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Damschroder LJ, Evans R, Kim HM, Sussman J, Freitag MB, Robinson CH, Burns JA, Yankey NR, Lowery JC. Effectiveness of a virtual quality improvement training program to improve reach of weight management programs within a large health system. Health Serv Res 2024. [PMID: 39054798 DOI: 10.1111/1475-6773.14344] [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] [Indexed: 07/27/2024] Open
Abstract
OBJECTIVE To test effectiveness of the LEAP (Learn Engage Act Process) Program on engaging frontline Veteran Health Administration (VHA) medical center teams in continuous quality improvement (QI), a core capability for learning health systems. DATA SOURCES AND STUDY SETTING Data sources included VHA electronic health record (EHR) data, surveys, and LEAP coaching field notes. STUDY DESIGN A staggered difference-in-differences study was conducted. Fifty-five facilities participated in LEAP across eight randomly assigned clusters of 6-8 facilities per cluster over 2 years. Non-participating facilities were used as controls. A MOVE! weight management program team completed a Plan-Do-Study-Act cycle of change supported by learning curriculum, coaching, and virtual collaboratives in LEAP facilities. Primary outcome was program reach to Veterans. A mixed-effects model compared pre- versus post-LEAP periods for LEAP versus control facilities. LEAP adherence, satisfaction, and cost to deliver LEAP were evaluated. DATA COLLECTION/EXTRACTION METHODS Thirty months of facility-level EHR MOVE! enrollment data were included in analyses. LEAP Satisfaction and QI skills were elicited via surveys at baseline and 6-month post-LEAP. PRINCIPAL FINDINGS Fifty-five facilities were randomly assigned to eight time-period-based clusters to receive LEAP (71% completed LEAP) and 82 non-participating facilities were randomly assigned as controls. Reach in LEAP and control facilities was comparable in the 12-month pre-LEAP period (p = 0.07). Though LEAP facilities experienced slower decline in reach in the 12-month post-LEAP period compared with controls (p < 0.001), this is likely due to unexplained fluctuations in controls. For LEAP facilities, satisfaction was high (all mean ratings >4 on a 5-point scale), self-reported use of QI methods increased significantly (p-values <0.05) 6 months post-LEAP, and delivery cost was $4024 per facility-based team. CONCLUSION Control facilities experienced declining reach in the 12-month post-LEAP period, but LEAP facilities did not, plus they reported higher engagement in QI, an essential capability for learning health systems.
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Affiliation(s)
- Laura J Damschroder
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Richard Evans
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - H Myra Kim
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Jeremy Sussman
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Michelle B Freitag
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Claire H Robinson
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Jennifer A Burns
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Nicholas R Yankey
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Julie C Lowery
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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Richards DA, Bollen J, Jones B, Melendez-Torres GJ, Hulme C, Cockcroft E, Cook H, Cooper J, Creanor S, Cruickshank S, Dawe P, Doris F, Iles-Smith H, Kent M, Logan P, O'Connell A, Onysk J, Owens R, Quinn L, Rafferty AM, Romanczuk L, Russell AM, Shepherd M, Singh SJ, Sugg HVR, Coon JT, Tooze S, Warren FC, Whale B, Wootton S. Evaluation of a COVID-19 fundamental nursing care guideline versus usual care: The COVID-NURSE cluster randomized controlled trial. J Adv Nurs 2024; 80:2137-2152. [PMID: 37986547 DOI: 10.1111/jan.15959] [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] [Revised: 11/01/2023] [Accepted: 11/01/2023] [Indexed: 11/22/2023]
Abstract
AIM To evaluate the impact of usual care plus a fundamental nursing care guideline compared to usual care only for patients in hospital with COVID-19 on patient experience, care quality, functional ability, treatment outcomes, nurses' moral distress, patient health-related quality of life and cost-effectiveness. DESIGN Parallel two-arm, cluster-level randomized controlled trial. METHODS Between 18th January and 20th December 2021, we recruited (i) adults aged 18 years and over with COVID-19, excluding those invasively ventilated, admitted for at least three days or nights in UK Hospital Trusts; (ii) nurses caring for them. We randomly assigned hospitals to use a fundamental nursing care guideline and usual care or usual care only. Our patient-reported co-primary outcomes were the Relational Aspects of Care Questionnaire and four scales from the Quality from the Patient Perspective Questionnaire. We undertook intention-to-treat analyses. RESULTS We randomized 15 clusters and recruited 581 patient and 418 nurse participants. Primary outcome data were available for 570-572 (98.1%-98.5%) patient participants in 14 clusters. We found no evidence of between-group differences on any patient, nurse or economic outcomes. We found between-group differences over time, in favour of the intervention, for three of our five co-primary outcomes, and a significant interaction on one primary patient outcome for ethnicity (white British vs. other) and allocated group in favour of the intervention for the 'other' ethnicity subgroup. CONCLUSION We did not detect an overall difference in patient experience for a fundamental nursing care guideline compared to usual care. We have indications the guideline may have aided sustaining good practice over time and had a more positive impact on non-white British patients' experience of care. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE We cannot recommend the wholescale implementation of our guideline into routine nursing practice. Further intervention development, feasibility, pilot and evaluation studies are required. IMPACT Fundamental nursing care drives patient experience but is severely impacted in pandemics. Our guideline was not superior to usual care, albeit it may sustain good practice and have a positive impact on non-white British patients' experience of care. REPORTING METHOD CONSORT and CONSERVE. PATIENT OR PUBLIC CONTRIBUTION Patients with experience of hospitalization with COVID-19 were involved in guideline development and writing, trial management and interpretation of findings.
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Affiliation(s)
- David A Richards
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
- Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Jess Bollen
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Ben Jones
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | | | - Claire Hulme
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Emma Cockcroft
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Heather Cook
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Joanne Cooper
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Siobhan Creanor
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | | | - Phoebe Dawe
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Faye Doris
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | | | - Merryn Kent
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Pip Logan
- Community Health Sciences, University of Nottingham, Nottingham, UK
| | - Abby O'Connell
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Jakub Onysk
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Rosie Owens
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Lynne Quinn
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Anne Marie Rafferty
- Florence Nightingale School of Nursing and Midwifery, Kings College University London, London, UK
| | | | | | - Maggie Shepherd
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Sally J Singh
- Department of Respiratory Science, University of Leicester, Leicester, UK
- University Hospitals of Leicester NHS Trust, Biomedical Research Centre - Respiratory, Glenfield Hospital, Leicester, UK
| | - Holly V R Sugg
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Jo Thompson Coon
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
- The National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), Exeter, UK
| | - Susannah Tooze
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Fiona C Warren
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Bethany Whale
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Stephen Wootton
- Institute of Human Nutrition, University of Southampton, Southampton, UK
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Garvey WT, Cheng M, Ramasamy A, Smolarz BG, Park S, Kumar N, Kim N, DerSarkissian M, Bhak RH, Duh MS, Wu M, Hansen S, Young-Xu Y. Clinical and Cost Benefits of Anti-Obesity Medication for US Veterans Participating in the MOVE! Weight Management Program. Popul Health Manag 2023; 26:72-82. [PMID: 36735596 DOI: 10.1089/pop.2022.0227] [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: 02/04/2023] Open
Abstract
Abstract This study investigated the clinical and economic impact of anti-obesity medications (AOMs; orlistat, liraglutide, phentermine/topiramate extended-release [ER], naltrexone ER/bupropion ER) among United States Veterans with obesity participating in Motivating Overweight/Obese Veterans Everywhere! (MOVE!), a government-initiated weight management program. The study population was identified from electronic medical records of the Veterans Health Administration (2010-2020). Clinical indices of obesity and health care resource utilization and costs were evaluated at 6, 12, and 24 months after the initial dispensing of an AOM in the AOM+MOVE! cohort (N = 3732, mean age 57 years, 79% male) or on the corresponding date of an inpatient or outpatient encounter in the MOVE! cohort (N = 7883, mean age 58 years, 81% male). At 6 months postindex, the AOM+MOVE! cohort had better cardiometabolic indices (eg, systolic blood pressure, diastolic blood pressure, total cholesterol, low-density lipoprotein cholesterol, hemoglobin A1c) than the MOVE! cohort, with the trends persisting at 12 and 24 months. The AOM+MOVE! cohort was significantly more likely than the MOVE! cohort to have weight decreases of 5%-10%, 10%-15%, and >15% and lower body mass index at 6, 12, and 24 months. The AOM+MOVE! cohort also had fewer inpatient and emergency department visits than the MOVE! cohort, which was associated with lower mean total medical costs including inpatient costs. These results suggest that combining AOM treatment with the MOVE! program could yield long-term cost savings for the Veterans Affairs network and meaningful clinical improvements for Veterans with obesity.
