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Harper PG, Van Riper K, Ramer T, Slattengren A, Adam P, Smithson A, Wicks C, Martin C, Wootten M, Carlson S, Miller E, Fallert C. Team-based care: an expanded medical assistant role - enhanced rooming and visit assistance. J Interprof Care 2023; 37:S95-S101. [PMID: 30388911 DOI: 10.1080/13561820.2018.1538107] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/16/2018] [Accepted: 10/08/2018] [Indexed: 01/17/2023]
Abstract
Primary care practices face significant challenges as they pursue the Quadruple Aim. Redistributing care across the interprofessional primary care team by expanding the role of the medical assistant (MA) is a potential strategy to address these challenges. Two sequential, linked processes to expand the role of the MA, called Enhanced Rooming and Visit Assistance, were implemented in four family medicine residency clinics in Minnesota. In Enhanced Rooming, MAs addressed preventive services, obtained a preliminary visit agenda, and completed a warm hand-off to the provider. In Visit Assistance, MAs stayed in the room the entire visit to assist with the visit workflow. Enhanced Rooming and Visit Assistance processes were successfully implemented and sustained for over one year. MAs and providers were satisfied with both processes, and patients accepted the expanded MA roles. Mammogram ordering rates increased from 10% to 25% (p < 0.0001). After Visit Summary (AVS) print rates increased by 12% (p < 0.0001). Visit Turn-Around-Time (TAT) decreased 3.1 minutes per visit (p = 0.0001). Expanding the MA role in a primary care interprofessional team is feasible and a potentially useful tool to address the Quadruple Aim.
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Affiliation(s)
- Peter G Harper
- Department of Family Medicine & Community Health, University of Minnesota, Minneapolis, MN, USA
| | | | - Timothy Ramer
- Department of Family Medicine & Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Andrew Slattengren
- Department of Family Medicine & Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Patricia Adam
- Department of Family Medicine & Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Angela Smithson
- Department of Family Medicine & Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Cherilyn Wicks
- Department of Family Medicine & Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Casey Martin
- Department of Family Medicine & Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Michael Wootten
- Department of Family Medicine & Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Samantha Carlson
- Department of Family Medicine & Community Health, University of Minnesota, Minneapolis, MN, USA
| | | | - Christopher Fallert
- Department of Family Medicine & Community Health, University of Minnesota, Minneapolis, MN, USA
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Akhtar A, Sosa E, Castro S, Sur M, Lozano V, D'Souza G, Yeung S, Macalintal J, Patel M, Zou X, Wu PC, Silver E, Sandoval J, Gray SW, Reckamp KL, Kim JY, Sun V, Raz DJ, Erhunmwunsee L. A Lung Cancer Screening Education Program Impacts both Referral Rates and Provider and Medical Assistant Knowledge at Two Federally Qualified Health Centers. Clin Lung Cancer 2021; 23:356-363. [PMID: 34991968 DOI: 10.1016/j.cllc.2021.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/12/2021] [Accepted: 12/02/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Federally Qualified Health Centers (FQHCs) serve minority and low-socioeconomic populations and provide care to high-risk smokers. These centers frequently experience barriers, including low provider and medical assistant (MA) knowledge around lung cancer screening (LCS). Subsequent low LCS referral rates by providers at FQHCs limit utilization of LCS in eligible, high-risk, underserved patients. METHODS Providers and MAs from two FQHCs participated in a LCS educational session. A pre-educational survey was administered at the start of the session and a post-educational survey at the end. The intervention included a presentation with education around non-small cell lung cancer, LCS, tobacco cessation, and shared-decision making. Both surveys were used to evaluate changes in provider and MA ability to determine eligible patients for LCS. The Pearson's Chi-squared test with Yates' continuity correction was used to measure the impact. RESULTS A total of 29 providers and 28 MAs enrolled in the study from two FQHCs. There was an improvement, P < .009 and P < .015 respectively, in provider and MA confidence in identifying patients for LCS. Additionally, one year prior to the program, 9 low-dose computed tomography (LDCTs) were ordered at one of the FQHCs and 0 at the other. After the program, over 100 LDCTs were ordered at each FQHC. CONCLUSIONS A targeted LCS educational program improves provider and MAs' ability to identify eligible LCS patients and is associated with an increase in the number of patients referred to LDCT at FQHCs.
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Affiliation(s)
- Aamna Akhtar
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Ernesto Sosa
- Department of Populations Sciences, City of Hope National Medical Center, Duarte, CA
| | - Samuel Castro
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Melissa Sur
- Department of Populations Sciences, City of Hope National Medical Center, Duarte, CA
| | - Vanessa Lozano
- Department of Populations Sciences, City of Hope National Medical Center, Duarte, CA
| | - Gail D'Souza
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Sophia Yeung
- Department of Nursing, City of Hope Comprehensive Cancer Center, Duarte, CA
| | - Jonjon Macalintal
- Department of Nursing, City of Hope Comprehensive Cancer Center, Duarte, CA
| | - Meghna Patel
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Xiaoke Zou
- Department of Populations Sciences, City of Hope National Medical Center, Duarte, CA
| | - Pei-Chi Wu
- Herald Christian Health Center, Rosemead, CA
| | | | - Jossie Sandoval
- Department of Medicine, City of Hope Cancer Center, Duarte, CA
| | - Stacy W Gray
- Department of Populations Sciences, City of Hope National Medical Center, Duarte, CA; Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA
| | - Karen L Reckamp
- Department of Medical Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jae Y Kim
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Virginia Sun
- Department of Populations Sciences, City of Hope National Medical Center, Duarte, CA
| | - Dan J Raz
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Loretta Erhunmwunsee
- Department of Surgery, City of Hope National Medical Center, Duarte, CA; Department of Populations Sciences, City of Hope National Medical Center, Duarte, CA.
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Sinha S, Xu MJ, Yee E, Buckmeier T, Park C, Braunstein SE. Interprofessional Education Curriculum for Medical Assistants in Radiation Oncology: A Single Institution Pilot Program. Adv Radiat Oncol 2021; 6:100800. [PMID: 34693079 PMCID: PMC8515404 DOI: 10.1016/j.adro.2021.100800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 08/23/2021] [Accepted: 08/27/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Medical assistants (MAs) occupy an increasingly prevalent role in the clinical setting. Subspecialized fields such as oncology require specific clinical knowledge; however, MAs have few requirements for continued education. Here we assess the role and effect of a pilot MA Radiation Oncology education curriculum. METHODS AND MATERIALS A needs assessment survey was conducted and reviewed to develop a comprehensive introductory oncology curriculum. A resident physician-led program was implemented in an academic cancer care center consisting of monthly, 1-hour lectures. Pre- and postlecture surveys were administered to assess learning. Quarterly surveys were conducted over the 20-month curriculum timeframe. RESULTS The needs assessment revealed that there were no pre-existing MA continuing education didactics, but all (100%) MAs surveyed were "very interested" in such a curriculum. Sessions were found to be clear, comprehensive, relevant, and associated with a significant increase in a sense of empowerment (P = .035). Topics in Head and Neck and Breast Cancer showed large improvements in understanding (change in median Likert score of 3-4 points each) whereas topics in Introduction to Oncology and New Patient Consultation showed the smallest change (change 0.5-1). For 20 months, there was a sustained improvement in clinical understanding within and outside the scope of the MA role and an improvement in perceived empathy for patients (from median Likert score 3.5-5). CONCLUSIONS Dedicated education programs for MAs show the potential to improve clinical understanding and participation in patient care. Further studies may demonstrate how such programs translate to staff productivity or patient clinical outcomes. Interprofessional education may facilitate collaboration and enhanced clinical workflow.
