Smart Change: Durable Outcomes

This project will address a number of industry knowledge gaps with regard to specific applications of this material in the polymers industry, and the potential for value-adding opportunities across a range of Australian manufacturing sectors. Currently, assets are replaced, which is costly and can cause major disruption. Lining technology may increase service life and prolong the need for asset replacement. Lining has had limited market penetration attributed to the limited demonstrable long-term performance, consistent standards and specifications.

This project aims to address these issues and increase the demand for lining. Cropping system requirements, agronomy and genetics will be explored and developed such that northern Australia can supply agricultural products to meet the quality, technical specifications and volume requirements of overseas and domestic markets. This CRC-P project will determine correlative factors associated with the occurrence of JPOMS and gather the essential knowledge required to instigate a selective breeding program targeting resistance.

Crocodile skins are produced for the high-end fashion market. Any skin with lesions is rejected because it will be visible on the finished product. We will develop and apply control strategies to prevent these diseases and reduce their transmission.

Conventional management of such threats such as weeds are not suited to such broad, harsh landscapes. The project will use an Internet of Things network with low-cost environmental sensors, drone mapping and big data analytics to develop and test data-driven, strategic pest management programs - ultimately improving both cattle industry and natural assets. Key areas to be investigated are nitrogen-based fertiliser usage, reduced fruit wastage, faster crop maturity, and enhancing nutrient content.

Outcomes aim to improve the competitiveness of the sector and will establish learnings that can be applied in other crop production in tropical regions. Probio-TICK will comprise a community of beneficial microbes applied to the hide to give a life-long shield of protection against cattle pests. It will improve decision making at exploration and mining drill sites, rapidly acquiring novel information from core and providing outputs in near-real time. It will be developed in and exported from Australia as a value-add service in the METS industry and an invaluable decision-making tool in exploration and mining.

AM of energetics will solve cost, safety and efficiency problems associated with traditional methods that have remained largely unchanged for over years. The project will deliver new processing methods for energetic materials in AM. Advancements in this field will have wide application in civil, mining, defence and construction industries. This project will deliver the efficient conversion of such waste to high-energy-density liquid fuel using catalytic, low temperature and low pressure depolymerisation.

Key to this will be the development of strategies, informed by detailed technoeconomic analysis, to optimise the process, maximise the energy efficiency and bridge the commercialisation valley of death. It is not suitable however, for all tests using traditional analysis methods.

This project will develop and commercialise high throughput dried blood spot sample testing using advanced liquid chromatography-mass spectrometry. The result is cheaper and improved consumer access to a wide range of health tests, improved self-monitoring and health outcomes and lowered national cost of health testing.

Printing enables batteries of almost any shape to be integrated with other printed electronic devices like sensors, transistors, printed PV and lights during the manufacturing process. Advanced printing technology will reduce manufacturing costs using abundant, non-toxic compounds. Numerical and experimental studies will underpin the development of cost-effective and durable decking solutions of optimal material distribution. These decking solutions will also be used globally to refurbish and construct rail or road bridges, thus leading to longer life and reducing disruption during refurbishment works.

Typhoon MK4 is an intervention ROV intended for use in oil and gas industry with cross-over capabilities in a wide range of subsea operations in different industries including research and oceanography, salvage and rescue, defence and fiber optic cable repair sectors. Remote housing will be the first target for the new, flexible metal manufacturing technology.

There is significant latent value in these datasets.

However, data access, integration and analytics capacity is lacking. This project will deliver two significant outcomes: This leads to a concentration of animal waste, high nitrogen loss, detrimental environmental impacts, and health risks. The project will develop cost-effective commercial management of waste for long-term sustainable intensification of the industries, while increasing agricultural productivity, protecting natural resources, and producing high value fertilisers.

The target is to reduce the resolution of the system from kilometres to hundreds of metres. The integrated technology will also remove range limitations of existing GPS-based technology, and will allow transmission of processed gravity data to project managers in real-time, allowing them to interactively optimise flight patterns. It is a hydraulic and electric power hub, converting hydraulic energy coming from wave energy converters WEC or tidal current devices, and delivering electricity to the grid.

O-Drive2 is compatible with different WEC technologies, such as heaving buoys and oscillating pitching devices, allowing them to connect into it simultaneously to build a wave energy farm. It will promote Australia as an industry leader in the global freight sector and a world leader in driver state sensing. This technology will be used to develop a prognostic assay for metastatic disease diagnosis.