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Affiliation(s)
- W Timothy Garvey
- UAB Diabetes Research Center, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mu Cheng
- Analysis Group, Inc., Boston, Massachusetts, USA
| | | | | | - Suna Park
- Analysis Group, Inc., Boston, Massachusetts, USA
| | - Neela Kumar
- Novo Nordisk, Inc., Plainsboro, New Jersey, USA
| | - Nina Kim
- Novo Nordisk, Inc., Plainsboro, New Jersey, USA
| | | | | | | | - Melody Wu
- Analysis Group, Inc., Boston, Massachusetts, USA
| | | | - Yinong Young-Xu
- Clinical Epidemiology Program, White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA
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Robinson KM, Vander Weg M, Laroche HH, Carrel M, Wachsmuth J, Kazembe K, Vaughan Sarrazin M. Obesity treatment initiation, retention, and outcomes in the Veterans Affairs MOVE! Program among rural and urban veterans. Obes Sci Pract 2022; 8:784-793. [PMID: 36483119 PMCID: PMC9722450 DOI: 10.1002/osp4.622] [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: 03/04/2022] [Revised: 05/10/2022] [Accepted: 05/23/2022] [Indexed: 11/08/2022] Open
Abstract
Objective Rural veterans have high obesity rates. Yet, little is known about this population's engagement with the Veterans Affairs (VA) weight management program (MOVE!). The study objective is to determine whether MOVE! enrollment, anti-obesity medication use, bariatric surgery use, retention, and outcomes differ by rurality for veterans with severe obesity. Methods This is a retrospective cohort study using Veterans Health Administration patient databases, including VA patients with severe obesity during 2015-2017. Patients were categorized using Rural-Urban Commuting Area codes. Primary outcomes included proportion of patients and risk-adjusted likelihood of initiating VA MOVE!, anti-obesity medication, or bariatric surgery and risk-adjusted highly rural|Hazard Ratio (HR) of any obesity treatment. Secondary outcomes included treatment retention (≥12 weeks) and successful weight loss (5%) among patients initiating MOVE!, and risk-adjusted odds of retention and successful weight loss. Results Among 640,555 eligible veterans, risk-adjusted relative likelihood of MOVE! treatment was significantly lower for rural and HR veterans (HR = 0.83, HR = 0.67, respectively). Initiation rates of anti-obesity medication use were significantly lower as well, whereas bariatric surgery rates, retention, and successful weight loss did not differ. Conclusions Overall treatment rates with MOVE!, bariatric surgery, and anti-obesity medications remain low. Rural veterans are less likely to enroll in MOVE! and less likely to receive anti-obesity medications than urban veterans.