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Affiliation(s)
| | | | - Emily Yee
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Troy Buckmeier
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Catherine Park
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Steve E. Braunstein
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
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DeJonckheere M, McKee MM, Guetterman TC, Schleicher LS, Mulhem E, Panzer K, Bradley K, Plegue MA, Rapai ME, Green LA, Zazove P. Implementation of a Hearing Loss Screening Intervention in Primary Care. Ann Fam Med 2021; 19:388-395. [PMID: 34546945 PMCID: PMC8437567 DOI: 10.1370/afm.2695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 11/16/2020] [Accepted: 12/03/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Hearing loss (HL) is underdiagnosed and often unaddressed. A recent study of screening for HL using an electronic prompt showed efficacy in increasing appropriate referrals for subsequent testing. We build on the results of this study using a qualitative lens to explore implementation processes through the perspectives of family medicine clinicians. METHODS We collected clinic observations and semistructured interviews of family medicine clinicians and residents who interacted with the HL prompt. All data were analyzed using thematic, framework, and mixed methods integration strategies. RESULTS We interviewed 27 clinicians and conducted 10 observations. Thematic analysis resulted in 6 themes: (1) the prompt was overwhelmingly viewed as easy, simple to use, accurate; (2) clinicians considered prompt as an effective way to increase awareness and conversations with patients about HL; (3) clinician and staff buy-in played a vital role in implementation; (4) clinicians prioritized prompt during annual visits; (5) medical assistant involvement in prompt workflow varied by health system, clinic, and clinician; (6) prompt resulted in more conversations about HL, but uncertain impact on patient outcomes. Themes are presented alongside constructs of normalization process theory and intervention outcomes. CONCLUSION Integration of a HL screening prompt into clinical practice varied by clinician buy-in and beliefs about the impact on patient outcomes, involvement of medical assistants, and prioritization during clinical visits. Further research is needed to understand how to leverage clinician and staff buy-in and whether implementation of a new clinical prompt has sustained impact on HL screening and patient outcomes.
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Affiliation(s)
| | - Michael M McKee
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan
| | | | | | - Elie Mulhem
- Department of Family Medicine and Community Health, Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | | | - Kathleen Bradley
- Department of Family Medicine and Community Health, Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Melissa A Plegue
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan
| | - Mary E Rapai
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan
| | - Lee A Green
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Philip Zazove
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan
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Vilendrer S, Brown-Johnson C, Kling SMR, Veruttipong D, Amano A, Bohman B, Daines WP, Overton D, Srivastava R, Asch SM. Financial Incentives for Medical Assistants: A Mixed-Methods Exploration of Bonus Structures, Motivation, and Population Health Quality Measures. Ann Fam Med 2021; 19:427-436. [PMID: 34546949 PMCID: PMC8437570 DOI: 10.1370/afm.2719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 01/29/2021] [Accepted: 03/17/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Medical assistants (MAs) have seen their roles expand as a result of team-based primary care models. Unlike their physician counterparts, MAs rarely receive financial incentives as a part of their compensation. This exploratory study aims to understand MA acceptability of financial incentives and perceived MA control over common population health measures. METHODS We conducted semistructured focus groups between August and December of 2019 across 10 clinics affiliated with 3 institutions in California and Utah. MAs' perceptions of experienced and hypothetical financial incentives, their potential influence on workflow processes, and perceived levels of control over population health measures were discussed, recorded, and qualitatively analyzed for emerging themes. Perceived levels of control were further quantified using a Likert survey; measures were grouped into factors representing vaccinations, and workflow completed in the same day or multiple days (multiday). Mean scores for each factor were compared using repeated 1-way ANOVA with Tukey-Kramer adjustment. RESULTS MAs reported little direct experience with financial incentives. They indicated that a hypothetical bonus representing 2% to 3% of their average annual base pay would be acceptable and influential in improving consistent performance during patient rooming workflow. MAs reported having greater perceived control over vaccinations (P <.001) and same-day measures (P <.001) as compared with multiday measures. CONCLUSIONS MAs perceived that relatively small financial incentives would increase their motivation and quality of care. Our findings suggests target measures should focus on MA work processes that are completed in the same day as the patient encounter, particularly vaccinations. Future investigation is needed to understand the effectiveness of MA financial incentives in practice.
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Affiliation(s)
- Stacie Vilendrer
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Cati Brown-Johnson
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Samantha M R Kling
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Darlene Veruttipong
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Alexis Amano
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Bryan Bohman
- Department of Anesthesiology Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - William P Daines
- Internal Medicine Clinical Program, Intermountain Healthcare, Murray, Utah
| | | | - Raj Srivastava
- Intermountain Healthcare Delivery Institute, Intermountain Healthcare, Salt Lake City, Utah
| | - Steven M Asch
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California.,Center for Innovation to Implementation, Veterans Affairs, Menlo Park, California
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Mahmoud AS, Alkhenizan A, Shafiq M, Alsoghayer S. The impact of the implementation of a clinical decision support system on the quality of healthcare services in a primary care setting. J Family Med Prim Care 2021; 9:6078-6084. [PMID: 33681044 PMCID: PMC7928113 DOI: 10.4103/jfmpc.jfmpc_1728_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 10/27/2020] [Accepted: 11/24/2020] [Indexed: 11/04/2022] Open
Abstract
Background In July 2015, King Faisal Hospital Family Medicine clinics (KFH-FMC) successfully implemented a paperless, fully integrated, electronic healthcare system. The aim of this study is to evaluate the impact of moving to a fully integrated electronic medical record system, with clinical decision support (CDS) systems, on the quality of healthcare services in a primary care setting. We aim to evaluate the impact of CDS on clinical outcomes such as screening and diagnosis of breast and colorectal cancers, as well as the management of chronic diseases such as diabetes and hypertension, and the uptake of immunizations. Inclusion and Exclusion Criteria Our study included all adult patients, over the age of 18, registered in the Family Medicine clinic linked to King Faisal Hospital, seen between January 2012 and December 2018. Design Retrospective cohort study. Setting Family Medicine clinics at King Faisal Hospital (KFH-FMC). Materials and Methods Data were collected retrospectively from the electronic health records of all adult patients above 18 years of age, who were seen in KFH-FMC between January 2012 and December 2018. We analyzed several processes of care and a number of clinical outcomes, comparing results for the three and a half years before CDS implementation with the three and a half years after implementation. Data collected included blood pressure measurements, lipid levels, HbA1c for diabetic patients, screening tests done, including PAP smear, mammogram, fecal occult blood tests, and bone densitometry. Other data included cancer diagnoses and immunizations received. Results Significant increases were found in adult vaccine uptake ranging from an 11-fold increase in influenza uptake, to a 22-fold increase in pneumococcal 23 uptake. The uptake of all the cancer screening tests increased (FOB 66%, mammogram 33%, PAP smear 16%). Diagnoses of breast and colorectal cancer showed significant increases. Breast cancer diagnoses increased from 2 to 14, and colorectal cancer from 3 to 11. No significant improvement was found in chronic disease outcomes. Discussion The electronic health record with CDS led to significantly improved uptake of immunizations and screening tests, with earlier diagnoses of breast and colon cancer. Evidence of improvement in chronic disease outcomes is still lacking.
