Importance: Healthy nutrition and appropriate supplementation during preconception have important implications for the health of the mother and newborn. The best way to deliver preconception care to address health risks related to nutrition is unknown. Methods: We conducted a secondary analysis of data from a randomized controlled trial designed to study the impact of conversational agent technology in 13 domains of preconception care among 528 non-pregnant African American and Black women. This analysis is restricted to those 480 women who reported at least one of the ten risks related to nutrition and dietary supplement use. Interventions: An online conversational agent, called "Gabby", assesses health risks and delivers 12 months of tailored dialogue for over 100 preconception health risks, including ten nutrition and supplement risks, using behavioral change techniques like shared decision making and motivational interviewing. The control group received a letter listing their preconception risks and encouraging them to talk to a health care provider. Results: After 6 months, women using Gabby (a) reported progressing forward on the stage of change scale for, on average, 52.9% (SD, 35.1%) of nutrition and supplement risks compared to 42.9% (SD, 35.4) in the control group (IRR 1.22, 95% CI 1.03-1.45, P = 0.019); and (b) reported achieving the action and maintenance stage of change for, on average, 52.8% (SD 37.1) of the nutrition and supplement risks compared to 42.8% (SD, 37.9) in the control group (IRR 1.26, 96% CI 1.08-1.48, P = 0.004). For subjects beginning the study at the contemplation stage of change, intervention subjects reported progressing forward on the stage of change scale for 75.0% (SD, 36.3%) of their health risks compared to 52.1% (SD, 47.1%) in the control group (P = 0.006). Conclusion: The scalability of Gabby has the potential to improve women's nutritional health as an adjunct to clinical care or at the population health level. Further studies are needed to determine if improving nutrition and supplement risks can impact clinical outcomes including optimization of weight. Clinical Trial Registration: ClinicalTrials.gov, identifier NCT01827215.

BACKGROUND: Racial and socioeconomic disparities in breast cancer mortality persist. In Boston, MA, Black, Non-Hispanic women and Medicaid-insured individuals are 2-3 times more likely to have delays in treatment compared to White or privately insured women. While evidence-based care coordination strategies for reducing delays exist, they are not systematically implemented across healthcare settings. METHODS: Translating Research Into Practice (TRIP) utilizes community engaged research methods to address breast cancer care delivery disparities. Four Massachusetts Clinical and Translational Science Institute (CTSI) hubs collaborated with the Boston Breast Cancer Equity Coalition (The Coalition) to implement an evidence-based care coordination intervention for Boston residents at risk for delays in breast cancer care. The Coalition used a community-driven process to define the problem of care delivery disparities, identify the target population, and develop a rigorous pragmatic approach. We chose a cluster-randomized, stepped-wedge hybrid type I effectiveness-implementation study design. The intervention implements three evidence-based strategies: patient navigation services, a shared patient registry for use across academic medical centers, and a web-based social determinants of health platform to identify and address barriers to care. Primary clinical outcomes include time to first treatment and receipt of guideline-concordant treatment, which are captured through electronic health records abstraction. We will use mixed methods to collect the secondary implementation outcomes of acceptability, adoption/penetration, fidelity, sustainability and cost. CONCLUSION: TRIP utilizes an innovative community-driven research strategy, focused on interdisciplinary collaborations, to design and implement a translational science study that aims to more efficiently integrate proven health services interventions into clinical practice.

BACKGROUND: Disabilities affect more than 1 in 5 US adults, and those with disabilities face multiple barriers in accessing health care. A digital gap, defined as the disparity caused by differences in the ability to use advanced technologies, is assumed to be prevalent among individuals with disabilities. OBJECTIVE: This study examined the associations between disability and use of information technology (IT) in obtaining health information and between trust factors and IT use. We hypothesized that compared to US adults without disabilities, those with disabilities are less likely to refer to the internet for health information, more likely to refer to a health care provider to obtain health information, and less likely to use IT to exchange medical information with a provider. Additionally, we hypothesized that trust factors, such as trust toward health information source and willingness to exchange health information, are associated with IT use. METHODS: The primary database was the 2013 Health Information National Trends Survey 4 Cycle 3 (N=3185). Disability status, the primary study covariate, was based on 6 questions that encompassed a wide spectrum of conditions, including impairments in mobility, cognition, independent living, vision, hearing, and self-care. Study covariates included sociodemographic factors, respondents' trust toward the internet and provider as information sources, and willingness to exchange medical information via IT with providers. Study outcomes were the use of the internet as the primary health information source, use of health care providers as the primary health information source, and use of IT to exchange medical information with providers. We conducted multivariate logistic regressions to examine the association between disability and study outcomes controlling for study covariates. Multiple imputations with fully conditional specification were used to impute missing values. RESULTS: We found presence of any disability was associated with decreased odds (adjusted odds ratio [AOR] 0.65, 95% CI 0.43-0.98) of obtaining health information from the internet, in particular for those with vision disability (AOR 0.27, 95% CI 0.11-0.65) and those with mobility disability (AOR 0.51, 95% CI 0.30-0.88). Compared to those without disabilities, those with disabilities were significantly more likely to consult a health care provider for health information in both actual (OR 2.21, 95% CI 1.54-3.18) and hypothetical situations (OR 1.80, 95% CI 1.24-2.60). Trust toward health information from the internet (AOR 3.62, 95% CI 2.07-6.33), and willingness to exchange via IT medical information with a provider (AOR 1.88, 95% CI 1.57-2.24) were significant predictors for seeking and exchanging such information, respectively. CONCLUSIONS: A potential digital gap may exist among US adults with disabilities in terms of their recent use of the internet for health information. Trust toward health information sources and willingness play an important role in people's engagement in use of the internet for health information. Future studies should focus on addressing trust factors associated with IT use and developing tools to improve access to care for those with disabilities.

This paper describes the development and implementation of the Boston Medical Center (BMC) Advanced Clinical Capacity for Engagement, Safety, and Services Project. In October 2002, the BMC Division of Psychiatry became the first such entity to open a Safe Haven shelter for people who are chronically homeless, struggling with severe mental illness, and actively substance abusing. The low-demand Safe Haven model targets the most difficult to reach population and serves as a "portal of entry" to the mental health and addiction service systems. In this paper, the process by which this blended funded, multi-level collaboration, consisting of a medical center, state, city, local, and community-based consumer organizations, was created and is maintained, as well as the clinical model of care is described. Lessons learned from creating the Safe Haven Shelter and the development and implementation of the consumer-informed evaluation are discussed as well as implications for future work with this population.

Pressure ulcer healing is an important quality measure for nursing homes, but the factors that predict healing have not been well studied. Using the Minimum Data Set, the authors identified candidate variables for a logistic regression, risk-adjustment model to predict ulcer healing. The authors then assessed model discrimination and calibration. Finally, the authors compared unadjusted with risk-adjusted performance for the individual facilities within a nursing home chain. Significant predictors of healing included mobility in bed, presence of a stage 2 ulcer (compared with a stage 4 ulcer), absence of paraplegia and quadriplegia, and absence of end-stage illness. The model C statistic was 0.67, and the calibration was acceptable. Judgments about nursing performance varied in 2 cases depending upon whether unadjusted or risk-adjusted performance was used. The model that the authors developed contains credible predictors of healing. Pressure ulcer healing may be one of many indicators used to evaluate nursing home quality.