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Affiliation(s)
- Kathleen M. Robinson
- Department of Internal MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - Mark Vander Weg
- Center for Access & Delivery Research and Evaluation (CADRE)Iowa City VA Health Care SystemIowa CityIowaUSA
- Department of Behavioral and Community HealthUniversity of Iowa College of Public Health Iowa CityIowa CityIowaUSA
| | - Helena H. Laroche
- Center for Children's Healthy Lifestyles and NutritionUniversity of Missouri‐Kansas City School of MedicineKansas CityMissouriUSA
| | - Margaret Carrel
- Department of GeographyUniversity of Iowa College of Liberal ArtsIowa CityIowaUSA
| | - Jason Wachsmuth
- Department of Internal MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - Krista Kazembe
- MOVE! Treatment ProgramIowa City VA Health Care SystemIowa CityIowaUSA
| | - Mary Vaughan Sarrazin
- Department of Internal MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
- Center for Access & Delivery Research and Evaluation (CADRE)Iowa City VA Health Care SystemIowa CityIowaUSA
- InvestigatorVA Office of Rural HealthVeterans Rural Health Resource Center‐Iowa City (VRHRC‐IC)Iowa City Veterans Affairs Health Care SystemIowa CityIowaUSA
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Rangachari P, Mushiana SS, Herbert K. A scoping review of applications of the Consolidated Framework for Implementation Research (CFIR) to telehealth service implementation initiatives. BMC Health Serv Res 2022; 22:1450. [PMID: 36447279 PMCID: PMC9708146 DOI: 10.1186/s12913-022-08871-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 11/22/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND The Consolidated Framework for Implementation Research (CFIR), introduced in 2009, has the potential to provide a comprehensive understanding of the determinants of implementation-effectiveness of health service innovations. Although the CFIR has been increasingly used in recent years to examine factors influencing telehealth implementation, no comprehensive reviews currently exist on the scope of knowledge gained exclusively from applications of the CFIR to telehealth implementation initiatives. This review sought to address this gap. METHODS PRISMA-ScR criteria were used to inform a scoping review of the literature. Five academic databases (PUBMED, PROQUEST, SCIDIRECT, CINAHL, and WoS) were searched for eligible sources of evidence from 01.01.2010 through 12.31.2021. The initial search yielded a total of 18,388 records, of which, 64 peer-reviewed articles met the inclusion criteria for the review. Included articles were reviewed in full to extract data, and data collected were synthesized to address the review questions. RESULTS Most included articles were published during or after 2020 (64%), and a majority (77%) were qualitative or mixed-method studies seeking to understand barriers or facilitators to telehealth implementation using the CFIR. There were few comparative- or implementation-effectiveness studies containing outcome measures (5%). The database search however, revealed a growing number of protocols for implementation-effectiveness studies published since 2020. Most articles (91%) reported the CFIR Inner Setting domain (e.g., leadership engagement) to have a predominant influence over telehealth implementation success. By comparison, few articles (14%) reported the CFIR Outer Setting domain (e.g., telehealth policies) to have notable influence. While more (63%) telehealth initiatives were focused on specialty (vs primary) care, a vast majority (78%) were focused on clinical practice over medical education, healthcare administration, or population health. CONCLUSIONS Organized provider groups have historically paid considerable attention to advocating for telehealth policy (Outer Setting) reform. However, results suggest that for effective telehealth implementation, provider groups need to refocus their efforts on educating individual providers on the complex inter-relationships between Inner Setting constructs and telehealth implementation-effectiveness. On a separate note, the growth in implementation-effectiveness study protocols since 2020, suggests that additional outcome measures may soon be available, to provide a more nuanced understanding of the determinants of effective telehealth implementation based on the CFIR domains and constructs.