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Affiliation(s)
- Ahmed Sherif Mahmoud
- Department of Family Medicine and Polyclinics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Abdullah Alkhenizan
- Department of Family Medicine and Polyclinics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohammed Shafiq
- Department of Family Medicine and Polyclinics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Suad Alsoghayer
- Department of Family Medicine and Polyclinics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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7
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Harper PG, Schafer KM, Van Riper K, Justesen K, Ramer T, Wicks C, Oyenuga A, Budd J. Team-based approach to improving medication reconciliation rates in family medicine residency clinics. J Am Pharm Assoc (2003) 2020; 61:e46-e52. [PMID: 32919924 DOI: 10.1016/j.japh.2020.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/30/2020] [Accepted: 08/03/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The objective of this quality improvement project was to design and implement a systematic team-based care approach to medication reconciliation, with a goal of physician-documented medication reconciliation at 70% of all patient office visits. SETTING Ambulatory clinics located in urban, underserved communities in Minneapolis and St. Paul, MN. PRACTICE DESCRIPTION Four family medicine residency clinics, with pharmacists integrated at each site. All clinics use the Epic electronic medical record (Epic Systems Corporation). PRACTICE INNOVATION A team-based care approach to medication reconciliation was designed and implemented involving medical assistants (MAs), physicians, and pharmacists. The MAs did an initial review with patients, the physicians addressed discrepancies, and difficult situations were escalated to the pharmacist for a detailed assessment. EVALUATION The percentage of visits with physician-documented medication reconciliation was measured preintervention and then for 18 months postintervention in 6-month intervals involving more than 118,000 patient visits. Satisfaction surveys of team members were done pre- and postintervention. RESULTS The percentage of visits with physician-documented medication reconciliation improved significantly from 6.5% preintervention to 58.7% (P < 0.001) postintervention, and was sustained and further improved to 70.3% (P < 0.001) 1 year later. The team members had a statistically significant improvement in their ability to articulate the medication reconciliation process. Satisfaction improved significantly for physicians, but MAs did not experience a statistically significant change. CONCLUSION A team-based care approach to medication reconciliation was successfully implemented and sustained at 4 family medicine clinics. There was significant improvement in physician-documented medication reconciliation. Future studies need to address whether this process improves medication-list discrepancies, completeness, and accuracy.
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Nguyen KH, Chien AT, Meyers DJ, Li Z, Singer SJ, Rosenthal MB. Team-Based Primary Care Practice Transformation Initiative and Changes in Patient Experience and Recommended Cancer Screening Rates. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2020; 57:46958020952911. [PMID: 32844691 PMCID: PMC7453437 DOI: 10.1177/0046958020952911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Team-based care has emerged as a promising strategy for primary care practices to provide high-quality care. We examine changes in patient experience of care and recommended cancer screening rates associated with a primary care transformation initiative that established team-based care. Our observational study included 13 academically affiliated primary care practices in the Boston, Massachusetts area that participated in 2 learning collaboratives: the first (2012-2014) aimed to establish team-based primary care, while the second (2014-2016) focused on improving patient safety and cancer screening. We identified 37 comparison practices of similar size and network affiliation. Using a difference-in-differences approach, we compared pre (2013) and post (2015) patient experience and recommended cancer screening rates between intervention and comparison practices. We estimated linear regression models, using inverse probability weighting to balance on observable differences. Massachusetts Health Quality Partners data on patient experience comes from surveys (with communication, integration, knowledge of patient, access, office staff, and willingness to recommend domains), and its data on screening rates for breast, colorectal, and cervical cancers is derived from chart abstraction. Relative to comparison practices, the communication score in intervention practices increased by 1.47 percentage points on a 100-point scale (P = .02) between pre and post periods. We did not detect immediate improvements in other measures of patient experience of care and recommended cancer screening rates. Communication may be the first dimension of patient experience that improves following establishment of team-based primary care, and changing care processes may require more time or attention in the transition to team-based care. Our findings also suggest a need to better understand the variation in implementation factors that facilitate some practices’ successful transitions to team-based care, and to use teams effectively to improve cancer screening processes.
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Affiliation(s)
- Kevin H Nguyen
- Brown University School of Public Health, Providence, RI, USA
| | - Alyna T Chien
- Harvard Medical School, Boston, MA, USA.,Boston Children's Hospital, Boston, MA, USA
| | - David J Meyers
- Brown University School of Public Health, Providence, RI, USA
| | - Zhonghe Li
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Sara J Singer
- Stanford University School of Medicine, Stanford, CA, USA.,Stanford Graduate School of Business, Stanford, CA, USA
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Harry ML, Saman DM, Truitt AR, Allen CI, Walton KM, O'Connor PJ, Ekstrom HL, Sperl-Hillen JM, Bianco JA, Elliott TE. Pre-implementation adaptation of primary care cancer prevention clinical decision support in a predominantly rural healthcare system. BMC Med Inform Decis Mak 2020; 20:117. [PMID: 32576202 PMCID: PMC7310565 DOI: 10.1186/s12911-020-01136-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 05/24/2020] [Indexed: 01/12/2023] Open
Abstract
Background Cancer is a leading cause of death in the United States. Primary care providers (PCPs) juggle patient cancer prevention and screening along with managing acute and chronic health problems. However, clinical decision support (CDS) may assist PCPs in addressing patients’ cancer prevention and screening needs during short clinic visits. In this paper, we describe pre-implementation study design and cancer screening and prevention CDS changes made to maximize utilization and better fit a healthcare system’s goals and culture. We employed the Consolidated Framework for Implementation Research (CFIR), useful for evaluating the implementation of CDS interventions in primary care settings, in understanding barriers and facilitators that led to those changes. Methods In a three-arm, pragmatic, 36 clinic cluster-randomized control trial, we integrated cancer screening and prevention CDS and shared decision-making tools (SDMT) into an existing electronic medical record-linked cardiovascular risk management CDS system. The integrated CDS is currently being tested within a predominately rural upper Midwestern healthcare system. Prior to CDS implementation, we catalogued pre-implementation changes made from 2016 to 2018 based on: pre-implementation site engagement; key informant interviews with healthcare system rooming staff, providers, and leadership; and pilot testing. We identified influential barriers, facilitators, and changes made in response through qualitative content analysis of meeting minutes and supportive documents. We then coded pre-implementation changes made and associated barriers and facilitators using the CFIR. Results Based on our findings from system-wide pre-implementation engagement, pilot testing, and key informant interviews, we made changes to accommodate the needs of the healthcare system based on barriers and facilitators that fell within the Intervention Characteristics, Inner Setting, and Outer Setting CFIR domains. Changes included replacing the expansion of medical assistant roles in one intervention arm with targeted SDMT, as well as altering cancer prevention CDS and study design elements. Conclusions Pre-implementation changes to CDS may help meet healthcare systems’ evolving needs and optimize the intervention by being responsive to real-world implementation barriers and facilitators. Frameworks like the CFIR are useful tools for identifying areas where pre-implementation barriers and facilitators may result in design changes, both to research studies and CDS systems. Trial registration NCT02986230.
