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Cabana MD, Marsh A, Treadwell MJ, Stemmler P, Rowland M, Bender MA, Bhasin N, Chung JH, Hassell K, Abdul Rashid NFN, Wong TE, Bardach NS. Improving Preventive Care for Children With Sickle Cell Anemia: A Quality Improvement Initiative. Pediatr Qual Saf 2021; 6:e379. [PMID: 33409431 PMCID: PMC7781296 DOI: 10.1097/pq9.0000000000000379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/02/2020] [Indexed: 11/25/2022] Open
Abstract
Sickle cell disease is a complex chronic disorder associated with increased morbidity and early mortality. The Pediatric Quality Measures Program has developed new sickle cell-specific quality measures focused on hydroxyurea (HU) counseling and annual transcranial Doppler (TCD) screening; however, these measures have not been used in a clinical setting to inform quality improvement (QI) efforts. METHODS From 2017 to 2018, 9 sickle cell subspecialty clinics from the Pacific Sickle Cell Regional Collaborative conducted a year-long QI collaborative focused on improving the percentage of patients with HU counseling and TCD screening based on the new quality measures. After an initial kick-off meeting, the 9 sites participated in monthly conference calls. We used run charts annotated with plan-do-study-act cycle activities to track each site's monthly progress and the overall mean percentage for the entire collaborative. RESULTS There was an overall improvement in the aggregate HU counseling from 85% to 98% (P < 0.01). For TCD screening, referral frequency changed from 85% to 90% (P = 0.76). For both measures, the variation in frequencies decreased over the year. CONCLUSION Over 1 year, we found that a regional QI collaborative increased HU counseling. Although referral for TCD screening increased, there was no overall change in TCD completion. Overall, this QI report's findings can help clinicians adopt and implement these quality measures to improve outcomes in children.
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Affiliation(s)
- Michael D. Cabana
- From the Department of Pediatrics, University of California, San Francisco (UCSF), San Francisco, Calif
- Epidemiology & Biostatistics, University of California, San Francisco (UCSF), San Francisco, Calif
- the Institute for Health Policy Studies, University of California, San Francisco (UCSF), San Francisco, Calif
- Children’s Hospital at Montefiore, Bronx, N.Y
- The Albert Einstein College of Medicine, Bronx, N.Y
| | - Anne Marsh
- From the Department of Pediatrics, University of California, San Francisco (UCSF), San Francisco, Calif
| | | | | | | | - M. A. Bender
- Department of Pediatrics, University of Washington, Seattle, Wash
- Seattle Children’s Hospital; Seattle, Wash
| | - Neha Bhasin
- Department of Pediatrics, University of Arizona, Tucson, Ariz
| | - Jong H. Chung
- Department of Pediatrics, University of California, Davis, Sacramento, Calif
| | - Kathryn Hassell
- Department of Internal Medicine, University of Colorado, Aurora, Colo
| | | | - Trisha E. Wong
- Children’s Hospital at Montefiore, Bronx, N.Y
- Departments of Pediatrics and Pathology, Oregon Health & Science University, Portland, Oreg
| | - Naomi S. Bardach
- From the Department of Pediatrics, University of California, San Francisco (UCSF), San Francisco, Calif
- the Institute for Health Policy Studies, University of California, San Francisco (UCSF), San Francisco, Calif
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Chapman SA, Blash LK. New Roles for Medical Assistants in Innovative Primary Care Practices. Health Serv Res 2016; 52 Suppl 1:383-406. [PMID: 27859097 DOI: 10.1111/1475-6773.12602] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To identify and describe new roles for medical assistants (MAs) in innovative care models that improve care while providing training and career advancement opportunities for MAs. DATA SOURCES/STUDY SETTING Primary data collected at 15 case study sites; 173 key informant interviews and de-identified secondary data on staffing, wages, patient satisfaction, and health outcomes. STUDY DESIGN Researchers used snowball sampling and screening calls to identify 15 organizations using MAs in new roles. Conducted site visits from 2010 to 2012 and updated information in 2014. DATA COLLECTION/EXTRACTION METHODS Thematic analysis explored key topics: factors driving MA role innovation, role description, training required, and wage gains. Categorized outcome data in patient and staff satisfaction, quality of care, and efficiency. PRINCIPAL FINDINGS New MA roles included health coach, medical scribe, dual role translator, health navigator, panel manager, cross-trained flexible role, and supervisor. Implementation of new roles required extensive training. MA incentives and enhanced compensation varied by role type. CONCLUSIONS New MA roles are part of a larger attempt to reform workflow and relieve primary care providers. Despite some evidence of success, spread has been limited. Key challenges to adoption included leadership and provider resistance to change, cost of additional MA training, and lack of reimbursement for nonbillable services.