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The project represents a great opportunity to bring innovation to the residential construction market in response to demand for affordable and diverse housing solutions. The information above was correct at time of announcement. Thanks for your feedback. If you have any ideas on how we can improve, we'd love to hear them.

Please provide your comments in the feedback form. Feedback News Subscribe Share. Process conditions to extract valuable metals from their ore are severe; high temperatures combine with extreme corrosion and erosion. This Project aims to integrate unobtrusive micro-sensors into bedding materials by developing technology to non-invasively monitor key human health parameters.

Building on core technology, the project will prototype and commercialise a patented real time biosensor with the ability to solve key challenges in the dairy industry. Medical imaging is an increasingly complex field requiring advanced subspecialty training.

This project will develop a robust industry platform for the application of artificial intelligence algorithms to neuro-imaging, heralding a new era in the precision diagnosis of brain disease; and transforming the delivery of Radiology through automation and increased productivity, enhanced reporting accuracy and the rapid identification of critical abnormalities.

This project will trial a new eco-friendly fertiliser technology, containing plant growth promoting rhizobacteria and innovative adaptive-release organic fertiliser, in tropical agriculture and horticulture sugarcane, avocado and macadamia. Successful development and demonstration of an In-Situ Recovery ISR process to extract copper and other metals from diverse geological environments will be a step change in Australian mining.

To meet the needs of rapid urban population growth, building construction productivity needs to improve. Since the discovery of penicillin, the greatest biomedical innovations have been fueled by microorganisms. Australia currently has no sovereign launch capability putting the nation at a strategic, economic and social disadvantage. Fire is a daily and pervasive threat to human life, property and assets and the environment and many polymers and textiles remain highly flammable.

Cancer is a major health burden with one in four Australians getting a diagnosis of cancer during their lifetime and with an estimated 48, Australians dying of cancer in Exosomes are small particles released by cells. Survey Instrument The survey instrument disseminated to participants in this study included items related to the technology, the work environment, quality of working life, performance, and demographics.

Data Analysis Regression analysis was used to identify the relationship between trust scores and the factors related to usefulness, safety, ease of use and usability. Results The average trust score mean 2. Table 1 Adjusted R—squared and significance from simple linear regression analyses for perceived technical performance of the smart pump technology items and trust. Open in a separate window. Table 2 R—squared from simple linear regressions on perceived usability items and trust in the smart IV pump features. Difficult to Easy 6. Frustrating to Satisfying 5. Rigid to Flexible 5.

Table 3 Stepwise regression analyses for model 2: Table 4 R—squared and significance from simple linear regression analyses for work environment and quality of work with trust. Crafting information technology solutions, not experiments, for the emergency department. Programmable infusion pumps in ICUs: Journal of General Internal Medicine. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients.

Letter to Infusion Pump Manufacturers. Castelfranchi C, Falcone R. Trust and deception in virtual societies. Theoretical issues in the study of trust and human intervention in automated systems. Parasuraman R, Riley V. Use, Misuse, Disuse, Abuse. How to Maximise Perceived Trustworthiness. Helander, Khalid, Tham, editors. Bloody Robots as Emotional Design3: International Journal of Design. How Consumers Perceive Product Appearance3: Personality and technology acceptance: Zhang W, Xu P. Do I have to learn something new?

Mental models and the acceptance of replacement technologies. Parasuraman R, Miller CA. Trust and etiquette in high-criticality automated systems. Communications of the ACM. Human Factors and Ergonomics Society; Introducing new technology into the operating room: User acceptance of information technology: International Journal of Man-Machine Studies. Technology anxiety as a potential mediating factor in response to medical technology.

Journal of medical systems. Browne M, Cook P. Inappropriate trust in technology: Nursing in critical care. A qualitative analysis of how advanced practice nurses use clinical decision support systems.

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Journal of the American Academy of Nurse Practitioners. Early experiences with the multidose drug dispensing system--a matter of trust? Scandinavian journal of primary health care. Framework for patient safety, part 1: The Journal of nursing administration. International journal of medical informatics. Sociotechnical principles for system design. Human factors of complex sociotechnical systems. The evolution of socio-technical systems: A conceptual framework and an action research program. Van de Ven A, Joyce W, editors.

