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Hoyt CR, Luo L, Rice HE, Shivakumar N, Housten AJ, Picinich A, Qashou N, Harris KM, Varughese T, King AA. "Everyone screens to some extent": Barriers and facilitators of developmental screening among children with sickle cell disease: A mixed methods study. Pediatr Blood Cancer 2024; 71:e31060. [PMID: 38757454 PMCID: PMC11304544 DOI: 10.1002/pbc.31060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/12/2024] [Accepted: 04/27/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Developmental delays are common among children with sickle cell disease (SCD). Existing guidelines support consistent screening to increase the identification of deficits and support referral to rehabilitative interventions, yet adherence remains variable. This study sought to assess current practices and identify barriers and facilitators to improve developmental screening for children 0-3 years with SCD. PROCEDURE A mixed methods approach, guided by the Exploration and Preparation stages of the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework, assessed developmental screening practices among primary care providers and hematologists. Phase 1 included the SCD Developmental Surveillance and Screening Guideline and Practice Survey. Phase 2 included the SCD Developmental Screening Organizational Survey alongside semi-structured interviews. Descriptive and qualitative methods summarized the findings. RESULTS Thirty-three providers from general pediatrics and hematology completed phase 1. Use of standardized developmental screening measures was variable, with the most frequently used being the Modified Checklist for Autism in Toddlers (77%) and the Ages and Stages Questionnaire (55%). Fifteen providers participated in phase 2, and reported they were most likely to engage in changes to improve their practice (mean = 4.4/5) and least likely to support spiritual health and well-being (mean = 3.5/5). Three themes emerged:(i) developmental screening is not standardized or specific to SCD, (ii) children with SCD benefit from a multidisciplinary team, and (iii) healthcare system limitations are a barrier. CONCLUSIONS Developmental screening is inconsistent and insufficient for young children with SCD. Providers are interested in supporting children with SCD, but report a lack of standardized measures and consistent guidance as barriers.
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Affiliation(s)
- Catherine R. Hoyt
- Washington University School of Medicine, Program in Occupational Therapy, St. Louis, MO USA
- Washington University School of Medicine, Department of Pediatrics, St. Louis, MO USA
- Washington University School of Medicine, Department of Neurology, St. Louis, MO USA
| | - Lingzi Luo
- New York University, School of Global Public Health, New York, New York, USA
| | - Hannah E. Rice
- Washington University School of Medicine, Division of Public Health Sciences, Department of Surgery, St. Louis, MO USA
| | - Nirmala Shivakumar
- Washington University School of Medicine, Department of Medicine, St. Louis, MO USA
| | - Ashley J. Housten
- Washington University School of Medicine, Program in Occupational Therapy, St. Louis, MO USA
- Washington University School of Medicine, Division of Public Health Sciences, Department of Surgery, St. Louis, MO USA
| | - Abigail Picinich
- Washington University School of Medicine, Department of Pediatrics, St. Louis, MO USA
| | - Nai Qashou
- Washington University School of Medicine, Department of Pediatrics, St. Louis, MO USA
| | - Kelly M. Harris
- Washington University School of Medicine, Program in Occupational Therapy, St. Louis, MO USA
- Washington University School of Medicine, Division of Public Health Sciences, Department of Surgery, St. Louis, MO USA
| | - Taniya Varughese
- Washington University School of Medicine, Department of Pediatrics, St. Louis, MO USA
| | - Allison A. King
- Washington University School of Medicine, Program in Occupational Therapy, St. Louis, MO USA
- Washington University School of Medicine, Department of Pediatrics, St. Louis, MO USA
- Washington University School of Medicine, Division of Public Health Sciences, Department of Surgery, St. Louis, MO USA
- Washington University School of Medicine, Department of Medicine, St. Louis, MO USA
- Washington University School of Medicine, Department of Education, St. Louis, MO USA
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O'Malley DM, Crabtree BF, Kaloth S, Ohman-Strickland P, Ferrante J, Hudson SV, Kinney AY. Strategic use of resources to enhance colorectal cancer screening for patients with diabetes (SURE: CRC4D) in federally qualified health centers: a protocol for hybrid type ii effectiveness-implementation trial. BMC PRIMARY CARE 2024; 25:242. [PMID: 38969987 PMCID: PMC11225128 DOI: 10.1186/s12875-024-02496-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Accepted: 06/26/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND Persons with diabetes have 27% elevated risk of developing colorectal cancer (CRC) and are disproportionately from priority health disparities populations. Federally qualified health centers (FQHCs) struggle to implement CRC screening programs for average risk patients. Strategies to effectively prioritize and optimize CRC screening for patients with diabetes in the primary care safety-net are needed. METHODS Guided by the Exploration, Preparation, Implementation and Sustainment Framework, we conducted a stakeholder-engaged process to identify multi-level change objectives for implementing optimized CRC screening for patients with diabetes in FQHCs. To identify change objectives, an implementation planning group of stakeholders from FQHCs, safety-net screening programs, and policy implementers were assembled and met over a 7-month period. Depth interviews (n = 18-20) with key implementation actors were conducted to identify and refine the materials, methods and strategies needed to support an implementation plan across different FQHC contexts. The planning group endorsed the following multi-component implementation strategies: identifying clinic champions, development/distribution of patient educational materials, developing and implementing quality monitoring systems, and convening clinical meetings. To support clinic champions during the initial implementation phase, two learning collaboratives and bi-weekly virtual facilitation will be provided. In single group, hybrid type 2 effectiveness-implementation trial, we will implement and evaluate these strategies in a in six safety net clinics (n = 30 patients with diabetes per site). The primary clinical outcomes are: (1) clinic-level colonoscopy uptake and (2) overall CRC screening rates for patients with diabetes assessed at baseline and 12-months post-implementation. Implementation outcomes include provider and staff fidelity to the implementation plan, patient acceptability, and feasibility will be assessed at baseline and 12-months post-implementation. DISCUSSION Study findings are poised to inform development of evidence-based implementation strategies to be tested for scalability and sustainability in a future hybrid 2 effectiveness-implementation clinical trial. The research protocol can be adapted as a model to investigate the development of targeted cancer prevention strategies in additional chronically ill priority populations. TRIAL REGISTRATION This study was registered in ClinicalTrials.gov (NCT05785780) on March 27, 2023 (last updated October 21, 2023).
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Affiliation(s)
- Denalee M O'Malley
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, 303 George Street, Rm 309, New Brunswick, NJ, USA.
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.
| | - Benjamin F Crabtree
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, 303 George Street, Rm 309, New Brunswick, NJ, USA
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Srivarsha Kaloth
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, 303 George Street, Rm 309, New Brunswick, NJ, USA
| | - Pamela Ohman-Strickland
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, 303 George Street, Rm 309, New Brunswick, NJ, USA
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, School of Public Health, Rutgers University, New Brunswick, NJ, USA
| | - Jeanne Ferrante
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, 303 George Street, Rm 309, New Brunswick, NJ, USA
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Shawna V Hudson
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, 303 George Street, Rm 309, New Brunswick, NJ, USA
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Anita Y Kinney
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, School of Public Health, Rutgers University, New Brunswick, NJ, USA
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Quigley DD, Slaughter ME, Qureshi N, Hays RD. Associations of Primary Care Provider Burnout with Quality Improvement, Patient Experience Measurement, Clinic Culture, and Job Satisfaction. J Gen Intern Med 2024; 39:1567-1574. [PMID: 38273070 PMCID: PMC11255139 DOI: 10.1007/s11606-024-08633-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 01/12/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND Burnout among providers negatively impacts patient care experiences and safety. Providers at Federally Qualified Health Centers (FQHC) are at high risk for burnout due to high patient volumes; inadequate staffing; and balancing the demands of patients, families, and team members. OBJECTIVE Examine associations of provider burnout with their perspectives on quality improvement (QI), patient experience measurement, clinic culture, and job satisfaction. DESIGN We conducted a cross-sectional provider survey about their perspectives including the single-item burnout measure. We fit separate regression models, controlling for provider type, gender, being multilingual, and fixed effects for clinic predicting outcome measures from burnout. PARTICIPANTS Seventy-four providers from 44 clinics in large, urban FQHC (52% response rate; n = 174). MAIN MEASURES Survey included a single-item, self-defined burnout measure adapted from the Physician Worklife Survey, and measures from the RAND AMA Study survey, Heath Tracking Physician survey, TransforMed Clinician and Staff Questionnaire, Physician Worklife Survey, Minimizing Errors Maximizing Outcomes survey, and surveys by Friedberg et al. 31 and Walling et al. 32 RESULTS: Thirty percent of providers reported burnout. Providers in clinics with more facilitative leadership reported not being burned out (compared to those reporting burnout; p-values < 0.05). More pressures related to patient care and lower job satisfaction were associated with burnout (p-values < 0.05). CONCLUSIONS Creating provider-team relationships and environments where providers have the time and space necessary to discuss changes to improve care, ideas are shared, leadership supports QI, and QI is monitored and discussed were related to not being burned out. Reducing time pressures and improving support needed for providers to address the high-need levels of FQHC patients can also decrease burnout. Such leadership and support to improving care may be a separate protective factor against burnout. Research is needed to further examine which aspects of leadership drive down burnout and increase provider involvement in change efforts and improving care.
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Affiliation(s)
- Denise D Quigley
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, USA.
| | | | - Nabeel Qureshi
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, USA
| | - Ron D Hays
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, USA
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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Gago C, De Leon E, Mandal S, de la Calle F, Garcia M, Colella D, Dapkins I, Schoenthaler A. "Hypertension is such a difficult disease to manage": federally qualified health center staff- and leadership-perceived readiness to implement a technology-facilitated team-based hypertension model. Implement Sci Commun 2024; 5:49. [PMID: 38698497 PMCID: PMC11067286 DOI: 10.1186/s43058-024-00587-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 04/25/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Despite decades of evidence demonstrating the efficacy of hypertension care delivery in reducing morbidity and mortality, a majority of hypertension cases remain uncontrolled. There is an urgent need to elucidate and address multilevel facilitators and barriers clinical staff face in delivering evidence-based hypertension care, patients face in accessing it, and clinical systems face in sustaining it. Through a rigorous pre-implementation evaluation, we aimed to identify facilitators and barriers bearing the potential to affect the planned implementation of a multilevel technology-facilitated hypertension management trial across six primary care sites in a large federally qualified health center (FQHC) in New York City. METHODS During a dedicated pre-implementation period (3-9 months/site, 2021-2022), a capacity assessment was conducted by trained practice facilitators, including (1) online anonymous surveys (n = 124; 70.5% of eligible), (2) hypertension training analytics (n = 69; 94.5% of assigned), and (3) audio-recorded semi-structured interviews (n = 67; 48.6% of eligible) with FQHC leadership and staff. Surveys measured staff sociodemographic characteristics, adaptive reserve, evidence-based practice attitudes, and implementation leadership scores via validated scales. Training analytics, derived from end-of-course quizzes, included mean score and number attempts needed to pass. Interviews assessed staff-reported facilitators and barriers to current hypertension care delivery and uptake; following audio transcription, trained qualitative researchers employed a deductive coding approach, informed by the Consolidated Framework for Implementation Research (CFIR). RESULTS Most survey respondents reported moderate adaptive reserve (mean = 0.7, range = 0-1), evidence-based practice attitudes (mean = 2.7, range = 0-4), and implementation leadership (mean = 2.5, range = 0-4). Most staff passed training courses on first attempt and demonstrated high scores (means > 80%). Findings from interviews identified potential facilitators and barriers to implementation; specifically, staff reported that complex barriers to hypertension care, control, and clinical communication exist; there is a recognized need to improve hypertension care; in-clinic challenges with digital tool access imposes workflow delays; and despite high patient loads, staff are motivated to provide high-quality cares. CONCLUSIONS This study serves as one of the first to apply the CFIR to a rigorous pre-implementation evaluation within the understudied context of a FQHC and can serve as a model for similar trials seeking to identify and address contextual factors known to impact implementation success. TRIAL REGISTRATION ClinicalTrials.gov NCT03713515 , date of registration: October 19, 2018.
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Affiliation(s)
- Cristina Gago
- Institute for Excellence in Health Equity, NYU Langone Health, 180 Madison Avenue, 7th Floor, New York, NY, 10016, USA.
| | - Elaine De Leon
- Institute for Excellence in Health Equity, NYU Langone Health, 180 Madison Avenue, 7th Floor, New York, NY, 10016, USA
| | - Soumik Mandal
- Institute for Excellence in Health Equity, NYU Langone Health, 180 Madison Avenue, 7th Floor, New York, NY, 10016, USA
| | - Franze de la Calle
- Institute for Excellence in Health Equity, NYU Langone Health, 180 Madison Avenue, 7th Floor, New York, NY, 10016, USA
| | - Masiel Garcia
- Family Health Centers at NYU Langone, Brooklyn, NY, USA
| | | | - Isaac Dapkins
- Family Health Centers at NYU Langone, Brooklyn, NY, USA
| | - Antoinette Schoenthaler
- Institute for Excellence in Health Equity, NYU Langone Health, 180 Madison Avenue, 7th Floor, New York, NY, 10016, USA
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Rodriguez SA, Lee SC, Higashi RT, Chen PM, Eary RL, Sadeghi N, Santini N, Balasubramanian BA. Factors influencing implementation of a care coordination intervention for cancer survivors with multiple comorbidities in a safety-net system: an application of the Implementation Research Logic Model. Implement Sci 2023; 18:68. [PMID: 38049844 PMCID: PMC10694894 DOI: 10.1186/s13012-023-01326-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 11/24/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Under- and uninsured cancer survivors have significant medical, social, and economic complexity. For these survivors, effective care coordination between oncology and primary care teams is critical for high-quality, comprehensive care. While evidence-based interventions exist to improve coordination between healthcare teams, testing implementation of these interventions for cancer survivors seen in real-world safety-net settings has been limited. This study aimed to (1) identify factors influencing implementation of a multicomponent care coordination intervention (nurse coordinator plus patient registry) focused on cancer survivors with multiple comorbidities in an integrated safety-net system and (2) identify mechanisms through which the factors impacted implementation outcomes. METHODS We conducted semi-structured interviews (patients, providers, and system leaders), structured observations of primary care and oncology operations, and document analysis during intervention implementation between 2016 and 2020. The practice change model (PCM) guided data collection to identify barriers and facilitators of implementation; the PCM, Consolidated Framework for Implementation Research, and Implementation Research Logic Model guided four immersion/crystallization data analysis and synthesis cycles to identify mechanisms and assess outcomes. Implementation outcomes included appropriateness, acceptability, adoption, and penetration. RESULTS The intervention was appropriate and acceptable to primary care and oncology teams based on reported patient needs and resources and the strength of the evidence supporting intervention components. Active and sustained partnership with system leaders facilitated these outcomes. There was limited adoption and penetration early in implementation because the study was narrowly focused on just breast and colorectal cancer patients. This created barriers to real-world practice where patients with all cancer types receive care. Over time, flexibility intentionally designed into intervention implementation facilitated adoption and penetration. Regular feedback from system partners and rapid cycles of implementation and evaluation led to real-time adaptations increasing adoption and penetration. DISCUSSION Evidence-based interventions to coordinate care for underserved cancer survivors across oncology and primary care teams can be implemented successfully when system leaders are actively engaged and with flexibility in implementation embedded intentionally to continuously facilitate adoption and penetration across the health system.
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Affiliation(s)
- Serena A Rodriguez
- Department of Health Promotion & Behavioral Sciences, School of Public Health, The University of Texas Health Science Center at Houston (UTHealth Houston), 2777 North Stemmons Freeway, Dallas, TX, 75207, USA.
- Center for Health Promotion & Prevention Research, UTHealth Houston School of Public Health, 7000 Fannin, Houston, TX, 77030, USA.
