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Chow EHY, Tiwari A. Perceptions of abused Chinese women on community-based participatory approach programme in addressing their needs. Int J Qual Stud Health Well-being 2024; 19:2331107. [PMID: 38564773 PMCID: PMC10989199 DOI: 10.1080/17482631.2024.2331107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 03/12/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND The community-based participatory approach (CBPA) has gained increasing recognition worldwide for enhancing the effectiveness of intervention. It is relatively new in Chinese societies and participants' perceptions are underexplored. This study aims to explore abused Chinese women's perceptions on the CBPA programme in addressing their needs. METHODS A total of 11 abused Chinese women were recruited for a focus group and individual interviews. A semi-structured interview guide was used. All interviews were audio-recorded and data were transcribed verbatim. Conventional content analysis was used for analysis. RESULTS Four themes were identified regarding the women's perceptions and experiences of the community-based participatory approach programme: (1) Women's perceived acceptability of the CBPA programme; (2) Women's perceived usefulness of the CBPA programme; (3) Women's perceived feasibility of the CBPA programme; and (4) Empowering the women through participating in CBPA. CONCLUSIONS Abused Chinese women had high perceived acceptance and positive experiences towards the community-based participatory approach. Women benefited from their robust participation throughout the process. The findings confirm the potential of using the community-based participatory approach in designing interventions for future programme planning and intervention to address the needs of abused Chinese women.
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Affiliation(s)
| | - Agnes Tiwari
- School of Nursing, Hong Kong Sanatorium & Hospital Limited, Hong Kong, China
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Kang H, Pen Y, He Y, Yang X, Su J, Yang Q, Luo W. The experience of shared decision-making for people with asthma: A systematic review and metasynthesis of qualitative studies. Health Expect 2024; 27:e14039. [PMID: 38613765 PMCID: PMC11015866 DOI: 10.1111/hex.14039] [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: 12/02/2023] [Revised: 02/28/2024] [Accepted: 03/20/2024] [Indexed: 04/15/2024] Open
Abstract
OBJECTIVES To identify, describe and synthesise the views and experiences of adults living with asthma regarding shared decision-making (SDM) in the existing qualitative literature METHODS: We conducted a comprehensive search of 10 databases (list databases) from inception until September 2023. Screening was performed according to inclusion criteria. Tools from the Joanna Briggs lnstitute were utilised for the purposes of data extraction and synthesis in this study. The data extraction process in this study employed the Capability, Opportunity and Motivation Model of Behaviour (COM-B model) as a framework, and a pragmatic meta-aggregative approach was employed to synthesise the collected results. RESULTS Nineteen studies were included in the metasynthesis. Three synthesised themes were identified: the capability of people living with asthma, the opportunities of people living with asthma in SDM, and the motivation of the people living with asthma in SDM. CONCLUSIONS We have identified specific factors influencing people living with asthma engaging in SDM. The findings of this study can serve as a basis for the implementation of SDM in people living with asthma and provide insights for the development of their SDM training programs. The ConQual score for the synthesised findings was rated as low. To enhance confidence, future studies should address dependability and credibility factors. PRACTICE IMPLICATIONS This review contemplates the implementation of SDM from the perspective of people living with asthma, with the aim of providing patient-centred services for them. The results of this review can benefit the implementation of SDM and facilitate information sharing. It offers guidance for SDM skills training among adults living with asthma, fosters a better doctor-patient relationship and facilitates consensus in treatment decisions, thereby enabling personalised and tailored medical care. PATIENT OR PUBLIC CONTRIBUTION Three nursing graduate students participated in the data extraction and integration process, with two students having extensive clinical experience that provided valuable insights for the integration.
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Affiliation(s)
- Hui‐qi Kang
- Jinan University, Tianhe DistrictGuangzhou cityGuangdong ProvinceChina
| | - Yueming Pen
- Shenzhen People's Hospital (The First Affiliated Hospital, Southern University of Science and Technology), Luohu DistrictShenzhen cityGuangdongChina
| | - Yuanyuan He
- Jinan University, Tianhe DistrictGuangzhou cityGuangdong ProvinceChina
| | - Xiufen Yang
- Department of GeriatricShenzhen People's Hospital (The First Affiliated Hospital, Southern University of Science and Technology), Luohu DistrictShenzhen cityGuangdongChina
| | - Jin Su
- Jinan University, Tianhe DistrictGuangzhou cityGuangdong ProvinceChina
| | - Qiaohong Yang
- Jinan University, Tianhe DistrictGuangzhou cityGuangdong ProvinceChina
| | - Weixiang Luo
- Shenzhen People's Hospital (The First Affiliated Hospital, Southern University of Science and Technology), Luohu DistrictShenzhen cityGuangdongChina
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Stolz-Klingenberg C, Bünzen C, Coors M, Flüh C, Margraf NG, Wehkamp K, Clayman ML, Scheibler F, Wehking F, Rüffer JU, Schüttig W, Sundmacher L, Synowitz M, Berg D, Geiger F. Sustainability of large-scale implementation of shared decision making with the SHARE TO CARE program. Front Neurol 2022; 13:1037447. [PMID: 36504657 PMCID: PMC9726727 DOI: 10.3389/fneur.2022.1037447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 11/01/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction SHARE TO CARE (S2C) is a comprehensive implementation program for shared decision making (SDM). It is run at the University Hospital Schleswig-Holstein (UKSH) in Kiel, Germany, and consists of four combined intervention modules addressing healthcare professionals and patients: (1) multimodal training of physicians (2) patient activation campaign including the ASK3 method, (3) online evidence-based patient decision aids (4) SDM support by nurses. This study examines the sustainability of the hospital wide SDM implementation by means of the Neuromedical Center comprising the Departments of Neurology and Neurosurgery. Methods Between 2018 and 2020, the S2C program was applied initially within the Neuromedical Center: We implemented the patient activation campaign, trained 89% of physicians (N = 56), developed 12 patient decision aids and educated two decision coaches. Physicians adjusted the patients' pathways to facilitate the use of decision aids. To maintain the initial implementation, the departments took care that new staff members received training and decision aids were updated. The patient activation campaign was continued. To determine the sustainability of the initial intervention, the SDM level after a maintenance phase of 6-18 months was compared to the baseline level before implementation. Therefore, in- and outpatients received a questionnaire via mail after discharge. The primary endpoint was the "Patient Decision Making" subscale of the Perceived Involvement in Care Scale (PICSPDM). Secondary endpoints were an additional scale measuring SDM (CollaboRATE), and the PrepDM scale, which determines patients' perceived health literacy while preparing for decision making. Mean scale scores were compared using t-tests. Results Patients reported a significantly increased SDM level (PICSPDM p = 0.02; Hedges' g = 0.33; CollaboRATE p = 0.05; Hedges' g = 0.26) and improved preparation for decision making (PrepDM p = 0.001; Hedges' g = 0.34) 6-18 months after initial implementation of S2C. Discussion The S2C program demonstrated its sustainability within the Neuromedical Center at UKSH Kiel in terms of increased SDM and health literacy. Maintaining the SDM implementation required a fraction of the initial intensity. The departments took on the responsibility for maintenance. Meanwhile, an additional health insurance-based reimbursement for S2C secures the continued application of the program. Conclusion SHARE TO CARE promises to be suitable for long-lasting implementation of SDM in hospitals.
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Affiliation(s)
- Constanze Stolz-Klingenberg
- National Competency Center for Shared Decision Making, University Hospital Schleswig-Holstein, Kiel, Germany,*Correspondence: Constanze Stolz-Klingenberg
| | - Claudia Bünzen
- National Competency Center for Shared Decision Making, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Marie Coors
- Chair of Health Economics, Technical University of Munich, Munich, Germany
| | - Charlotte Flüh
- Department of Neurosurgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Nils G. Margraf
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Kai Wehkamp
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Kiel, Germany,Department of Medical Management, MSH Medical School Hamburg, Hamburg, Germany
| | - Marla L. Clayman
- Center for Healthcare Organization and Implementation Research (CHOIR), Veterans Administration, Bedford, MA, United States,Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Fueloep Scheibler
- National Competency Center for Shared Decision Making, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Felix Wehking
- Department of Emergency Medicine, University Hospital Jena, Jena, Germany
| | | | - Wiebke Schüttig
- Chair of Health Economics, Technical University of Munich, Munich, Germany
| | - Leonie Sundmacher
- Chair of Health Economics, Technical University of Munich, Munich, Germany
| | - Michael Synowitz
- Department of Neurosurgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Daniela Berg
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Friedemann Geiger
- National Competency Center for Shared Decision Making, University Hospital Schleswig-Holstein, Kiel, Germany,Department of Psychology, MSH Medical School Hamburg, Hamburg, Germany
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Ludden T, O’Hare K, Shade L, Reeves K, Patterson CG, Tapp H. Implementation of Coach McLungsSM into primary care using a cluster randomized stepped wedge trial design. BMC Med Inform Decis Mak 2022; 22:285. [PMID: 36333727 PMCID: PMC9636750 DOI: 10.1186/s12911-022-02030-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022] Open
Abstract
Background Asthma is a prevalent chronic disease that is difficult to manage and associated with marked disparities in outcomes. One promising approach to addressing disparities is shared decision making (SDM), a method by which the patient and provider cooperatively make a decision about asthma care. SDM is associated with improved outcomes for patients; however, time constraints and staff availability are noted implementation barriers. Use of health information technology (IT) solutions may facilitate the utilization of SDM. Coach McLungsSM is a collaborative web-based application that involves pediatric patients, their caregivers, and providers in a personalized experience while gathering patient-reported data. Background logic provides decision support so both audiences can develop a well-informed treatment plan together. The goal of this study is to evaluate the implementation of the Coach McLungsSM intervention into primary care. Methods Implementation will be evaluated using a stepped wedge randomized control study design at 21 pediatric and family medicine practices within a large, integrated, nonprofit healthcare system. We will measure changes in emergency department visits, hospitalizations, and oral steroid use, which serve as surrogate measures for patient-centered asthma outcomes. We will use a generalized linear mixed models with logit link to test the hypothesis for the reduction in exacerbation rates specifying the fixed effects of intervention and time and random effects for practice and practice*time. This design achieves 84% power to detect the hypothesized effect size difference of 10% in overall exacerbation between control (40%) and intervention (30%) periods (two-sided, p = 0.05). Implementation will be guided using the Expert Recommendations for Implementing Change (ERIC), a compilation of implementation strategies, and evaluated using the CFIR (Consolidated Framework for Implementation Research) and RE-AIM (Reach Effectiveness, Adoption, Implementation, Maintenance). Discussion We anticipate that a tailored implementation of Coach McLungsSM across diverse primary care practices will lead to a decrease in emergency department visits, hospitalizations, and oral steroid use for patients in the intervention group as compared to the control condition. Trial Registration: Clincaltrials.gov, NCT05059210. Registered 28 September 2021, https://www.clinicaltrials.gov/ct2/show/NCT05059210 Supplementary Information The online version contains supplementary material available at 10.1186/s12911-022-02030-1.