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Affiliation(s)
- Pavani Rangachari
- grid.266831.80000 0001 2168 8754Department of Population Health and Leadership, School of Health Sciences, University of New Haven, 300 Boston Post Road, West Haven, CT 06516 USA
| | - Swapandeep S. Mushiana
- grid.410372.30000 0004 0419 2775Veterans Affairs (VA) Quality Scholars Program - San Francisco VA Healthcare System, San Francisco, CA 94121 USA
| | - Krista Herbert
- Portland Veterans Affairs (VA) Healthcare System, Portland, OR 97239 USA
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Funk LM, Alagoz E, Jolles SA, Shea GE, Gunter RL, Raffa SD, Voils CI. A Qualitative Study of the System-level Barriers to Bariatric Surgery Within the Veterans Health Administration. Ann Surg 2022; 275:e181-e188. [PMID: 32886462 PMCID: PMC7674184 DOI: 10.1097/sla.0000000000003982] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To characterize system-level barriers to bariatric surgery from the perspectives of Veterans with severe obesity and obesity care providers. SUMMARY OF BACKGROUND DATA Bariatric surgery is the most effective weight loss option for Veterans with severe obesity, but fewer than 0.1% of Veterans with severe obesity undergo it. Addressing low utilization of bariatric surgery and weight management services is a priority for the veterans health administration. METHODS We conducted semi-structured interviews with Veterans with severe obesity who were referred for or underwent bariatric surgery, and providers who delivered care to veterans with severe obesity, including bariatric surgeons, primary care providers, registered dietitians, and health psychologists. We asked study participants to describe their experiences with the bariatric surgery delivery process in the VA system. All interviews were audio-recorded and transcribed. Four coders iteratively developed a codebook and used conventional content analysis to identify relevant systems or "contextual" barriers within Andersen Behavioral Model of Health Services Use. RESULTS Seventy-three semi-structured interviews with veterans (n = 33) and providers (n = 40) throughout the veterans health administration system were completed. More than three-fourths of Veterans were male, whereas nearly three-fourths of the providers were female. Eight themes were mapped onto Andersen model as barriers to bariatric surgery: poor care coordination, lack of bariatric surgery guidelines, limited primary care providers and referring provider knowledge about bariatric surgery, long travel distances, delayed referrals, limited access to healthy foods, difficulties meetings preoperative requirements, and lack of provider availability and/or time. CONCLUSIONS Addressing system-level barriers by improving coordination of care and standardizing some aspects of bariatric surgery care may improve access to evidence-based severe obesity care within VA.
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Affiliation(s)
- Luke M. Funk
- William S. Middleton VA Memorial Hospital, Madison, WI
- Department of Surgery, Wisconsin Surgical Outcomes Research Program (WiSOR), University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Esra Alagoz
- Department of Surgery, Wisconsin Surgical Outcomes Research Program (WiSOR), University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sally A. Jolles
- William S. Middleton VA Memorial Hospital, Madison, WI
- Department of Surgery, Wisconsin Surgical Outcomes Research Program (WiSOR), University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Grace E. Shea
- Department of Surgery, Wisconsin Surgical Outcomes Research Program (WiSOR), University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Rebecca L. Gunter
- Department of Surgery, Wisconsin Surgical Outcomes Research Program (WiSOR), University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Susan D. Raffa
- Department of Veterans Affairs, National Center for Health Promotion and Disease Prevention, Durham, NC
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine
| | - Corrine I. Voils
- William S. Middleton VA Memorial Hospital, Madison, WI
- Department of Surgery, Wisconsin Surgical Outcomes Research Program (WiSOR), University of Wisconsin School of Medicine and Public Health, Madison, WI
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Espel-Huynh HM, Goldstein CM, Stephens ML, Finnegan OL, Elwy AR, Wing RR, Thomas JG. Contextual influences on implementation of online behavioral obesity treatment in primary care: formative evaluation guided by the consolidated framework for implementation research. Transl Behav Med 2021; 12:214-224. [PMID: 34971381 PMCID: PMC8849001 DOI: 10.1093/tbm/ibab160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Online behavioral obesity treatment is a promising first-line approach to weight management in primary care. However, little is known about contextual influences on implementation. Understand qualitative contextual factors that affect the implementation process, as experienced by key primary care stakeholders implementing the program. Online behavioral obesity treatment was implemented across a 60-clinic primary care practice network. Patients were enrolled by nurse care managers (NCMs; N = 14), each serving 2-5 practices. NCMs were randomized to one of two implementation conditions-"Basic" (standard implementation) or "Enhanced" (i.e., with added patient tracking features and more implementation strategies employed). NCMs completed qualitative interviews guided by the Consolidated Framework for Implementation Research (CFIR). Interviews were transcribed and analyzed via directed content analysis. Emergent categories were summarized by implementation condition and assigned a valence according to positive/negative influence. Individuals in the Enhanced condition viewed two aspects of the intervention as more positively influencing than Basic NCMs: Design Quality & Packaging (i.e., online program aesthetics), and Cost (i.e., no-cost program, clinician time savings). In both conditions, strongly facilitating factors included: Compatibility between intervention and clinical context; Intervention Source (from a trusted local university); and Evidence Strength & Quality supporting effectiveness. Findings highlight the importance of considering stakeholders' perspectives on the most valued types of evidence when introducing a new intervention, ensuring the program aligns with organizational priorities, and considering how training resources and feedback on patient progress can improve implementation success for online behavioral obesity treatment in primary care.