Perspectives on Organizational Design and Behaviour. Sociotechnical systems in health care: The Journal of Applied Behavioral Science. International Journal of Industrial Ergonomics. Workarounds to Barcode Medication Administration Systems: Journal of the American Medical Informatics Association. Intravenous medication safety and smart infusion systems: Journal of infusion nursing3: Empirical research in on-line trust: International Journal of Human-Computer Studies. An integrative model of organizational trust. The Academy of Management Review. Hassenzahl M, Tractinsky N.

User experience - a research agenda. Sauer J, Sonderegger A. Trust in sociotechnical systems. With up to 70 million individuals in the United States affected by sleep problems, 31 the current sleep medicine model encounters difficulties in managing all patients with these conditions. The PCCM approach relies on sleep specialists and allied health professionals sleep medicine-trained nurses and sleep technologists to assist local PCPs in screening their patients for sleep disorders e. The sleep specialists, sleep medicine-trained nurses, and sleep technologists serve as a resource for sleep related information to the PCPs, and through their interactions with the PCPs, provide improved access for the comanagement of their patients.

We believe that this co-management approach enables greater identification of sleep disorders within the community, provides timelier and more efficient care than the current sleep medicine approach, and reserves specialty sleep medical care for complex patients. In addition, it will allow PCPs to play a greater role in the recognition and management of sleep disorders in their patients and allow patients to become more active participants in their health care.

Within the past decade there has been an increased emphasis on the importance of assessing patient satisfaction as a health-care outcome. Patient access to personalized health-related information facilitates more informed decision making, which leads to greater patient satisfaction. To deliver this type of access, we are creating a new secure, password-protected, online SMART DOCS web portal that will serve to meet personalized patient-centered needs and will be accessible to each patient 24 h a day, 7 days a week.

This web portal contains integrated information about a patient's initial evaluation, tests, diagnoses, and treatments that are communicated with specific details, yet written in a clear and concise manner for a lay reader. This information will also be available as paper documents if the patient is without Internet access.

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We expect that the enhanced record sharing of patient-specific information and results will provide substantial value to the patient, and we will be tracking the use of the web portal by each patient to assess its impact on outcomes. We have discussed this integration with our medical center's information technology IT leadership, and our IT team has constructed the web portal to ensure that it is complementary and not redundant to Epic Verona, WI, USA software, which is one of the most common EHR software currently in use.

Longitudinal outcomes data will be collected through a new patient registry that is a modified version of a patient registry proof-of-concept developed during the COMET Study. The registry data will be accessible through the web portal, which will enable providers and patients to better collaborate in improving these outcomes by adjustment of therapy. In addition to personalized reports, the new web portal will also contain educational information and resources about an array of sleep topics, including the most prevalent of the approximately 90 different sleep disorders.

This library of documents and videos about sleep and its disorders is currently being developed by our team of stakeholders to provide the interested patient with added information, enabling more informed decisions about their care.



Further, we will hold free, small-group classes led by allied health professionals sleep medicine-trained nurses and sleep technologists that comprehensively cover the benefits and adverse effects of various treatment options. These classes will also encourage patients to ask questions and to serve as a forum for patients to relay successes or problems they have encountered with treatment. We have piloted this approach at our sleep center on a limited basis, and found it effectively supplements clinic visits with respect to patient understanding of management options and strengthening the patient-provider relationship.

These classes will also be videotaped and provided online so that patients can view them when they desire. Conventionally, the sleep specialist captures medical history and physical examination data during an initial evaluation, with an emphasis on signs and symptoms of sleep disorders, as well as existing medical conditions. The patient is usually given one or more preliminary diagnoses belonging to the following six major diagnostic categories: In the PCCM approach, if the patient is suspected of having a sleep disorder, the patient will either be referred to a sleep specialist, or evaluated by the PCP with the assistance from the sleep specialist or sleep medicine-trained nurse.

The ASQ will be completed either online or by electronic tablets in the waiting room prior to the sleep evaluation. Upon review of the ASQ report by the clinician, and taking into consideration all the information collected, the patient will be given one or more preliminary sleep disorder diagnoses. In the conventional approach, the patient undergoes diagnostic testing that consists of an in-laboratory PSG or out-of-center sleep test OCST to confirm the diagnosis and to assess the severity of the disorder.