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Community-Based Participatory Research and Human-Centered Design Principles to Advance Hearing Health Equity. Ear Hear 2022; 43:33S-44S. [PMID: 35724253 PMCID: PMC9219558 DOI: 10.1097/aud.0000000000001183] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Inclusive and equitable research is an ethical imperative. Community-based participatory research (CBPR) as well as human-centered design are approaches that center partnership between community members and academic researchers. Together, academic-community research teams iteratively study community priorities, collaboratively develop ethical study designs, and co-create innovations that are accessible and meaningful to the community partners while advancing science. The foundation of the CBPR approach is reliant on its core principles of equity, colearning, shared power in decision-making, reciprocity, and mutual benefit. While the CBPR approach has been used extensively in public health and other areas of healthcare research, the approach is relatively new to audiology, otolaryngology, and hearing health research. The purpose of the present article is to advance an understanding of the CBPR approach, along with principles from human-centered design, in the context of research aimed to advance equity and access in hearing healthcare. DESIGN The literature is reviewed to provide an introduction for auditory scientists to the CBPR approach and human-centered design, including discussion of the underlying principles of CBPR and where it fits along a community-engaged continuum, theoretical and evaluation frameworks, as well as applications within auditory research. RESULTS Recent applications of CBPR have been framed broadly within the theoretical positions of the socioecological model for a systems-level approach to community-engaged research and the Health Services Utilization model within health services and disparities research using CBPR. Utilizing human-centered design strategies can work in tandem with a CBPR approach to engage a wide range of people in the research process and move toward the development of innovative yet feasible solutions. CONCLUSIONS Leveraging the principles of CBPR is an intricate and dynamic process, may not be a fit for some topics, some researchers' skillsets, and may be beyond some projects' resources. When implemented skillfully and authentically, CBPR can be of benefit by elevating and empowering community voices and cultural perspectives historically marginalized in society and underrepresented within research. With a focus on health equity, this review of CBPR in the study of hearing healthcare emphasizes how this approach to research can help to advance inclusion, diversity, and access to innovation.
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Kakar R, Combs R, Ali N, Muvuka B, Porter J. Enhancing the design and utilization of asthma action plans through community-based participatory research in an urban African American community. PATIENT EDUCATION AND COUNSELING 2021; 104:276-281. [PMID: 32921519 DOI: 10.1016/j.pec.2020.08.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 04/17/2020] [Accepted: 08/20/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Across the U.S., large inequities in asthma prevalence and outcomes persist, disproportionately affecting low-income, minoritized children. West Louisville is particularly impacted by these inequities due to a complex interplay of socioeconomic, historical, and industrial processes. Additionally, low health literacy and mistrust in healthcare exacerbate poor asthma self-management. OBJECTIVE To engage community members and health professionals to address childhood asthma management in a marginalized community experiencing significant health inequities. PATIENT INVOLVEMENT Although prior asthma knowledge was not required, the majority of our community advisory council (CAC) members either had asthma or cared for children/grandchildren with asthma. Through facilitated decision-making using the Boot Camp Translation approach, the CAC chose to focus on improving asthma self-management in their community through enhancing the design and utilization of asthma action plans (AAPs). METHODS Upon adding inhaler images to a user-friendly AAP, the CAC developed and implemented a provider incentive program and a health communication campaign to promote the Tool's utilization. Evaluation of the intervention consisted of a short questionnaire measuring relevant patient demographics and campaign knowledge, and phone interviews with providers to gather feedback on the incentive and Tool design. RESULTS Over the short two-month intervention, a total of 8 practices with 28 providers used 153 Tools to provide asthma self-management counseling. The majority of providers preferred the enhanced Tool to other AAPs they had used. Inhaler images facilitating improved communication regarding asthma medications. DISCUSSION Using a participatory approach, a community preferred intervention targeting barriers to effective asthma control increased provider utilization and community awareness of AAPs and bridged a communication gap between patients and providers. PRACTICAL VALUE Leveraging community members' (including patients/caregivers) and health professionals' expertise led to the development of an enhanced patient-education tool and an effective provider incentive program with the potential to improve childhood asthma management in marginalized populations.
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Affiliation(s)
- Rishtya Kakar
- Department of Health Promotion and Behavioral Sciences, University of Louisville School of Public Health and Information Sciences, Louisville, KY, USA.
| | - Ryan Combs
- Department of Health Promotion and Behavioral Sciences, University of Louisville School of Public Health and Information Sciences, Louisville, KY, USA.
| | - Nida Ali
- Department of Health Promotion and Behavioral Sciences, University of Louisville School of Public Health and Information Sciences, Louisville, KY, USA.
| | - Baraka Muvuka
- Department of Health Promotion and Behavioral Sciences, University of Louisville School of Public Health and Information Sciences, Louisville, KY, USA.
| | - Jennifer Porter
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY, USA.
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Lakhanpaul M, Culley L, Robertson N, Alexander EC, Bird D, Hudson N, Johal N, McFeeters M, Hamlyn-Williams C, Manikam L, Boo YY, Lakhanpaul M, Johnson MRD. A structured collaborative approach to intervention design using a modified intervention mapping approach: a case study using the Management and Interventions for Asthma (MIA) project for South Asian children. BMC Med Res Methodol 2020; 20:271. [PMID: 33138784 PMCID: PMC7607819 DOI: 10.1186/s12874-020-01148-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 10/14/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND To describe how using a combined approach of community-based participatory research and intervention mapping principles could inform the development of a tailored complex intervention to improve management of asthma for South Asian (SA) children; Management and Interventions for Asthma (MIA) study. METHODS A qualitative study using interviews, focus groups, workshops, and modified intervention mapping procedures to develop an intervention planning framework in an urban community setting in Leicester, UK. The modified form of intervention mapping (IM) included: systematic evidence synthesis; community study; families and healthcare professionals study; and development of potential collaborative intervention strategies. Participants in the community study were 63 SA community members and 12 key informants; in-depth semi-structured interviews involved 30 SA families, 14 White British (WB) families and 37 Healthcare Professionals (HCPs) treating SA children living with asthma; prioritisation workshops involved 145 SA, 6 WB and 37 HCP participants; 30 participants in finalisation workshops. RESULTS Two key principles were utilised throughout the development of the intervention; community-based participatory research (CBPR) principles and intervention mapping (IM) procedures. The CBPR approach allowed close engagement with stakeholders and generated valuable knowledge to inform intervention development. It accounted for diverse perceptions and experiences with regard to asthma and recognised the priorities of patients and their families/caregivers for service improvement. The 'ACT on Asthma' programme was devised, comprising four arms of an intervention strategy: education and training, clinical support, advice centre and raising awareness, to be co-ordinated by a central team. CONCLUSIONS The modified IM principles utilised in this study were systematic and informed by theory. The combined IM and participatory approach could be considered when tailoring interventions for other clinical problems within diverse communities. The IM approach to intervention development was however resource intensive. Working in meaningful collaboration with minority communities requires specific resources and a culturally competent methodology.
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Affiliation(s)
- Monica Lakhanpaul
- Population, Policy and Practice, UCL Great Ormond Street Institute of Child Health, 30 Guildford Street, London, WC1N 1EH, UK. .,Whittington Health NHS Trust, London, UK.