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Affiliation(s)
- Hallie M Espel-Huynh
- Weight Control and Diabetes Research Center, The Miriam Hospital, Providence, RI, USA,Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA,Correspondence to: H Espel-Huynh,
| | - Carly M Goldstein
- Weight Control and Diabetes Research Center, The Miriam Hospital, Providence, RI, USA,Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| | - Michael L Stephens
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| | - Olivia L Finnegan
- Department of Kinesiology, University of Rhode Island, Kingston, RI, USA
| | - A Rani Elwy
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA,Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
| | - Rena R Wing
- Weight Control and Diabetes Research Center, The Miriam Hospital, Providence, RI, USA,Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| | - J Graham Thomas
- Weight Control and Diabetes Research Center, The Miriam Hospital, Providence, RI, USA,Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
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The LEAP Program: Quality Improvement Training to Address Team Readiness Gaps Identified by Implementation Science Findings. J Gen Intern Med 2021; 36:288-295. [PMID: 32901440 PMCID: PMC7878618 DOI: 10.1007/s11606-020-06133-1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 08/11/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND Integrating evidence-based innovations (EBIs) into sustained use is challenging; most implementations in health systems fail. Increasing frontline teams' quality improvement (QI) capability may increase the implementation readiness and success of EBI implementation. OBJECTIVES Develop a QI training program ("Learn. Engage. Act. Process." (LEAP)) and evaluate its impact on frontline obesity treatment teams to improve treatment delivered within the Veterans Health Administration (VHA). DESIGN This was a pre-post evaluation of the LEAP program. MOVE! coordinators (N = 68) were invited to participate in LEAP; 24 were randomly assigned to four starting times. MOVE! coordinators formed teams to work on improvement aims. Pre-post surveys assessed team organizational readiness for implementing change and self-rated QI skills. Program satisfaction, assignment completion, and aim achievement were also evaluated. PARTICIPANTS VHA facility-based MOVE! teams. INTERVENTIONS LEAP is a 21-week QI training program. Core components include audit and feedback reports, structured curriculum, coaching and learning community, and online platform. MAIN MEASURES Organizational readiness for implementing change (ORIC); self-rated QI skills before and after LEAP; assignment completion and aim achievement; program satisfaction. KEY RESULTS Seventeen of 24 randomized teams participated in LEAP. Participants' self-ratings across six categories of QI skills increased after completing LEAP (p< 0.0001). The ORIC measure showed no statistically significant change overall; the change efficacy subscale marginally improved (p < 0.08), and the change commitment subscale remained the same (p = 0.66). Depending on the assignment, 35 to 100% of teams completed the assignment. Nine teams achieved their aim. Most team members were satisfied or very satisfied (81-89%) with the LEAP components, 74% intended to continue using QI methods, and 81% planned to continue improvement work. CONCLUSIONS LEAP is scalable and does not require travel or time away from clinical responsibilities. While QI skills improved among participating teams and most completed the work, they struggled to do so amid competing clinical priorities.