- UTHealth Houston Institute for Implementation Science, 2777 North Stemmons Freeway, Dallas, TX, 75207, USA.
| | - Simon Craddock Lee
- Department of Population Health, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
- University of Kansas Cancer Center, 2650 Shawnee Mission Parkway, Westwood, KS, 66205, USA
| | - Robin T Higashi
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Patricia M Chen
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Rebecca L Eary
- Department of Family and Community Medicine, University of Texas Southwestern Medical Center, 5939 Harry Hines Blvd., Suite 303, Dallas, TX, 75390, USA
| | - Navid Sadeghi
- Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, 6202 Harry Hines Blvd, Dallas, TX, 75235, USA
- Parkland Health, 5200 Harry Hines Blvd, Dallas, TX, 75235, USA
| | - Noel Santini
- Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
- Parkland Health, 5200 Harry Hines Blvd, Dallas, TX, 75235, USA
| | - Bijal A Balasubramanian
- Center for Health Promotion & Prevention Research, UTHealth Houston School of Public Health, 7000 Fannin, Houston, TX, 77030, USA
- UTHealth Houston Institute for Implementation Science, 2777 North Stemmons Freeway, Dallas, TX, 75207, USA
- Department of Epidemiology, Human Genetics & Environmental Sciences, UTHealth Houston School of Public Health, 2777 North Stemmons Freeway, Dallas, TX, 75207, USA
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Piotrowski A, Coenen J, Rupietta C, Basten J, Muth C, Söling S, Zimmer V, Karbach U, Kellermann-Mühlhoff P, Köberlein-Neu J. Factors facilitating the implementation of a clinical decision support system in primary care practices: a fuzzy set qualitative comparative analysis. BMC Health Serv Res 2023; 23:1161. [PMID: 37884934 PMCID: PMC10605331 DOI: 10.1186/s12913-023-10156-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/16/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Understanding how to implement innovations in primary care practices is key to improve primary health care. Aiming to contribute to this understanding, we investigate the implementation of a clinical decision support system (CDSS) as part of the innovation fund project AdAM (01NVF16006). Originating from complexity theory, the practice change and development model (PCD) proposes several interdependent factors that enable organizational-level change and thus accounts for the complex settings of primary care practices. Leveraging the PCD, we seek to answer the following research questions: Which combinations of internal and external factors based on the PCD contribute to successful implementation in primary care practices? Given these results, how can implementation in the primary care setting be improved? METHODS We analyzed the joint contributions of internal and external factors on implementation success using qualitative comparative analysis (QCA). QCA is a set-theoretic approach that allows to identify configurations of multiple factors that lead to one outcome (here: successful implementation of a CDSS in primary care practices). Using survey data, we conducted our analysis based on a sample of 224 primary care practices. RESULTS We identified two configurations of internal and external factors that likewise enable successful implementation. The first configuration enables implementation based on a combination of Strong Inside Motivation, High Capability for Development, and Strong Outside Motivation; the second configuration based on a combination of Strong Inside Motivators, Many Options for Development and the absence of High Capability for Development. CONCLUSION In line with the PCD, our results demonstrate the importance of the combination of internal and external factors for implementation outcomes. Moreover, the two identified configurations show that different ways exist to achieve successful implementation in primary care practices. TRIAL REGISTRATION AdAM was registered on ClinicalTrials.gov ( NCT03430336 ) on February 6, 2018.
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Affiliation(s)
- Alexandra Piotrowski
- Center for Health Economics and Health Services Research, University of Wuppertal, Wuppertal, Germany.
- Chair of General Practice II and Patient-Centeredness in Primary Care, Institute of General Practice and Primary Care, Faculty of Health, Witten/Herdecke University, Witten, Germany.
| | - Jana Coenen
- Jackstädt Center of Entrepreneurship and Innovation Research, University of Wuppertal, Wuppertal, Germany
| | - Christian Rupietta
- Jackstädt Center of Entrepreneurship and Innovation Research, University of Wuppertal, Wuppertal, Germany
- Queen's Business School, Queen's University Belfast, Belfast, UK
| | - Jale Basten
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum, Bochum, Germany
| | - Christiane Muth
- Department of General Practice and Family Medicine, Medical School OWL, Bielefeld University, Bielefeld, Germany
| | - Sara Söling
- Center for Health Economics and Health Services Research, University of Wuppertal, Wuppertal, Germany
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Department of Rehabilitation and Special Education, Faculty of Human Sciences, University of Cologne, Cologne, Germany
| | - Viola Zimmer
- Center for Health Economics and Health Services Research, University of Wuppertal, Wuppertal, Germany
| | - Ute Karbach
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Department of Rehabilitation and Special Education, Faculty of Human Sciences, University of Cologne, Cologne, Germany
| | | | - Juliane Köberlein-Neu
- Center for Health Economics and Health Services Research, University of Wuppertal, Wuppertal, Germany
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Freund J, Ebert DD, Thielecke J, Braun L, Baumeister H, Berking M, Titzler I. Using the Consolidated Framework for Implementation Research to evaluate a nationwide depression prevention project (ImplementIT) from the perspective of health care workers and implementers: Results on the implementation of digital interventions for farmers. Front Digit Health 2023; 4:1083143. [PMID: 36761450 PMCID: PMC9907445 DOI: 10.3389/fdgth.2022.1083143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 12/28/2022] [Indexed: 01/24/2023] Open
Abstract
Introduction Depression has a significant impact on individuals and society, which is why preventive measures are important. Farmers represent an occupational group exposed to many risk factors for depression. The potential of guided, tailored internet-based interventions and a personalized telephone coaching is evaluated in a German project of the Social Insurance for Agriculture, Forestry and Horticulture (SVLFG). While user outcomes are promising, not much is known about actual routine care use and implementation of the two digital health interventions. This study evaluates the implementation from the perspective of social insurance employees to understand determinants influencing the uptake and implementation of digital interventions to prevent depression in farmers. Methods The data collection and analysis are based on the Consolidated Framework for Implementation Research (CFIR). Health care workers (n = 86) and implementers (n = 7) completed online surveys and/or participated in focus groups. The surveys consisted of validated questionnaires used in implementation research, adapted items from the CFIR guide or from other CFIR studies. In addition, we used reporting data to map implementation based on selected CFIR constructs. Results Within the five CFIR dimensions, many facilitating factors emerged in relation to intervention characteristics (e.g., relative advantage compared to existing services, evidence and quality) and the inner setting of the SVLFG (e.g., tension for change, compatibility with values and existing working processes). In addition, barriers to implementation were identified in relation to the outer setting (patient needs and resources), inner setting (e.g., available resources, access to knowledge and information) and characteristics of individuals (e.g., self-efficacy). With regard to the implementation process, facilitating factors (formal implementation leaders) as well as hindering factors (reflecting and evaluating) were identified. Discussion The findings shed light on the implementation of two digital prevention services in an agricultural setting. While both offerings seem to be widely accepted by health care workers, the results also point to revealed barriers and contribute to recommendations for further service implementation. For instance, special attention should be given to "patient needs and resources" by raising awareness of mental health issues among the target population as well as barriers regarding the inner setting. Clinical Trial Registration German Clinical Trial Registration: [DRKS00017078]. Registered on 18.04.2019.
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Affiliation(s)
- Johanna Freund
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- TUM Department of Sport and Health Sciences, TU Munich, Munich, Germany
| | | | - Janika Thielecke
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- TUM Department of Sport and Health Sciences, TU Munich, Munich, Germany
| | - Lina Braun
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - Harald Baumeister
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - Matthias Berking
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Ingrid Titzler
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Kegler MC, Rana S, Vandenberg AE, Hastings SN, Hwang U, Eucker SA, Vaughan CP. Use of the consolidated framework for implementation research in a mixed methods evaluation of the EQUIPPED medication safety program in four academic health system emergency departments. FRONTIERS IN HEALTH SERVICES 2022; 2:1053489. [PMID: 36925898 PMCID: PMC10012623 DOI: 10.3389/frhs.2022.1053489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/15/2022] [Indexed: 12/13/2022]
Abstract
Background Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED) is an effective quality improvement program initially designed in the Veterans Administration (VA) health care system to reduce potentially inappropriate medication prescribing for adults aged 65 years and older. This study examined factors that influence implementation of EQUIPPED in EDs from four distinct, non-VA academic health systems using a convergent mixed methods design that operationalized the Consolidated Framework for Implementation Research (CFIR). Fidelity of delivery served as the primary implementation outcome. Materials and methods Four EDs implemented EQUIPPED sequentially from 2017 to 2021. Using program records, we scored each ED on a 12-point fidelity index calculated by adding the scores (1-3) for each of four components of the EQUIPPED program: provider receipt of didactic education, one-on-one academic detailing, monthly provider feedback reports, and use of order sets. We comparatively analyzed qualitative data from focus groups with each of the four implementation teams (n = 22) and data from CFIR-based surveys of ED providers (108/234, response rate of 46.2%) to identify CFIR constructs that distinguished EDs with higher vs. lower levels of implementation. Results Overall, three sites demonstrated higher levels of implementation (scoring 8-9 of 12) and one ED exhibited a lower level (scoring 5 of 12). Two constructs distinguished between levels of implementation as measured through both quantitative and qualitative approaches: patient needs and resources, and organizational culture. Implementation climate distinguished level of implementation in the qualitative analysis only. Networks and communication, and leadership engagement distinguished level of implementation in the quantitative analysis only. Discussion Using CFIR, we demonstrate how a range of factors influence a critical implementation outcome and build an evidence-based approach on how to prime an organizational setting, such as an academic health system ED, for successful implementation. Conclusion This study provides insights into implementation of evidence-informed programs targeting medication safety in ED settings and serves as a potential model for how to integrate theory-based qualitative and quantitative methods in implementation studies.
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Affiliation(s)
- Michelle C. Kegler
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Shaheen Rana
- School of Medicine, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | | | | | - Ula Hwang
- Yale University School of Medicine, New Haven, CT, United States
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Gresh A, Hofley C, Acosta J, Mendelson T, Kennedy C, Platt R. Examining Processes of Care Redesign: Direct Observation of Group Well-Child Care. Clin Pediatr (Phila) 2022; 62:423-432. [PMID: 36286247 DOI: 10.1177/00099228221133138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We sought to describe processes of psychosocial screening and discussion with immigrant Latino families in the context of group well-child care. We conducted longitudinal direct observations of the 1-, 2-, 4-, and 6-month visits of 7 group well-child care cohorts at an academic pediatric clinic using unstructured observations of visit and group processes as well as structured observations to code facilitators' behavior. A range of psychosocial and social determinants of health topics were incorporated into discussions. In general, providers skillfully navigated group discussions, but inconsistently introduced the visit purpose. Asking participants to define psychosocial terms (eg, stress) and conversations about managing fussy infants were effective strategies to engage families in psychosocial discussions (eg, about postpartum depression). Some challenges with workflow were identified. Strategies to enhance screening and discussion of psychosocial topics may benefit from adaptation to maximize the effectiveness of this care mechanism.
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Affiliation(s)
- Ashley Gresh
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | - Carolyn Hofley
- Georgetown University School of Medicine, Washington, DC, USA
| | - Jennifer Acosta
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tamar Mendelson
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Caitlin Kennedy
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Rheanna Platt
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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10
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Beima-Sofie K, Wagner AD, Soi C, Liu W, Tollefson D, Njuguna IN, Ogutu E, Gaitho D, Mburu N, Oluoch G, Mwaura P, Cherutich P, Oyiengo L, John-Stewart GC, Nduati R, Sherr K, Gimbel S. Providing "a beam of light to see the gaps": determinants of implementation of the Systems Analysis and Improvement Approach applied to the pediatric and adolescent HIV cascade in Kenya. Implement Sci Commun 2022; 3:73. [PMID: 35842734 PMCID: PMC9287987 DOI: 10.1186/s43058-022-00304-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 05/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background Children and adolescents living with HIV have poorer rates of HIV testing, treatment, and virologic suppression than adults. Strategies that use a systems approach to optimize these multiple, linked steps simultaneously are critical to close these gaps. Methods The Systems Analysis and Improvement Approach (SAIA) was adapted and piloted for the pediatric and adolescent HIV care and treatment cascade (SAIA-PEDS) at 6 facilities in Kenya. SAIA-PEDS includes three tools: continuous quality improvement (CQI), flow mapping, and pediatric cascade analysis (PedCAT). A predominately qualitative evaluation utilizing focus group discussions (N = 6) and in-depth interviews (N = 19) was conducted with healthcare workers after implementation to identify determinants of implementation. Data collection and analysis were grounded in the Consolidated Framework for Implementation Research (CFIR). Results Overall, the adapted SAIA-PEDS strategy was acceptable, and the three tools complemented one another and provided a relative advantage over existing processes. The flow mapping and CQI tools were compatible with existing workflows and resonated with team priorities and goals while providing a structure for group problem solving that transcended a single department’s focus. The PedCAT was overly complex, making it difficult to use. Leadership and hierarchy were complex determinants. All teams reported supportive leadership, with some describing in detail how their leadership was engaged and enthusiastic about the SAIA-PEDS process, by providing recognition, time, and resources. Hierarchy was similarly complex: in some facilities, leadership stifled rapid innovation by insisting on approving each change, while at other facilities, leadership had strong and supportive oversight of processes, checking on the progress frequently and empowering teams to test innovative ideas. Conclusion CQI and flow mapping were core components of SAIA-PEDS, with high acceptability and consistent use, but the PedCAT was too complex. Leadership and hierarchy had a nuanced role in implementation. Future SAIA-PEDS testing should address PedCAT complexity and further explore the modifiability of leadership engagement to maximize implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-022-00304-3.
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Affiliation(s)
| | - Anjuli D Wagner
- Department of Global Health, University of Washington, Seattle, USA.
| | - Caroline Soi
- Department of Global Health, University of Washington, Seattle, USA
| | - Wenjia Liu
- Department of Child, Family & Population Health Nursing, University of Washington, Seattle, USA
| | - Deanna Tollefson
- Department of Global Health, University of Washington, Seattle, USA
| | - Irene N Njuguna
- Department of Global Health, University of Washington, Seattle, USA.,Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Emily Ogutu
- Gangarosa Department of Environmental Health, Emory University, Atlanta, USA
| | - Douglas Gaitho
- Network of AIDS Researchers in Eastern and Southern Africa, Nairobi, Kenya
| | - Nancy Mburu
- Network of AIDS Researchers in Eastern and Southern Africa, Nairobi, Kenya
| | - Geoffrey Oluoch
- Network of AIDS Researchers in Eastern and Southern Africa, Nairobi, Kenya
| | - Peter Mwaura
- Network of AIDS Researchers in Eastern and Southern Africa, Nairobi, Kenya
| | | | | | - Grace C John-Stewart
- Department of Global Health, University of Washington, Seattle, USA.,Department of Epidemiology, University of Washington, Seattle, USA.,Department of Pediatrics, School of Medicine, Seattle, USA.,Department of Medicine, University of Washington, Seattle, USA
| | - Ruth Nduati
- Network of AIDS Researchers in Eastern and Southern Africa, Nairobi, Kenya.,Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, USA.,Department of Epidemiology, University of Washington, Seattle, USA.,Department of Industrial & Systems Engineering, University of Washington, Seattle, USA
| | - Sarah Gimbel
- Department of Global Health, University of Washington, Seattle, USA.,Department of Child, Family & Population Health Nursing, University of Washington, Seattle, USA
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11
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Marino M, Solberg L, Springer R, McConnell KJ, Lindner S, Ward R, Edwards ST, Stange KC, Cohen DJ, Balasubramanian BA. Cardiovascular Disease Preventive Services Among Smaller Primary Care Practices. Am J Prev Med 2022; 62:e285-e295. [PMID: 34937670 DOI: 10.1016/j.amepre.2021.10.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 10/14/2021] [Accepted: 10/17/2021] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Cardiovascular disease preventive services (aspirin use, blood pressure control, and smoking-cessation support) are crucial to controlling cardiovascular diseases. This study draws from 1,248 small-to-medium-sized primary care practices participating in the EvidenceNOW Initiative from 2015-2016 across 12 states to provide practice-level aspirin use, blood pressure control, and smoking-cessation support estimates; report the percentage of practices that meet Million Hearts targets; and identify the practice characteristics associated with better performance. METHODS This cross-sectional study utilized linear regression modeling (analyzed in 2020-2021) to examine the association of aspirin use, blood pressure control, and smoking-cessation support performance with practice characteristics that included structural attributes (e.g., size, ownership, rurality), practice capacity and contextual characteristics, health information technology, and patient panel demographics. RESULTS On average, practice performance on aspirin use, blood pressure control, and smoking-cessation support quality measures was 64% for aspirin, 63% for blood pressure, and 62% for smoking-cessation support. The 2012 Million Hearts goal of achieving the rates of 70% was achieved by 52% (aspirin), 32% (blood pressure), and 54% (smoking) of practices. Practice characteristics associated with aspirin use, blood pressure control, and smoking-cessation support performance included ownership (hospital/health system-owned practices had 11% higher aspirin performance than clinician-owned practices [p=0.001]), rurality (rural practices had lower performance than urban practices in all aspirin use, blood pressure control, and smoking-cessation support quality metrics [difference in aspirin=11.1%, p=0.001; blood pressure=4.2%, p=0.022; smoking=14.4%, p=0.009]), and disruptions (practices that experienced >1 major disruption showed lower aspirin performance [-7.1%, p<0.001]). CONCLUSIONS Achieving the Million Hearts targets may be assisted by collecting and reporting practice-level performance, which can promote change at the practice level and identify areas where additional support is needed to achieve initiative goals.