| | - Lorraine Culley
- School of Applied Social Sciences, De Montfort University, The Gateway, Leicester, LE1 9BH, UK
| | - Noelle Robertson
- Clinical Psychology, Department of Neuroscience, Psychology and Behaviour, University of Leicester, Lancaster Road, Leicester, LE1 7HA, UK
| | - Emma C Alexander
- Paediatric Liver, GI and Nutrition Centre and Mowatlabs, King's College Hospital, London, SE5 9RS, UK.,Aceso Global Health Consultants Ltd., 3 Abbey Terrace, London, SE2 9EY, UK
| | - Deborah Bird
- Child Development Team, Ealing Services for Children with Additional Needs, West London NHS Trust, Carmelita House, 21-22 The Mall, Ealing, W5 2PJ, UK
| | - Nicky Hudson
- School of Applied Social Sciences, De Montfort University, The Gateway, Leicester, LE1 9BH, UK
| | | | - Melanie McFeeters
- Specialised Commissioning, NHS England and NHS Improvement, Midlands Region, Fosse House, 6 Smith Way, Grove Park, Enderby, Leicester, LE19 1SX, UK
| | - Charlotte Hamlyn-Williams
- Center for Health Services and Clinical Research, University of Hertfordshire, College Lane Campus, Hatfield, AL10 9AB, UK
| | - Logan Manikam
- Aceso Global Health Consultants Ltd., 3 Abbey Terrace, London, SE2 9EY, UK.,UCL Institute of Epidemiology & Healthcare, 1 - 19 Torrington Place, London, WC1E 7HB, UK
| | - Yebeen Ysabelle Boo
- Population, Policy and Practice, UCL Great Ormond Street Institute of Child Health, 30 Guildford Street, London, WC1N 1EH, UK.,Aceso Global Health Consultants Ltd., 3 Abbey Terrace, London, SE2 9EY, UK.,Nuffield Department of Population Health, University of Oxford Richard Doll Building, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Maya Lakhanpaul
- Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Mark R D Johnson
- Faculty of Health and Life Sciences, Mary Seacole Research Centre, De Montfort University, The Gateway, Leicester, LE1 9BH, UK
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Shade L, Reeves K, Rees J, Hendrickson L, Halladay J, Dolor RJ, Bray P, Tapp H. Research nurses as practice facilitators to disseminate an asthma shared decision making intervention. BMC Nurs 2020; 19:40. [PMID: 32477003 PMCID: PMC7236364 DOI: 10.1186/s12912-020-00414-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 03/20/2020] [Indexed: 12/01/2022] Open
Abstract
Background Practice facilitation is a method of introducing and sustaining organizational change. It involves the use of skilled healthcare professionals called practice facilitators (PFs) to help address the challenges associated with implementing evidence-based guidelines and complex interventions into practice. PFs provide a framework for translating research into practice by building relationships, improving communication, fostering change, and sharing resources. Nurses are well positioned to serve as PFs for the implementation of complex interventions, however, there is little evidence currently available to describe nurses in this role. Additionally, the best strategies to implement complex interventions into practices are still not fully understood. Combining practice facilitation with the train-the-trainer model has the potential to spread knowledge and skills. Shared decision making (SDM), which involves patients and providers jointly engaging in decisions around treatment options, has been shown to improve outcomes for patients with asthma. The goal of this manuscript is to describe and evaluate the practice facilitation process from the ADAPT-NC Study which successfully utilized research nurses to implement a complex asthma SDM toolkit intervention into primary care practices. Methods As part of a larger study, 10 primary care practices were recruited for a facilitator-led dissemination intervention involving a 12-week rollout of an asthma SDM toolkit (trial registration: 1.28.2014, #NCT02047929). An experienced lead PF trained research nurses as PFs from each of the 4 participating practice-based research networks (PBRNs) in a train-the-trainer model utilizing a one-day training event and subsequent remote meetings. Evaluation of PF engagement was measured through process improvement surveys. Results Overall, the asthma SDM intervention was successfully implemented within the 4 PBRNs. All 10 facilitator-led practices remained engaged with their PFs, with 8 out of the 10 practices able to incorporate and sustain SDM visits or clinics. Responses from the surveys for process improvement yielded improved PF communication and team dynamics over time. Conclusions This study demonstrated effective use of research nurses as practice facilitators during the dissemination of an asthma SDM intervention into primary care practices, adding to the knowledge of best practices by describing a model of large-scale implementation of a complex intervention through practice facilitation with nurses. Trial registration “Comparing Traditional and Participatory Dissemination of a Shared Decision Making Intervention” was retrospectively registered at https://clinicaltrials.gov/ on January 28th, 2014 (NCT02047929).
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Affiliation(s)
- Lindsay Shade
- 1Atrium Health, Department of Family Medicine Research, 2001 Vail Avenue, Suite 400B Mercy Medical Plaza, Charlotte, NC 28207 USA
| | - Kelly Reeves
- 1Atrium Health, Department of Family Medicine Research, 2001 Vail Avenue, Suite 400B Mercy Medical Plaza, Charlotte, NC 28207 USA
| | - Jennifer Rees
- 2University of North Carolina at Chapel Hill, 160 N. Medical Drive, CB 7064, Chapel Hill, NC 27599 USA
| | - Lori Hendrickson
- 3Duke University Medical Center, 2608 Erwin Road, Suite 210, Durham, NC 27705 USA
| | - Jacqueline Halladay
- 4Department of Family Medicine, University of North Carolina at Chapel Hill, 590 Manning Drive, CB 7595, Chapel Hill, NC 27599-7595 USA
| | - Rowena J Dolor
- 5Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, 200 Morris Street, 3rd Floor, Durham, NC 27701 USA
| | - Paul Bray
- Vidant Medical Group, 2000 Venture Tower Drive, Greenville, NC 27834 USA
| | - Hazel Tapp
- 1Atrium Health, Department of Family Medicine Research, 2001 Vail Avenue, Suite 400B Mercy Medical Plaza, Charlotte, NC 28207 USA
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Reeves K, O’Hare K, Shade L, Ludden T, McWilliams A, Manning M, Hogg M, Reynolds S, Shea CM, Burton EC, Calvert M, Derkowski DM, Tapp H. Evaluation of a shared decision-making intervention for pediatric patients with asthma in the emergency department. Implement Sci Commun 2020; 1:22. [PMID: 32885182 PMCID: PMC7427946 DOI: 10.1186/s43058-020-00010-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 12/09/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Asthma is a difficult-to-manage chronic disease marked with associated outcome disparities including an increase rate of emergency department (ED) visits for uncontrolled asthma among patients who are most at-risk. Shared decision making (SDM) is a process by which the patient and provider jointly make a healthcare choice. SDM improves patient outcomes; however, implementation barriers of time constraints and staff availability are limitations. The use of health IT solutions may increase the adoption of SDM, but best practices for implementation are not well understood. The Consolidated Framework for Implementation Research (CFIR) is a flexible comprehensive model used to identify barriers and facilitators influencing implementation. The goal of this study is to implement an innovative web-based pediatric SDM tool in the real-world setting of two large healthcare system EDs through the following aims: (1) convene a patient, research, and ED stakeholder advisory board to oversee review of protocol and study materials prior to implementation, (2) implement the SDM intervention where providers and staff will be trained to incorporate use of this SDM intervention, (3) conduct on-going evaluation of barriers, facilitators, and implementation outcomes to tailor implementation in the EDs, (4) evaluate patient-centered outcomes of primary care utilization and changes in ED visits and hospitalizations before and after the SDM intervention, and (5) understand and document best practices for ED implementation. METHODS The CFIR model will guide the implementation evaluation. Researchers will administer surveys to the clinical team and patients at baseline, 3, 6, and 12 months to inform implementation design, determine barriers and facilitators, and resource-needs to allow for real-time process adjustments within the EDs. Focus group or key-informant interviews and analysis will provide additional feedback to the stakeholder team to iterate the implementation process. Researchers will track patient-centered outcomes including increased primary care, ED, and inpatient utilization over the duration of the study. DISCUSSION To advance asthma care and the field of implementation science, further research is needed to assess best practices for incorporating SDM into high-need healthcare settings such as the ED. This knowledge will facilitate improved outcomes and appropriate policy changes towards further use of SDM interventions in local and national acute care settings.
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Affiliation(s)
- Kelly Reeves
- Department of Family Medicine Research, Atrium Health, 2001 Vail Avenue, Suite 400B Mercy Medical Plaza, Charlotte, NC 28207 USA
| | - Katherine O’Hare
- Department of Family Medicine Research, Atrium Health, 2001 Vail Avenue, Suite 400B Mercy Medical Plaza, Charlotte, NC 28207 USA
| | - Lindsay Shade
- Department of Family Medicine Research, Atrium Health, 2001 Vail Avenue, Suite 400B Mercy Medical Plaza, Charlotte, NC 28207 USA
| | - Thomas Ludden
- Department of Family Medicine Research, Atrium Health, 2001 Vail Avenue, Suite 400B Mercy Medical Plaza, Charlotte, NC 28207 USA
| | - Andrew McWilliams
- Center for Outcomes Research and Evaluation (CORE), Atrium Health, Research Office Building, 1540 Garden Terrace, Charlotte, NC 28203 USA
| | - Melinda Manning
- Department of Family Medicine Research, Atrium Health, 2001 Vail Avenue, Suite 400B Mercy Medical Plaza, Charlotte, NC 28207 USA
| | - Melanie Hogg
- Department of Emergency Medicine, Atrium Health, 1000 Blythe Blvd., 306 Medical Education Building, Charlotte, NC 28203 USA
| | - Stacy Reynolds
- Department of Emergency Medicine, Atrium Health, 1000 Blythe Blvd., 306 Medical Education Building, Charlotte, NC 28203 USA
| | - Christopher M. Shea
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Elizabeth C. Burton
- Community Care Partners, 1423 E. Franklin St., Suite A, Monroe, NC 28112 USA
| | - Melissa Calvert
- Department of Family Medicine Research, Atrium Health, 2001 Vail Avenue, Suite 400B Mercy Medical Plaza, Charlotte, NC 28207 USA
| | - Diane M. Derkowski
- Atrium Health, 1025 Morehead Medical Drive, Suite 600, Charlotte, NC 28204 USA
| | - Hazel Tapp
- Department of Family Medicine Research, Atrium Health, 2001 Vail Avenue, Suite 400B Mercy Medical Plaza, Charlotte, NC 28207 USA
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Coates D, Clerke T. Training Interventions to Equip Health Care Professionals With Shared Decision-Making Skills: A Systematic Scoping Review. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2020; 40:100-119. [PMID: 32433322 DOI: 10.1097/ceh.0000000000000289] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION To support the development, implementation, and evaluation of shared decision-making (SDM) training programs, this article maps the relevant evidence in terms of training program design and content as well as evaluation outcomes. METHOD A systematic scoping review methodology was used. To identify studies, the databases PubMed, Medline, and CINAHL were searched from 2009 to 2019, and reference lists of included studies were examined. After removal of duplicates, 1367 articles were screened for inclusion. To be included, studies were to be published in peer-reviewed journals, and should not merely be descriptive but report on evaluation outcomes. Articles were reviewed for inclusion by both authors, and data were extracted using a purposely designed data charting form implemented using REDCap. RESULTS The review identified 49 studies evaluating 36 unique SDM training programs. There was considerable variation in terms of program design and duration. Most programs included an overview of SDM theories and key competencies, as well as SDM skill development through role plays. Few programs provided training in reflective practice, in identifying and working with patients' individually preferred decision-making style, or in relation to SDM in a context of medical uncertainty or ambiguity. Most programs were evaluated descriptively, mostly using mixed methods, and there were 18 randomized controlled trials, showing that training was feasible, well received, and improved participants' knowledge and skills, but was limited in its impact on patients. DISCUSSION Although there is limited capacity to comment on which types of training programs are most effective, overall training was feasible, well received, and improved participants' knowledge and skills.