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Affiliation(s)
- Susan A Chapman
- Department of Social and Behavioral Sciences, UCSF School of Nursing, Healthforce Center, Philip R. Lee Institute for Health Policy Studies, San Francisco, CA
| | - Lisel K Blash
- UCSF Healthforce Center and Philip R. Lee Institute for Health Policy Studies, San Francisco, CA
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Abstract
The 2014 United States Preventive Services Task Force systematic review found abdominal aortic aneurysm (AAA) screening decreased related mortality by close to half. Despite the simplicity of screening, research suggests poor adherence to the recommended AAA screening guidelines. Using the quality improvement plan-study-do-act cycle, we retrospectively established poor adherence to AAA screening and poor documentation of smoking history in our resident clinic. An electronic reminder was prospectively implemented into our electronic medical record (EMR) with the goal of improving screening rates. After 1 year, a retrospective chart review was conducted. Comparisons of the pre- and post-electronic reminder intervention data were made using chi-square tests and odds ratios (OR). The purposeful AAA screening rate improved 27.8% during the intervention, 40.3% (95% confidence interval [CI]: 28.6-52.0%) versus 12.5% (95% CI: 3.1-21.9%), p = .002, suggesting patients were more likely to be screened as a result of the electronic reminder, OR = 4.73 (95% CI: 1.77-12.65). This improvement translates to a large effect size, Cohen's d = 0.86 (95% CI: 0.31-1.40). Electronic reminders are a simple EMR addition that can provide evidence-based education while improving adherence rates with preventive health screening measures.
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Blank L, Baxter S, Woods HB, Goyder E, Lee A, Payne N, Rimmer M. What is the evidence on interventions to manage referral from primary to specialist non-emergency care? A systematic review and logic model synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03240] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BackgroundDemand management describes any method used to monitor, direct or regulate patient referrals. Several strategies have been developed to manage the referral of patients to secondary care, with interventions targeting primary care, specialist services, or infrastructure.ObjectiveThis research aimed to conduct an inclusive systematic review and logic model synthesis in order to better understand factors impacting on the effectiveness of interventions targeting referral between primary and secondary medical health care.DesignThe approach combined systematic review with logic modelling synthesis techniques to develop an evidence-based framework of factors influencing the pathway between interventions and system-wide changes.SettingPrimary health care.Main outcome measuresReferral from primary to secondary care.Review methodsSystematic searches were undertaken to identify recent, relevant studies. Quality of individual studies was appraised, with consideration of overall strength of evidence. A narrative synthesis and logic model summary of the data was completed.ResultsFrom a database of 8327 unique papers, 290 were included in the review. The intervention studies were grouped into four categories of education interventions (n = 50); process change interventions (n = 49); system change interventions (n = 38); and patient-focused interventions (n = 3). Effectiveness was assessed variously in these papers; however, there was a gap regarding the mechanisms whereby these interventions lead to demand management impacts. The findings suggest that, although individual-level interventions may be popular, the stronger evidence relates only to peer-review and feedback interventions. Process change interventions appeared to be more effective when the change resulted in the specialist being provided with more or better quality information about the patient. System changes including the community provision of specialist services by general practitioners, outreach provision by specialists and the return of inappropriate referrals appeared to have evidence of effect. The pathway whereby interventions might lead to service-wide impact was complex, with multiple factors potentially acting as barriers or facilitators to the change process. Factors related, first, to the doctor (including knowledge, attitudes and beliefs, and previous experiences of a service), second, to the patient (including condition and social factors) and, third, to the influence of the doctor–patient relationship. We also identified a number of potentially influential factors at a local level, such as perceived waiting times and the availability of a specialist. These elements are key factors in the pathway between an intervention and intended demand management outcomes influencing both applicability and effectiveness.ConclusionsThe findings highlight the complexity of the referral process and multiple elements that will impact on intervention outcomes and applicability to a local area. Any interventions seeking to change referral practice need to address factors relating to the individual practitioner, the patient and also the situation in which the referral is taking place. These conclusions apply especially to referral management in a UK context where this whole range of factors/issues lies well within the remit of the NHS. This work highlights that intermediate outcomes are important in the referral pathway. It is recommended that researchers include measure of these intermediate outcomes in their evaluation of intervention effectiveness in order to determine where blocks to or facilitators of system-wide impact may be occurring.Study registrationThe study is registered as PROSPERO CRD42013004037.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Lindsay Blank