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Affiliation(s)
- Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon; School of Public Health, Oregon Health & Science University, Portland, Oregon.
| | - Leif Solberg
- HealthPartners Institute, Minneapolis, Minnesota
| | - Rachel Springer
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - K John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon; Department of Emergency Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Stephan Lindner
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon
| | - Rikki Ward
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Dallas, Texas
| | - Samuel T Edwards
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Kurt C Stange
- Center for Community Health Integration, Case Western Reserve University, Cleveland, Ohio
| | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon; Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Bijal A Balasubramanian
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Dallas, Texas
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Abstract
Aim: To determine whether environmental house calls that improved indoor air quality (IAQ) is effective in reducing symptoms of chemical intolerance (CI). Background: Prevalence of CI is increasing worldwide. Those affected typically report symptoms such as headaches, fatigue, ‘brain fog’, and gastrointestinal problems – common primary care complaints. Substantial evidence suggests that improving IAQ may be helpful in reducing symptoms associated with CI. Methods: Primary care clinic patients were invited to participate in a series of structured environmental house calls (EHCs). To qualify, participants were assessed for CI with the Quick Environmental Exposure and Sensitivity Inventory. Those with CI volunteered to allow the EHC team to visit their homes to collect air samples for volatile organic compounds (VOCs). Initial and post-intervention IAQ sampling was analyzed by an independent lab to determine VOC levels (ng/L). The team discussed indoor air exposures, their health effects, and provided guidance for reducing exposures. Findings: Homes where recommendations were followed showed the greatest improvements in IAQ. The improvements were based upon decreased airborne VOCs associated with reduced use of cleaning chemicals, personal care products, and fragrances, and reduction in the index patients’ symptoms. Symptom improvement generally was not reported among those whose homes showed no VOC improvement. Conclusion: Improvements in both IAQ and patients’ symptoms occur when families implement an action plan developed and shared with them by a trained EHC team. Indoor air problems simply are not part of most doctors’ differential diagnoses, despite relatively high prevalence rates of CI in primary care clinics. Our three-question screening questionnaire – the BREESI – can help physicians identify which patients should complete the QEESI. After identifying patients with CI, the practitioner can help by counseling them regarding their home exposures to VOCs. The future of clinical medicine could include environmental house calls as standard of practice for susceptible patients.
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13
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Thomas K, Dannapfel P. Organizational readiness to implement a care model in primary care for frail older adults living at home in Sweden. FRONTIERS IN HEALTH SERVICES 2022; 2:958659. [PMID: 36925790 PMCID: PMC10012617 DOI: 10.3389/frhs.2022.958659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/27/2022] [Indexed: 11/25/2022]
Abstract
Background The demographic change of an aging population constitutes a challenge for primary care organizations worldwide. The systematic implementation of preventative and proactive care models is needed to cope with increased care demands. Objective To investigate the organizational readiness in primary care to implement a new care model to prevent hospitalization among frail older adults. Method Individual qualitative interviews with health care staff investigated organizational readiness at seven primary care units in Sweden. A semi-structured interview guide was used during the interviews and included broad questions on individual and collective readiness to change. Directed content analysis and organizational readiness to change theory were used in data analysis. Results Positive beliefs among staff such as perceived benefits and compatibility with existing values contributed to a strong commitment to implement the new care model. However, perceptions such as unclear task demands, limited resources and concerns about new collaborative structures challenged implementation. Conclusions The findings emphasize implementation as an inter-organizational phenomenon, especially for holistic practices that span across multiple health care providers and disciplines. Furthermore, implementing care models in healthcare may require a change of culture as much as a change of practice.
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Affiliation(s)
- Kristin Thomas
- Division of Society and Health, Department of Health, Medicine and Caring Sciences, Faculty of Medicine and Health, Linköping University, Linköping, Sweden
| | - Petra Dannapfel
- Division of Society and Health, Department of Health, Medicine and Caring Sciences, Faculty of Medicine and Health, Linköping University, Linköping, Sweden.,Region Östergötland, Linköping, Sweden
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14
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Jonas DE, Barclay C, Grammer D, Weathington C, Birken SA, DeWalt DA, Shoenbill KA, Boynton MH, Mackey M, Riley S, Cykert S. The STUN (STop UNhealthy) Alcohol Use Now trial: study protocol for an adaptive randomized trial on dissemination and implementation of screening and management of unhealthy alcohol use in primary care. Trials 2021; 22:810. [PMID: 34784953 PMCID: PMC8593635 DOI: 10.1186/s13063-021-05641-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 09/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Unhealthy alcohol use is a leading cause of preventable deaths in the USA and is associated with many societal and health problems. Less than a third of people who visit primary care providers in the USA are asked about or ever discuss alcohol use with a health professional. METHODS/DESIGN This study is an adaptive, randomized, controlled trial to evaluate the effect of primary care practice facilitation and telehealth services on evidence-based screening, counseling, and pharmacotherapy for unhealthy alcohol use in small-to-medium-sized primary care practices. Study participants will include primary care practices in North Carolina with 10 or fewer providers. All enrolled practices will receive a practice facilitation intervention that includes quality improvement (QI) coaching, electronic health record (EHR) support, training, and expert consultation. After 6 months, practices in the lower 50th percentile (based on performance) will be randomized to continued practice facilitation or provision of telehealth services plus ongoing facilitation for the next 6 months. Practices in the upper 50th percentile after the initial 6 months of intervention will continue to receive practice facilitation alone. The main outcome measures include the number (and %) of patients in the target population who are screened for unhealthy alcohol use, screen positive, and receive brief counseling. Additional measures include the number (and %) of patients who receive pharmacotherapy for AUD or are referred for AUD services. Sample size calculations determined that 35 practices are needed to detect a 10% increase in the main outcome (percent screened for unhealthy alcohol use) over 6 months. DISCUSSION A successful intervention would significantly reduce morbidity among adults from unhealthy alcohol use by increasing counseling and other treatment opportunities. The study will produce important evidence about the effect of practice facilitation on uptake of evidence-based screening, counseling, and pharmacotherapy for unhealthy alcohol use when delivered on a large scale to small and medium-sized practices. It will also generate scientific knowledge about whether embedded telehealth services can improve the use of evidence-based screening and interventions for practices with slower uptake. The results of this rigorously conducted evaluation are expected to have a positive impact by accelerating the dissemination and implementation of evidence related to unhealthy alcohol use into primary care practices. TRIAL REGISTRATION ClinicalTrials.gov NCT04317989 . Registered on March 23, 2020.
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Affiliation(s)
- Daniel E Jonas
- Division of General Internal Medicine and Geriatrics, Department of Internal Medicine, The Ohio State University, 2050 Kenny Road, Columbus, Ohio, 43221, USA.
- Cecil G. Sheps Center for Health Services Research, CB 7590, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.
| | - Colleen Barclay
- Division of General Internal Medicine and Geriatrics, Department of Internal Medicine, The Ohio State University, 2050 Kenny Road, Columbus, Ohio, 43221, USA
- Cecil G. Sheps Center for Health Services Research, CB 7590, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Debbie Grammer
- North Carolina Area Health Education Centers, CB 7165, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Chris Weathington
- North Carolina Area Health Education Centers, CB 7165, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, 27101, USA
| | - Darren A DeWalt
- Cecil G. Sheps Center for Health Services Research, CB 7590, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
- Division of General Medicine and Clinical Epidemiology, CB 7110, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Kimberly A Shoenbill
- Department of Family Medicine, CB 7370, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
- Program on Health and Clinical Informatics, CB 7064, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Marcella H Boynton
- Division of General Medicine and Clinical Epidemiology, CB 7110, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Monique Mackey
- North Carolina Area Health Education Centers, CB 7165, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Sean Riley
- Division of General Internal Medicine and Geriatrics, Department of Internal Medicine, The Ohio State University, 2050 Kenny Road, Columbus, Ohio, 43221, USA
- Cecil G. Sheps Center for Health Services Research, CB 7590, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Samuel Cykert
- Cecil G. Sheps Center for Health Services Research, CB 7590, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
- Division of General Medicine and Clinical Epidemiology, CB 7110, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
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Sunderji N, Ion A, Tang V, Rayner J, Mulder C, Ivers N, Alyass A. Conceptualizing success factors for patient engagement in patient medical homes: a cross-sectional survey. CMAJ Open 2021; 9:E1159-E1167. [PMID: 34906991 PMCID: PMC8687489 DOI: 10.9778/cmajo.20200152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Patient engagement is a priority for health care quality improvement and health system design, but many organizations struggle to engage patients meaningfully. We describe patient engagement activities and success factors that influence organizational decision-making in Ontario's patient medical homes. METHODS From March to May 2018, we conducted an online survey focused on practice-level patient engagement that targeted primary care organization leaders at all Ontario family health teams, community health centres, nurse practitioner-led clinics and Aboriginal Health Access Centres. We asked questions from the Measuring Organizational Readiness for Engagement (MORE) and Public and Patient Engagement Evaluation Tool (PPEET) questionnaires. We used factor and mediation analysis to identify organizational conditions and activities that are associated with the outcomes of patient engagement, affecting board decisions, program-level decisions and the formation of collaborative partnerships. RESULTS We achieved a 53% response rate (n = 149/283); after removing missing data, our final sample size was 141 respondents. Most respondents perceived that their organization's patient engagement activities and resources were insufficient. Processes that had a direct effect on outcomes (β = 0.7, p < 0.0001) included planning, training and supporting employees; identifying, recruiting and supporting relevant patients; and using leaders. Structures - including an organizational mission and vision for patient engagement, and policies, procedures, job positions, training programs and organizational culture that reflect that mission - indirectly affected outcomes, mediated by the aforementioned processes (β = 0.7, p < 0.0001). INTERPRETATION Based on the perceptions of primary care leaders, organizational structures and processes are related to successful patient engagement. Organizations that seek to improve patient engagement should assess their commitment and follow-through with associated resources and activities.
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Affiliation(s)
- Nadiya Sunderji
- Waypoint Centre for Mental Health Care (Sunderji); Department of Psychiatry (Sunderji, Tang) University of Toronto; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Sunderji), Toronto, Ont.; McMaster University School of Social Work (Ion), Hamilton, Ont.; St. Michael's Hospital Mental Health Research Group (Ion), Toronto, Ont.; Research and Evaluation (Rayner), Alliance for Healthier Communities, Toronto, Ont.; Centre for Studies in Family Medicine (Rayner), Western University, London, Ont.; Queen's University (Mulder), Kingston, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Alyass), McMaster University, Hamilton, Ont.
| | - Allyson Ion
- Waypoint Centre for Mental Health Care (Sunderji); Department of Psychiatry (Sunderji, Tang) University of Toronto; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Sunderji), Toronto, Ont.; McMaster University School of Social Work (Ion), Hamilton, Ont.; St. Michael's Hospital Mental Health Research Group (Ion), Toronto, Ont.; Research and Evaluation (Rayner), Alliance for Healthier Communities, Toronto, Ont.; Centre for Studies in Family Medicine (Rayner), Western University, London, Ont.; Queen's University (Mulder), Kingston, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Alyass), McMaster University, Hamilton, Ont
| | - Vincent Tang
- Waypoint Centre for Mental Health Care (Sunderji); Department of Psychiatry (Sunderji, Tang) University of Toronto; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Sunderji), Toronto, Ont.; McMaster University School of Social Work (Ion), Hamilton, Ont.; St. Michael's Hospital Mental Health Research Group (Ion), Toronto, Ont.; Research and Evaluation (Rayner), Alliance for Healthier Communities, Toronto, Ont.; Centre for Studies in Family Medicine (Rayner), Western University, London, Ont.; Queen's University (Mulder), Kingston, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Alyass), McMaster University, Hamilton, Ont
| | - Jennifer Rayner
- Waypoint Centre for Mental Health Care (Sunderji); Department of Psychiatry (Sunderji, Tang) University of Toronto; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Sunderji), Toronto, Ont.; McMaster University School of Social Work (Ion), Hamilton, Ont.; St. Michael's Hospital Mental Health Research Group (Ion), Toronto, Ont.; Research and Evaluation (Rayner), Alliance for Healthier Communities, Toronto, Ont.; Centre for Studies in Family Medicine (Rayner), Western University, London, Ont.; Queen's University (Mulder), Kingston, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Alyass), McMaster University, Hamilton, Ont
| | - Carol Mulder
- Waypoint Centre for Mental Health Care (Sunderji); Department of Psychiatry (Sunderji, Tang) University of Toronto; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Sunderji), Toronto, Ont.; McMaster University School of Social Work (Ion), Hamilton, Ont.; St. Michael's Hospital Mental Health Research Group (Ion), Toronto, Ont.; Research and Evaluation (Rayner), Alliance for Healthier Communities, Toronto, Ont.; Centre for Studies in Family Medicine (Rayner), Western University, London, Ont.; Queen's University (Mulder), Kingston, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Alyass), McMaster University, Hamilton, Ont
| | - Noah Ivers
- Waypoint Centre for Mental Health Care (Sunderji); Department of Psychiatry (Sunderji, Tang) University of Toronto; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Sunderji), Toronto, Ont.; McMaster University School of Social Work (Ion), Hamilton, Ont.; St. Michael's Hospital Mental Health Research Group (Ion), Toronto, Ont.; Research and Evaluation (Rayner), Alliance for Healthier Communities, Toronto, Ont.; Centre for Studies in Family Medicine (Rayner), Western University, London, Ont.; Queen's University (Mulder), Kingston, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Alyass), McMaster University, Hamilton, Ont
| | - Akram Alyass
- Waypoint Centre for Mental Health Care (Sunderji); Department of Psychiatry (Sunderji, Tang) University of Toronto; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Sunderji), Toronto, Ont.; McMaster University School of Social Work (Ion), Hamilton, Ont.; St. Michael's Hospital Mental Health Research Group (Ion), Toronto, Ont.; Research and Evaluation (Rayner), Alliance for Healthier Communities, Toronto, Ont.; Centre for Studies in Family Medicine (Rayner), Western University, London, Ont.; Queen's University (Mulder), Kingston, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Alyass), McMaster University, Hamilton, Ont
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16
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Edwards ST, Marino M, Solberg LI, Damschroder L, Stange KC, Kottke TE, Balasubramanian BA, Springer R, Perry CK, Cohen DJ. Cultural And Structural Features Of Zero-Burnout Primary Care Practices. Health Aff (Millwood) 2021; 40:928-936. [PMID: 34097508 DOI: 10.1377/hlthaff.2020.02391] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Although much attention has been focused on individual-level drivers of burnout in primary care settings, examining the structural and cultural factors of practice environments with no burnout could identify solutions. In this cross-sectional analysis of survey data from 715 small-to-medium-size primary care practices in the United States participating in the Agency for Healthcare Research and Quality's EvidenceNOW initiative, we found that zero-burnout practices had higher levels of psychological safety and adaptive reserve, a measure of practice capacity for learning and development. Compared with high-burnout practices, zero-burnout practices also reported using more quality improvement strategies, more commonly were solo and clinician owned, and less commonly had participated in accountable care organizations or other demonstration projects. Efforts to prevent burnout in primary care may benefit from focusing on enhancing organization and practice culture, including promoting leadership development and fostering practice agency.