The patient will be provided the OCST device and instructed on its use by the sleep technologist; the patient will then use the device at home, and return the device the next day. The data will be downloaded, reviewed, and scored by the technologist, and a sleep specialist will examine the scored data and generate a report. At the follow-up visit, PSG results and treatment options are discussed with the patient by the sleep specialist; these results are also available to the PCP and patient through the web portal.

Additionally, the following diagnostic and therapeutic tools, methods, and algorithms will be employed as necessary in the PCCM approach:. Conventionally, a patient with an initial evaluation indicative of disorders of excessive sleep and sleepiness typically undergoes diagnostic testing for narcolepsy e.

Associated Data

The patient may be prescribed medications, and is assessed through regular follow-up visits. In the PCCM approach, a patient with symptoms of these disorders identified at either the sleep center or PCP office will undergo diagnostic testing at the sleep center. Sleep diaries and actigraphy will be used to aid in the objective assessment of the quality and quantity of sleep as well as changes in sleep-wake cycles over time and following treatment. Blood samples will be collected to identify possible genetic markers for narcolepsy, and will include human leukocyte antigen HLA typing.

The patient, sleep specialist, and PCP will have access to the reports through the secure web portal, and the patient will have follow-up visits at regular intervals. In the PCCM approach, we will employ a stepped care algorithm, in which a patient with symptoms consistent with an uncomplicated insomnia disorder i. For the nurse-administered brief CBTI, the nurse, trained to competency by sleep center insomnia specialists, will deliver in-person individual treatment.

Studies demonstrate that CBTI can be successfully administered in the primary care setting by nurses, physicians, or psychologists, with effect sizes that are roughly equivalent to those found in meta-analytic studies of CBTI in the general population. A patient who has symptoms consistent with an uncomplicated circadian rhythm sleep disorder will be managed by a sleep specialist using medications, carefully timed light exposure, and behavioral techniques. Blood samples will be collected to identify possible genetic markers for insomnia and circadian rhythm sleep disorders.

For both insomnia and circadian rhythm sleep disorders, longitudinal outcomes will be assessed by sleep diaries and actigraphy. The patient, sleep specialist, and PCP will have access to information from the longitudinal actigraphy reports on the secure web portal, and the patient will have regular follow-up visits. In cases where comorbid insomnia is present, the circadian rhythm sleep disorder will be managed prior to delivering CBTI. Conventionally, a patient with an initial evaluation consistent with a parasomnia diagnosis undergoes an in-laboratory PSG to identify and record the abnormal behavior and to rule out other possibilities e.

Blood samples will be collected to identify possible genetic markers for parasomnias. Via the web portal, the patient, sleep specialist, and PCP will also have access to findings from the sleep study reports and summaries of regular follow-up visits. A patient may also wear the limb movement recorder at regular intervals to objectively measure treatment response. The limb movement recorder also continuously measures and records blood pressure to assess potential periodic limb movement-related blood pressure spikes, 23 — 26 which can provide further data for the patient, specialist, and PCP regarding possible cardiovascular associations with this condition.

Patients with restless legs syndrome will also have ferritin levels checked to assess iron deficiency, as in the conventional approach. Blood samples will be collected to identify possible genetic markers for sleep related movement disorders. The patient, sleep specialist, and PCP will have access to longitudinal reports and visit summaries on the secure web portal, and the patient will have regular follow-up visits.

Thus, a randomized comparative effectiveness trial has been designed and will be conducted to inform health care decisions by providing evidence on patient-centered outcomes for these two different approaches of delivering outpatient sleep medical care. The CONV Arm is defined as the standard approach by which providers in a typical sleep medicine outpatient clinic manage their patients.

Our study follows the standard methods and procedures for the management of the aforementioned sleep disorders, many of which were developed and published as practice parameters by the American Academy of Sleep Medicine AASM to guide the diagnosis and treatment of patients with sleep disorders. The PCCM Arm is defined as an approach that enables providers and patients access to specific and relevant information and resources, thereby allowing patients to make more informed health care decisions and providers to assist patients in achieving their preferred outcomes described previously for each disorder.

PCP, primary care physician. In order to have a study population representative of a typical clinic population, there are no exclusion criteria. Each new patient consecutively seen at the Stanford Sleep Medicine Center or Stanford Primary Care will be informed about the study, and will also be apprised that he or she will be consenting to grant access to any and all clinical data collected during his or her evaluation and treatment to study personnel.