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Affiliation(s)
- Melissa L Harry
- Essentia Health, Essentia Institute of Rural Health, 6AV-2, 502 East Second Street, Duluth, MN, 55805, USA
| | - Daniel M Saman
- Essentia Health, Essentia Institute of Rural Health, 6AV-2, 502 East Second Street, Duluth, MN, 55805, USA.
| | - Anjali R Truitt
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - Clayton I Allen
- Essentia Health, Essentia Institute of Rural Health, 6AV-2, 502 East Second Street, Duluth, MN, 55805, USA
| | - Kayla M Walton
- Essentia Health, Essentia Institute of Rural Health, 6AV-2, 502 East Second Street, Duluth, MN, 55805, USA
| | - Patrick J O'Connor
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - Heidi L Ekstrom
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - JoAnn M Sperl-Hillen
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - Joseph A Bianco
- Essentia Health - Ely Clinic, 300 W Conan Street, Ely, MN, 55731, USA
| | - Thomas E Elliott
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
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Yacoob Z, Cook C, Kotovicz F, Kram JJ, Klumph M, Stanley M, Hunter P, Baumgardner DJ. Enhancing Immunization Rates in Two Urban Academic Primary Care Clinics: A Before and After Assessment. J Patient Cent Res Rev 2020; 7:47-56. [PMID: 32002447 PMCID: PMC6988711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Abstract
PURPOSE Immunization rates in many cities in the United States remain suboptimal compared to Healthy People 2020 Goals and are lower than national averages. This study aimed to determine whether a lecture-based educational intervention targeted at nurses and medical assistants would improve vaccination rates. METHODS We conducted a quality improvement study in two urban academic family medicine clinics serving a predominantly Medicaid patient population as well as a sizable proportion of refugees. The intervention consisted of 3 lectures that were delivered to clinic nurses and medical assistants. Vaccinations in 1689 patients - 872 in the 3-month preintervention period, 817 in the 3-month postintervention period - were analyzed. RESULTS Following the educational intervention, a statistically significant increase was seen only in human papillomavirus vaccine immunization rates for 13-18-year-olds (from 90.7% [n=54] to 100% [n=45]; P=0.036). When the results were stratified by clinic, only 1 site showed statistically significant increases in: pneumococcal polysaccharide vaccine (23-valent) for high-risk 19-to-64-year-olds (from 36.4% [n=154] to 47.8% [n=136]; P=0.049); Haemophilus influenzae type B vaccine for 2-month-to-5-year-olds (from 91.1% [n=112] to 97.3% [n=111]; P=0.048); and meningococcal conjugate vaccine (quadrivalent) for 13-18-year olds (from 85.2% [n=27] to 100% [n=26]; P=0.042). No increases were seen for our study's refugee patient population (n=171), and a significant decrease of the second-dose measles, mumps, and rubella vaccine (P=0.036) occurred in this subcohort. CONCLUSIONS Ultimately, this quality improvement study demonstrated that educational interventions alone have a limited impact on increasing immunization rates.
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Affiliation(s)
- Zeeshan Yacoob
- University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Family Medicine, Aurora UW Medical Group, Aurora Health Care, Milwaukee, WI
| | - Christopher Cook
- Department of Family Medicine, Aurora UW Medical Group, Aurora Health Care, Milwaukee, WI
| | - Fabiana Kotovicz
- University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Family Medicine, Aurora UW Medical Group, Aurora Health Care, Milwaukee, WI
| | - Jessica J.F. Kram
- University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Family Medicine, Aurora UW Medical Group, Aurora Health Care, Milwaukee, WI
- Center for Urban Population Health, Milwaukee, WI
| | - Marianne Klumph
- Department of Family Medicine, Aurora UW Medical Group, Aurora Health Care, Milwaukee, WI
- Center for Urban Population Health, Milwaukee, WI
| | - Marisa Stanley
- Eau Claire City-County Health Department, Eau Claire, WI
| | - Paul Hunter
- University of Wisconsin School of Medicine and Public Health, Madison, WI
- City of Milwaukee Health Department, Milwaukee, WI
| | - Dennis J. Baumgardner
- University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Family Medicine, Aurora UW Medical Group, Aurora Health Care, Milwaukee, WI
- Center for Urban Population Health, Milwaukee, WI
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Hunter P, Fryhofer SA, Szilagyi PG. Vaccination of Adults in General Medical Practice. Mayo Clin Proc 2020; 95:169-183. [PMID: 31902413 DOI: 10.1016/j.mayocp.2019.02.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/31/2019] [Accepted: 02/14/2019] [Indexed: 01/04/2023]
Abstract
In vaccinating adults, clinicians face 2 types of challenges: (1) staying current on recommendations for influenza, pneumococcal, hepatitis A and B, zoster, and other vaccines and (2) addressing systemic barriers to implementing practices that increase vaccination rates. Although adult immunization rates remain suboptimal, there has been much good news in adult vaccination recently. New high-dose and adjuvanted influenza vaccines help improve immune response and may reduce influenza complications in older adults. The new recombinant zoster vaccine offers significantly more efficacy against zoster outbreaks and postherpetic neuralgia than zoster vaccine live. Pertussis vaccine given during the third trimester of pregnancy may prevent between 50% and 90% of pertussis infections in infants. Shorter time for completion (1 vs 6 months) of new, adjuvanted hepatitis B vaccine may increase adherence. Clinicians can address systemic barriers to increasing vaccination rates in their clinics and health care systems by following the Centers for Disease Control and Prevention's Standards for Adult Immunization Practice. Clinicians can help increase vaccination rates by writing standing orders and by advocating for nurses or medical assistants to receive training and protected time for assessing and documenting vaccination histories and administration. Strong recommendations that presume acceptance of vaccination are effective with most patients. Communication techniques similar to motivational interviewing can help with vaccine-hesitant patients. Clinicians, as experts on providing preventive services, can educate community leaders about the benefits of immunization and can inform vaccine experts about challenges of implementing vaccination recommendations in clinical practice and strategies that can work to raise vaccination rates.
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Affiliation(s)
- Paul Hunter
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI; City of Milwaukee Health Department, WI.
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Primary Outcomes of a Randomized Controlled Crossover Trial to Explore the Effects of a High Chlorophyll Dietary Intervention to Reduce Colon Cancer Risk in Adults: The Meat and Three Greens (M3G) Feasibility Trial. Nutrients 2019; 11:nu11102349. [PMID: 31581743 PMCID: PMC6835237 DOI: 10.3390/nu11102349] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/18/2019] [Accepted: 09/23/2019] [Indexed: 12/13/2022] Open
Abstract
Preclinical and observational research suggests green leafy vegetables (GLVs) may reduce the risk of red meat (RM)-induced colonic DNA damage and colon cancer (CC). We sought to determine the feasibility of a high GLV dietary intervention in adults with an increased risk of CC (NCT03582306) via a 12-week randomized controlled crossover trial. Participants were randomized to immediate or delayed (post-4-week washout) intervention groups. During the 4-week intervention period, participants were given frozen GLVs and counseled to consume one cooked cup equivalent daily. The primary outcomes were: accrual—recruiting 50 adults in 9 months; retention—retaining 80% of participants at completion; and adherence—meeting GLV intake goals on 90% of days. Adherence data were collected twice weekly and 24-h dietary recalls at each time point provided nutrient and food group measures. The Food Acceptability Questionnaire (FAQ) was completed to determine acceptability. On each of the four study visits, anthropometrics, stool, saliva, and blood were obtained. Fifty adults were recruited in 44 days. Participants were 48 ± 13 years of age, 62% female, and 80% Caucasian, with an average BMI at screening of 35.9 ± 5.1. Forty-eight (96%) participants were retained and completed the study. During the intervention phase, participants consumed GLVs on 88.8% of days; the adherence goal of one cup was met on 73.2% of days. Dietary recall-derived Vitamin K and GLVs significantly increased for all participants during the intervention periods. Overall satisfaction did not differ between intervention and control periods (p = 0.214). This feasibility trial achieved accrual, retention and acceptability goals, but fell slightly short of the benchmark for adherence. The analysis of biological specimens will determine the effects of GLVs on gut microbiota, oxidative DNA damage, and inflammatory cytokines.