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Affiliation(s)
- Samuel T Edwards
- Samuel T. Edwards is an assistant professor of medicine at Oregon Health and Science University and a staff physician in the Section of General Internal Medicine, Veterans Affairs Portland Health Care System, both in Portland, Oregon
| | - Miguel Marino
- Miguel Marino is an associate professor of biostatistics in the Department of Family Medicine, Oregon Health and Science University, and at the OHSU-Portland State University School of Public Health, in Portland, Oregon
| | - Leif I Solberg
- Leif I. Solberg is a senior research investigator at HealthPartners Institute, in Minneapolis, Minnesota
| | - Laura Damschroder
- Laura Damschroder is an implementation research consultant through Implementation Pathways, LLC, and a research investigator in the Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, in Ann Arbor, Michigan
| | - Kurt C Stange
- Kurt C. Stange is the Dorothy Jones Weatherhead Professor of Medicine; a professor of family medicine and community health, population and quantitative health sciences, oncology, and sociology; and the director of the Center for Community Health Integration, Case Western Reserve University, in Cleveland, Ohio
| | - Thomas E Kottke
- Thomas E. Kottke is a senior research investigator at HealthPartners Institute
| | - Bijal A Balasubramanian
- Bijal A. Balasubramanian is an associate professor in the Department of Epidemiology, Human Genetics, and Environmental Sciences and regional dean of UTHealth School of Public Health, in Dallas, Texas
| | - Rachel Springer
- Rachel Springer is a biostatistician in the Department of Family Medicine, Oregon Health and Science University
| | - Cynthia K Perry
- Cynthia K. Perry is a professor in the School of Nursing, Oregon Health and Science University
| | - Deborah J Cohen
- Deborah J. Cohen is a professor of family medicine and vice chair of research in the Department of Family Medicine, Oregon Health and Science University
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Schuttner L, Coleman K, Ralston J, Parchman M. The role of organizational learning and resilience for change in building quality improvement capacity in primary care. Health Care Manage Rev 2021; 46:E1-E7. [PMID: 33630509 PMCID: PMC7541444 DOI: 10.1097/hmr.0000000000000281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The extent that organizational learning and resilience for the change process, that is, adaptive reserve (AR), is a component of building practice capacity for continuous quality improvement (QI) is unknown. PURPOSE The aim of the study was to examine the association of AR and development of QI capacity. METHODOLOGY One hundred forty-two primary care practices were evaluated at baseline and 12 months in a randomized trial to improve care quality. Practice AR was measured by staff survey along with a validated QI capacity assessment (QICA). We assessed the association of baseline QICA with baseline AR and both baseline and change in AR with change in QICA from 0 to 12 months. Effect modification by presence of QI infrastructure in parent organizations and trial arm was examined. RESULTS Mean QICA increased from 6.5 to 8.1 (p < .001), and mean AR increased from 71.8 to 73.9 points (p < .001). At baseline, there was a significant association between AR and QICA scores: The QICA averaged 0.34 points higher (95% CI [0.04, 0.64], p = .03) per 10-point difference in AR. There was a significant association between baseline AR and 12-month QICA-which averaged 0.30 points higher (95% CI [0.02, 0.57], p = .04) per 10 points in baseline AR. There was no association between changes in AR and the QICA from 0 to 12 months and no effect modification by trial arm or external QI infrastructure. CONCLUSIONS Baseline AR was positively associated with both baseline and follow-up QI capacity, but there was no association between change in AR and change in the QICA, suggesting AR may be a precondition to growth in QI capacity. PRACTICE IMPLICATIONS Findings suggest that developing AR may be a valuable step prior to undertaking QI-oriented growth, with implications for sequencing of development strategies, including added gain in QI capacity development from building AR prior to engaging in transformation efforts.
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Schoenthaler A, De La Calle F, Soto A, Barrett D, Cruz J, Payano L, Rosado M, Adhikari S, Ogedegbe G, Rosal M. Bridging the evidence-to-practice gap: a stepped-wedge cluster randomized controlled trial evaluating practice facilitation as a strategy to accelerate translation of a multi-level adherence intervention into safety net practices. Implement Sci Commun 2021; 2:21. [PMID: 33597041 PMCID: PMC7888171 DOI: 10.1186/s43058-021-00111-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/17/2021] [Indexed: 11/11/2022] Open
Abstract
Background Poor adherence to antihypertensive medications is a significant contributor to the racial gap in rates of blood pressure (BP) control among Latino adults, as compared to Black and White adults. While multi-level interventions (e.g., those aiming to influence practice, providers, and patients) have been efficacious in improving medication adherence in underserved patients with uncontrolled hypertension, the translation of these interventions into routine practice within “real world” safety-net primary care settings has been inadequate and slow. This study will fill this evidence-to-practice gap by evaluating the effectiveness of practice facilitation (PF) as a practical and tailored strategy for implementing Advancing Medication Adherence for Latinos with Hypertension through a Team-based Care Approach (ALTA), a multi-level approach to improving medication adherence and BP control in 10 safety-net practices in New York that serve Latino patients. Methods and design We will conduct this study in two phases: (1) a pre-implementation phase where we will refine the PF strategy, informed by the Consolidated Framework for Implementation Research, to facilitate the implementation of ALTA into routine care at the practices; and (2) an implementation phase during which we will evaluate, in a stepped-wedge cluster randomized controlled trial, the effect of the PF strategy on ALTA implementation fidelity (primary outcome), as well as on clinical outcomes (secondary outcomes) at 12 months. Implementation fidelity will be assessed using a mixed methods approach based on the five core dimensions outlined by Proctor’s Implementation Outcomes Framework. Clinical outcome measures include BP control (defined as BP< 130/80 mmHg) and medication adherence (assessed using the proportion of days covered via pharmacy records). Discussion The study protocol applies rigorous research methods to identify how implementation strategies such as PF may work to expedite the translation process for implementing evidence-based approaches into routine care at safety-net practices to improve health outcomes in Latino patients with hypertension, who suffer disproportionately from poor BP control. By examining the barriers and facilitators that affect implementation, this study will contribute knowledge that will increase the generalizability of its findings to other safety-net practices and guide effective scale-up across primary care practices nationally. Trial registration ClinicalTrials.gov NCT03713515, date of registration: October 19, 2018.
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Affiliation(s)
- Antoinette Schoenthaler
- Department of Population Health, Center for Healthful Behavior Change, NYU Langone Health, 180 Madison Avenue, 752, New York, NY, 10016, USA.
| | - Franzenith De La Calle
- Department of Population Health, Center for Healthful Behavior Change, NYU Langone Health, 180 Madison Avenue, 752, New York, NY, 10016, USA
| | - Amanda Soto
- Department of Population Health, Center for Healthful Behavior Change, NYU Langone Health, 180 Madison Avenue, 752, New York, NY, 10016, USA
| | - Derrel Barrett
- Department of Population Health, Center for Healthful Behavior Change, NYU Langone Health, 180 Madison Avenue, 752, New York, NY, 10016, USA
| | - Jocelyn Cruz
- Department of Population Health, Center for Healthful Behavior Change, NYU Langone Health, 180 Madison Avenue, 752, New York, NY, 10016, USA
| | - Leydi Payano
- Department of Population Health, Center for Healthful Behavior Change, NYU Langone Health, 180 Madison Avenue, 752, New York, NY, 10016, USA
| | - Marina Rosado
- Department of Population Health, Center for Healthful Behavior Change, NYU Langone Health, 180 Madison Avenue, 752, New York, NY, 10016, USA
| | - Samrachana Adhikari
- Department of Population Health, Center for Healthful Behavior Change, NYU Langone Health, 180 Madison Avenue, 752, New York, NY, 10016, USA
| | - Gbenga Ogedegbe
- Department of Population Health, Center for Healthful Behavior Change, NYU Langone Health, 180 Madison Avenue, 752, New York, NY, 10016, USA
| | - Milagros Rosal
- Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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Hsiung KS, Colditz JB, McGuier EA, Switzer GE, VonVille HM, Folb BL, Kolko DJ. Measures of Organizational Culture and Climate in Primary Care: a Systematic Review. J Gen Intern Med 2021; 36:487-499. [PMID: 33140272 PMCID: PMC7878641 DOI: 10.1007/s11606-020-06262-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/21/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Primary care is increasingly contributing to improving the quality of patient care. This has imposed significant demands on clinicians with rising needs and limited resources. Organizational culture and climate have been found to be crucial in improving workforce well-being and hence quality of care. The objectives of this study are to identify organizational culture and climate measures used in primary care from 2008 to 2019 and evaluate their psychometric properties. METHODS Data sources include PubMed, PsycINFO, HAPI, CINAHL, and Mental Measurements Yearbook. Bibliographies of relevant articles were reviewed and a cited reference search in Scopus was performed. Eligibility criteria include primary health care professionals, primary care settings, and use of measures representing the general concept of organizational culture and climate. Consensus-Based Standards for the selection of health Measurement Instruments (COSMIN) guidelines were followed to evaluate individual studies for methodological quality, rate results of measurement properties, qualitatively pool studies by measure, and grade evidence. RESULTS Of 1745 initial studies, 42 studies met key study inclusion criteria, with 27 measures available for review (16 for organizational culture, 11 for organizational climate). There was considerable variability in measures, both conceptually and in psychometric quality. Many reported limited or no psychometric information. DISCUSSION Notable measures selected for frequent use and strength and applicability of measurement properties include the Culture Questionnaire adapted for health care settings, Practice Culture Assessment, and Medical Group Practice Culture Assessment for organizational culture. Notable climate measures include the Nurse Practitioner Primary Care Organizational Climate Questionnaire, Practice Climate Survey, and Task and Relational Climate Scale. This synthesis and appraisal of organizational culture and climate measures can help investigators make informed decisions in choosing a measure or deciding to develop a new one. In terms of limitations, ratings should be considered conservative due to adaptations of the COSMIN protocol for clinician populations. PROSPERO REGISTRATION NUMBER CRD 42019133117.
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Affiliation(s)
- Kimberly S Hsiung
- University of Pittsburgh School of Medicine, , Pittsburgh, PA, USA.
- Clinical and Translational Science Institute, University of Pittsburgh, , Pittsburgh, PA, USA.
| | - Jason B Colditz
- University of Pittsburgh School of Medicine, , Pittsburgh, PA, USA
| | | | - Galen E Switzer
- Department of Medicine, University of Pittsburgh, , Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs Pittsburgh Healthcare System, , Pittsburgh, PA, USA
| | - Helena M VonVille
- Health Sciences Library System, University of Pittsburgh, , Pittsburgh, PA, USA
| | - Barbara L Folb
- Health Sciences Library System, University of Pittsburgh, , Pittsburgh, PA, USA
| | - David J Kolko
- University of Pittsburgh School of Medicine, , Pittsburgh, PA, USA
- UPMC Western Psychiatric Hospital, , Pittsburgh, PA, USA
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Shoemaker-Hunt SJ, Evans L, Swan H, Bacon O, Ike B, Baldwin LM, Parchman ML. Study protocol for evaluating Six Building Blocks for opioid management implementation in primary care practices. Implement Sci Commun 2020; 1:16. [PMID: 32885178 PMCID: PMC7427954 DOI: 10.1186/s43058-020-00008-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/09/2019] [Indexed: 11/10/2022] Open
Abstract
Background The Six Building Blocks for improving opioid management (6BBs) is a program for improving the management of patients in primary care practices who are on long-term opioid therapy for chronic pain. The 6BBs include building leadership and consensus; aligning policies, patient agreements, and workflows; tracking and monitoring patient care; conducting planned, patient-centered visits; tailoring care for complex patients; and measuring success. The Agency for Healthcare Research and Quality funded the development of a 6BBs implementation guide: a step-by-step approach for independently implementing the 6BBs in a practice. This mixed-method study seeks to assess practices’ use of the implementation guide to implement the 6BBs and the effectiveness of 6BBs implementation on opioid management processes of care among practices using the implementation guide. Methods Data collection is guided by the Consolidated Framework for Implementation Research, Proctor’s taxonomy of implementation outcomes, and the Centers for Disease Control and Prevention’s Guideline for Prescribing Opioids for Chronic Pain. A diverse group of health care organizations with primary care clinics across the USA will participate in the study over 15 months. Qualitative data collection will include semi-structured interviews with stakeholders at each organization at two time points, notes from routine check-in calls, and document review. These data will be used to understand practices’ motivation for participation, history with opioid management efforts, barriers and facilitators to implementation, and implementation progress. Quantitative data collection will consist of a provider and staff survey, an implementation milestones assessment, and quarterly opioid prescribing quality measures. These data will supplement our understanding of implementation progress and will allow us to assess changes over time in providers’ opioid prescribing practices, prescribing self-efficacy, challenges to providing guideline-driven care, and practices’ opioid prescribing quality measures. Qualitative data will be coded and analyzed for emergent themes. Quantitative data will be analyzed using descriptive statistics and clustered multivariate regression. Discussion This study contributes to the knowledge of the implementation and effectiveness of a team-based approach to opioid management in primary care practices. Information gleaned from this study can be used to inform efforts to curtail opioid prescribing and assist primary care practices considering implementing the 6BBs.
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Affiliation(s)
| | - Leigh Evans
- Division of Health and Environment, Abt Associates, Inc., Cambridge, USA
| | - Holly Swan
- Division of Health and Environment, Abt Associates, Inc., Cambridge, USA
| | - Olivia Bacon
- Division of Health and Environment, Abt Associates, Inc., Cambridge, USA
| | - Brooke Ike
- Department of Family Medicine, University of Washington, Seattle, USA
| | - Laura-Mae Baldwin
- Department of Family Medicine, University of Washington, Seattle, USA
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Huffstetler AN, Kuzel AJ, Sabo RT, Richards A, Brooks EM, Lail Kashiri P, Villalobos G, Arias AJ, Svikis D, Bortz BA, Edwards A, Epling J, Cohen DJ, Parchman ML, Winter J, Wessler P, Yu TJ, Krist AH. Practice facilitation to promote evidence-based screening and management of unhealthy alcohol use in primary care: a practice-level randomized controlled trial. BMC FAMILY PRACTICE 2020; 21:93. [PMID: 32434467 PMCID: PMC7240919 DOI: 10.1186/s12875-020-01147-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/20/2020] [Indexed: 12/14/2022]
Abstract
Background Unhealthy alcohol use is the third leading cause of preventable death in the United States. Evidence demonstrates that screening for unhealthy alcohol use and providing persons engaged in risky drinking with brief behavioral and counseling interventions improves health outcomes, collectively termed screening and brief interventions. Medication assisted therapy (MAT) is another effective method for treatment of moderate or severe alcohol use disorder. Yet, primary care clinicians are not regularly screening for or treating unhealthy alcohol use. Methods and analysis We are initiating a clinic-level randomized controlled trial aimed to evaluate how primary care clinicians can impact unhealthy alcohol use through screening, counseling, and MAT. One hundred and 25 primary care practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN) will be engaged; each will receive practice facilitation to promote screening, counseling, and MAT either at the beginning of the trial or at a 6-month control period start date. For each practice, the intervention includes provision of a practice facilitator, learning collaboratives with three practice champions, and clinic-wide information sessions. Clinics will be enrolled for 6–12 months. After completion of the intervention, we will conduct a mixed methods analysis to identify changes in screening rates, increase in provision of brief counseling and interventions as well as MAT, and the reduction of alcohol intake for patients after practices receive practice facilitation. Discussion This study offers a systematic process for dissemination and implementation of the evidence-based practice of screening, counseling, and treatment for unhealthy alcohol use. Practices will be asked to implement a process for screening, counseling, and treatment based on their practice characteristics, patient population, and workflow. We propose practice facilitation as a robust and feasible intervention to assist in making changes within the practice. We believe that the process can be replicated and used in a broad range of clinical settings; we anticipate this will be supported by our evaluation of this approach. Trial registration ClinicalTrials.gov, ClinicalTrials.gov Identifier: NCT04248023, Registered 5 February 2020.