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Affiliation(s)
- Dominiek Coates
- Dr. Coates: Senior Research Fellow, University of Technology Sydney, Faculty of Health, Sydney, Australia.Clerke: Project Officer, Maridulu Budyari Gumal, the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE) Maridulu Budyari Gumal, the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Sydney, Australia
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Shade L, Ludden T, Dolor RJ, Halladay J, Reeves K, Rees J, Hendrickson L, Bray P, Tapp H. Using the Consolidated Framework for Implementation Research (CFIR) to evaluate implementation effectiveness of a facilitated approach to an asthma shared decision making intervention. J Asthma 2019; 58:554-563. [PMID: 31868043 DOI: 10.1080/02770903.2019.1702200] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To describe the evaluation of implementation effectiveness of an asthma shared decision making (SDM) intervention at the 10 individual facilitator-led primary care practices in the ADAPT-NC Study using the Consolidated Framework for Implementation Research (CFIR). METHODS Practices were scored across 40 CFIR constructs within 5 domains using a previously published scoring system of -2 to +2. Based on overall construct scores, practices were then classified as high, medium, or low adopters. To evaluate clinical outcomes, changes in asthma exacerbations were assessed for emergency department (ED) visits, hospitalizations, and oral steroid prescription orders. Using regression analysis, the absolute change in percent for each outcome relative to the CFIR score for each practice was analyzed. (Trial registration #NCT02047929). RESULTS Implementation effectiveness was reflected in CFIR score differences with 7 high, 1 medium, and 2 low adopter practices. High adopters mostly scored well across all domains. Weaknesses were consistent amongst the 2 low adopters with lower scores in the Inner Setting, Characteristics of Individuals, and Process domains. While no significant correlations were seen between the practices' CFIR scores and the absolute change in ED visits, hospitalizations, or oral steroid prescription orders, practices with higher percentages of children had greater improvements in clinical outcomes. CONCLUSIONS The CFIR was used to evaluate the asthma SDM intervention implementation at 10 facilitator-led practices. While there was no significant correlation between higher implementation effectiveness and greater improvement in clinical outcomes, practices with a higher proportion of pediatric patients did experience a significant reduction in overall exacerbations post-implementation.
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Affiliation(s)
- Lindsay Shade
- Department of Family Medicine Research, Atrium Health, Charlotte, NC, USA
| | - Thomas Ludden
- Department of Family Medicine Research, Atrium Health, Charlotte, NC, USA
| | - Rowena J Dolor
- Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jacqueline Halladay
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kelly Reeves
- Department of Family Medicine Research, Atrium Health, Charlotte, NC, USA
| | - Jennifer Rees
- School of Medicine, University of North Carolina at Chapel Hill, NC, USA
| | - Lori Hendrickson
- Duke Vaccine and Trials Unit, Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC, USA
| | - Paul Bray
- Vidant Medical Group, Vidant Medical Center, Greenville, NC, USA
| | - Hazel Tapp
- Department of Family Medicine Research, Atrium Health, Charlotte, NC, USA
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Perez Jolles M, Richmond J, Thomas KC. Minority patient preferences, barriers, and facilitators for shared decision-making with health care providers in the USA: A systematic review. PATIENT EDUCATION AND COUNSELING 2019; 102:1251-1262. [PMID: 30777613 DOI: 10.1016/j.pec.2019.02.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 01/31/2019] [Accepted: 02/05/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES This systematic review of contemporary literature sought to better understand racial and ethnic minority patients' shared decision-making (SDM) preferences, challenges and facilitators. METHODS Data sources were PubMed, CINAHL, Embase, Google Scholar, PsycINFO, Sociological Abstracts, and Web of Science databases for publications between 2011 and 2016. Publications were included if they studied SDM during the clinical encounter for minority adults in clinical care in the United States. We conducted a narrative, descriptive synthesis of each study. RESULTS From over 5000 publications identified through the search strategy, 18 met eligibility criteria following an abstract and full text (n = 685) review in Covidence. Studies focused on SDM in developing treatment plans (n = 10), and were conducted in primary care (n = 6) or hospital/health system settings (n = 6). Patients' decision preferences ranged from physician-driven altogether or initially, to patient-driven style. A comprehensive list of SDM facilitators and barriers was developed. CONCLUSION Despite strong policy and research SDM support to increase patient communication and a growing published literature, results suggest lack of representation of minority populations in contemporary literature. PRACTICE IMPLICATIONS Provider training may be needed to facilitate patient-provider transition from a passive toward a more active SDM engagement over time while confidence, trust and rapport is established.
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Affiliation(s)
- Monica Perez Jolles
- The Gehr Family Center for Health Systems Science, Keck School of Medicine, University of Southern California, Los Angeles, USA.
| | - Jennifer Richmond
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Behavior, 135 Dauer Drive, 302 Rosenau Hall, CB #7440, Chapel Hill, NC 27599-7440, USA; American Institutes for Research, Research and Evaluation, 100 Europa Drive, Suite 315, Chapel Hill, NC 27517, USA.
| | - Kathleen C Thomas
- Division of Pharmaceutical Outcomes and Policy UNC Eshelman School of Pharmacy, UNC Health Sciences at MAHEC, University of North Carolina at Chapel Hill, 121 Hendersonville Road, Asheville, NC, 28803, USA.
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Siyam T, Shahid A, Perram M, Zuna I, Haque F, Archundia-Herrera MC, Vohra S, Olson K. A scoping review of interventions to promote the adoption of shared decision-making (SDM) among health care professionals in clinical practice. PATIENT EDUCATION AND COUNSELING 2019; 102:1057-1066. [PMID: 30642716 DOI: 10.1016/j.pec.2019.01.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 11/20/2018] [Accepted: 01/01/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To identify and summarize evidence on interventions to promote the adoption of shared decision-making (SDM) among health care professionals (HCPs) in clinical practice. METHODS Electronic databases including: MEDLINE, EMBASE, CINAHL, PsycINFO and Cochrane library were searched to determine eligible peer-reviewed articles. Grey literature was searched for additional interventions. Eligibility screening and data extraction were independently completed. Results are presented as written evidence summaries and tables. RESULTS Our search yielded 238 articles that met our inclusion criteria. Interventions mostly targeted physicians (46%), had multiple educational modalities (46%), and were administered in group settings (44%) before the clinical encounter (71%). Very few were developed based on the learning needs of targeted HCPs (24%). Many of the SDM outcome tools used for evaluation were developed for the respective study and lacked evidence of validity and reliability (30%). CONCLUSION We identified a sizable number of interventions to promote the adoption of SDM, however, these interventions were heterogeneous in their assessments for effectiveness and implementation. Therefore, it is a challenge to infer which strategies and practices are best to promote SDM adoption. PRACTICE IMPLICATIONS The need for evidence-based standards for developing SDM interventions targeting HCPs and assessing acceptability, effectiveness and implementation is suggested.
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Affiliation(s)
- Tasneem Siyam
- 3-015 Edmonton Clinic Health Academy (ECHA), Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, T6G 2C9, Canada.
| | - Anmol Shahid
- Vascular Biology Research Group, University of Alberta, Edmonton, AB, T6G 2C9, Canada.
| | - Megan Perram
- Department of Modern Languages and Cultural Studies, 200 Arts Building1-50A Assiniboia Hall, University of Alberta, Edmonton, AB, T6G 2H4, Canada.
| | - Ines Zuna
- Faculty of Medicine & Dentistry, 2J2.00 Walter C Mackenzie Health Sciences Centre, University of Alberta, Edmonton, AB, T6G 2R7, Canada.
| | - Farhia Haque
- Neuroscience and Mental Health Institute, Faculty of Medicine & Dentistry - Physiology Dept, 2J2.00 Walter C Mackenzie Health Sciences Centre, University of Alberta, Edmonton, AB, T6G 2R7, Canada.
| | - M Carolina Archundia-Herrera
- Nutrition and Metabolism, 6-126 Li Ka Shing Centre for Health Research Innovation, University of Alberta, Edmonton, AB, T6G 2E1, Canada.
| | - Sunita Vohra
- Department of Pediatrics, Faculty of Medicine and Dentistry Director, Integrative Health Institute, 1702 Suite College Plaza, Edmonton, AB, T6G 2C8, Canada.
| | - Karin Olson
- Faculty of Nursing, Education Director, Integrative Health Institute, Faculty of Nursing, Edmonton Clinic Heath Academy (ECHA), University of Alberta, Edmonton, AB, T6G 1C9, Canada.
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Scalia P, Durand MA, Berkowitz JL, Ramesh NP, Faber MJ, Kremer JAM, Elwyn G. The impact and utility of encounter patient decision aids: Systematic review, meta-analysis and narrative synthesis. PATIENT EDUCATION AND COUNSELING 2019; 102:817-841. [PMID: 30612829 DOI: 10.1016/j.pec.2018.12.020] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/23/2018] [Accepted: 12/18/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To determine the effect of encounter patient decision aids (PDAs) as evaluated in randomized controlled trials (RCTs) and conduct a narrative synthesis of non-randomized studies assessing feasibility, utility and their integration into clinical workflows. METHODS Databases were systematically searched for RCTs of encounter PDAs to enable the conduct of a meta-analysis. We used a framework analysis approach to conduct a narrative synthesis of non-randomized studies. RESULTS We included 23 RCTs and 30 non-randomized studies. Encounter PDAs significantly increased knowledge (SMD = 0.42; 95% CI 0.30, 0.55), lowered decisional conflict (SMD= -0.33; 95% CI -0.56, -0.09), increased observational-based assessment of shared decision making (SMD = 0.94; 95% CI 0.40, 1.48) and satisfaction with the decision-making process (OR = 1.78; 95% CI 1.19, 2.66) without increasing visit durations (SMD= -0.06; 95% CI -0.29, 0.16). The narrative synthesis showed that encounter tools have high utility for patients and clinicians, yet important barriers to implementation exist (i.e. time constraints) at the clinical and organizational level. CONCLUSION Encounter PDAs have a positive impact on patient-clinician collaboration, despite facing implementation barriers. PRACTICAL IMPLICATIONS The potential utility of encounter PDAs requires addressing the systemic and structural barriers that prevent adoption in clinical practice.