A sleep medicine-trained nurse will assist in the screening and recruitment of patients at Stanford Primary Care. The patient will be notified that the study is a randomized trial and he or she could be assigned to either the CONV or PCCM arms, and will be followed for at least 1 y within the 3-y duration of the study. If he or she agrees to participate, informed consent will be obtained, he or she will be randomized to one of the study arms, detailed instruction about the study activities will be provided, and the patient will be asked to adhere to the study protocol, related to the diagnosis and treatment of his or her specific sleep disorder s.

The estimated proportion of sleep disorders diagnosed in our patient population are: We would expect that our patient population is demographically and diagnostically representative of other communities; however, we can adjust for selection bias through analyses 53 , 54 that weight clinical and demographic subpopulations within our sample to match the distribution of patients across these subpopulations nationwide see section on Selection Bias in the supplemental material.

The goals of this study are to provide better overall patient care and to improve the health of patients while controlling cost. In this light, there are two primary endpoints and a secondary endpoint associated with these goals Table 2. For the secondary endpoint of cost containment, we will track the out-of-pocket costs of administering each pathway, including costs of the treatment, but excluding research data collection from survey instruments as well as related personnel time and other cost factors not related to patient care. In both approaches, we will track out-of-pocket healthcare costs for participants focusing particularly on costs associated with all outpatient visits, emergency department visits, and inpatient stays during the study period.

With these data, out-of-pocket costs of treatment as well as the health care utilization between pathways can be compared. Other secondary endpoints are listed in Table 2 , and the statistical methods are described in the section on Statistical Methodology for Data Analyses in the supplemental material. We hypothesize that the more efficient and convenient use of time, resources, and personnel in the PCCM approach will translate to improved delivery of care.

In addition to the emphasis on new tests and technologies, expansion of the roles of allied health professionals and increased communication with PCP staff are major aspects of the PCCM approach. The care for many sleep disorders patients is a natural extension of traditional nursing care, requiring some additional knowledge, but utilizing traditional nursing methods and skills that generalize well to sleep medicine.

The sleep medicine-trained nurse in this study will assist PCPs in the screening and diagnosis of sleep disorders in their patients, monitor outcomes and adverse events, provide cognitive behavioral treatment for their patients with insomnia, and assist PCPs and patients in using the patient-provider web portal especially with respect to assessing treatment efficacy, adherence, and next steps. Additionally, there are more than 15, registered sleep technologists in the United States and several thousand more who are employed but awaiting certification. These technologists are primarily responsible for conducting in-laboratory PSGs, but due to rapidly evolving technology in out-of-center sleep testing, it is anticipated that the number of these in-laboratory studies will significantly decrease within the next decade.

This in turn will likely decrease the need for technologists to conduct in-laboratory procedures; however, these knowledgeable and skilled individuals can be rapidly reassigned to modified roles with minimal training. The PCCM approach will utilize sleep technologists to enhance care delivery and to serve as a resource for PCPs in the long-term comanagement of sleep disorders with sleep specialists. Specifically, sleep technologists will provide the setup and data collection for home testing in the diagnosis of sleep related breathing disorders, colead small-group classes with nurses for patients who have questions or issues with major treatment modalities, aid in patient treatment effectiveness and adherence issues, and assist in the collection and analysis of data from new diagnostic and treatment outcomes.

For example, sleep technologists will contact patients with OSA shortly after they initiate PAP treatment to address any issues and concerns, and will recontact them at time intervals of 1 mo, 3 mo, and 6 mo, as necessary, until all problems are resolved.

It is our belief that the integration of sleep medicine-trained nurses and sleep technologists into the primary care setting will improve access to care and the management of patients with sleep disorders. The PCCM approach for sleep medicine has been developed in direct response to our patients' needs and reflects the type of approach that our patients consider desirable.

Our review of the Press Ganey quality of care data from the Stanford Sleep Medicine Center consistently reveals that the top three desires of our patients are better access to care, improved access to their records, and more information about their diseases. We believe that the PCCM approach will meet these patient needs and that our approach is patient centered in that it serves to address the following key patient-centered questions posed by PCORI. Through the use of technology and reallocation of healthcare personnel time, the PCCM approach provides a more tailored and customized method for patient care delivery that places more information and results related to the patient's care in the patient's hands.