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Affiliation(s)
- Alison N Huffstetler
- Department of Family Medicine and Population Health, Virginia Commonwealth University, One Capitol Square, Room 637, 830 East Main Street, Richmond, VA, 23219, USA.
| | - Anton J Kuzel
- Department of Family Medicine and Population Health, Virginia Commonwealth University, One Capitol Square, Room 637, 830 East Main Street, Richmond, VA, 23219, USA
| | - Roy T Sabo
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Alicia Richards
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - E Marshall Brooks
- Department of Family Medicine and Population Health, Virginia Commonwealth University, One Capitol Square, Room 637, 830 East Main Street, Richmond, VA, 23219, USA
| | - Paulette Lail Kashiri
- Department of Family Medicine and Population Health, Virginia Commonwealth University, One Capitol Square, Room 637, 830 East Main Street, Richmond, VA, 23219, USA
| | - Gabriela Villalobos
- Department of Family Medicine and Population Health, Virginia Commonwealth University, One Capitol Square, Room 637, 830 East Main Street, Richmond, VA, 23219, USA
| | - Albert J Arias
- Department of Psychiatry, Virginia Commonwealth University, Richmond, VA, USA
| | - Dace Svikis
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
| | - Beth A Bortz
- Virginia Center for Health Innovation, Henrico, VA, USA
| | | | - John Epling
- Department of Family and Community Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Michael L Parchman
- MacColl Center, Kaiser Permanente of Washington Health Research Institute, Seattle, WA, USA
| | - Jonathan Winter
- Shenandoah Valley Family Practice Residency, Virginia Commonwealth University, Front Royal, VA, USA
| | - Patricia Wessler
- Riverside Family Medicine Residency, Virginia Commonwealth University, Newport News, VA, USA
| | - Timothy J Yu
- St. Francis Family Medicine Residency, Virginia Commonwealth University, Midlothian, VA, USA
| | - Alex H Krist
- Department of Family Medicine and Population Health, Virginia Commonwealth University, One Capitol Square, Room 637, 830 East Main Street, Richmond, VA, 23219, USA
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Crabtree BF, Howard J, Miller WL, Cromp D, Hsu C, Coleman K, Austin B, Flinter M, Tuzzio L, Wagner EH. Leading Innovative Practice: Leadership Attributes in LEAP Practices. Milbank Q 2020; 98:399-445. [PMID: 32401386 DOI: 10.1111/1468-0009.12456] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Policy Points An onslaught of policies from the federal government, states, the insurance industry, and professional organizations continually requires primary care practices to make substantial changes; however, ineffective leadership at the practice level can impede the dissemination and scale-up of these policies. The inability of primary care practice leadership to respond to ongoing policy demands has resulted in moral distress and clinician burnout. Investments are needed to develop interventions and educational opportunities that target a broad array of leadership attributes. CONTEXT Over the past several decades, health care in the United States has undergone substantial and rapid change. At the heart of this change is an assumption that a more robust primary care infrastructure helps achieve the quadruple aim of improved care, better patient experience, reduced cost, and improved work life of health care providers. Practice-level leadership is essential to succeed in this rapidly changing environment. Complex adaptive systems theory offers a lens for understanding important leadership attributes. METHODS A review of the literature on leadership from a complex adaptive system perspective identified nine leadership attributes hypothesized to support practice change: motivating others to engage in change, managing abuse of power and social influence, assuring psychological safety, enhancing communication and information sharing, generating a learning organization, instilling a collective mind, cultivating teamwork, fostering emergent leaders, and encouraging boundary spanning. Through a secondary qualitative analysis, we applied these attributes to nine practices ranking high on both a practice learning and leadership scale from the Learning from Effective Ambulatory Practice (LEAP) project to see if and how these attributes manifest in high-performing innovative practices. FINDINGS We found all nine attributes identified from the literature were evident and seemed important during a time of change and innovation. We identified two additional attributes-anticipating the future and developing formal processes-that we found to be important. Complexity science suggests a hypothesized developmental model in which some attributes are foundational and necessary for the emergence of others. CONCLUSIONS Successful primary care practices exhibit a diversity of strong local leadership attributes. To meet the realities of a rapidly changing health care environment, training of current and future primary care leaders needs to be more comprehensive and move beyond motivating others and developing effective teams.
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Affiliation(s)
| | | | | | - DeANN Cromp
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Clarissa Hsu
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Katie Coleman
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Brian Austin
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | | | - Leah Tuzzio
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Edward H Wagner
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
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Linzer M, Ford BR, Guthrie KF, Vickery KD. Team-Based Care: Caring for the team under payment reform. J Gen Intern Med 2020; 35:1600-1602. [PMID: 31650397 PMCID: PMC7210356 DOI: 10.1007/s11606-019-05452-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 07/15/2019] [Accepted: 09/27/2019] [Indexed: 11/24/2022]
Affiliation(s)
| | - Becky R Ford
- Hennepin Healthcare Research Institute, Minneapolis, MN, USA
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Gold R, Bunce A, Cowburn S, Davis JV, Nelson JC, Nelson CA, Hicks E, Cohen DJ, Horberg MA, Melgar G, Dearing JW, Seabrook J, Mossman N, Bulkley J. Does increased implementation support improve community clinics' guideline-concordant care? Results of a mixed methods, pragmatic comparative effectiveness trial. Implement Sci 2019; 14:100. [PMID: 31805968 PMCID: PMC6894475 DOI: 10.1186/s13012-019-0948-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 10/14/2019] [Indexed: 11/18/2022] Open
Abstract
Background Disseminating care guidelines into clinical practice remains challenging, partly due to inadequate evidence on how best to help clinics incorporate new guidelines into routine care. This is particularly true in safety net community health centers (CHCs). Methods This pragmatic comparative effectiveness trial used a parallel mixed methods design. Twenty-nine CHC clinics were randomized to receive increasingly intensive implementation support (implementation toolkit (arm 1); toolkit + in-person training + training webinars (arm 2); toolkit + training + webinars + offered practice facilitation (arm 3)) targeting uptake of electronic health record (EHR) tools focused on guideline-concordant cardioprotective prescribing for patients with diabetes. Outcomes were compared across study arms, to test whether increased support yielded additive improvements, and with 137 non-study CHCs that share the same EHR as the study clinics. Quantitative data from the CHCs’ EHR were used to compare the magnitude of change in guideline-concordant ACE/ARB and statin prescribing, using adjusted Poisson regressions. Qualitative data collected using diverse methods (e.g., interviews, observations) identified factors influencing the quantitative outcomes. Results Outcomes at CHCs receiving higher-intensity support did not improve in an additive pattern. ACE/ARB prescribing did not improve in any CHC group. Statin prescribing improved overall and was significantly greater only in the arm 1 and arm 2 CHCs compared with the non-study CHCs. Factors influencing the finding of no additive impact included: aspects of the EHR tools that reduced their utility, barriers to providing the intended implementation support, and study design elements, e.g., inability to adapt the provided support. Factors influencing overall improvements in statin outcomes likely included a secular trend in awareness of statin prescribing guidelines, selection bias where motivated clinics volunteered for the study, and study participation focusing clinic staff on the targeted outcomes. Conclusions Efforts to implement care guidelines should: ensure adaptability when providing implementation support and conduct formative evaluations to determine the optimal form of such support for a given clinic; consider how study data collection influences adoption; and consider barriers to clinics’ ability to use/accept implementation support as planned. More research is needed on supporting change implementation in under-resourced settings like CHCs. Trial registration ClinicalTrials.gov, NCT02325531. Registered 15 December 2014.
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Affiliation(s)
- Rachel Gold
- Kaiser Permanente Center for Health Research, 3800 N Interstate Ave, Portland, OR, 97227, USA. .,OCHIN, Inc., 1881 NW Naito Pkwy, Portland, OR, 97201, USA.
| | - Arwen Bunce
- OCHIN, Inc., 1881 NW Naito Pkwy, Portland, OR, 97201, USA
| | - Stuart Cowburn
- OCHIN, Inc., 1881 NW Naito Pkwy, Portland, OR, 97201, USA
| | - James V Davis
- Kaiser Permanente Center for Health Research, 3800 N Interstate Ave, Portland, OR, 97227, USA
| | - Joan C Nelson
- OCHIN, Inc., 1881 NW Naito Pkwy, Portland, OR, 97201, USA
| | | | - Elisabeth Hicks
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Deborah J Cohen
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Michael A Horberg
- Kaiser Permanente Mid-Atlantic Permanente Research Institute, 2101 East Jefferson St, Rockville, MD, 20852, USA
| | - Gerardo Melgar
- Cowlitz Family Health Center, 1057 12th Avenue, Longview, WA, 98632, USA
| | - James W Dearing
- Michigan State University, 404 Wilson Rd, Room 473, East Lansing, MI, 48824, USA
| | - Janet Seabrook
- Community HealthNet Health Centers, 1021 West 5th Avenue, Gary, IN, 46402, USA
| | - Ned Mossman
- OCHIN, Inc., 1881 NW Naito Pkwy, Portland, OR, 97201, USA
| | - Joanna Bulkley
- Kaiser Permanente Center for Health Research, 3800 N Interstate Ave, Portland, OR, 97227, USA
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Fetters MD, Rubinstein EB. The 3 Cs of Content, Context, and Concepts: A Practical Approach to Recording Unstructured Field Observations. Ann Fam Med 2019; 17:554-560. [PMID: 31712294 PMCID: PMC6846267 DOI: 10.1370/afm.2453] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 04/12/2019] [Accepted: 05/07/2019] [Indexed: 12/17/2022] Open
Abstract
Most primary care researchers lack a practical approach for including field observations in their studies, even though observations can offer important qualitative insights and provide a mechanism for documenting behaviors, events, and unexpected occurrences. We present an overview of unstructured field observations as a qualitative research method for analyzing material surroundings and social interactions. We then detail a practical approach to collecting and recording observational data through a "3 Cs" template of content, context, and concepts. To demonstrate how this method works in practice, we provide an example of a completed template and discuss the analytical approach used during a study on informed consent for research participation in the primary care setting of Qatar.
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Affiliation(s)
- Michael D Fetters
- Mixed Methods Program, Department of Family Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Ellen B Rubinstein
- Department of Sociology and Anthropology, North Dakota State University, Fargo, North Dakota
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Jones SMW, Parchman M, McDonald S, Cromp D, Austin B, Flinter M, Hsu C, Wagner E. Measuring attributes of team functioning in primary care settings: development of the TEAMS tool. J Interprof Care 2019; 34:407-413. [PMID: 31573363 DOI: 10.1080/13561820.2019.1670628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This study examines attributes of a high-functioning primary care team by creating a survey measuring staff perceptions of team culture in primary care practices with innovative team-based workforce models. Survey data from a national study of 30 exemplar primary care practices with innovative team-based workforce models was used. Staff and clinicians (n = 943) at the 30 primary care sites completed a 31-item survey online. Survey items came from previous surveys of adaptive reserve and team culture. Factor analysis, reliability and validity were examined for the survey. Case summaries from site visits and survey comments were compared for high and low scoring sites to establish validity. Three core attributes of a high-functioning team were identified: joy in practice (4 items), personal growth (3 items), and leadership and learning (20 items). Four items did not measure any attribute. Using item correlations, the 20 items for leadership and learning were reduced to 7 items. All three attribute subscales had good reliability and validity. The final 14-item survey measuring joy in practice, personal growth and leadership and learning may be useful in clinical practice as a practical tool to gauge progress in developing a high-functioning team. Further research is needed to determine the sensitivity of this instrument to change over time with interventions designed to improve team functioning in primary care.
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Affiliation(s)
| | - Michael Parchman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Sarah McDonald
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - DeAnn Cromp
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Brian Austin
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Clarissa Hsu
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Ed Wagner
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
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O'Loughlin M, Mills J, McDermott R, Harriss L. Review of patient-reported experience within Patient-Centered Medical Homes: insights for Australian Health Care Homes. Aust J Prim Health 2019; 23:429-439. [PMID: 28927493 DOI: 10.1071/py17063] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 07/24/2017] [Indexed: 12/24/2022]
Abstract
Understanding patient experience is necessary to advance the patient-centred approach to health service delivery. Australia's primary healthcare model, the 'Health Care Home', is based on the 'Patient-Centered Medical Home' (PCMH) model developed in the United States. Both these models aim to improve patient experience; however, the majority of existing PCMH model evaluations have focussed on funding, management and quality assurance measures. This review investigated the scope of evidence reported by adult patients using a PCMH. Using a systematic framework, the review identified 39 studies, sourced from 33 individual datasets, which used both quantitative and qualitative approaches. Patient experience was reported for model attributes, including the patient-physician and patient-practice relationships; care-coordination; access to care; and, patient engagement, goal setting and shared decision-making. Results were mixed, with the patient experience improving under the PCMH model for some attributes, and some studies indicating no difference in patient experience following PCMH implementation. The scope and quality of existing evidence does not demonstrate improvement in adult patient experience when using the PCMH. Better measures to evaluate patient experience in the Australian Health Care Home model are required.
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Affiliation(s)
- Mary O'Loughlin
- Australian Institute of Tropical Health and Medicine, Centre for Chronic Disease Prevention, College of Public Health, Medical and Veterinary Sciences, James Cook University, PO Box 6811, Cairns, Qld 4870, Australia
| | - Jane Mills
- College of Health, Massey University, PO Box 756, Wellington 6140, New Zealand
| | - Robyn McDermott
- Australian Institute of Tropical Health and Medicine, Centre for Chronic Disease Prevention, College of Public Health, Medical and Veterinary Sciences, James Cook University, PO Box 6811, Cairns, Qld 4870, Australia
| | - Linton Harriss
- Australian Institute of Tropical Health and Medicine, Centre for Chronic Disease Prevention, College of Public Health, Medical and Veterinary Sciences, James Cook University, PO Box 6811, Cairns, Qld 4870, Australia
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Does Ownership Make a Difference in Primary Care Practice? J Am Board Fam Med 2019; 32:398-407. [PMID: 31068404 PMCID: PMC6566859 DOI: 10.3122/jabfm.2019.03.180271] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 02/01/2019] [Accepted: 02/05/2019] [Indexed: 11/08/2022] Open
Abstract
PURPOSE We assessed differences in structural characteristics, quality improvement processes, and cardiovascular preventive care by ownership type among 989 small to medium primary care practices. METHODS This cross-sectional analysis used electronic health record and survey data collected between September 2015 and April 2017 as part of an evaluation of the EvidenceNOW: Advancing Heart Health in Primary Care Initiative by the Agency for Health Care Research and Quality. We compared physician-owned practices, health system or medical group practices, and Federally Qualified Health Centers (FQHC) by using 15 survey-based practice characteristic measures, 9 survey-based quality improvement process measures, and 4 electronic health record-based cardiovascular disease prevention quality measures, namely, aspirin prescription, blood pressure control, cholesterol management, and smoking cessation support (ABCS). RESULTS Physician-owned practices were more likely to be solo (45.0% compared with 8.1%, P < .001 for health system practices and 12.8%, P = .009 for FQHCs) and less likely to have experienced a major change (eg, moved to a new location) in the last year (43.1% vs 65.4%, P = .01 and 72.1%, P = .001, respectively). FQHCs reported the highest use of quality improvement processes, followed by health system practices. ABCS performance was similar across ownership type, with the exception of smoking cessation support (51.0% for physician-owned practices vs 67.3%, P = .004 for health system practices and 69.3%, P = .004 for FQHCs). CONCLUSIONS Primary care practice ownership was associated with differences in quality improvement process measures, with FQHCs reporting the highest use of such quality-improvement strategies. ABCS were mostly unrelated to ownership, suggesting a complex path between quality improvement strategies and outcomes.
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Lee SJC, Jetelina KK, Marks E, Shaw E, Oeffinger K, Cohen D, Santini NO, Cox JV, Balasubramanian BA. Care coordination for complex cancer survivors in an integrated safety-net system: a study protocol. BMC Cancer 2018; 18:1204. [PMID: 30514267 PMCID: PMC6278055 DOI: 10.1186/s12885-018-5118-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 11/20/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The growing numbers of cancer survivors challenge delivery of high-quality survivorship care by healthcare systems. Innovative ways to improve care coordination for patients with cancer and multiple chronic conditions ("complex cancer survivors") are needed to achieve better care outcomes, improve patient experience of care, and lower cost. Our study, Project CONNECT, will adapt and implement three evidence-based care coordination strategies, shown to be effective for primary care conditions, among complex cancer survivors. Specifically, the purpose of this study is to: 1) Implement a system-level EHR-driven intervention for 500 complex cancer survivors at Parkland; 2) Test effectiveness of the strategies on system- and patient-level outcomes measured before and after implementation; and 3) Elucidate system and patient factors that facilitate or hinder implementation and result in differences in experiences of care coordination between complex patients with and without cancer. METHODS Project CONNECT is a quasi-experimental implementation study among 500 breast and colorectal cancer survivors with at least one of the following chronic conditions: diabetes, hypertension, chronic lung disease, chronic kidney disease, or heart disease. We will implement three evidence-based care coordination strategies in a large, county integrated safety-net health system: 1) an EHR-driven registry to facilitate patient transitions between primary and oncology care; 2) co-locating a nurse practitioner trained in care coordination within a complex care team; 3) and enhancing teamwork through coaching. Segmented regression analysis will evaluate change in system-level (i.e. composite care quality score) and patient-level outcomes (i.e. self-reported care coordination). To evaluate implementation, we will merge quantitative findings with structured observations and physician and patient interviews. DISCUSSION This study will result in an evaluation toolkit identifying key model elements, barriers, and facilitators that can be used to guide care coordination interventions in other safety-net settings. Because Parkland is a vanguard of safety-net healthcare nationally, findings will be widely applicable as other safety-nets move toward increased integration, enhanced EHR capability, and experience with growing patient diversity. Our proposal recognizes the complexity of interventions and scaffolds evidence-based strategies together to meet the needs of complex patients, systems of care, and service integration. TRIAL REGISTRATION ClinicalTrials.gov, NCT02943265 . Registered 24 October 2016.