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Affiliation(s)
- Peter Scalia
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Marie-Anne Durand
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Julia L Berkowitz
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Nithya P Ramesh
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Marjan J Faber
- Radboud university medical center, Scientific Institute for Quality of Healthcare, PO Box 9101, Nijmegen, 6500, HB, the Netherlands.
| | - Jan A M Kremer
- Radboud university medical center, Scientific Institute for Quality of Healthcare, PO Box 9101, Nijmegen, 6500, HB, the Netherlands.
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, NH, 03756, USA.
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Ludden T, Shade L, Reeves K, Welch M, Taylor YJ, Mohanan S, McWilliams A, Halladay J, Donahue K, Coyne-Beasley T, Dolor RJ, Bray P, Tapp H. Asthma dissemination around patient-centered treatments in North Carolina (ADAPT-NC): a cluster randomized control trial evaluating dissemination of an evidence-based shared decision-making intervention for asthma management. J Asthma 2018; 56:1087-1098. [PMID: 30252544 DOI: 10.1080/02770903.2018.1514630] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Objective: To compare three dissemination approaches for implementing an asthma shared decision-making (SDM) intervention into primary care practices. Methods: We randomized thirty practices into three study arms: (1) a facilitator-led approach to implementing SDM; (2) a one-hour lunch-and-learn training on SDM; and (3) a control group with no active intervention. Patient perceptions of SDM were assessed in the active intervention arms using a one-question anonymous survey. Logistic regression models compared the frequency of asthma exacerbations (emergency department (ED) visits, hospitalizations, and oral steroid prescriptions) between the three arms. Results: We collected 705 surveys from facilitator-led sites and 523 from lunch-and-learn sites. Patients were more likely to report that they participated equally with the provider in making the treatment decision in the facilitator-led sites (75% vs. 66%, p = 0.001). Comparisons of outcomes for patients in the facilitator-led (n = 1,658) and lunch-and-learn (n = 2,613) arms respectively vs. control (n = 2,273) showed no significant differences for ED visits (Odds Ratio [OR] [95%CI] = 0.77[0.57-1.04]; 0.83[0.66-1.07]), hospitalizations (OR [95%CI] = 1.30[0.59-2.89]; 1.40 [0.68-3.06]), or oral steroids (OR [95%CI] =0.95[0.79-1.15]; 1.03[0.81-1.06]). Conclusion: Facilitator-led dissemination was associated with a significantly higher proportion of patients sharing equally in decision-making with the provider compared to a traditional lunch-and-learn approach. While there was no significant difference in health outcomes between the three arms, the results were most likely confounded by a concurrent statewide asthma initiative and the pragmatic implementation of the intervention. These results offer support for the use of structured approaches such as facilitator-led dissemination of complex interventions into primary care practices.
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Affiliation(s)
- Thomas Ludden
- Department of Family Medicine, Atrium Health, Charlotte, NC, USA
| | - Lindsay Shade
- Department of Family Medicine, Atrium Health, Charlotte, NC, USA
| | - Kelly Reeves
- Department of Family Medicine, Atrium Health, Charlotte, NC, USA
| | - Madelyn Welch
- Department of Family Medicine, Atrium Health, Charlotte, NC, USA
| | - Yhenneko J Taylor
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, USA
| | - Sveta Mohanan
- Department of Family Medicine, Atrium Health, Charlotte, NC, USA
| | - Andrew McWilliams
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, USA
| | - Jacqueline Halladay
- University of North Carolina Department of Family Medicine, Chapel Hill, NC, USA.,Cecil G Sheps Center for Health Services Research, Chapel Hill, NC, USA
| | - Katrina Donahue
- University of North Carolina Department of Family Medicine, Chapel Hill, NC, USA.,Cecil G Sheps Center for Health Services Research, Chapel Hill, NC, USA
| | - Tamera Coyne-Beasley
- University of North Carolina Department of Family Medicine, Chapel Hill, NC, USA.,Cecil G Sheps Center for Health Services Research, Chapel Hill, NC, USA
| | - Rowena J Dolor
- Division General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Paul Bray
- Vidant Medical Group, Greenville, NC, USA
| | - Hazel Tapp
- Department of Family Medicine, Atrium Health, Charlotte, NC, USA
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Liu TL, Taylor YJ, Mahabaleshwarkar R, Blanchette CM, Tapp H, Dulin MF. Shared decision making and time to exacerbation in children with asthma. J Asthma 2018; 55:949-955. [PMID: 28892418 PMCID: PMC7213970 DOI: 10.1080/02770903.2017.1378357] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 08/28/2017] [Accepted: 09/07/2017] [Indexed: 10/18/2022]
Abstract
Objective: Although shared decision making (SDM) is a promising approach for improving outcomes for patients with chronic diseases, no evidence currently supports the use of SDM to delay asthma exacerbations. We evaluated the impact of an SDM intervention implemented by providers in a real-world setting on time to exacerbation in children with asthma. Methods: This study used a prospective cohort observed between 2011 and 2013 at five primary care practices that serve vulnerable populations (e.g., Medicaid and uninsured patients) in Charlotte, NC. Patients aged 2 to 17 receiving SDM were matched to those receiving usual care using propensity scores. Time to asthma exacerbation (asthma hospitalization, emergency department visit or oral steroid prescription in the outpatient setting) was compared between groups using Kaplan-Meier curves and conditional Cox proportional hazards models. Results: The cohort included 746 children, 60.5% male and 54.2% African American, with a mean age of 8.6 years. Of these, 625 received usual care and 121 received SDM. The final analysis included 100 matched pairs of children. Kaplan-Meier curves showed longer exacerbation-free time for patients in the SDM intervention compared to those in usual care (p = 0.005). The difference in risk of experiencing an exacerbation was marginally significant between the two groups (HR = 0.56, 95% C.I. = 0.29-1.08, p = 0.08). Conclusions: SDM was found to delay exacerbations among children with asthma. Clinicians should consider incorporating patient preferences in treatment decisions through SDM as a means for longer exacerbation-free time among children with poor asthma control.
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Affiliation(s)
- Tsai-Ling Liu
- Center for Outcomes Research and Evaluation, Carolinas HealthCare System, Charlotte, NC, USA
| | - Yhenneko J. Taylor
- Center for Outcomes Research and Evaluation, Carolinas HealthCare System, Charlotte, NC, USA
| | - Rohan Mahabaleshwarkar
- Center for Outcomes Research and Evaluation, Carolinas HealthCare System, Charlotte, NC, USA
| | | | - Hazel Tapp
- Department of Family Medicine, Carolinas HealthCare System, Charlotte, NC, USA
| | - Michael F. Dulin
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA
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Welch M, Ludden T, Mottus K, Bray P, Hendrickson L, Rees J, Halladay J, Tapp H. Patient and provider perspectives on uptake of a shared decision making intervention for asthma in primary care practices. J Asthma 2018; 56:562-572. [PMID: 29927661 DOI: 10.1080/02770903.2018.1471703] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Poor outcomes and health disparities related to asthma result in part from difficulty disseminating new evidence such as shared decision making (SDM) into clinical practice. As part of a three-arm cluster randomized dissemination study, evaluation of the impact of different dissemination methods was studied. Here we evaluate themes from patient and provider focus groups to assess the impact of a facilitated, traditional dissemination approach, or no intervention, on patient and provider perspectives of asthma care. METHODS Using semi-structured questions, twenty-four pre- and post-intervention focus groups with patients and providers took place across primary care practices. Discussions were held in all three arms both before and after the time of intervention rollout. Audio recordings were transcribed and analyzed for themes. RESULTS Across all sites patients and providers discussed themes of communication, asthma self-management, barriers, education, and patient awareness. After the intervention, compared to traditional sites, facilitated practices were more likely to discuss themes related to SDM, such as patient-centered communication, patient-provider negotiation on treatment plan, planning, goal-setting, and solutions to barriers. CONCLUSIONS Emergent themes allowed for further understanding of how the SDM implementation was perceived at the patient and provider level. The facilitated implementation was associated with higher adoption of the SDM intervention. These themes and supporting quotes add to knowledge of best practices associated with implementing an evidence-based SDM intervention for asthma into primary care and will inform researchers, practices, and providers as they work to improve adoption of evidence-based interventions into practice.
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Affiliation(s)
- Madelyn Welch
- a Atrium Health, Department of Family Medicine Research , Charlotte , NC , USA
| | - Thomas Ludden
- a Atrium Health, Department of Family Medicine Research , Charlotte , NC , USA
| | - Kathleen Mottus
- b University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | - Paul Bray
- c Vidant Medical Group , Greenville , NC , USA
| | | | - Jennifer Rees
- b University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | | | - Hazel Tapp
- a Atrium Health, Department of Family Medicine Research , Charlotte , NC , USA
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Taylor YJ, Tapp H, Shade LE, Liu TL, Mowrer JL, Dulin MF. Impact of shared decision making on asthma quality of life and asthma control among children. J Asthma 2018; 55:675-683. [PMID: 28800266 PMCID: PMC7229989 DOI: 10.1080/02770903.2017.1362423] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 07/11/2017] [Accepted: 07/13/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Few studies have examined the effectiveness of shared decision making (SDM) in clinical practice. This study evaluated the impact of SDM on quality of life and symptom control in children with asthma. METHODS We conducted a prospective 3-year study in six community-based practices serving a low-income patient population. Practices received training on SDM using an evidence-based toolkit. Patients aged 2-17 with a diagnosis of asthma were identified from scheduling and billing data. At approximate 6-month intervals, patients completed a survey consisting of the Mini Pediatric Asthma Quality of Life Questionnaire (range 1-7) and the control domain of the Pediatric Asthma Therapy Assessment Questionnaire (range 0-7). We used propensity scores to match 46 children receiving SDM to 46 children receiving usual care with decision support. Included children had completed a baseline survey and at least one follow-up survey. Random coefficient models incorporated repeated measures to assess the effect of SDM on asthma quality of life and asthma control. RESULTS The sample was primarily of non-White patients (94.6%) with Medicaid insurance (92.4%). Receipt of SDM using an evidence-based toolkit was associated with higher asthma quality of life [mean difference 0.9; 95% confidence interval (CI) 0.4-1.4] and fewer asthma control problems (mean difference -0.9; 95% CI -1.6--0.2) compared to usual care with decision support. CONCLUSIONS Implementation of SDM within clinical practices using a standardized toolkit is associated with improved asthma quality of life and asthma control for low-income children with asthma when compared to usual care with decision support.