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Kapila N, Singh H, Kandragunta K, Castro FJ. Open Access Colonoscopy for Colorectal Cancer Prevention: An Evaluation of Appropriateness and Quality. Dig Dis Sci 2019; 64:2798-2805. [PMID: 30955174 DOI: 10.1007/s10620-019-05612-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 04/02/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Open access colonoscopy (OAC) has gained widespread acceptance and has the potential to increase colorectal cancer (CRC) screening. However, there is little data evaluating its appropriateness for CRC prevention. AIMS The aim of this study is to evaluate the appropriateness of OAC in CRC screening and polyp surveillance by comparing to procedures ordered by gastroenterologists (NOAC). As secondary outcomes, we compared the quality of bowel preparation and adenoma detection rate (ADR) between OAC and NOAC. METHODS It is retrospective single-center study. Inclusion criteria included patients > 50 years of age undergoing a colonoscopy for CRC screening and surveillance. Appropriateness was defined as those colonoscopies performed within 12 months of the recommended 2012 consensus guidelines. Secondary outcomes included the quality of bowel preparation and ADR. RESULTS 5211 colonoscopies met inclusion criteria, and 64.9% were OAC. Screening OAC was appropriately 91.6% and NOAC 92.9% of the time (p = 0.179). Surveillance NOAC were inappropriate in 26.4% of cases, and surveillance OAC was 32.6% (p = 0.008). Multivariate analysis demonstrated that OAC did not influence ADR (OR for NOAC 0.97; 95% CI 0.86-1.1; p = 0.644) or an adequate bowel preparation (OR for NOAC 1.11; 95% CI 0.91-1.36; p = 0.306). CONCLUSION OAC performed similarly to NOAC for screening indications, quality of bowel preparation, and ADR. However, more surveillance procedures were inappropriate in the OAC group although both groups had a high number of inappropriate indications. Although OAC can be efficiently performed for screening indications, measures to decrease inappropriate surveillance colonoscopies are needed.
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Affiliation(s)
- Nikhil Kapila
- Department of Gastroenterology, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL, USA.
| | - Harjinder Singh
- Department of Gastroenterology, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL, USA
| | - Kiranmayee Kandragunta
- Department of Gastroenterology, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL, USA
| | - Fernando J Castro
- Department of Gastroenterology, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL, USA
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Identifying and Addressing Language Needs in Primary Care: a Pilot Implementation Study. J Racial Ethn Health Disparities 2018; 6:505-516. [PMID: 30511122 DOI: 10.1007/s40615-018-00549-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/15/2018] [Accepted: 11/23/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Medical interpreters improve care for patients with Limited English Proficiency but are underused. Protocols to improve interpreter use in primary care are needed. METHODS Medical Assistants (MAs) screened patients for language needs and arranged for telephone interpreters during rooming in two pilot clinics (PCs). We interviewed MAs and providers and analyzed interviews using modified grounded theory, linking themes to the Promoting Action on Research Implementation in Health Services (PARiHS) framework categories of Context, Evidence, and Facilitation. Providers in PCs and four comparison clinics were surveyed. RESULTS Context themes included issues with the telephone interpreter vendor; having established teams, roles and workflows; and difficulty incorporating time-sensitive tasks. Evidence themes included engagement in language screening; preferring in-person interpreters; improving the patient experience; and having mixed responses to the protocol. Facilitation themes included MAs needing more support. PC providers were more satisfied with care (OR = 12.7) and communication (OR = 7.6) than comparison clinic providers. CONCLUSIONS The protocol may improve patient care and communication, but implementation was inconsistent. Language screening is a complex process and further research is needed to improve screening questions and procedures. Future interventions should capitalize on team members' drives to improve patient care and control costs but also need to consider the impacts of health system changes, and to consider the culture, training needs, roles, and relationships of team members.
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Abstract
As health care moves to a value-based system, the need for team-based models of care becomes increasingly important to adequately address the growing number of clinical quality metrics required of health care providers. Finding ways to better engage certified medical assistants (CMAs) in the process allows providers to focus on more complex tasks while improving the efficiency of each office visit. Although the roles and responsibilities for CMAs across the specialties can vary widely, standardizing the work can be a helpful step in scaling best practices across an institution. This article presents the results of a survey that evaluated various components of a CMA workflow in adult primary care practices within an academic medical center. Although the survey identified improved engagement and satisfaction with standardized changes overall, it also showed time constraints and provider discretion forcing unplanned modifications. Reviewing and reconciling medications seemed to be the most challenging for CMA staff, leading us to reconsider their involvement in this aspect of each visit. It will be important to continue innovating and testing team-based care models to keep up with the demands of a quality-based health care system.
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Akenroye AT, Kumthekar AA, Alevizos MK, Mowrey WB, Broder A. Implementing an Electronic Medical Record-Based Reminder for Cardiovascular Risk Screening in Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2017; 69:625-632. [PMID: 27390217 DOI: 10.1002/acr.22966] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 05/22/2016] [Accepted: 06/21/2016] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Although cardiovascular disease (CVD) is the leading cause of death among individuals with rheumatoid arthritis (RA), CVD risks are not being assessed frequently and systematically in RA. We implemented an electronic medical record (EMR)-based reminder in a tertiary care center and assessed the effects of this intervention on CVD risk screening by rheumatologists and primary care providers. METHODS The EMR reminder was implemented in December 2013 and included the most recent value and target ranges for body mass index, blood pressure (BP), and lipid profiles. It was displayed for every rheumatology and primary care visit for all patients with the International Classification of Diseases, Ninth Revision code for RA (714.0). Lipid screening rates, as well as changes in BP and obesity rates were compared pre- and postimplementation. Factors associated with lipid screening postimplementation were assessed using multivariate logistic regression. RESULTS A total of 138 and 112 RA patients were seen in the outpatient clinics pre- and postimplementation, respectively. The demographic characteristics were similar in the pre- and postimplementation groups. Lipid screening rates were 50% preimplementation and 46% postimplementation (P = 0.58). There were no significant improvements in BP or obesity rates postimplementation. Factors associated with the higher odds of lipid screening included older age and history of diabetes mellitus. CONCLUSION Implementing an EMR reminder did not improve CVD risk screening among RA patients. Future research is needed to identify and address barriers to CVD screening, and to educate patients and providers about RA-related risks.
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Affiliation(s)
- Ayobami T Akenroye
- Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Anand A Kumthekar
- Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Michail K Alevizos
- Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
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Abstract
In recent years, the role of primary care physicians (PCPs) in the diagnosis and management of gastrointestinal disorders, including screening for colorectal cancer (CRC), has been recognized as very important. The available data indicate that PCPs are not adequately following CRC screening guidelines because a number of factors have been identified as significant barriers to the proper application of CRC screening guidelines. These factors include lack of time, patient reluctance, and challenges related to scheduling colonoscopy. Further positive engagement of PCPs with CRC screening is required to overcome these barriers and reach acceptable levels in screening rates. To meet the expectations of modern medicine, PCPs should not only be able to recommend occult blood testing or colonoscopy but also, under certain conditions, able to perform colonoscopy. In this review, the authors aim to provide the current knowledge of the role of PCPs in increasing the rate and successfully implementing a screening program for CRC by applying the relevant international guidelines.