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Affiliation(s)
- Simon J. Craddock Lee
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, E5.506, Dallas, TX 75390-9066 USA
- Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Road, Dallas, TX 75235 USA
| | - Katelyn K. Jetelina
- Department of Epidemiology, University of Texas Health Science Center, School of Public Health, 6011 Harry Hines Blvd, V8.112, Dallas, TX 75235 USA
| | - Emily Marks
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, E5.506, Dallas, TX 75390-9066 USA
| | - Eric Shaw
- Department of Community Medicine, Mercer University, 1250 E. 66th St, Savannah, GA 31404 USA
| | - Kevin Oeffinger
- Department of Medicine, Division of Medical Oncology, Duke Cancer Institute and Duke University Medical Center, 20 Duke Medicine Cir, Durham, NC 27710 USA
| | - Deborah Cohen
- Department of Family Medicine, Oregon Health and Science Center, 3181 SW Sam Jackson Park Rd, Portland, OR 97239-3098 USA
| | - Noel O. Santini
- Parkland Health and Hospital System, 5201 Harry Hines Blvd, Dallas, TX 75235 USA
| | - John V. Cox
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, E5.506, Dallas, TX 75390-9066 USA
- Parkland Health and Hospital System, 5201 Harry Hines Blvd, Dallas, TX 75235 USA
| | - Bijal A. Balasubramanian
- Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Road, Dallas, TX 75235 USA
- Department of Epidemiology, University of Texas Health Science Center, School of Public Health, 6011 Harry Hines Blvd, V8.112, Dallas, TX 75235 USA
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Misra-Hebert AD, Perzynski A, Rothberg MB, Fox J, Mercer MB, Liu X, Hu B, Aron DC, Stange KC. Implementing team-based primary care models: a mixed-methods comparative case study in a large, integrated health care system. J Gen Intern Med 2018; 33:1928-1936. [PMID: 30084018 PMCID: PMC6206362 DOI: 10.1007/s11606-018-4611-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 06/07/2018] [Accepted: 07/19/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Successful implementation of new care models within a health system is likely dependent on contextual factors at the individual sites of care. OBJECTIVE To identify practice setting components contributing to uptake of new team-based care models. DESIGN Convergent mixed-methods design. PARTICIPANTS Employees and patients of primary care practices implementing two team-based models in a large, integrated health system. MAIN MEASURES Field observations of 9 practices and 75 interviews, provider and staff surveys to assess adaptive reserve and burnout, analysis of quality metrics, and patient panel comorbidity scores. The data were collected simultaneously, then merged, thematically analyzed, and interpreted by a multidisciplinary team. KEY RESULTS Based on analysis of observations and interviews, the 9 practices were categorized into 3 groups-high, partial, and low uptake of new team-based models. Uptake was related to (1) practices' responsiveness to change and (2) flexible workflow as related to team roles. Strength of local leadership and stable staffing mediated practices' ability to achieve high performance in these two domains. Higher performance on several quality metrics was associated with high uptake practices compared to the lower uptake groups. Mean Adaptive Reserve Measure and Maslach Burnout Inventory scores did not differ significantly between higher and lower uptake practices. CONCLUSION Uptake of new team-based care delivery models is related to practices' ability to respond to change and to adapt team roles in workflow, influenced by both local leadership and stable staffing. Better performance on quality metrics may identify high uptake practices. Our findings can inform expectations for operational and policy leaders seeking to implement change in primary care practices.
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Affiliation(s)
- Anita D Misra-Hebert
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA. .,Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA. .,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.
| | - Adam Perzynski
- Center for Health Care Research and Policy, Case Western Reserve University at MetroHealth, Cleveland, OH, USA
| | - Michael B Rothberg
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA.,Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA
| | - Jaqueline Fox
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA
| | - Mary Beth Mercer
- Office of Patient Experience, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaobo Liu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Bo Hu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - David C Aron
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA
| | - Kurt C Stange
- Center for Community Health Integration, and Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, Oncology and Sociology, Case Western Reserve University, Cleveland, OH, USA
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Kegler MC, Liang S, Weiner BJ, Tu SP, Friedman DB, Glenn BA, Herrmann AK, Risendal B, Fernandez ME. Measuring Constructs of the Consolidated Framework for Implementation Research in the Context of Increasing Colorectal Cancer Screening in Federally Qualified Health Center. Health Serv Res 2018; 53:4178-4203. [PMID: 30260471 DOI: 10.1111/1475-6773.13035] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE To operationalize constructs from each of the Consolidated Framework for Implementation Research domains and to present psychometric properties within the context of evidence-based approaches for promoting colorectal cancer screening in federally qualified health centers (FQHCs). METHODS Data were collected from FQHC clinics across seven states. A web-based Staff Survey and a Clinic Characteristics Survey were completed by staff and leaders (n = 277) from 59 FQHCs. RESULTS Internal reliability of scales was adequate ranging from 0.62 for compatibility to 0.88 for other personal attributes (openness). Intraclass correlations for the scales indicated that 2.4 percent to 20.9 percent of the variance in scale scores occurs within clinics. Discriminant validity was adequate at the clinic level, with all correlations less than 0.75. Convergent validity was more difficult to assess given lack of hypothesized associations between factors expected to predict implementation. CONCLUSIONS Our results move the field forward by describing initial psychometric properties of constructs across CFIR domains.
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Affiliation(s)
- Michelle C Kegler
- Department of Behavioral Sciences and Health Education, Emory Prevention Research Center, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Shuting Liang
- Department of Behavioral Sciences and Health Education, Emory Prevention Research Center, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Bryan J Weiner
- Departments of Global Health and Health Services, University of Washington, Seattle, WA
| | - Shin Ping Tu
- General Internal Medicine, University of California Davis, Sacramento, CA
| | - Daniela B Friedman
- Department of Health Promotion, Education, and Behavior and the Statewide Cancer Prevention and Control Program, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | - Beth A Glenn
- UCLA Kaiser Permanente Center for Health Equity, Fielding School of Public Health & Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA
| | - Alison K Herrmann
- UCLA Kaiser Permanente Center for Health Equity, Fielding School of Public Health & Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA
| | - Betsy Risendal
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Comprehensive Cancer Center, Aurora, CO
| | - Maria E Fernandez
- School of Public Health, University of Texas Health Science Center at Houston, Houston, TX
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Jetelina KK, Woodson TT, Gunn R, Muller B, Clark KD, DeVoe JE, Balasubramanian BA, Cohen DJ. Evaluation of an Electronic Health Record (EHR) Tool for Integrated Behavioral Health in Primary Care. J Am Board Fam Med 2018; 31:712-723. [PMID: 30201667 PMCID: PMC6261664 DOI: 10.3122/jabfm.2018.05.180041] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/21/2018] [Accepted: 05/25/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Integrating behavioral health into primary care can improve care quality; however, most electronic health records are not designed to meet the needs of integrated teams. We worked with practices and behavioral health (BH) clinicians to design a suite of electronic health record tools to address these needs ("BH e-Suite"). The purpose of this article is to examine whether implementation of the BH e-Suite changes process of care, intermediate clinical outcomes, and patient experiences, and whether its use is acceptable to practice members and BH clinicians. METHODS We conducted a convergent mixed-methods proof-of-concept study, implementing the BH e-Suite across 6 Oregon federally qualified community health centers ("intervention clinics"). We matched intervention clinics to 6 control clinics, based on location and patient panel characteristics, to assess whether process of care (Patient Health Questionnaire-9 [PHQ-9] and Generalized Anxiety Disorder-7 screening) and intermediate outcomes (PHQ-9, Generalized Anxiety Disorder-7 scores) changed postimplementation. Prepost patient surveys were used to assess changes in patient experience. To elucidate factors influencing implementation, we merged quantitative findings with structured observations, surveys, and interviews with practice members. RESULTS Implementation improved process of care (PHQ-9 screening). During the course of the study, change in intermediate outcomes was not observed. Degree of BH e-Suite implementation varied: 2 clinics fully implemented, 2 partially implemented, and 2 practices did not implement at all. Initial practice conditions (eg, low resistance to change, higher capacity), process characteristics (eg, thoughtful planning), and individual characteristics (eg, high self-efficacy) were related to degree of implementation. CONCLUSIONS Health information technology tools designed for behavioral health integration must fit the needs of clinics for the successful uptake and improvement in patient experiences. Research is needed to further assess the effectiveness of this tool in improving patient outcomes and to optimize broader dissemination of this tool among primary care clinics integrating behavioral health.
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Affiliation(s)
- Katelyn K Jetelina
- From Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (KKJ, BAB); Department of Family Medicine, Oregon Health & Science University, Portland, OR (TTW, RG, BM, KDC, JED, DJC); OCHIN, Inc., Portland (JED).
| | - Tanisha Tate Woodson
- From Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (KKJ, BAB); Department of Family Medicine, Oregon Health & Science University, Portland, OR (TTW, RG, BM, KDC, JED, DJC); OCHIN, Inc., Portland (JED)
| | - Rose Gunn
- From Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (KKJ, BAB); Department of Family Medicine, Oregon Health & Science University, Portland, OR (TTW, RG, BM, KDC, JED, DJC); OCHIN, Inc., Portland (JED)
| | - Brianna Muller
- From Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (KKJ, BAB); Department of Family Medicine, Oregon Health & Science University, Portland, OR (TTW, RG, BM, KDC, JED, DJC); OCHIN, Inc., Portland (JED)
| | - Khaya D Clark
- From Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (KKJ, BAB); Department of Family Medicine, Oregon Health & Science University, Portland, OR (TTW, RG, BM, KDC, JED, DJC); OCHIN, Inc., Portland (JED)
| | - Jennifer E DeVoe
- From Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (KKJ, BAB); Department of Family Medicine, Oregon Health & Science University, Portland, OR (TTW, RG, BM, KDC, JED, DJC); OCHIN, Inc., Portland (JED)
| | - Bijal A Balasubramanian
- From Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (KKJ, BAB); Department of Family Medicine, Oregon Health & Science University, Portland, OR (TTW, RG, BM, KDC, JED, DJC); OCHIN, Inc., Portland (JED)
| | - Deborah J Cohen
- From Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (KKJ, BAB); Department of Family Medicine, Oregon Health & Science University, Portland, OR (TTW, RG, BM, KDC, JED, DJC); OCHIN, Inc., Portland (JED)
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Klemenc-Ketis Z, Makivić I, Poplas Susic A. The development and validation of a new interprofessional team approach evaluation scale. PLoS One 2018; 13:e0201385. [PMID: 30092005 PMCID: PMC6084891 DOI: 10.1371/journal.pone.0201385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 07/13/2018] [Indexed: 11/18/2022] Open
Abstract
A team approach in health care involves an interprofessional approach to patient care. We wanted to develop and validate a tool that would evaluate the interprofessional team approach to patients of a family medicine team. We performed a descriptive study in three consecutive phases: a literature review, consensus development panels, and a cross-sectional validation study. Three rounds of consensus development panels were carried out in order to evaluate and adapt the initial scale. The cross-sectional study was carried out in all Slovenian family medicine practices, each invited 10 consecutive patients. In the quantitative study, 3,292 patients participated (a 50.7% response rate), of which 1,810 (55.0%) were women. The mean age of the sample was 53.1 ± 1.2 years. The final Cronbach’s alpha was 0.901. A factor analysis of the 9-item scale put forward two factors (Team Approach and Person-Centred approach) which explained 68.6% of the variance. This study provided a new scale for the evaluation of patient satisfaction with the interprofessional family medicine team from the patients’ point of view. It opened the question of family medicine team competencies and pointed towards the need to develop a family medicine interprofessional team competency framework and a comprehensive tool for its assessment.
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Affiliation(s)
- Zalika Klemenc-Ketis
- Community Health Centre Ljubljana, Ljubljana, Slovenia
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Family Medicine, Faculty of Medicine, University of Maribor, Maribor, Slovenia
- * E-mail:
| | - Irena Makivić
- Community Health Centre Ljubljana, Ljubljana, Slovenia
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Design of healthy hearts in the heartland (H3): A practice-randomized, comparative effectiveness study. Contemp Clin Trials 2018; 71:47-54. [PMID: 29870868 DOI: 10.1016/j.cct.2018.06.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 05/25/2018] [Accepted: 06/01/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND The Healthy Hearts in the Heartland (H3) study is part of a nationwide effort, EvidenceNOW, seeking to better understand the ability of small primary care practices to improve "ABCS" clinical quality measures: appropriate Aspirin therapy, Blood pressure control, Cholesterol management, and Smoking cessation. H3 aimed to assess feasibility of implementing Point-of-Care (POC) or POC plus Population Management (POC + PM) quality improvement (QI) strategies to improve ABCS at practices in Illinois, Indiana, and Wisconsin. We describe the design and randomization of the H3 study. METHODS We conducted a two-arm (1:1, POC:POC + PM), practice-randomized, comparative effectiveness study in 226 primary care practices across four "waves" of randomization with a 12-month intervention period, followed by a six-month sustainability period. Randomization controlled imbalance in nine baseline variables through a modified constrained algorithm. Among others, we used initial, unverified estimates of baseline ABCS values. RESULTS We randomized 112 and 114 practices to POC and POC + PM arms, respectively. Randomization ensured baseline comparability for all nine key variables, including the ABCS measures indicating proportion of patients at the practice level meeting each quality measure. Median(Inner Quartile Range) values were A: 0.78(0.66-0.86) in POC arm vs. 0.77(0.63-0.86) in POC + PM arm, B: 0.64(0.53-0.73) vs. 0.64(0.53-0.75), C: 0.78(0.63-0.86) vs. 0.75(0.64-0.81), S: 0.80(0.65-0.81) vs. 0.79(0.61-0.91). DISCUSSION Surrogate estimates for the true ABCS at baseline coupled with the unique randomization logic achieved adequate baseline balance on these outcomes. Similar practice- or cluster-randomized trials may consider adaptations of this design. Final analyses on 12- and 18-month ABCS outcomes for the H3 study are forthcoming. TRIAL REGISTRATION This trial is registered on ClinicalTrials.gov (Initial post: 11/05/2015; identifier: NCT02598284; https://clinicaltrials.gov/ct2/show/NCT02598284?term=NCT02598284&rank=1).
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Friedberg MW, Reid RO, Timbie JW, Setodji C, Kofner A, Weidmer B, Kahn K. Federally Qualified Health Center Clinicians And Staff Increasingly Dissatisfied With Workplace Conditions. Health Aff (Millwood) 2018; 36:1469-1475. [PMID: 28784740 DOI: 10.1377/hlthaff.2017.0205] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Better working conditions for clinicians and staff could help primary care practices implement delivery system innovations and help sustain the US primary care workforce. Using longitudinal surveys, we assessed the experience of clinicians and staff in 296 clinical sites that participated in the Centers for Medicare and Medicaid Services (CMS) Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration. Participating FQHCs were expected to achieve, within three years, patient-centered medical home recognition at level 3-the highest level possible. During 2013-14, clinicians and staff in these FQHCs reported statistically significant declines in multiple measures of professional satisfaction, work environment, and practice culture. There were no significant improvements on any surveyed measure. These findings suggest that working conditions in FQHCs have deteriorated recently. Whether findings would be similar in other primary care practices is unknown. Although we did not identify the causes of these declines, possible stressors include the adoption of health information technology, practice transformation, and increased demand for services.
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Affiliation(s)
- Mark W Friedberg
- Mark W. Friedberg is a senior natural scientist at the RAND Corporation in Boston, Massachusetts
| | - Rachel O Reid
- Rachel O. Reid is an associate natural scientist at the RAND Corporation in Boston
| | - Justin W Timbie
- Justin W. Timbie is a senior health policy researcher at RAND in Arlington, Virginia
| | - Claude Setodji
- Claude Setodji is a senior statistician at RAND in Pittsburgh, Pennsylvania
| | - Aaron Kofner
- Aaron Kofner is a research programmer at RAND in Arlington
| | - Beverly Weidmer
- Beverly Weidmer is survey director at RAND in Santa Monica, California
| | - Katherine Kahn
- Katherine Kahn is Distinguished Chair in Health Care Delivery Measurement and Evaluation at RAND in Santa Monica and a professor of medicine at the University of California, Los Angeles
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Abstract
Increasing attention has been devoted to the important role that primary care will play in improving population health. One innovation, the patient-centered medical home (PCMH), aims to unite a variety of professionals with patients in the prevention and treatment of illness. Although patient perspectives are critical to this model, this article questions whether the PCMH in practice is truly community-based. That is, do physicians, planners, and other health care professionals take seriously the value of integrating local knowledge into medical care? The argument presented is that community-based philosophy contains a foundational principle that the perspectives of health care practitioners and community members must be integrated. Although many proponents of the PCMH aim to offer patient-centered and sustainable health care, focusing on this philosophical shift will ensure that services are organized by communities in collaboration with health care professionals.