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Affiliation(s)
| | - Hazel Tapp
- Carolinas HealthCare System, Charlotte, North Carolina
| | | | - Tsai-Ling Liu
- Carolinas HealthCare System, Charlotte, North Carolina
| | | | - Michael F. Dulin
- Carolinas HealthCare System, Charlotte, North Carolina
- University of North Carolina at Charlotte, Charlotte, North Carolina
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Perspectives on PAs as researchers. JAAPA 2018; 31:1-2. [PMID: 29698376 DOI: 10.1097/01.jaa.0000532123.84917.4b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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McWilliams A, Reeves K, Shade L, Burton E, Tapp H, Courtlandt C, Gunter A, Dulin MF. Patient and Family Engagement in the Design of a Mobile Health Solution for Pediatric Asthma: Development and Feasibility Study. JMIR Mhealth Uhealth 2018; 6:e68. [PMID: 29567637 PMCID: PMC5887041 DOI: 10.2196/mhealth.8849] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 01/18/2018] [Accepted: 02/05/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Asthma is a highly prevalent, chronic disease with significant morbidity, cost, and disparities in health outcomes. While adherence to asthma treatment guidelines can improve symptoms and decrease exacerbations, most patients receive care that is not guideline-based. New approaches that incorporate shared decision-making (SDM) and health information technology (IT) are needed to positively impact asthma management. Despite the promise of health IT to improve efficiency and outcomes in health care, new IT solutions frequently suffer from a lack of widespread adoption and do not achieve desired results, as a consequence of not involving end-users in design. OBJECTIVE To describe a case study of a pediatric asthma SDM health IT solution's development and demonstrate a methodology for engaging actual patients and families in IT development. Perspectives are shared from the vantage point of the research team and a parent of a child with asthma, who participated on the development team. METHODS We adapted user-centric design principles to engage actual users across three main development phases: project initiation, ideation, and usability testing. To facilitate the necessary level of user engagement, our approach included: (1) a Development Workgroup consisting of patients, caregivers, and providers who met regularly with the research team; and (2) "real-world users" consisting of patients, caregivers, and providers recruited from a variety of care locations, including safety-net clinics. RESULTS Using this methodology, we successful partnered with asthma patients and families to create an interactive, digital solution called Carolinas Asthma Coach. Carolinas Asthma Coach incorporates SDM principles to elicit patient information, including goals and preferences, and provides health-literate, tailored education with specific guideline-based recommendations for patients and their providers. Of the patients, caregivers, and providers surveyed, 100% (n=60) said they would recommend Carolinas Asthma Coach to a friend or colleague. Qualitative feedback from users provided support for the usability and engaging nature of the app. CONCLUSIONS This project demonstrates the feasibility and benefits of deploying user-centric design methods that engage real patients and caregivers throughout the health IT design process.
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Affiliation(s)
- Andrew McWilliams
- Center for Outcomes Research and Evaluation, Carolinas HealthCare System, Charlotte, NC, United States
| | - Kelly Reeves
- Department of Family Medicine, Carolinas HealthCare System, Charlotte, NC, United States
| | - Lindsay Shade
- Department of Family Medicine, Carolinas HealthCare System, Charlotte, NC, United States
| | - Elizabeth Burton
- Community Care Partners of Greater Mecklenburg, Carolinas HealthCare System, Charlotte, NC, United States
| | - Hazel Tapp
- Department of Family Medicine, Carolinas HealthCare System, Charlotte, NC, United States
| | - Cheryl Courtlandt
- Department of Pediatrics, Carolinas HealthCare System, Charlotte, NC, United States
| | - Andrew Gunter
- Department of Pediatrics, Carolinas HealthCare System, Charlotte, NC, United States
| | - Michael F Dulin
- Academy of Population Health Innovation, Department of Public Health Sciences, University of North Carolina Charlotte, Charlotte, NC, United States
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Scholl I, LaRussa A, Hahlweg P, Kobrin S, Elwyn G. Organizational- and system-level characteristics that influence implementation of shared decision-making and strategies to address them - a scoping review. Implement Sci 2018. [PMID: 29523167 PMCID: PMC5845212 DOI: 10.1186/s13012-018-0731-z] [Citation(s) in RCA: 161] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background Shared decision-making (SDM) is poorly implemented in routine care, despite being promoted by health policies. No reviews have solely focused on an in-depth synthesis of the literature around organizational- and system-level characteristics (i.e., characteristics of healthcare organizations and of healthcare systems) that may affect SDM implementation. A synthesis would allow exploration of interventions to address these characteristics. The study aim was to compile a comprehensive overview of organizational- and system-level characteristics that are likely to influence the implementation of SDM, and to describe strategies to address those characteristics described in the literature. Methods We conducted a scoping review using the Arksey and O’Malley framework. The search strategy included an electronic search and a secondary search including gray literature. We included publications reporting on projects that promoted implementation of SDM or other decision support interventions in routine healthcare. We screened titles and abstracts, and assessed full texts for eligibility. We used qualitative thematic analysis to identify organizational- and system-level characteristics. Results After screening 7745 records and assessing 354 full texts for eligibility, 48 publications on 32 distinct implementation projects were included. Most projects (N = 22) were conducted in the USA. Several organizational-level characteristics were described as influencing the implementation of SDM, including organizational leadership, culture, resources, and priorities, as well as teams and workflows. Described system-level characteristics included policies, clinical guidelines, incentives, culture, education, and licensing. We identified potential strategies to influence the described characteristics, e.g., examples how to facilitate distribution of decision aids in a healthcare institution. Conclusions Although infrequently studied, organizational- and system-level characteristics appear to play a role in the failure to implement SDM in routine care. A wide range of characteristics described as supporting and inhibiting implementation were identified. Future studies should assess the impact of these characteristics on SDM implementation more thoroughly, quantify likely interactions, and assess how characteristics might operate across types of systems and areas of healthcare. Organizations that wish to support the adoption of SDM should carefully consider the role of organizational- and system-level characteristics. Implementation and organizational theory could provide useful guidance for how to address facilitators and barriers to change. Electronic supplementary material The online version of this article (10.1186/s13012-018-0731-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Isabelle Scholl
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Level 5, Williamson Translational Research Building, One Medical Center Drive, Lebanon, NH, 03756, USA. .,Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, W26, 20246, Hamburg, Germany.
| | - Allison LaRussa
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Level 5, Williamson Translational Research Building, One Medical Center Drive, Lebanon, NH, 03756, USA
| | - Pola Hahlweg
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, W26, 20246, Hamburg, Germany
| | - Sarah Kobrin
- Healthcare Delivery Research Program, National Cancer Institute, 9609 Medical Center Drive, Rockville, MD, 20852, USA
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Level 5, Williamson Translational Research Building, One Medical Center Drive, Lebanon, NH, 03756, USA
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Coffman MJ, de Hernandez BU, Smith HA, McWilliams A, Taylor YJ, Tapp H, Schuch JC, Furuseth O, Dulin M. Using CBPR to Decrease Health Disparities in a Suburban Latino Neighborhood. HISPANIC HEALTH CARE INTERNATIONAL 2017; 15:121-129. [PMID: 29164939 DOI: 10.1177/1540415317727569] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION This project tested the feasibility of using a community-based participatory research (CBPR) approach to deliver health and social resources in two high-risk, suburban neighborhoods. METHOD An established research network was used to engage stakeholders to design and deliver a neighborhood-based intervention targeting a Latino immigrant population. The intervention provided screenings for hypertension, diabetes, and depression; primary care provider visits; and information about navigating health care delivery systems and related community-based resources. Participants ( N = 216) were consented for participation and their subsequent use of health and social services were measured at baseline and 1 year post intervention. RESULTS At baseline, 5.1% of participants had health insurance, 16.7% had a primary care provider, and 38.4% had a chronic illness. SF-12 scores showed a majority of participants with low perceived health status (56%) and high risk for clinical depression (33%). Self-reported use of primary care services increased from 33.8% at baseline to 48% 1 year after the intervention, and 62% reported use of social services. CONCLUSION Neighborhood-based interventions informed by a CBPR approach are effective in both identifying community members who lack access to health care-related services and connecting them into needed primary care and social services.
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Affiliation(s)
| | | | | | | | | | - Hazel Tapp
- 2 Carolinas HealthCare System, Charlotte, NC, USA
| | | | - Owen Furuseth
- 1 University of North Carolina at Charlotte, NC, USA
| | - Michael Dulin
- 1 University of North Carolina at Charlotte, NC, USA
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Tapp H, Derkowski D, Calvert M, Welch M, Spencer S. Patient perspectives on engagement in shared decision-making for asthma care. Fam Pract 2017; 34:353-357. [PMID: 28034918 PMCID: PMC6080565 DOI: 10.1093/fampra/cmw122] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Introduction Engagement of patient and advocacy group stakeholders is increasingly considered essential to meaningful outcomes research. Patient-centred research benefits from partnership formation between patients, clinicians and research team members. Here, we describe the rationale for engaging patients on a research team and a case study of patient engagement on an asthma shared decision-making study. Methods Here, we describe a case study of patient engagement in outcomes research and examine the variety of roles patients are engaged in and the associated impact on the study. Results Patients assisted the project at various levels and were integrated into the research team by (i) advising on study development; (ii) assisting with design and usability of study materials, including the toolkit, patient surveys and dissemination strategies; and (iii) advocacy via membership in external disease-specific organizations and participating in outcomes research conferences. Patients were engaged both individually and as members of a patient advisory board. Primary lessons learned were the importance of building a trusting partnership with patients through understanding perspectives, being aware of clearly explaining patients' roles, research methods and jargon, providing training, listening to patients' needs and understanding what the partnership means from a patient perspective. Conclusions For the case study described, patient engagement directly influenced multiple aspects of the study, including study design, implementation, data analysis and dissemination through incorporation of the patients' and caregivers' input and concerns.
