recommendation (62%), age appropriateness (49%), and prostate-related symptoms (12%). 21 men had not been/did not intend to be tested (PSA-decliners); reasons included no physician recommendation (33%), age (19%), and no prostate issues (10%). Most men (83%) would find a normal result reassuring, and most (80%) believed a PSA test would reduce their chances of dying from prostate cancer; accepters held stronger beliefs about these benefits than decliners (p<.10). Overall, 24% would be nervous about what a PSA test might find and 13% agreed having a PSA test is unpleasant. The latter belief (but not the former) was stronger in PSA-decliners than accepters (p<.05). There were no statistically significant differences between PSA-accepters and decliners on health literacy test scores, however those who did not know what sort of cancer a PSA test screened for scored lower than those who did (p<.05). Overall, 35% of men had read or been given conflicting information about PSA testing; these men were more likely to report mixed feelings about PSA testing, would be less likely to find a normal result reassuring, and were less likely to believe that PSA testing reduces chances of dying from prostate cancer (p<.05). Conclusions Many men in this study were unfamiliar with PSA testing. Most believed that PSA testing would reduce their chances of dying from prostate cancer, and were not aware of conflicting information about PSA testing. Patient education about PSA testing is needed.

Background/Aims Mastectomy and breast conserving surgery followed by radiotherapy are considered initial guideline therapies for early stage breast cancer with randomized trials demonstrating reduced risk of recurrence. However, older women and those with comorbidities frequently receive only breast conserving surgery. The interaction of age and comorbidity with breast cancer severity and their impact on receipt of guideline therapy have not been well studied. Methods In the population-based BOW cohort of 1837 women age=65 years receiving initial treatment for early stage breast cancer in 6 integrated healthcare delivery systems in 1990-1994 and followed for 10 years, we examined predictors of receiving less than guideline therapy. We also assessed the impact of less than guideline therapy on breast cancer recurrence stratified by breast cancer severity (low, moderate, or high risk for recurrence using the 1992 St Gallen criteria). Results Age and comorbidity were independently associated with receipt of less than guideline therapy after controlling for breast cancer severity and race. However, compared to those at lowest risk for recurrence, women at the highest risk were unlikely to receive less than guideline therapy (odds ratio (OR) 0.31, 95% confidence interval (CI) 0.21, 0.46) while women at moderate risk were about half as likely (OR 0.55, CI 0.36, 0.85). During follow-up, 295 women had a breast cancer recurrence. Using Cox regression modeling stratified by the 3 levels of risk for recurrence, non-receipt of guideline therapy was associated with recurrence among women at moderate (HR 5.10, CI 1.93, 13.49) and even low risk (HR 3.24, CI 1.15, 9.12). The elevated hazard rate ratio was not observed for the high risk level group (HR 1.29, CI 0.78, 2.15). Age and comorbidity were not associated with recurrence in any of the analyses. Conclusions Among these older women with early stage breast cancer, decisions about guideline therapy appear to have partially balanced breast cancer severity against age and comorbidity. However, even among women at low risk of recurrence, omitting guideline therapy placed them at elevated risk of recurrence.

METHODS: Forty-six adults with hand pain were randomly assigned to a massage therapy or a standard treatment control group. Those assigned to the massage therapy group were massaged by a therapist on the affected hand once a week for a 4-week period and were also taught self-massage on the hand that was to be done by the individual participant once daily. RESULTS: The massage therapy group versus the control group had less pain and greater grip strength after the first and last sessions, and their anxiety and depressed mood scores decreased more than the control group. Over the four-week period the massage group had a greater decrease in pain and a greater increase in grip strength as well as lower scores on anxiety, depressed mood and sleep disturbance scales.