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Affiliation(s)
- Berkeley A Franz
- Assistant Professor of Community-Based Health at the Heritage College of Osteopathic Medicine in Athens, OH.
| | - John W Murphy
- Professor of Sociology at the University of Miami in FL.
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Wu JP, Damschroder LJ, Fetters MD, Zikmund-Fisher BJ, Crabtree BF, Hudson SV, Ruffin MT, Fucinari J, Kang M, Taichman LS, Creswell JW. A Web-Based Decision Tool to Improve Contraceptive Counseling for Women With Chronic Medical Conditions: Protocol For a Mixed Methods Implementation Study. JMIR Res Protoc 2018; 7:e107. [PMID: 29669707 PMCID: PMC5932336 DOI: 10.2196/resprot.9249] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 12/18/2017] [Accepted: 02/05/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Women with chronic medical conditions, such as diabetes and hypertension, have a higher risk of pregnancy-related complications compared with women without medical conditions and should be offered contraception if desired. Although evidence based guidelines for contraceptive selection in the presence of medical conditions are available via the United States Medical Eligibility Criteria (US MEC), these guidelines are underutilized. Research also supports the use of decision tools to promote shared decision making between patients and providers during contraceptive counseling. OBJECTIVE The overall goal of the MiHealth, MiChoice project is to design and implement a theory-driven, Web-based tool that incorporates the US MEC (provider-level intervention) within the vehicle of a contraceptive decision tool for women with chronic medical conditions (patient-level intervention) in community-based primary care settings (practice-level intervention). This will be a 3-phase study that includes a predesign phase, a design phase, and a testing phase in a randomized controlled trial. This study protocol describes phase 1 and aim 1, which is to determine patient-, provider-, and practice-level factors that are relevant to the design and implementation of the contraceptive decision tool. METHODS This is a mixed methods implementation study. To customize the delivery of the US MEC in the decision tool, we selected high-priority constructs from the Consolidated Framework for Implementation Research and the Theoretical Domains Framework to drive data collection and analysis at the practice and provider level, respectively. A conceptual model that incorporates constructs from the transtheoretical model and the health beliefs model undergirds patient-level data collection and analysis and will inform customization of the decision tool for this population. We will recruit 6 community-based primary care practices and conduct quantitative surveys and semistructured qualitative interviews with women who have chronic medical conditions, their primary care providers (PCPs), and clinic staff, as well as field observations of practice activities. Quantitative survey data will be summarized with simple descriptive statistics and relationships between participant characteristics and contraceptive recommendations (for PCPs), and current contraceptive use (for patients) will be examined using Fisher exact test. We will conduct thematic analysis of qualitative data from interviews and field observations. The integration of data will occur by comparing, contrasting, and synthesizing qualitative and quantitative findings to inform the future development and implementation of the intervention. RESULTS We are currently enrolling practices and anticipate study completion in 15 months. CONCLUSIONS This protocol describes the first phase of a multiphase mixed methods study to develop and implement a Web-based decision tool that is customized to meet the needs of women with chronic medical conditions in primary care settings. Study findings will promote contraceptive counseling via shared decision making and reflect evidence-based guidelines for contraceptive selection. TRIAL REGISTRATION ClinicalTrials.gov NCT03153644; https://clinicaltrials.gov/ct2/show/NCT03153644 (Archived by WebCite at http://www.webcitation.org/6yUkA5lK8).
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Affiliation(s)
- Justine P Wu
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | | | - Michael D Fetters
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Brian J Zikmund-Fisher
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, United States.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Benjamin F Crabtree
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Shawna V Hudson
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Mack T Ruffin
- Department of Family and Community Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Juliana Fucinari
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Minji Kang
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | - L Susan Taichman
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | - John W Creswell
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
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Implementation of Practice Transformation: Patient Experience According to Practice Leaders. Qual Manag Health Care 2018; 26:140-151. [PMID: 28665905 DOI: 10.1097/qmh.0000000000000141] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Examine practice leaders' perceptions and experiences of how patient-centered medical home (PCMH) transformation improves patient experience. SUBJECTS Thirty-six interviews with lead physicians (n = 13), site clinic administrators (n = 13), and nurse supervisors (n = 10). METHODS Semi-structured interviews at 14 primary care practices within a large urban Federally Qualified Health Center (FQHC) delivery system to identify critical patient experience domains and mechanisms of change. Identified patient experience domains were compared with Consumer Assessment of Healthcare Providers and Systems (CAHPS) items. RESULTS We identified 28 patient experience domains improved by PCMH transformation, of which 22 are measured by CAHPS, and identified 24 mechanisms of change commonly reported by practice leaders during PCMH transformation. CONCLUSIONS PCMH practice transformation can improve patient experience. Most patient experience domains reported as improved during PCMH efforts are measured by CAHPS items. Practices would benefit from collecting specific information on staff behaviors related to teamwork, team-based communication, scheduling, emergency and inpatient follow-up, and referrals. All 3 types of practice leaders reported 4 main mechanisms of PCMH change that improved patient experience. Our findings provide guidance for practice leaders on which strategies of PCMH practice transformation lead to specific improvements in patient experience measures. Further research is needed on the relationship between PCMH changes and changes in CAHPS patient experience scores.
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Henderson KH, DeWalt DA, Halladay J, Weiner BJ, Kim JI, Fine J, Cykert S. Organizational Leadership and Adaptive Reserve in Blood Pressure Control: The Heart Health NOW Study. Ann Fam Med 2018; 16:S29-S34. [PMID: 29632223 PMCID: PMC5891311 DOI: 10.1370/afm.2210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 01/21/2018] [Accepted: 01/24/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Our purpose was to assess whether a practice's adaptive reserve and high leadership capability in quality improvement are associated with population blood pressure control. METHODS We divided practices into quartiles of blood pressure control performance and considered the top quartile as the benchmark for comparison. Using abstracted clinical data from electronic health records, we performed a cross-sectional study to assess the association of top quartile hypertension control and (1) the baseline practice adaptive reserve (PAR) scores and (2) baseline practice leadership scores, using modified Poisson regression models adjusting for practice-level characteristics. RESULTS Among 181 practices, 46 were in the top quartile, which averaged 68% or better blood pressure control. Practices with higher PAR scores compared with lower PAR scores were not more likely to reside in the top quartile of performance (prevalence ratio [PR] = 1.92 for highest quartile; 95% CI, 0.9-4.1). Similarly, high quality improvement leadership capability compared with lower capability did not predict better blood pressure control performance (PR = 0.94; 95% CI, 0.57-1.56). Practices with higher proportions of commercially insured patients were more likely than practices with lower proportions of commercially insured patients to have top quartile performance (37% vs 26%, P =.002), whereas lower proportions of the uninsured (8% vs 14%, P =.055) were associated with better performance. CONCLUSIONS Our findings show that adaptive reserve and leadership capability in quality improvement implementation are not statistically associated with achieving top quartile practice-level hypertension control at baseline in the Heart Health NOW project. Our findings, however, may be limited by a lack of patient-related factors and small sample size to preclude strong conclusions.
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Affiliation(s)
- Kamal H Henderson
- Division of Cardiology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina .,Division of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Darren A DeWalt
- Division of General Medicine and Clinical Epidemiology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Jacquie Halladay
- Division of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Bryan J Weiner
- Departments of Global Health and Biostatistics, University of Washington, Seattle, Washington
| | - Jung I Kim
- UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Jason Fine
- UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Samuel Cykert
- Division of General Medicine and Clinical Epidemiology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
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Shelley D, Blechter B, Siman N, Jiang N, Cleland C, Ogedegbe G, Williams S, Wu W, Rogers E, Berry C. Quality of Cardiovascular Disease Care in Small Urban Practices. Ann Fam Med 2018; 16:S21-S28. [PMID: 29632222 PMCID: PMC5891310 DOI: 10.1370/afm.2174] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 10/06/2017] [Accepted: 10/11/2017] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We wanted to describe small, independent primary care practices' performance in meeting the Million Hearts ABCSs (aspirin use, blood pressure control, cholesterol management, and smoking screening and counseling), as well as on a composite measure that captured the extent to which multiple clinical targets are achieved for patients with a history of arteriosclerotic cardiovascular disease (ASCVD). We also explored relationships between practice characteristics and ABCS measures. METHODS We conducted a cross-sectional, bivariate analysis using baseline data from 134 practices in New York City. ABCS data were extracted from practices' electronic health records and aggregated to the site level. Practice characteristics were obtained from surveys of clinicians and staff at each practice. RESULTS The proportion of at-risk patients meeting clinical goals for each of the ABCS measures was 73.0% for aspirin use, 69.6% for blood pressure, 66.7% for cholesterol management, and 74.2% screened for smoking and counseled. For patients with a history of ASCVD, only 49% were meeting all ABC (aspirin use, blood pressure control, cholesterol management) targets (ie, composite measure). Solo practices were more likely to meet clinical guidelines for aspirin (risk ratio [RR] =1.17, P =.007) and composite (RR=1.29, P = .011) than practices with multiple clinicians. CONCLUSION Achieving targets for ABCS measures varied considerably across practices; however, small practices were meeting or exceeding Million Hearts goals (ie, 70% or greater). Practices were less likely to meet consistently clinical targets that apply to patients with a history of ASCVD risk factors. Greater emphasis is needed on providing support for small practices to address the complexity of managing patients with multiple risk factors for primary and secondary ASCVD.
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Affiliation(s)
- Donna Shelley
- School of Medicine, New York University, New York, New York
| | - Batel Blechter
- School of Medicine, New York University, New York, New York
| | - Nina Siman
- School of Medicine, New York University, New York, New York
| | - Nan Jiang
- School of Medicine, New York University, New York, New York
| | - Charles Cleland
- Rory Meyers College of Nursing, New York University New York, New York
| | | | | | - Winfred Wu
- Department of Health and Mental Hygiene, Queens, New York
| | - Erin Rogers
- School of Medicine, New York University, New York, New York
| | - Carolyn Berry
- School of Medicine, New York University, New York, New York.,School of Public Service, New York University, New York, New York. New York
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Balasubramanian BA, Marino M, Cohen DJ, Ward RL, Preston A, Springer RJ, Lindner SR, Edwards S, McConnell KJ, Crabtree BF, Miller WL, Stange KC, Solberg LI. Use of Quality Improvement Strategies Among Small to Medium-Size US Primary Care Practices. Ann Fam Med 2018; 16:S35-S43. [PMID: 29632224 PMCID: PMC5891312 DOI: 10.1370/afm.2172] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 11/07/2017] [Accepted: 11/15/2017] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Improving primary care quality is a national priority, but little is known about the extent to which small to medium-size practices use quality improvement (QI) strategies to improve care. We examined variations in use of QI strategies among 1,181 small to medium-size primary care practices engaged in a national initiative spanning 12 US states to improve quality of care for heart health and assessed factors associated with those variations. METHODS In this cross-sectional study, practice characteristics were assessed by surveying practice leaders. Practice use of QI strategies was measured by the validated Change Process Capability Questionnaire (CPCQ) Strategies Scale (scores range from -28 to 28, with higher scores indicating more use of QI strategies). Multivariable linear regression was used to examine the association between practice characteristics and the CPCQ strategies score. RESULTS The mean CPCQ strategies score was 9.1 (SD = 12.2). Practices that participated in accountable care organizations and those that had someone in the practice to configure clinical quality reports from electronic health records (EHRs), had produced quality reports, or had discussed clinical quality data during meetings had higher CPCQ strategies scores. Health system-owned practices and those experiencing major disruptive changes, such as implementing a new EHR system or clinician turnover, had lower CPCQ strategies scores. CONCLUSION There is substantial variation in the use of QI strategies among small to medium-size primary care practices across 12 US states. Findings suggest that practices may need external support to strengthen their ability to do QI and to be prepared for new payment and delivery models.
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Affiliation(s)
- Bijal A Balasubramanian
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Miguel Marino
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Deborah J Cohen
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Rikki L Ward
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Alex Preston
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Rachel J Springer
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Stephan R Lindner
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Samuel Edwards
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - K John McConnell
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Benjamin F Crabtree
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - William L Miller
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Kurt C Stange
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Leif I Solberg
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
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Shoemaker SJ, McNellis RJ, DeWalt DA. The Capacity of Primary Care for Improving Evidence-Based Care: Early Findings From AHRQ's EvidenceNOW. Ann Fam Med 2018; 16:S2-S4. [PMID: 29632218 PMCID: PMC5891306 DOI: 10.1370/afm.2227] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 02/20/2018] [Indexed: 01/17/2023] Open
Affiliation(s)
- Sarah J Shoemaker
- Health Policy Practice, Abt Associates, Inc, Cambridge, Massachusetts
| | - Robert J McNellis
- Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, Maryland
| | - Darren A DeWalt
- Division of General Medicine and Clinical Epidemiology, Department of Medicine University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Fernandez ME, Walker TJ, Weiner BJ, Calo WA, Liang S, Risendal B, Friedman DB, Tu SP, Williams RS, Jacobs S, Herrmann AK, Kegler MC. Developing measures to assess constructs from the Inner Setting domain of the Consolidated Framework for Implementation Research. Implement Sci 2018; 13:52. [PMID: 29587804 PMCID: PMC5870186 DOI: 10.1186/s13012-018-0736-7] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 03/05/2018] [Indexed: 01/13/2023] Open
Abstract
Background Scientists and practitioners alike need reliable, valid measures of contextual factors that influence implementation. Yet, few existing measures demonstrate reliability or validity. To meet this need, we developed and assessed the psychometric properties of measures of several constructs within the Inner Setting domain of the Consolidated Framework for Implementation Research (CFIR). Methods We searched the literature for existing measures for the 7 Inner Setting domain constructs (Culture Overall, Culture Stress, Culture Effort, Implementation Climate, Learning Climate, Leadership Engagement, and Available Resources). We adapted items for the healthcare context, pilot-tested the adapted measures in 4 Federally Qualified Health Centers (FQHCs), and implemented the revised measures in 78 FQHCs in the 7 states (N = 327 respondents) with a focus on colorectal cancer (CRC) screening practices. To psychometrically assess our measures, we conducted confirmatory factor analysis models (CFA; structural validity), assessed inter-item consistency (reliability), computed scale correlations (discriminant validity), and calculated inter-rater reliability and agreement (organization-level construct reliability and validity). Results CFAs for most constructs exhibited good model fit (CFI > 0.90, TLI > 0.90, SRMR < 0.08, RMSEA < 0.08), with almost all factor loadings exceeding 0.40. Scale reliabilities ranged from good (0.7 ≤ α < 0.9) to excellent (α ≥ 0.9). Scale correlations fell below 0.90, indicating discriminant validity. Inter-rater reliability and agreement were sufficiently high to justify measuring constructs at the clinic-level. Conclusions Our findings provide psychometric evidence in support of the CFIR Inner Setting measures. Our findings also suggest the Inner Setting measures from individuals can be aggregated to represent the clinic-level. Measurement of the Inner Setting constructs can be useful in better understanding and predicting implementation in FQHCs and can be used to identify targets of strategies to accelerate and enhance implementation efforts in FQHCs.