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Affiliation(s)
- Hazel Tapp
- Department of Family Medicine, Carolinas HealthCare System, Charlotte, NC, USA
| | - Diane Derkowski
- Transplant Center, Carolinas HealthCare System, Charlotte, NC, USA
| | | | - Madelyn Welch
- Department of Family Medicine, Carolinas HealthCare System, Charlotte, NC, USA
| | - Sara Spencer
- Elizabeth Family Medicine Patient Advisory Board, Carolinas HealthCare System, Charlotte, NC, USA
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Pollard S, Bansback N, FitzGerld JM, Bryan S. The burden of nonadherence among adults with asthma: a role for shared decision-making. Allergy 2017; 72:705-712. [PMID: 27873330 DOI: 10.1111/all.13090] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2016] [Indexed: 01/29/2023]
Abstract
A shared approach to decision-making framework has been suggested for chronic disease management especially where multiple treatment options exist. Shared decision-making (SDM) requires that both physician and patients are actively engaged in the decision-making process, including information exchange; expressing treatment preferences; as well as agreement over the final treatment decision. Although SDM appears well supported by patients, practitioners and policymakers alike, the current challenge is to determine how best to make SDM a reality in everyday clinical practice. Within the context of asthma, adherence rates are poor and are linked to outcomes such as reduced asthma control, increased symptoms, healthcare expenditures, and lower patient quality of life. It has been suggested that SDM can improve treatment adherence and that ignoring patients' personal goals and preferences may result in reduced rates of adherence. Furthermore, understanding predictors of poor treatment adherence is a necessary step toward developing effective strategies to improve the patient-reported and clinically important outcomes. Here, we describe why a shared approach to treatment decision-making for asthma has the potential to be an effective tool for improving adherence, with associated clinical and patient-related outcomes. In addition, we explore insights into the reasons why SDM has not been implemented into routine clinical practice.
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Affiliation(s)
- S. Pollard
- School of Population and Public Health; University of British Columbia; Vancouver BC Canada
- Centre for Clinical Epidemiology and Evaluation; Vancouver Coastal Research Institute; Vancouver BC Canada
| | - N. Bansback
- School of Population and Public Health; University of British Columbia; Vancouver BC Canada
- Centre for Clinical Epidemiology and Evaluation; Vancouver Coastal Research Institute; Vancouver BC Canada
- Centre for Health Evaluation and Outcome Sciences; St Paul's Hospital; Vancouver BC Canada
| | - J. M. FitzGerld
- Centre for Clinical Epidemiology and Evaluation; Vancouver Coastal Research Institute; Vancouver BC Canada
- Institute for Heart and Lung Health; Faculty of Medicine; University of British Columbia; Vancouver BC Canada
| | - S. Bryan
- School of Population and Public Health; University of British Columbia; Vancouver BC Canada
- Centre for Clinical Epidemiology and Evaluation; Vancouver Coastal Research Institute; Vancouver BC Canada
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25
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The Mecklenburg County Interlocal Agreement: An 18-Year Collaboration Between Medicine and Public Health. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2017; 24:e1-e7. [PMID: 28257405 DOI: 10.1097/phh.0000000000000531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
CONTEXT Better integration of public health and medical services has been a long-standing goal in the United States and has been widely discussed in the scientific literature. OBJECTIVE To identify key lessons and outcomes of the Mecklenburg County Interlocal Agreement, one of the longest running efforts integrating health care delivery and public health services in a major metropolitan area. DESIGN In-depth key informant interviews and brief questionnaires of leaders involved in the Mecklenburg County Interlocal Agreement. SETTING Charlotte-Mecklenburg County, North Carolina. PARTICIPANTS Convenience sample of 15 past and present employees and administrative leaders of the Mecklenburg County Privatization Initiative from the Mecklenburg County Health Department (N = 7) and Carolinas Healthcare System (N = 8). MAIN OUTCOME MEASURES Attitudes reflecting the effects of the Mecklenburg County Privatization Initiative, based on 6 "synergies" for evaluating the effectiveness of health care and public health system collaboration. RESULTS Mean scores were calculated for 21 questionnaire items, using 5-point Likert scales (1 = no impact; 5 = great impact). Mean scores were calculated by averaging the multiple-item question sets reflecting each of the 6 synergies. Synergy scores ranged from a low of 3.1 (3 items reflecting whether the collaboration "Used clinical practice to identify and address community health problems") to a high of 3.7 (3 items reflecting whether the collaboration "Improved health care by coordinating services for individuals"). The in-depth interviews indicated a clear impact for the 2 synergies linked to individual care. Increased access to care emerged as a strong theme, along with the belief that medical care services were improved and that these improvements persist. CONCLUSION The findings of this study provide perspective from an 18-year contractual agreement for a large health care system to operate county public health functions. Implications include the need to incorporate well-defined public health principles in any collaborative agreement and to focus these efforts at the primary care level.
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26
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Tapp H, Shade L, Mahabaleshwarkar R, Taylor YJ, Ludden T, Dulin MF. Results from a pragmatic prospective cohort study: Shared decision making improves outcomes for children with asthma. J Asthma 2016; 54:392-402. [PMID: 27813670 DOI: 10.1080/02770903.2016.1227333] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Patient/provider shared decision making (SDM) improves asthma control in a pragmatic clinical trial setting. This study evaluated the impact of an evidence-based SDM toolkit on outcomes for patients with asthma implemented by providers in a real world setting. We hypothesized that these patients with asthma would demonstrate improved outcomes such as reduced emergency department (ED) visits, hospitalizations, and oral steroid use in the 12 months following a SDM visit compared to those who did not receive the intervention. METHODS Patients with asthma were identified within six primary care practices that serve vulnerable populations in Charlotte, NC (746 children; 718 adult patients). Propensity scores were used to match 200 children and 206 adults for analysis. The primary outcome variable was asthma exacerbation defined as an ED visit or hospitalization for asthma or outpatient prescription of an oral steroid. Patients were monitored at 3, 6, and 12 months after the intervention date. The outcome variables of ED visits, hospitalizations, and oral steroids were compared between intervention and matched control patients. RESULTS The proportion of pediatric patients with one or more exacerbations was significantly lower in the SDM intervention group compared to controls during 12 months after exposure to the intervention (33% vs. 47%, p = 0.023). For adults, there was not a strong association between use of the SDM intervention and outcomes improvement. CONCLUSIONS The evidence-based SDM intervention implemented in this study was associated with improved asthma outcomes for pediatric patients but not adult patients in a real world clinical setting.
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Affiliation(s)
- Hazel Tapp
- a Department of Family Medicine , Carolinas HealthCare System , Charlotte , NC , USA
| | - Lindsay Shade
- a Department of Family Medicine , Carolinas HealthCare System , Charlotte , NC , USA
| | - Rohan Mahabaleshwarkar
- b Center for Outcome Research and Evaluation, Carolinas HealthCare System , Charlotte , NC , USA
| | - Yhenneko J Taylor
- b Center for Outcome Research and Evaluation, Carolinas HealthCare System , Charlotte , NC , USA
| | - Thomas Ludden
- a Department of Family Medicine , Carolinas HealthCare System , Charlotte , NC , USA
| | - Michael F Dulin
- a Department of Family Medicine , Carolinas HealthCare System , Charlotte , NC , USA
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27
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Reeves KW, Taylor Y, Tapp H, Ludden T, Shade LE, Burton B, Courtlandt C, Dulin M. Evaluation of a Pilot Asthma Care Program for Electronic Communication between School Health and a Healthcare System's Electronic Medical Record. Appl Clin Inform 2016; 7:969-982. [PMID: 27757472 DOI: 10.4338/aci-2016-02-ra-0022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 09/10/2016] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Asthma is a common childhood chronic lung disease affecting greater than 10% of children in the United States. School nurses are in a unique position to close gaps in care. Indeed, effective asthma management is more likely to result when providers, family, and schools work together to optimize the patient's treatment plan. Currently, effective communication between schools and healthcare systems through electronic medical record (EMR) systems remains a challenge. The goal of this feasibility pilot was to link the school-based care team with primary care providers in the healthcare system network via electronic communication through the EMR, on behalf of pediatric asthma patients who had been hospitalized for an asthma exacerbation. The implementation process and the potential impact of the communication with providers on the reoccurrence of asthma exacerbations with the linked patients were evaluated. METHODS By engaging stakeholders from the school system and the healthcare system, we were able to collaboratively design a communication process and implement a pilot which demonstrated the feasibility of electronic communication between school nurses and primary care providers. Outcomes data was collected from the electronic medical record to examine the frequency of asthma exacerbations among patients with a message from their school nurse. The percent of exacerbations in the 12 months before and after electronic communication was compared using McNemar's test. RESULTS The pilot system successfully established communication between the school nurse and primary care provider for 33 students who had been hospitalized for asthma and a decrease in hospital admissions was observed with students whose school nurse communicated through the EMR with the primary care provider. CONCLUSIONS Findings suggest a collaborative model of care that is enhanced through electronic communication via the EMR could positively impact the health of children with asthma or other chronic illnesses.
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Affiliation(s)
- Kelly W Reeves
- Kelly W. Reeves, BSN, RN, UXC, Department of Family Medicine, Carolinas HealthCare System, 2001 Vail Ave., Suite 400 Mercy Medical Plaza, Charlotte, NC 28207,
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28
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Action research methodology in clinical pharmacy: how to involve and change. Int J Clin Pharm 2016; 38:739-45. [PMID: 27156114 DOI: 10.1007/s11096-016-0310-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 04/26/2016] [Indexed: 10/21/2022]
Abstract
Introduction The focus in clinical pharmacy practice is and has for the last 30-35 years been on changing the role of pharmacy staff into service orientation and patient counselling. One way of doing this is by involving staff in change process and as a researcher to take part in the change process by establishing partnerships with staff. On the background of the authors' widespread action research (AR)-based experiences, recommendations and comments for how to conduct an AR-study is described, and one of their AR-based studies illustrate the methodology and the research methods used. Methodology AR is defined as an approach to research which is based on a problem-solving relationship between researchers and clients, which aims at both solving a problem and at collaboratively generating new knowledge. Research questions relevant in AR-studies are: what was the working process in this change oriented study? What learning and/or changes took place? What challenges/pitfalls had to be overcome? What were the influence/consequences for the involved parts? When to use If you want to implement new services and want to involve staff and others in the process, an AR methodology is very suitable. The basic advantages of doing AR-based studies are grounded in their participatory and democratic basis and their starting point in problems experienced in practice. Limitations Some of the limitations in AR-studies are that neither of the participants in a project steering group are the only ones to decide. Furthermore, the collective process makes the decision-making procedures relatively complex.