Educational materials regarding sleep disorders will also be available on the secure web portal. The PCCM approach will allow the patient to evaluate various treatment options through small group classes with other sleep medicine patients and by visits with the PCP, sleep specialist, and allied health professionals as well as through review of educational content on the web portal.

These avenues of information will allow thorough discussions of the potential benefits and limitations of the various treatment options so that the optimal management plan is selected. SMART DOCS is expected to demonstrate several methods of providing results and information to patients, including from home-based devices, a secure web portal, and discussions with their PCPs, specialists, and allied health professionals through visits and group settings. It is our team's hope that SMART DOCS will lead to meaningful improvements in patient health and quality of care by transforming the manner in which patients with sleep problems are currently diagnosed and managed, via a new PCCM approach that is designed to be sustainable, effective, and exportable to other academic institutions, hospitals, private practices, free-standing sleep centers, and rural communities.

The selection of the methods, algorithms, and tools to be tested in the PCCM arm were considered by our Core Team as having the highest likelihood of improving patient health and quality of care by providing patients greater access to personalized results and relevant outcomes, and ultimately placing the patient more in control of his or her choice of treatment.

It is anticipated that the PCCM approach and other new approaches for sleep medicine will help remedy the current inefficiencies and gaps in effective patient care delivery by enabling providers and patients access to specific and relevant information and educational resources, thereby enabling patients to make more informed health care decisions and allowing providers to assist patients in achieving their preferred outcomes.

All statements in this report, including its findings and conclusions, are solely those of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute PCORI , its Board of Governors or Methodology Committee. Manber has served as a consultant for General Sleep and has received royalties from New Harbinger. The other authors have indicated no financial conflicts of interest.

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Louis, MO , Pamela R. A sample size of 1, is feasible for this pilot trial given our current estimated annual new patient volume of 4, at Stanford. For each outcome, means will be compared using a two-tailed, two-sample t -test, 2 with correction for unequal variances, if necessary. Randomization will be 1: Demographic and other baseline features will be compared between study arms.

These two-group comparisons will employ t -tests with correction for unequal variances as needed. Categorical variables, including dichotomous factors, will be summarized as percentages that will be compared between arms using chi-square tests, two-sample t -tests, 2 or Boschloo exact unconditional tests, 5 depending on the smallest expected cell sizes. Categorical variables, including dichotomous factors, will be summarized as percentages that will be compared between arms using chi-square tests or Boschloo exact unconditional tests, 5 depending on the smallest expected cell sizes.

This dichotomized outcome will be logistically regressed on study arm. Hypothesis testing will employ a Wald statistic t -test. In secondary analyses, random intercepts will be employed for providers to account for possible nesting of patients' responses within providers; and the CGCAHPS global rating score without dichotomization, will be regressed on study arm using a finite mixture 6 of binomial distributions with random intercepts employed for providers. Binomial distributions will be employed because the CGCAHPS global rating score is discrete and bounded above by a positive integer and below by zero.

Means of the component binomial distributions will be formulated in terms of the same regression coefficient for study arm but different intercepts , a parsimonious model structure that will facilitate interpretation. Hypothesis testing for secondary analyses will also employ a Wald statistic t -test. For the primary endpoint of improved health, the vitality scale score for improved health from the SF will be collected at baseline and end-of-study. Baseline value will be centered and scaled 7 via subtracting the sample mean and dividing that difference by the sample standard deviation prior to analysis in order to improve numerical stability of the fitting algorithm.

A finite mixture of binomial distributions is recommended here as well because the distribution of vitality scale scores may be complex with some floor and ceiling effects Table 7 in Gandek et al. All secondary outcomes are longitudinal, with measurement planned at more than two visits per person.

Regression analyses will be performed using generalized linear mixed models GLMM , 9 with regression of longitudinal outcome values on study arm, baseline value, and visit. Baseline value will be centered and scaled 7 as previously described. GLMMs are useful because they accommodate a wide variety of parametric outcome distributions. To account for the repeated-measures structure, each GLMM model will include a random intercept for patient.

A random intercept will be employed for provider to account for nesting of patients' responses within providers. For the secondary endpoint of out-of-pocket cost, because within either arm, some individuals may have out-of-pocket costs that are much larger than most other participants e.