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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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Examining the Feasibility of a Simple Intervention to Improve Blood Pressure Control for Primary Care Patients. J Cardiovasc Nurs 2016; 31:291-5. [DOI: 10.1097/jcn.0000000000000254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Alberti LR, Garcia DPC, Coelho DL, Lima DCAD, Petroianu A. How to improve colon cancer screening rates. World J Gastrointest Oncol 2015; 7:484-491. [PMID: 26688708 PMCID: PMC4678395 DOI: 10.4251/wjgo.v7.i12.484] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 10/08/2015] [Accepted: 11/17/2015] [Indexed: 02/05/2023] Open
Abstract
Colorectal carcinoma is a common cause of death throughout the world and may be prevented by routine control, which can detect precancerous neoplasms and early cancers before they undergo malignant transformation or metastasis. Three strategies may improve colon cancer screening rates: convince the population about the importance of undergoing a screening test; achieve higher efficacy in standard screening tests and make them more available to the community and develop new more sensitive and efficacious screening methods and make them available as routine tests. In this light, the present study seeks to review these three means through which to increase colon cancer screening rates.
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Chapman SA, Marks A, Dower C. Positioning Medical Assistants for a Greater Role in the Era of Health Reform. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2015; 90:1347-1352. [PMID: 26039141 DOI: 10.1097/acm.0000000000000775] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Medical assistants (MAs) are one of the fastest-growing occupations in the United States. As of 2014 there were about 585,000 MAs in the United States, and the Bureau of Labor Statistics projected the MA workforce to grow by 29% from 2012 to 2022. The MA population is primarily female, ethnically and racially diverse, and paid about $15.01 per hour. MAs are primarily educated in private schools, many at for-profit institutions. The MA curriculum and length of training can be quite varied and can lead to uneven preparation for practice. Traditionally, the MA role has involved a limited clinical role and little involvement with team care, particularly in larger practices or clinics. Medical groups, clinics, and health systems are now taking a new look at MAs and how they can play a greater role in reforming health care delivery models. Expanded roles for MAs might include health coach, referral coordinator, disease registry manager, and health screener using protocols. In expanding MA roles, education and regulatory issues need to be addressed by the provider community including current inconsistent regulation and certification requirements and the lack of preparation for expanded roles in traditional MA training programs. MAs are well positioned to help address challenges in the health care delivery system including improving access to care while reducing overall cost. Successful model practices using MAs in expanded roles need further formal evaluation and replication across practice settings.
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Affiliation(s)
- Susan A Chapman
- S.A. Chapman is professor, Department of Social and Behavioral Sciences, School of Nursing, and faculty, Center for Health Professions and Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California.A. Marks is a senior manager, Center for the Health Professions, University of California, San Francisco, San Francisco, California.C. Dower is health policy and law director, Center for the Health Professions, University of California, San Francisco, San Francisco, California
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Park J. Nurse practitioner and physician assistant staffing in the patient-centered medical homes in New York State. Nurs Outlook 2015. [PMID: 26211843 DOI: 10.1016/j.outlook.2015.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND A cornerstone of patient-centered medical homes (PCMHs) is team-based care; however, there is little information about the composition of staff who deliver direct primary care in PCMHs. PURPOSE The purpose of this study was to examine the number and distribution of primary care physicians (PCPs), nurse practitioners (NPs), and physician assistants (PAs) in PCMH and non-PCMH practices located in New York State (N = 7,431). METHOD Practice based ratios of primary care NPs and PAs to PCP were calculated and compared by PCMH designations. Designated PCMHs had more NPs and PAs per PCP relative to non-PCMHs. The ratios of NPs to PCPs were almost twice as high in PCMHs compared with non-PCMHs (0.20 and 0.11), and ratios were similarly different for PAs to PCPs (0.16 and 0.09, respectively). The multivariate analyses also support that higher NP and PA staffing was associated with PCMH designation (i.e., there was one additional NP and/or PA for every 25 PCPs). DISCUSSION The growth of PCMHs may require more NPs and PAs to meet the anticipated growth in demand for health care. Policy- and practice-level changes are necessary to use them in the most effective ways.
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Affiliation(s)
- Jeongyoung Park
- The George Washington University School of Nursing, Washington, DC.
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Rogers EA, Hessler D, Dube K, Willard-Grace R, Gupta R, Bodenheimer T, Grumbach K. The panel management questionnaire: a tool to measure panel management capability. Perm J 2015; 19:4-9. [PMID: 25785637 DOI: 10.7812/tpp/14-170] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Primary care practices are turning toward team-based strategies such as panel management, in which nonclinicians address routine preventive and chronic disease care tasks for a group of patients. No known validated instruments have been published for measuring panel management implementation. The authors developed the 12-item Panel Management Questionnaire (PMQ) measuring 4 domains. Data were assembled from self-administered cross-sectional surveys of 136 staff and 204 clinicians in 9 county and 5 university adult primary care clinics. Staff and clinician PMQ scores in each clinic were correlated. The clinic-level median PMQ score was positively associated with a composite clinic quality measure.
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Affiliation(s)
- Elizabeth Ann Rogers
- Assistant Professor of Internal Medicine in the Applied Clinical Research Program at the University of Minnesota in Minneapolis.
| | - Danielle Hessler
- Assistant Professor of Family and Community Medicine at the University of California, San Francisco.
| | - Kate Dube
- Evaluation Coordinator in the Department of Family and Community Medicine at the University of California, San Francisco.
| | - Rachel Willard-Grace
- Research Manager in the Department of Family and Community Medicine at the University of California, San Francisco.
| | - Reena Gupta
- Assistant Professor of Internal Medicine at the University of California, San Francisco.
| | - Thomas Bodenheimer
- Professor of Family and Community Medicine at the University of California, San Francisco.
| | - Kevin Grumbach
- Professor of Family and Community Medicine at the University of California, San Francisco.
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Tu SP, Chun A, Yasui Y, Kuniyuki A, Yip MP, Taylor V, Bastani R. Adaptation of an evidence-based intervention to promote colorectal cancer screening: a quasi-experimental study. Implement Sci 2014; 9:85. [PMID: 24989083 PMCID: PMC4226971 DOI: 10.1186/1748-5908-9-85] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 06/23/2014] [Indexed: 02/07/2023] Open
Abstract
Background To accelerate the translation of research findings into practice for underserved populations, we investigated the adaptation of an evidence-based intervention (EBI), designed to increase colorectal cancer (CRC) screening in one limited English-proficient (LEP) population (Chinese), for another LEP group (Vietnamese) with overlapping cultural and health beliefs. Methods Guided by Diffusion of Innovations Theory, we adapted the EBI to achieve greater reach. Core elements of the adapted intervention included: small media (a DVD and pamphlet) translated into Vietnamese from Chinese; medical assistants distributing the small media instead of a health educator; and presentations on CRC screening to the medical assistants. A quasi-experimental study examined CRC screening adherence among eligible Vietnamese patients at the intervention and control clinics, before and after the 24-month intervention. The proportion of the adherence was assessed using generalized linear mixed models that account for clustering under primary care providers and also within-patient correlation between baseline and follow up. Results Our study included two cross-sectional samples: 1,016 at baseline (604 in the intervention clinic and 412 in the control clinic) and 1,260 post-intervention (746 in the intervention and 514 in the control clinic), including appreciable overlaps between the two time points. Pre-post change in CRC screening over time, expressed as an odds ratio (OR) of CRC screening adherence by time, showed a marginally-significant greater increase in CRC screening adherence at the intervention clinic compared to the control clinic (the ratio of the two ORs = 1.42; 95% CI 0.95, 2.15). In the sample of patients who were non-adherent to CRC screening at baseline, compared to the control clinic, the intervention clinic had marginally-significant greater increase in FOBT (adjusted OR = 1.77; 95% CI 0.98, 3.18) and a statistically-significantly greater increase in CRC screening adherence (adjusted OR = 1.70; 95% CI 1.05, 2.75). Conclusions Theoretically guided adaptations of EBIs may accelerate the translation of research into practice. Adaptation has the potential to mitigate health disparities for hard-to-reach populations in a timely manner.