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Ramsey AT, Wetherell JL, Depp C, Dixon D, Lenze E. Feasibility and Acceptability of Smartphone Assessment in Older Adults with Cognitive and Emotional Difficulties. JOURNAL OF TECHNOLOGY IN HUMAN SERVICES 2016; 34:209-223. [PMID: 27683018 PMCID: PMC5036573 DOI: 10.1080/15228835.2016.1170649] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Ecological momentary assessment (EMA) has several advantages in clinical research yet little is known about the feasibility of collecting EMA data with mobile technologies in older adults, particularly those with emotional or cognitive difficulties. The aim of this feasibility study was to assess perceived acceptability, adherence rates, and reasons for non-adherence to smartphone-based EMA. METHOD At two sites, participants (n=103) aged 65 years or older with a DSM-IV-defined anxiety or depressive disorder and cognitive concerns responded three times daily to smartphone-based EMA questions assessing clinical outcomes for two 10-day periods. Quantitative and qualitative measures assessed acceptability, adherence, and reasons for non-adherence following both 10-day EMA periods. RESULTS Participants were moderately satisfied with and comfortable using smartphone-based EMA. Overall, 76% of participants completed surveys on ≥10 of the 20 assessment days, and 70% of participants completed at least 30% of the total surveys. Reasons for non-adherence included technical (malfunction), logistical (competing demands), physiological (hearing difficulties), and cognitive (forgetting) issues. DISCUSSION Smartphone-based EMA is feasible in older adults with cognitive and emotional difficulties. EMA tools should be responsive to the needs and preferences of participants to ensure adequate acceptability and adherence in this population. Our findings can inform the design, development, and implementation of mobile technologies in older adults in research and clinical contexts.
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Affiliation(s)
- Alex T Ramsey
- Washington University in St. Louis, School of Medicine, 660 S. Euclid, St. Louis, MO 63110
| | - Julie Loebach Wetherell
- VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161; University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093
| | - Colin Depp
- VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161; University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093
| | - David Dixon
- Washington University in St. Louis, School of Medicine, 660 S. Euclid, St. Louis, MO 63110
| | - Eric Lenze
- Washington University in St. Louis, School of Medicine, 660 S. Euclid, St. Louis, MO 63110
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Mowrer JL, Tapp H, Ludden T, Kuhn L, Taylor Y, Courtlandt C, Alkhazraji T, Reeves K, Steuerwald M, Andrew M, Dulin M. Patients' and providers' perceptions of asthma and asthma care: a qualitative study. J Asthma 2015; 52:949-56. [PMID: 25975701 DOI: 10.3109/02770903.2015.1010731] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Differences in patients' and providers' perceptions of asthma and asthma care can create barriers to successful treatment. The primary goal of this qualitative study was to further explore patient and provider perceptions of asthma and asthma care as part of a larger Asthma Comparative Effectiveness Study. METHODS Focus groups held every 6 months for 3 years were designed to have a mix of both patients and providers allowing for unique understanding around asthma care. RESULTS The discussion centered on goal setting, asthma action plans and prevention strategies for asthma exacerbations. Three overarching themes, with a variety of subthemes, emerged as the main findings of this study. The three main themes were Cost/Economic Barriers/Process, Self-Governance/Adherence and Education. CONCLUSIONS These themes indicated a strong need for patient educational interventions around asthma as well as education for providers around cost, insurance coverage and patient-centered communication. Specifically, education on learning to use inhalers properly, avoiding triggers and understanding the importance of a controller medication will benefit patients in the long-term management of asthma.
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Affiliation(s)
- J Lauren Mowrer
- a Dickson Advanced Analytics, Carolinas HealthCare System , Charlotte , NC , USA
| | - Hazel Tapp
- b Family Medicine Research, Carolinas HealthCare System , Charlotte , NC , USA
| | - Thomas Ludden
- a Dickson Advanced Analytics, Carolinas HealthCare System , Charlotte , NC , USA
| | - Lindsay Kuhn
- b Family Medicine Research, Carolinas HealthCare System , Charlotte , NC , USA
| | - Yhenneko Taylor
- a Dickson Advanced Analytics, Carolinas HealthCare System , Charlotte , NC , USA
| | - Cheryl Courtlandt
- c Department of Pediatrics , Carolinas HealthCare System , Charlotte , NC , USA , and
| | - Tami Alkhazraji
- a Dickson Advanced Analytics, Carolinas HealthCare System , Charlotte , NC , USA
| | - Kelly Reeves
- b Family Medicine Research, Carolinas HealthCare System , Charlotte , NC , USA
| | | | - McWilliams Andrew
- b Family Medicine Research, Carolinas HealthCare System , Charlotte , NC , USA
| | - Michael Dulin
- a Dickson Advanced Analytics, Carolinas HealthCare System , Charlotte , NC , USA
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Mohanan S, Tapp H, McWilliams A, Dulin M. Obesity and asthma: pathophysiology and implications for diagnosis and management in primary care. Exp Biol Med (Maywood) 2014; 239:1531-40. [PMID: 24719380 PMCID: PMC4230977 DOI: 10.1177/1535370214525302] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The effects of obesity on asthma diagnosis, control, and exacerbation severity are increasingly recognized; however, the underlying pathophysiology of this association is poorly understood. Mainstream clinical practice has yet to adopt aggressive management of obesity as a modifiable risk factor in asthma care, as is the case with a risk factor like tobacco or allergen exposure. This review summarizes existing data that support the pathophysiologic mechanisms underlying the association between obesity and asthma, as well as the current and future state of treatment for the obese patient with asthma. Our review suggests that evidence of chronic inflammatory response linking obesity and asthma indicates a need to address obesity during asthma management, possibly using patient-centered approaches such as shared decision making. There is a need for research to better understand the mechanisms of asthma in the obese patient and to develop new therapies specifically targeted to this unique patient population.
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Affiliation(s)
- Sveta Mohanan
- Department of Family Medicine, Carolinas HealthCare System, Charlotte, NC 28207, USA
| | - Hazel Tapp
- Department of Family Medicine, Carolinas HealthCare System, Charlotte, NC 28207, USA
| | - Andrew McWilliams
- Department of Family Medicine, Carolinas HealthCare System, Charlotte, NC 28207, USA
| | - Michael Dulin
- Department of Family Medicine, Carolinas HealthCare System, Charlotte, NC 28207, USA
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Tapp H, McWilliams A, Ludden T, Kuhn L, Taylor Y, Alkhazraji T, Halladay J, Derkowski D, Mohanan S, Dulin M. Comparing traditional and participatory dissemination of a shared decision making intervention (ADAPT-NC): a cluster randomized trial. Implement Sci 2014; 9:158. [PMID: 25359128 PMCID: PMC4219101 DOI: 10.1186/s13012-014-0158-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 10/07/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Asthma is a common disease that affects people of all ages and has significant morbidity and mortality. Poor outcomes and health disparities related to asthma result in part from the difficulty of disseminating new evidence and care delivery methods such as shared decision making (SDM) into clinical practice. METHODS/DESIGN This non-blinded study will randomize 30 primary care clinics in NC stratified by four PBRNs. We will test dissemination across these practices using a facilitator-led participatory approach to dissemination (FLOW), a novel method of participatory dissemination involving key principles of community-based participatory research, and a more typical "lunch and learn" dissemination method. Specifically, we will use cluster randomization to assign each of the 30 practices to one of three arms: (1) control, no dissemination; (2) traditional dissemination, one didactic session a year and distribution of educational material; and (3) FLOW dissemination. We hypothesize that at the unit of randomization, the clinic, patients in the FLOW dissemination arm will be more likely to share in their treatment decisions compared to patients in the traditional dissemination or control arms. All outcomes will be measured at the level of the clinic. Adoption of the SDM approach will be evaluated by 1) asthma exacerbations, 2) level of patient involvement in the decision making process, and 3) qualitative assessments from patients and providers. TRIAL REGISTRATION The trial was registered on January 27, 2014 through the United States National Institutes of Health's ClinicalTrials.gov NCT02047929 and funded by the Patient-Centered Outcomes Research Institute (PCORI).
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Affiliation(s)
- Hazel Tapp
- />Department of Family Medicine, Carolinas HealthCare System, 2001 Vail Avenue, Suite 400 Mercy Medical Plaza, Charlotte, NC 28207 USA
| | - Andrew McWilliams
- />Department of Family Medicine, Carolinas HealthCare System, 2001 Vail Avenue, Suite 400 Mercy Medical Plaza, Charlotte, NC 28207 USA
| | - Thomas Ludden
- />Dickson Advanced Analytics, Carolinas HealthCare System, Charlotte, USA
| | - Lindsay Kuhn
- />Department of Family Medicine, Carolinas HealthCare System, 2001 Vail Avenue, Suite 400 Mercy Medical Plaza, Charlotte, NC 28207 USA
| | - Yhenneko Taylor
- />Dickson Advanced Analytics, Carolinas HealthCare System, Charlotte, USA
| | - Thamara Alkhazraji
- />Dickson Advanced Analytics, Carolinas HealthCare System, Charlotte, USA
| | - Jacquie Halladay
- />Department of Family Medicine, UNC Chapel Hill and The Cecil G. Sheps Center for Health Services Research, Chapel Hill, USA
| | | | - Sveta Mohanan
- />Department of Family Medicine, Carolinas HealthCare System, 2001 Vail Avenue, Suite 400 Mercy Medical Plaza, Charlotte, NC 28207 USA
| | - Michael Dulin
- />Dickson Advanced Analytics, Carolinas HealthCare System, Charlotte, USA
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