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Susan Baxter
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Helen Buckley Woods
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Lee
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Nick Payne
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Melanie Rimmer
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Blank L, Baxter S, Woods HB, Goyder E, Lee A, Payne N, Rimmer M. Referral interventions from primary to specialist care: a systematic review of international evidence. Br J Gen Pract 2014; 64:e765-74. [PMID: 25452541 PMCID: PMC4240149 DOI: 10.3399/bjgp14x682837] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 06/11/2014] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Demand management defines any method used to monitor, direct, or regulate patient referrals. Strategies have been developed to manage the referral of patients to secondary care, with interventions that target primary care, specialist services, or infrastructure. AIM To review the international evidence on interventions to manage referral from primary to specialist care. DESIGN AND SETTING Systematic review. METHOD Iterative, systematic searches of published and unpublished sources public health, health management, management, and grey literature databases from health care and other industries were undertaken to identify recent, relevant studies. A narrative synthesis of the data was completed to structure the evidence into groups of similar interventions. RESULTS The searches generated 8327 unique results, of which 140 studies were included. Interventions were grouped into four intervention categories: GP education (n = 50); process change (n = 49); system change (n = 38); and patient-focused (n = 3). It is clear that there is no 'magic bullet' to managing demand for secondary care services: although some groups of interventions may have greater potential for development, given the existing evidence that they can be effective in specific contexts. CONCLUSIONS To tackle demand management of primary care services, the focus cannot be on primary care alone; a whole-systems approach is needed because the introduction of interventions in primary care is often just the starting point of the referral process. In addition, more research is needed to develop and evaluate interventions that acknowledge the role of the patient in the referral decision.
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Affiliation(s)
- Lindsay Blank
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Susan Baxter
- School of Health and Related Research, University of Sheffield, Sheffield
| | | | - Elizabeth Goyder
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Andrew Lee
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Nick Payne
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Melanie Rimmer
- School of Health and Related Research, University of Sheffield, Sheffield
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Tu SP, Feng S, Storch R, Yip MP, Sohng H, Fu M, Chun A. Applying systems engineering to implement an evidence-based intervention at a community health center. J Health Care Poor Underserved 2014; 23:1399-409. [PMID: 23698657 DOI: 10.1353/hpu.2012.0190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Impressive results in patient care and cost reduction have increased the demand for systems-engineering methodologies in large health care systems. This Report from the Field describes the feasibility of applying systems-engineering techniques at a community health center currently lacking the dedicated expertise and resources to perform these activities.
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Affiliation(s)
- Shin-Ping Tu
- Department of Medicine, University of Washington, Seattle, USA.
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Petroll AE, Phelps JK, Fletcher KE. Implementation of an electronic medical record does not change delivery of preventive care for HIV-positive patients. Int J Med Inform 2014; 83:273-7. [PMID: 24440204 DOI: 10.1016/j.ijmedinf.2013.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 12/10/2013] [Accepted: 12/16/2013] [Indexed: 01/12/2023]
Abstract
PURPOSE This study sought to determine the impact that an electronic medical record (EMR) had on the provision of preventive health measures - including obtaining serologies for viral hepatitis and administering vaccinations to non-immune patients - to HIV patients at a hospital-based clinic. METHODS Using a pre-post study design, we compared rates of preventive health delivery to HIV patients at an outpatient clinic during the use of a paper medical record (PMR) and after implementation of an EMR. Retrospective chart reviews were conducted at two time points: 12-16 months prior to and 24 months following EMR implementation. The records of 160 active patients were randomly selected for review during both time periods. RESULTS There was no difference between the PMR and EMR samples with regard to the proportion of patients who had hepatitis A (83% in PMR group; 77% in EMR) and hepatitis C (94% in both groups) serologies measured or the proportion of eligible patients who were given hepatitis vaccinations. Slightly fewer patients had a serology for hepatitis B measured in the EMR sample. CONCLUSIONS As EMR implementation expands, it is important to evaluate the effects that EMRs have on patient outcomes, including preventive health provision. Our study showed that after implementation of an EMR, the provision of most preventive care measures did not improve. This finding is in agreement with many published studies. Some studies have found positive effects from EMRs that may be attributable to specific aspects of EMRs. Further study of the effect of specific EMR attributes on health care outcomes is needed.