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Affiliation(s)
- Maria E Fernandez
- University of Texas Health Science Center at Houston, Center for Health Promotion and Prevention Research, School of Public Health, 7000 Fannin St, Houston, TX, 77030, USA.
| | - Timothy J Walker
- University of Texas Health Science Center at Houston, Center for Health Promotion and Prevention Research, School of Public Health, 7000 Fannin St, Houston, TX, 77030, USA
| | - Bryan J Weiner
- Department of Global Health, University of Washington, Box 357965, 1510 San Juan Road, Seattle, WA, 98195, USA
| | - William A Calo
- Department of Public Health Sciences, Penn State College of Medicine, Mail Code CH69
- 500 University Drive, Hershey, PA, 17033, USA
| | - Shuting Liang
- Emory Prevention Research Center, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30033, USA
| | - Betsy Risendal
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Comprehensive Cancer Center, 13001 E. 17th Place, MSF538, Aurora, CO, 80045, USA
| | - Daniela B Friedman
- Department of Health Promotion, Education, and Behavior and the Statewide Cancer Prevention and Control Program, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Columbia, SC, 29208, USA
| | - Shin Ping Tu
- Department of Internal Medicine, University of California Davis, Suite 2400 , 4150 V Street, Sacramento, CA, 95817, USA
| | - Rebecca S Williams
- Center for Health Promotion and Disease Prevention, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, CB 7424, Chapel Hill, NC, 27599, USA
| | - Sara Jacobs
- Public Health Research Division, RTI International, 3040 East Cornwallis Road, Research Triangle Park, Durham, NC, 27709-2194, USA
| | - Alison K Herrmann
- UCLA Kaiser Permanente Center for Health Equity, Fielding School of Public Health and Jonsson Comprehensive Cancer Center, 650 Charles E. Young Dr. S., A2-125 CHS, Box 690015, Los Angeles, CA, 90095-6900, USA
| | - Michelle C Kegler
- Emory Prevention Research Center, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30033, USA
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Huynh C, Bowles D, Yen MS, Phillips A, Waller R, Hall L, Tu SP. Change implementation: the association of adaptive reserve and burnout among inpatient medicine physicians and nurses. J Interprof Care 2018; 32:549-555. [PMID: 29558229 DOI: 10.1080/13561820.2018.1451307] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Adaptive Reserve (AR) is positively associated with implementing change in ambulatory settings. Deficits in AR may lead to change fatigue or burnout. We studied the association of self-reported AR and burnout among providers to hospitalized medicine patients in an academic medical center. An electronic survey containing a 23-item Adaptive Reserve scale, burnout inventory, and demographic questions was sent to a convenience sample of nurses, house staff team members, and hospitalists. A total of 119 self-administered, online surveys collected from June 2014 to March 2015 were analyzed. Ordinal regression analyses were used to examine the association between AR and burnout. Eighty percent of participants reported either level 1 or 2 burnout. Additionally, 10.9% of participants responded level 0% and 7.6% of participants reported level 3. Participants reporting higher burnout were about three times more likely to report lower AR levels. AR is strongly associated with self-reported burnout by physicians and nurses providing inpatient care at this academic medical center. Growing evidence supports the positive association of AR to successful change implementation in ambulatory settings. Similar studies are needed to determine whether certain levels of AR can predict successful change in hospital settings.
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Affiliation(s)
- Christine Huynh
- a Department of Internal Medicine , Virginia Commonwealth University , Richmond , VA , USA
| | - Darci Bowles
- b School of Nursing , Virginia Commonwealth University , Richmond , VA , USA
| | - Miao-Shan Yen
- c Department of Biostatistics , Virginia Commonwealth University , Richmond , VA , USA
| | - Allison Phillips
- a Department of Internal Medicine , Virginia Commonwealth University , Richmond , VA , USA
| | - Rachel Waller
- a Department of Internal Medicine , Virginia Commonwealth University , Richmond , VA , USA
| | - Lindsey Hall
- a Department of Internal Medicine , Virginia Commonwealth University , Richmond , VA , USA
| | - Shin-Ping Tu
- a Department of Internal Medicine , Virginia Commonwealth University , Richmond , VA , USA
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A Quasi-experimental Evaluation of Performance Improvement Teams in the Safety-Net: A Labor-Management Partnership Model for Engaging Frontline Staff. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2018; 22:E1-7. [PMID: 26193049 DOI: 10.1097/phh.0000000000000303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Unit-based teams (UBTs), initially developed by Kaiser Permanente and affiliated unions, are natural work groups of clinicians, managers, and frontline staff who work collaboratively to identify areas for improvement and implement solutions. OBJECTIVE We evaluated the UBT model implemented by the Los Angeles County Department of Health Services in partnership with its union to engage frontline staff in improving patient care. DESIGN We conducted a quasi-experimental study, comparing surveys at baseline and 6 months, among personnel in 10 clinics who received UBT training to personnel in 5 control clinics. We also interviewed staff from 5 clinics that received UBT training and 3 control clinics. PARTICIPANTS We conducted 330 surveys and 38 individual, semi-structured interviews with staff at an outpatient facility in South Los Angeles. INTERVENTIONS Each UBT leader received an 8-hour training in basic performance improvement methods, and each UBT was assigned a team "coach." MAIN MEASURES Our outcome measure was 6-month change in the "adaptive reserve" score, the units' self-reported ability to make and sustain change. We analyzed transcripts of the interviews to find common themes regarding the UBT intervention. KEY RESULTS The survey response rate was 63% (158/252) at baseline and 75% (172/231) at 6 months. There was a significant difference-in-change in adaptive reserve between UBTs and non-UBTs at 6 months (+0.11 vs -0.13; P = .02). Nine of the 10 UBTs reported increases in adaptive reserve and 8 UBTs reported decreased no-show rates or patient length of stay in clinic. Staff overwhelmingly felt the UBTs were a positive intervention because it allowed all levels of staff to have a voice in improvement. CONCLUSIONS Our results indicate that partnership between management and unions to engage frontline staff in teams may be a useful tool to improve delivery of health care in a safety-net setting.
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Quigley DD, Predmore ZS, Hays RD. Tools to Gauge Progress During Patient-Centered Medical Home Transformation. AMERICAN JOURNAL OF ACCOUNTABLE CARE 2017; 5:e8-e18. [PMID: 38784429 PMCID: PMC11113621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
OBJECTIVES To review tools designed to evaluate and improve the extent of patient-centered medical home (PCMH) implementation. STUDY DESIGN Literature search and review of tools to evaluate PCMH "medical homeness" and track progress toward practice transformation. METHODS We conducted a literature search to identify tools designed for evaluation and quality improvement during the PCMH change process. We identified and reviewed the content of 5 publicly available PCMH survey tools used by an administrator or clinical lead to collect data at the practice level for evaluation and/or quality improvement during PCMH implementation. We assessed each tool's coverage of PCMH content, standards, and requirements. RESULTS We found that 3 tools (Patient-Centered Medical Home Assessment [PCMH-A], Primary Care Assessment Tool-Facility Edition, and Medical Home Care Coordination Survey-Healthcare Team [MHCCS-H]) are actionable for quality improvement. PCMH-A assesses the broadest array of practice capabilities and includes items pertaining to all National Committee for Quality Assurance PCMH standards. MHCCS-H was the only tool to contain items on comprehensiveness of care. There was variation in emphasis on main domains, with some content areas covered by only 1 tool. CONCLUSIONS There is currently little evidence on which PCMH tools are associated with improved quality outcomes, as relatively few longitudinal studies have been conducted. Of the 5 tools we reviewed, only PCMH-A and MHCCS-H impose a light administrative burden (less than 10 minutes to complete) and can identify specific actions to improve a given practice capability. Each tool is lacking in a particular content area: PCMH-A, for example, lacks items on comprehensiveness of care, whereas MHCCS-H lacks items addressing access to care.
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Affiliation(s)
- Denise D Quigley
- RAND Corporation (DDQ), Santa Monica, CA; RAND Corporation (ZSP), Boston, MA; Division of General Internal Medicine and Health Services Research, University of California, Los Angeles (RDH), Los Angeles, CA
| | - Zachary S Predmore
- RAND Corporation (DDQ), Santa Monica, CA; RAND Corporation (ZSP), Boston, MA; Division of General Internal Medicine and Health Services Research, University of California, Los Angeles (RDH), Los Angeles, CA
| | - Ron D Hays
- RAND Corporation (DDQ), Santa Monica, CA; RAND Corporation (ZSP), Boston, MA; Division of General Internal Medicine and Health Services Research, University of California, Los Angeles (RDH), Los Angeles, CA
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Weiner BJ, Rohweder CL, Scott JE, Teal R, Slade A, Deal AM, Jihad N, Wolf M. Using Practice Facilitation to Increase Rates of Colorectal Cancer Screening in Community Health Centers, North Carolina, 2012-2013: Feasibility, Facilitators, and Barriers. Prev Chronic Dis 2017; 14:E66. [PMID: 28817791 PMCID: PMC5566800 DOI: 10.5888/pcd14.160454] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction Practice facilitation involves trained individuals working with practice staff to conduct quality improvement activities and support delivery of evidence-based clinical services. We examined the feasibility of using practice facilitation to assist federally qualified health centers (FQHCs) to increase colorectal cancer screening rates in North Carolina. Methods The intervention consisted of 12 months of facilitation in 3 FQHCs. We conducted chart audits to obtain data on changes in documented recommendation for colorectal cancer screening and completed screening. Key informant interviews provided qualitative data on barriers to and facilitators of implementing office systems. Results Overall, the percentage of eligible patients with a documented colorectal cancer screening recommendation increased from 15% to 29% (P < .001). The percentage of patients up to date with colorectal cancer screening rose from 23% to 34% (P = .03). Key informants in all 3 clinics said the implementation support from the practice facilitator was critical for initiating or improving office systems and that modifying the electronic medical record was the biggest challenge and most time-consuming aspect of implementing office systems changes. Other barriers were staff turnover and reluctance on the part of local gastroenterology practices to perform free or low-cost diagnostic colonoscopies for uninsured or underinsured patients. Conclusion Practice facilitation is a feasible, acceptable, and promising approach for supporting universal colorectal cancer screening in FQHCs. A larger-scale study is warranted.
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Affiliation(s)
- Bryan J Weiner
- Department of Global Health, University of Washington, 1510 San Juan Rd, Seattle, WA 98195.
| | | | - Jennifer E Scott
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Randall Teal
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Alecia Slade
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Allison M Deal
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Naima Jihad
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Marti Wolf
- North Carolina Community Health Center Association, Raleigh, North Carolina
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Scuffham PA, Mihala G, Ward L, McMurray A, Connor M. Evaluation of the Gold Coast Integrated Care for patients with chronic disease or high risk of hospitalisation through a non-randomised controlled clinical trial: a pilot study protocol. BMJ Open 2017; 7:e016776. [PMID: 28674147 PMCID: PMC5734577 DOI: 10.1136/bmjopen-2017-016776] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Chronic diseases are the leading cause of illness, disability and death in Australia. The prevalence and associated health expenditure are projected to soar. There is no 'whole system' approach to healthcare in Australia. To overcome this fragmentation, the Gold Coast Hospital and Health Service (GCHHS) is developing a new model known as Gold Coast Integrated Care (GCIC). To evaluate GCIC a 4-year pilot trial commenced in March 2015. This protocol paper describes the evaluation of GCIC. METHODS AND ANALYSIS A pragmatic non-randomised controlled clinical trial is conducted to test the hypothesis that GCIC will result in improved health and well-being at no additional cost to the healthcare system. Using a mixed methods approach, impact, outcome and process evaluations will be undertaken to assess the effectiveness and acceptability, including the balance of costs between primary and public secondary care sectors, staff and training requirements, clinical service delivery, and trial implementation.Fifteen general practices have agreed to deliver GCIC. One thousand five hundred of their adult patients with treated chronic diseases, high risk of hospitalisation or healthcare utilisation were recruited to the intervention arm. Approximately 3000 patients not associated with the participating general practices were identified as controls using propensity matching which will provide service utilisation and disease data for usual care.Baseline data and follow-up observations are collected annually until the end of 2018. Quantitative analyses will measure patient healthcare costs, utilisation of health services, and health outcomes, and general practice clinical service delivery according to clinical guidelines (number of foot exams, HbA1c tests). Qualitative analyses will focus on patient and staff experiences, satisfaction, engagement and implementation of the programme as planned. ETHICS AND DISSEMINATION Approval was received from the GCHHS and Griffith University. The study is registered with the Australian New Zealand Clinical Trial Registry (ACTRN12616000821493). Findings will be communicated via yearly reports to funding bodies and scientific publications. TRIAL REGISTRATION NUMBER ACTRN12616000821493; Pre-results.
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Affiliation(s)
- Paul A Scuffham
- Centre for Applied Health Economics, School of Medicine, Menzies Health Institute Queensland, Griffith University, Nathan, Australia
| | - Gabor Mihala
- Centre for Applied Health Economics, School of Medicine, Menzies Health Institute Queensland, Griffith University, Nathan, Australia
| | - Lauren Ward
- Centre for Health Innovation, Griffith University and the Gold Coast Health and Hospital Service, Gold Coast, Australia
| | - Anne McMurray
- Gold Coast Integrated Care, Gold Coast Hospital and Health Service, Gold Coast, Australia and the Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Martin Connor
- Centre for Health Innovation, Griffith University and the Gold Coast Health and Hospital Service, Gold Coast, Australia
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Abstract
BACKGROUND The effectiveness of community clinics and health centers' efforts to improve the quality of care might be modified by clinics' workplace climates. Several surveys to measure workplace climate exist, but their relationships to each other and to distinguishable dimensions of workplace climate are unknown. OBJECTIVE To assess the psychometric properties of a survey instrument combining items from several existing surveys of workplace climate and to generate a shorter instrument for future use. MATERIALS AND METHODS We fielded a 106-item survey, which included items from 9 existing instruments, to all clinicians and staff members (n=781) working in 30 California community clinics and health centers, receiving 628 responses (80% response rate). We performed exploratory factor analysis of survey responses, followed by confirmatory factor analysis of 200 reserved survey responses. We generated a new, shorter survey instrument of items with strong factor loadings. RESULTS Six factors, including 44 survey items, emerged from the exploratory analysis. Two factors (Clinic Workload and Teamwork) were independent from the others. The remaining 4 factors (staff relationships, quality improvement orientation, managerial readiness for change, and staff readiness for change) were highly correlated, indicating that these represented dimensions of a higher-order factor we called "Clinic Functionality." This 2-level, 6-factor model fit the data well in the exploratory and confirmatory samples. For all but 1 factor, fewer than 20 survey responses were needed to achieve clinic-level reliability >0.7. CONCLUSIONS Survey instruments designed to measure workplace climate have substantial overlap. The relatively parsimonious item set we identified might help target and tailor clinics' quality improvement efforts.
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Ribisl KM, Fernandez ME, Friedman DB, Hannon PA, Leeman J, Moore A, Olson L, Ory M, Risendal B, Sheble L, Taylor VM, Williams RS, Weiner BJ. Impact of the Cancer Prevention and Control Research Network: Accelerating the Translation of Research Into Practice. Am J Prev Med 2017; 52:S233-S240. [PMID: 28215371 PMCID: PMC5812747 DOI: 10.1016/j.amepre.2016.08.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 07/29/2016] [Accepted: 08/18/2016] [Indexed: 12/18/2022]
Abstract
The Cancer Prevention and Control Research Network (CPCRN) is a thematic network dedicated to accelerating the adoption of evidence-based cancer prevention and control practices in communities by advancing dissemination and implementation science. Funded by the Centers for Disease Control and Prevention and National Cancer Institute, CPCRN has operated at two levels: Each participating network center conducts research projects with primarily local partners as well as multicenter collaborative research projects with state and national partners. Through multicenter collaboration, thematic networks leverage the expertise, resources, and partnerships of participating centers to conduct research projects collectively that might not be feasible individually. Although multicenter collaboration is often advocated, it is challenging to promote and assess. Using bibliometric network analysis and other graphical methods, this paper describes CPCRN's multicenter publication progression from 2004 to 2014. Searching PubMed, Scopus, and Web of Science in 2014 identified 249 peer-reviewed CPCRN publications involving two or more centers out of 6,534 total. The research and public health impact of these multicenter collaborative projects initiated by CPCRN during that 10-year period were then examined. CPCRN established numerous workgroups around topics such as: 2-1-1, training and technical assistance, colorectal cancer control, federally qualified health centers, cancer survivorship, and human papillomavirus. This paper discusses the challenges that arise in promoting multicenter collaboration and the strategies that CPCRN uses to address those challenges. The lessons learned should broadly interest those seeking to promote multisite collaboration to address public health problems, such as cancer prevention and control.
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Affiliation(s)
- Kurt M Ribisl
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Maria E Fernandez
- Department of Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston, Houston, Texas
| | - Daniela B Friedman
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina
| | - Peggy A Hannon
- Department of Health Services, University of Washington, Seattle, Washington
| | - Jennifer Leeman
- Department of Health Care Environments, University of North Carolina School of Nursing, Chapel Hill, North Carolina
| | - Alexis Moore
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lindsay Olson
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Marcia Ory
- Department of Health Promotion and Community Health Sciences, Texas A&M University, College Station, Texas
| | - Betsy Risendal
- Department of Community and Behavioral Health, University of Colorado Denver, Denver, Colorado
| | - Laura Sheble
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Vicky M Taylor
- Department of Health Services, University of Washington, Seattle, Washington
| | - Rebecca S Williams
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Bryan J Weiner
- Department of Health Policy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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