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Affiliation(s)
- Shin-Ping Tu
- Department of Medicine, Virginia Commonwealth University, 1201 East Marshall Street, Richmond, VA 23298, USA.
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Khullar K, Peitzmeier S, Koffman R, Potter J. Impact of electronic documentation on Pap screening rates in an urban health center. J Community Health 2014; 39:416-22. [PMID: 24481710 DOI: 10.1007/s10900-014-9822-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Providers and non-physician staff in primary care settings have reported barriers to full electronic health record (EHR) utilization. This study evaluates the effectiveness of EHR use for accurately documenting cervical cancer screening in a community healthcare setting, and proposes strategies to improve documentation. An electronic query generated data on average-risk patients aged 21-64 who had a medical visit at Fenway Health in 2012 and were overdue for a Papanicolaou (Pap) test according to the 2012 American Society for Colposcopy and Cervical Pathology guidelines. We then conducted a manual review of these records to determine the accuracy of EHR documentation. Of a total 5,279 patients, the electronic query classified 2,982 (56.5%) as up-to-date (UTD) for a Pap and 2,297 patients (43.5%) as overdue. Upon manual review, 65 (2.2%) patients thought to be UTD were actually overdue. Of those 2,297 patients classified by the query as overdue, 816 (35.5%) were reclassified as UTD due to evidence of a recent Pap in their chart that was not extractable by electronic query and 208 (9.1%) were ineligible for a Pap; only 1,272 patients (55.4%) of the 2,297 classified by the query were truly overdue. The cervical cancer screening rate indicated by electronic query was 56.5 %; after manual review, the adjusted rate was 73.6%. Overall, 1,090 patients (20.6%) were misclassified by the query. Inefficient EHR use can have serious implications for clinical practice and performance measures. Primary care practices need to develop mechanisms to capture outside medical records and create a team-based approach to facilitate accurate EHR documentation.
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Green BB, Wang CY, Anderson ML, Chubak J, Meenan RT, Vernon SW, Fuller S. An automated intervention with stepped increases in support to increase uptake of colorectal cancer screening: a randomized trial. Ann Intern Med 2013; 158:301-11. [PMID: 23460053 PMCID: PMC3953144 DOI: 10.7326/0003-4819-158-5-201303050-00002] [Citation(s) in RCA: 150] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Screening decreases colorectal cancer (CRC) incidence and mortality, yet almost half of age-eligible patients are not screened at recommended intervals. OBJECTIVE To determine whether interventions using electronic health records (EHRs), automated mailings, and stepped increases in support improve CRC screening adherence over 2 years. DESIGN 4-group, parallel-design, randomized, controlled comparative effectiveness trial with concealed allocation and blinded outcome assessments. (ClinicalTrials.gov: NCT00697047) SETTING 21 primary care medical centers. PATIENTS 4675 adults aged 50 to 73 years not current for CRC screening. INTERVENTION Usual care, EHR-linked mailings ("automated"), automated plus telephone assistance ("assisted"), or automated and assisted plus nurse navigation to testing completion or refusal ("navigated"). Interventions were repeated in year 2. MEASUREMENTS The proportion of participants current for screening in both years, defined as colonoscopy or sigmoidoscopy (year 1) or fecal occult blood testing (FOBT) in year 1 and FOBT, colonoscopy, or sigmoidoscopy (year 2). RESULTS Compared with those in the usual care group, participants in the intervention groups were more likely to be current for CRC screening for both years with significant increases by intensity (usual care, 26.3% [95% CI, 23.4% to 29.2%]; automated, 50.8% [CI, 47.3% to 54.4%]; assisted, 57.5% [CI, 54.5% to 60.6%]; and navigated, 64.7% [CI, 62.5% to 67.0%]; P < 0.001 for all pair-wise comparisons). Increases in screening were primarily due to increased uptake of FOBT being completed in both years (usual care, 3.9% [CI, 2.8% to 5.1%]; automated, 27.5% [CI, 24.9% to 30.0%]; assisted, 30.5% [CI, 27.9% to 33.2%]; and navigated, 35.8% [CI, 33.1% to 38.6%]). LIMITATION Participants were required to provide verbal consent and were more likely to be white and to participate in other types of cancer screening, limiting generalizability. CONCLUSION Compared with usual care, a centralized, EHR-linked, mailed CRC screening program led to twice as many persons being current for screening over 2 years. Assisted and navigated interventions led to smaller but significant stepped increases compared with the automated intervention only. The rapid growth of EHRs provides opportunities for spreading this model broadly.
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Affiliation(s)
- Beverly B Green
- Group Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101-1466, USA.
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Saleh KJ, Bozic KJ, Graham DB, Shaha SH, Swiontkowski MF, Wright JG, Robinson BS, Novicoff WM. Quality in orthopaedic surgery--an international perspective: AOA critical issues. J Bone Joint Surg Am 2013; 95:e3. [PMID: 23283380 DOI: 10.2106/jbjs.l.00093] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Quality is a hallmark of health care, although it is difficult to come to a consensus on who gets to define what "quality health care" is. Most health-care workers enter this field with the goal of improving the health of their patients (and the community), and while everyone tries to do the best job possible, we must continuously seek better methods and techniques for achieving better outcomes. The passion for continuous improvement is fundamental, but passion is not sufficient by itself. There is substantial opportunity to improve quality and reduce cost in health care. Multidisciplinary teams that include physicians, nurses, and other ancillary care providers have led to decreased waiting times to see specialists and have also led to better management of chronic disease. By including ancillary care, providers can increase cancer-screening rates and have the potential to decrease readmissions. Moreover, the addition of hospitalists and physician assistants can produce quality and efficiency outcomes that are commensurate with those enjoyed by traditional house staff. However, truly improving performance is difficult due to questions about how we define "quality," design care processes, measure inputs and outputs, develop multi-stakeholder collaborations, and develop incentive programs for delivering "good" care. There is a definite need for more thorough and robust studies of the impact of pay-for-performance programs, with the inclusion of ancillary care providers. Current research has not shown that there is not enough evidence to be able to determine what incentive structure might "work" in a particular health-care system. Payment systems will continue to evolve to incentivize greater collaboration among providers to yield higher-quality, lower-cost care. Future efforts will necessitate the need for strong physician leadership in helping to develop an optimal care team that is as patient-centered as possible. Technology adds dimensions of capability to making improvement real and systematic, as well as providing safer care with fewer errors and better adherence to proven best practices. The drive for quality with technology produces better clinical outcomes and maximizes efficiencies and financial metrics of organizational performance. Technology also adds capabilities for capturing key metrics and reporting them back to clinicians and others. Improved data transparency informs those who can actually do things differently to produce better results and outcomes. While health-care entities strive to focus on quality of care, measuring and reporting such care in a meaningful way are difficult. The best chance of improving overall care for patients is through the adoption of systems that improve coordination and continuity, not by health-care staff working harder. Only through collaboration and integration can health care incorporate a culture for improving quality and patient safety.
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Affiliation(s)
- Khaled J Saleh
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL 62702, USA.