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Affiliation(s)
- Andrew E Petroll
- Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research, Medical College of Wisconsin, Milwaukee, WI, USA; Department of Medicine, Division of Infectious Diseases, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Jenise K Phelps
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | - Kathlyn E Fletcher
- Department of Medicine, Division of General Internal Medicine, College of Wisconsin, Milwaukee, WI, USA; Department of Medicine, Clement J Zablocki VA Medical Center, Milwaukee, WI, USA
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Scammon DL, Tomoaia-Cotisel A, Day RL, Day J, Kim J, Waitzman NJ, Farrell TW, Magill MK. Connecting the dots and merging meaning: using mixed methods to study primary care delivery transformation. Health Serv Res 2013; 48:2181-207. [PMID: 24279836 DOI: 10.1111/1475-6773.12114] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2013] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To demonstrate the value of mixed methods in the study of practice transformation and illustrate procedures for connecting methods and for merging findings to enhance the meaning derived. DATA SOURCE/STUDY SETTING An integrated network of university-owned, primary care practices at the University of Utah (Community Clinics or CCs). CC has adopted Care by Design, its version of the Patient Centered Medical Home. STUDY DESIGN Convergent case study mixed methods design. DATA COLLECTION/EXTRACTION METHODS Analysis of archival documents, internal operational reports, in-clinic observations, chart audits, surveys, semistructured interviews, focus groups, Centers for Medicare and Medicaid Services database, and the Utah All Payer Claims Database. PRINCIPAL FINDINGS Each data source enriched our understanding of the change process and understanding of reasons that certain changes were more difficult than others both in general and for particular clinics. Mixed methods enabled generation and testing of hypotheses about change and led to a comprehensive understanding of practice change. CONCLUSIONS Mixed methods are useful in studying practice transformation. Challenges exist but can be overcome with careful planning and persistence.
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Affiliation(s)
- Debra L Scammon
- David Eccles School of Business, University of Utah, Salt Lake City, UT; Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT
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Abstract
Medical record review was used to identify missed opportunities for chlamydia screening among 103 American Indian/Alaska Native women. Of these, 69% had received a pregnancy test and 74% had received a urine test in the previous 12 months. Chlamydia screening may increase if linked to the other routine clinical testing.
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Witkin LR, Farrar JT, Ashburn MA. Can assessing chronic pain outcomes data improve outcomes? PAIN MEDICINE 2013; 14:779-91. [PMID: 23574493 DOI: 10.1111/pme.12075] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE This manuscript reviews how patient-reported outcomes data can be used to guide efforts to improve patient outcomes. DESIGN Review Manuscript. SETTING The clinical management of chronic, non-cancer pain. SUBJECTS Adult patients receiving treatment for chronic, non-cancer pain. RESULTS While there have been great advances in the science of pain and various therapeutic medications and interventions, patient outcomes are variable. This manuscript reviews how outcomes data can be used to guide efforts to improve patient outcomes. CONCLUSIONS Patient outcomes can be improved with standardization of the process of patient care, as well as through other quality improvement efforts. The cornerstone to any effort to improve patient outcomes starts with the integration of valid outcomes data collection into ongoing patient care. Outcome measurement tools should provide information on several key domains, yet the process of data collection should not pose a significant burden on either the patient or health care team. Efforts to improve patient outcomes are ongoing, and should be a high priority for every health care team.
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Affiliation(s)
- Lisa R Witkin
- Penn Pain Medicine Center, Department of Anesthesiology and Critical Care, The University of Pennsylvania, Philadelphia, Pennsylvania 19146, USA
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Abstract
Relief from pain is itself a marker of high-quality medical care. Quality assurance in the case of pain management could simply mean successful elimination of pain. Because the means of controlling pain are imperfect, it is essential to consider whether pain interventions actually achieve the primary goal of pain relief and also whether they are safe, cost-effective, and even capable of producing secondary benefits such as early recovery from surgery. Quality assurance and assessment in pain management therefore becomes a complex undertaking that must incorporate into its processes the often-conflicting goals of comfort versus safety versus patients' rights.
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