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Hatch MN, Martinez RN, Etingen B, Cotner B, Hogan TP, Wickremasinghe IM, Sippel J, Smith BM. Characterization of Telehealth Use in Veterans With Spinal Cord Injuries and Disorders. PM R 2020; 13:1094-1103. [PMID: 33098620 DOI: 10.1002/pmrj.12515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 09/24/2020] [Accepted: 10/05/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Individuals with spinal cord injuries and disorders (SCI/D) require frequent interdisciplinary health care to address impairments in mobility, autonomic function, and secondary complications. Telehealth has the capacity to substantially transform health care delivery and improve care by increasing access and communication. However, relatively little is known about telehealth use in this specific population. Here we attempt to fill part of this gap. OBJECTIVE To investigate the frequency and characteristics associated with telehealth use in Veterans with SCI/D. DESIGN Cross-sectional, descriptive project. SETTING Veterans Health Administration (VHA) facilities. PARTICIPANTS A total of 15 028 Veterans living with SCI/D who received services from the VHA SCI/D System of Care. INTERVENTION Not applicable. OUTCOME MEASURES Frequency and characteristics associated with VHA telehealth utilization. RESULTS Of the 15 028 Veterans with SCI/D included in the evaluation, 17% used some form of telehealth in VHA Fiscal Year (FY)2017. Veterans older than 65 years of age had lower odds (odds ratio [OR] = 0.88, P < .05, confidence interval [CI] 0.80-0.98) of using telehealth. Being Caucasian (OR = 1.29, P < .01, CI 1.09-1.52), living in rural areas (OR = 1.16, P < .01, CI 1.05-1.28), living greater distances away from the VHA (P < .01 for all distances), and being in priority group 8, meaning that Veterans have higher copayment requirements (OR = 1.46, P < .001, CI 1.19-1.81), were all significantly associated with greater odds of telehealth use. The most frequent types of telehealth used were real-time clinical video and store-and-forward between a provider and patient within the same hub network. CONCLUSION There are opportunities to increase telehealth adoption in the SCI/D arena. The findings from this project highlight which Veterans are currently using telehealth services, as well as gaps regarding telehealth adoption in this population.
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Affiliation(s)
- Maya N Hatch
- Spinal Cord Injury/Disorder Center, Long Beach Veterans Affairs (VA) Medical Center, Long Beach, CA, USA
- Physical Medicine & Rehabilitation Department, UC Irvine School of Medicine, Irvine, CA, USA
| | - Rachael N Martinez
- Edward Hines Jr. Department of VA Hospital, Center of Innovation for Complex Chronic Healthcare, Chicago, IL, USA
| | - Bella Etingen
- Edward Hines Jr. Department of VA Hospital, Center of Innovation for Complex Chronic Healthcare, Chicago, IL, USA
| | - Bridget Cotner
- Rehabilitation Outcomes Research Section, Research Service, James A. Haley VA Medical Center, Tampa, FL, USA
- Department of Anthropology, University of South Florida, Tampa, FL, USA
| | - Timothy P Hogan
- Center for Healthcare Organization and Implementation Research, Edith Norse Rogers Memorial VA Hospital, Bedford, MA, USA
- Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Itala M Wickremasinghe
- U.S. Department of Veterans Affairs, Spinal Cord Injuries and Disorders System of Care Program Office, Seattle, WA, USA
| | - Jennifer Sippel
- U.S. Department of Veterans Affairs, Spinal Cord Injuries and Disorders System of Care Program Office, Seattle, WA, USA
| | - Bridget M Smith
- Edward Hines Jr. Department of VA Hospital, Center of Innovation for Complex Chronic Healthcare, Chicago, IL, USA
- Institute for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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10