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Ahluwalia SC, Leos RL, Goebel JR, Asch SM, Lorenz KA. Provider approaches to palliative dyspnea assessment: implications for informatics-based clinical tools. Am J Hosp Palliat Care 2012; 30:231-8. [PMID: 22669935 DOI: 10.1177/1049909112448922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
AIM To understand provider practices around dyspnea assessment to inform the development of an electronic medical record (EMR)-based dyspnea assessment module in an inpatient palliative care consultation template. DESIGN Qualitative analysis of palliative care provider interviews. RESULTS Three themes emerged: (1) integration of patient self-report of breathlessness with a clinical observation of dyspnea; (2) identification of patients for dyspnea assessment based on perceived patient need; and (3) variability in preferences for and use of existing severity scales for dyspnea. CONCLUSIONS The assessment approaches described by providers underscore the challenge of developing an informatics tool that supports the natural clinical experience and facilitates standardized care. The complexity of the dyspnea assessment process and variation in provider practices necessitate a level of flexibility and choice to be built into a computer-based tool.
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Affiliation(s)
- Sangeeta C Ahluwalia
- Center for the Study of Healthcare Provider Behavior, VA Greater Los Angeles Healthcare System, CA 90064, USA.
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Saba GW, Villela TJ, Chen E, Hammer H, Bodenheimer T. The myth of the lone physician: toward a collaborative alternative. Ann Fam Med 2012; 10:169-73. [PMID: 22412010 PMCID: PMC3315136 DOI: 10.1370/afm.1353] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Cultural values and beliefs about the primary care physician bolster the myth of the lone physician: a competent professional who is esteemed by colleagues and patients for his or her willingness to sacrifice self, accept complete responsibility for care, maintain continuity and accessibility, and assume the role of lone decision maker in clinical care. Yet the reality of current primary care models is often fragmented, impersonal care for patients and isolation and burnout for many primary care physicians. An alternative to the mythological lone physician would require a paradigm shift that places the primary care physician within the context of a highly functioning health care team. This new mythology better fulfills the collaborative, interprofessional, patient-centered needs of new models of care, and might help to ensure that the work of primary care physicians remains compassionate, gratifying, and meaningful.
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Affiliation(s)
- George W Saba
- University of California, San Francisco at the San Francisco General Hospital, San Francisco, California, USA.
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Bronner JP, Fontanesi J, Goel A. Improving Prompt Effectiveness in Diabetes Care. Am J Med Qual 2012; 27:406-10. [DOI: 10.1177/1062860611430378] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Curry WJ, Lengerich EJ, Kluhsman BC, Graybill MA, Liao JZ, Schaefer EW, Spleen AM, Dignan MB. Academic detailing to increase colorectal cancer screening by primary care practices in Appalachian Pennsylvania. BMC Health Serv Res 2011; 11:112. [PMID: 21600059 PMCID: PMC3128846 DOI: 10.1186/1472-6963-11-112] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Accepted: 05/23/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the United States, colorectal cancer (CRC) is the third most frequently diagnosed cancer and second leading cause of cancer death. Screening is a primary method to prevent CRC, yet screening remains low in the U.S. and particularly in Appalachian Pennsylvania, a largely rural area with high rates of poverty, limited health care access, and increased CRC incidence and mortality rates. Receiving a physician recommendation for CRC screening is a primary predictor for patient adherence with screening guidelines. One strategy to disseminate practice-oriented interventions is academic detailing (AD), a method that transfers knowledge or methods to physicians, nurses or office staff through the visit(s) of a trained educator. The objective of this study was to determine acceptability and feasibility of AD among primary care practices in rural Appalachian Pennsylvania to increase CRC screening. METHODS A multi-site, practice-based, intervention study with pre- and 6-month post-intervention review of randomly selected medical records, pre- and post-intervention surveys, as well as a post-intervention key informant interview was conducted. The primary outcome was the proportion of patients current with CRC screening recommendations and having received a CRC screening within the past year. Four practices received three separate AD visits to review four different learning modules. RESULTS We reviewed 323 records pre-intervention and 301 post-intervention. The prevalence of being current with screening recommendation was 56% in the pre-intervention, and 60% in the post-intervention (p=0.29), while the prevalence of having been screened in the past year increased from 17% to 35% (p<0.001). Colonoscopies were the most frequently performed screening test. Provider knowledge was improved and AD was reported to be an acceptable intervention for CRC performance improvement by the practices. CONCLUSIONS AD appears to be acceptable and feasible for primary care providers in rural Appalachia. A ceiling effect for CRC screening may have been a factor in no change in overall screening rates. While the study was not designed to test the efficacy of AD on CRC screening rates, our evidence suggests that AD is acceptable and may be efficacious in increasing recent CRC screening rates in Appalachian practices which could be tested through a randomized controlled study.
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Affiliation(s)
- William J Curry
- Department of Family and Community Medicine, College of Medicine, The Pennsylvania State University, Hershey, PA 17033-0850, USA
- Penn State Ambulatory Research Network, The Pennsylvania State University, Hershey, PA 17033-0850, USA
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA 17033-0855, USA
| | - Eugene J Lengerich
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA 17033-0855, USA
- Penn State Hershey Cancer Institute, The Pennsylvania State University, Hershey, PA 17033-0850, USA
| | - Brenda C Kluhsman
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA 17033-0855, USA
- Penn State Hershey Cancer Institute, The Pennsylvania State University, Hershey, PA 17033-0850, USA
| | - Marie A Graybill
- Department of Family and Community Medicine, College of Medicine, The Pennsylvania State University, Hershey, PA 17033-0850, USA
- Penn State Ambulatory Research Network, The Pennsylvania State University, Hershey, PA 17033-0850, USA
| | - Jason Z Liao
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA 17033-0855, USA
- Penn State Hershey Cancer Institute, The Pennsylvania State University, Hershey, PA 17033-0850, USA
| | - Eric W Schaefer
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA 17033-0855, USA
| | - Angela M Spleen
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA 17033-0855, USA
| | - Mark B Dignan
- Department of Internal Medicine, University of Kentucky, Lexington, KY 40506-0093, USA
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Denberg TD, Kraus H, Soenksen A, Mizrahi T, Shields L, Lin CT. Rates of screening colonoscopy are not increased when women are offered a female endoscopist in a health promotion outreach program. Gastrointest Endosc 2010; 72:1014-9. [PMID: 20822769 DOI: 10.1016/j.gie.2010.06.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Accepted: 06/03/2010] [Indexed: 01/16/2023]
Abstract
BACKGROUND In surveys, almost 50% of women prefer a female endoscopist (FE) to perform their screening colonoscopies (SCOs). OBJECTIVE To assess whether offering women an FE is associated with higher rates of SCOs. DESIGN Prospective cohort study. SETTING University of Colorado Hospital primary care clinics. PATIENTS Women of ages 50 to 69 years eligible for an SCO. INTERVENTIONS SCO offers through mail and telephone outreach, with and without an explicit FE option. MAIN OUTCOME MEASUREMENTS Outreach intervention differences in SCO completion rates and percentages of women requesting FE. RESULTS Of 396 women, 72 (18.2%) underwent SCO without difference by type of invitation. Women who received an FE invitation were more likely to request an FE than patients who received no invitation (44.2% and 4.8%, respectively, P < .001), but women who requested an FE were not more likely to undergo an SCO than those who did not. LIMITATIONS SCO was offered through an outreach program rather than through in-clinic referrals. The study used a nonrandomized trial comparison group. CONCLUSIONS Women offered an FE were not more likely to undergo an SCO than those who were not. This study is unique in describing outcomes associated with actual offers of an FE at the time of scheduling. More direct evidence is needed to support the notion that the absence of FEs is an important barrier to colorectal cancer screening among women.
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Affiliation(s)
- Thomas D Denberg
- Quality and Safety, Harvard Vanguard/Atrius Health, Newton, Massachusetts 02466-2272, USA.
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