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Odlum M, Yoon S. Understanding Comorbidities and Their Contribution to Predictors of Medical Resource Utilization for an Age- and Sex-Matched Patient Population Living With HIV: Cross-Sectional Study. JMIR Aging 2019; 2:e13865. [PMID: 31516123 PMCID: PMC6746060 DOI: 10.2196/13865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/19/2019] [Accepted: 07/17/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND More than 60% of people aging with HIV are observed to have multiple comorbidities, which are attributed to a variety of factors (eg, biological and environmental), with sex differences observed. However, understanding these differences and their contribution to medical resource utilization remains challenging as studies conducted exclusively and predominantly among males do not translate well to females, resulting in inconsistent findings across study cohorts and limiting our knowledge of sex-specific comorbidities. OBJECTIVE The objective of the study was to provide further insight into aging-related comorbidities, their associated sex-based differences, and their contribution to medical resource utilization, through the analysis of HIV patient data matched by sex. METHODS International Classification of Disease 9/10 diagnostic codes that comprise the electronic health records of males (N=229) and females (N=229) were categorized by individual characteristics, chronic and mental health conditions, treatment, high-risk behaviors, and infections and the codes were used as predictors of medical resource utilization represented by Charlson comorbidity scores. RESULTS Significant contributors to high Charlson scores in males were age (beta=2.37; 95% CI 1.45-3.29), longer hospital stay (beta=.046; 95% CI 0.009-0.083), malnutrition (beta=2.96; 95% CI 1.72-4.20), kidney failure (beta=2.23; 95% CI 0.934-3.52), chemotherapy (beta=3.58; 95% CI 2.16-5.002), history of tobacco use (beta=1.40; 95% CI 0.200-2.61), and hepatitis C (beta=1.49; 95% CI 0.181-2.79). Significant contributors to high Charlson scores in females were age (beta=1.37; 95% CI 0.361-2.38), longer hospital stay (beta=.042; 95% CI 0.005-0.078), heart failure (beta=2.41; 95% CI 0.833-3.98), chemotherapy (beta=3.48; 95% CI 1.626-5.33), and substance abuse beta=1.94; 95% CI 0.180, 3.702). CONCLUSIONS Our findings identified sex-based differences in medical resource utilization. These include kidney failure for men and heart failure for women. Increased prevalence of comorbidities in people living long with HIV has the potential to overburden global health systems. The development of narrower HIV phenotypes and aging-related comorbidity phenotypes with greater clinical validity will support intervention efficacy.
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Affiliation(s)
- Michelle Odlum
- Columbia University School of Nursing, New York, NY, United States
| | - Sunmoo Yoon
- Columbia University Irving Medical Center, New York, NY, United States
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11
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Wischik DL, Magny-Normilus C, Whittemore R. Risk Factors of Obesity in Veterans of Recent Conflicts: Need for Diabetes Prevention. Curr Diab Rep 2019; 19:70. [PMID: 31368008 PMCID: PMC7530827 DOI: 10.1007/s11892-019-1191-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW To identify factors associated with obesity in veterans of the recent, Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) war conflicts. RECENT FINDINGS Over 44% OEF/OIF/OND veterans are obese (BMI > 30 kg/m2), which exceeds the national obesity prevalence rate of 39% in people younger than 45. Obesity increases morbidity, risk for type 2 diabetes (T2D), and mortality as well as decreases quality of life. A scoping review method was used to identify factors associated with obesity in young veterans. Military exposures, such as multiple deployments and exposure to combat, contribute to challenges in re-integration to civilian life in all veterans. Factors that contribute to increased risk for obesity include changes in eating patterns/eating disorders, changes in physical activity, physical disability, and psychological comorbidity. These conditions can contribute to a rapid weight gain trajectory, changes in metabolism, and obesity. Young veterans face considerable challenges related to obesity risk. Further research is needed to better understand young veterans' experiences and health needs in order to adapt or expand existing programs and improve access, engagement, and metabolic outcomes in this vulnerable population.
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Affiliation(s)
| | | | - Robin Whittemore
- Yale School of Nursing, 400 West Campus Drive, Orange, CT, 06477, USA
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