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Berry CA, Kwok L, Gofine M, Kaufman M, Williams DA, Terlizzi K, Alvaro M, Neighbors CJ. Utilization and Staff Perspectives on an On-Demand Telemedicine Model for People with Intellectual and Developmental Disabilities Who Reside in Certified Group Residences. Telemed Rep 2023; 4:204-214. [PMID: 37529771 PMCID: PMC10389255 DOI: 10.1089/tmr.2023.0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 08/03/2023]
Abstract
Background Non-emergent medical problems that arise when a usual provider is unavailable can often result in emergency department or urgent care visits, which can be particularly distressing to people with intellectual and developmental disabilities (PIDD). On-demand, synchronous telemedicine may be a promising supplement when immediate care from usual sources is unavailable. Prior research demonstrated that high-quality telemedicine can be effectively delivered to PIDD. The aim of this article is to describe the utilization and staff perspectives on the implementation of the Telemedicine Triage Project (TTP), an innovative model that provides telemedicine consultations for PIDD who reside in state-certified group residences and present with an urgent but non-emergent medical concern when their usual provider is unavailable. Methods Call frequency data for calendar years 2020 and 2021 were reviewed. The study team conducted semi-structured interviews, with 19 key informants representing organizational- and agency-level leadership and staff. The interview data were analyzed using a protocol-driven, rapid qualitative methodology. Results Telemedicine consultations increased from 7953 in 2020 to 15,011 calls in 2021, and call volume peaked between 10 am and 1 pm. Key informants reported high satisfaction with TTP; universal benefits and a few barriers to implementation; and strong interest in maintaining the program beyond the grant period. Discussion Over the first 2 years of its implementation, the TTP program was widely utilized and proved extremely feasible and acceptable to staff. This model is a promising and highly feasible way to provide equitable access to telemedicine for PIDD by addressing barriers to and disparities in access to health care that affect PIDD.
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Affiliation(s)
- Carolyn A. Berry
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Lorraine Kwok
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Miriam Gofine
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | | | - Debra A. Williams
- Cerebral Palsy Associations of New York State, Cohoes, New York, USA
| | - Kelly Terlizzi
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Mike Alvaro
- Cerebral Palsy Associations of New York State, Cohoes, New York, USA
| | - Charles J. Neighbors
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
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Berry CA, Dávila Saad A, Blecker S, Billings J, Bouchonville MF, Arora S, Paul MM. Comparison of Care Provided to Underserved Patients With Diabetes by a Telementoring Model of Care to Care Provided by a Specialty Clinic: Endo ECHO Versus an Academic Specialty Clinic. Sci Diabetes Self Manag Care 2023; 49:239-246. [PMID: 37129282 DOI: 10.1177/26350106231169245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
PURPOSE The purpose of the study was to examine differences among adult patients with diabetes who receive care through a telementoring model versus care at an academic specialty clinic on guideline-recommended diabetes care and self-management behaviors. METHODS Endocrinology-focused Extension for Community Healthcare Outcomes (ECHO Endo) patients completed surveys assessing demographics, access to care, health care quality, and self-management behaviors at enrollment and 1 year after program enrollment. Diabetes Comprehensive Care Center (DCCC) patients completed surveys at comparable time points. RESULTS At baseline, ECHO patients were less likely than DCCC patients to identify English as their primary language, have postsecondary education, and private insurance. One year postenrollment, ECHO patients visited their usual source of diabetic care more frequently. There were no differences in A1C testing or feet checking by health care professionals, but ECHO patients were less likely to report eye exams and smoking status assessment. ECHO and DCCC patients did not differ in consumption of high-fat foods and soda, physical activity, or home feet checks. ECHO patients were less likely to space carbohydrates evenly and test glucose levels and more likely to have smoked cigarettes. CONCLUSIONS Endo ECHO is a suitable alternative to specialty care for patients in underserved communities with restricted access to specialty care. Results support the value of the Project ECHO telementoring model in addressing barriers to high-quality care for underserved communities.
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Affiliation(s)
- Carolyn A Berry
- Department of Population Health, New York University Grossman School of Medicine, New York, New York
| | - Andrea Dávila Saad
- School of Public and International Affairs, Virginia Polytechnic Institute, Blacksburg, Virginia
| | - Saul Blecker
- Department of Population Health, New York University Grossman School of Medicine, New York, New York
| | - John Billings
- Robert F. Wagner Graduate School of Public Service, New York University, New York, New York
| | - Matthew F Bouchonville
- Division of Endocrinology, Diabetes, and Metabolism, University of New Mexico, Albuquerque, New Mexico
| | - Sanjeev Arora
- Department of Internal Medicine, Division of Gastroenterology, University of New Mexico, Albuquerque, New Mexico
| | - Margaret M Paul
- Department of Population Health, New York University Grossman School of Medicine, New York, New York
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Cohen DJ, Wyte-Lake T, Bonsu P, Albert SL, Kwok L, Paul MM, Nguyen AM, Berry CA, Shelley DR. Organizational Factors Associated with Guideline Concordance of Chronic Disease Care and Management Practices. J Am Board Fam Med 2022; 35:1128-1142. [PMID: 36564193 DOI: 10.3122/jabfm.2022.210502r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/08/2022] [Accepted: 06/27/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Guidelines for managing and preventing chronic disease tend to be well-known. Yet, translation of this evidence into practice is inconsistent. We identify a combination of factors that are connected to guideline concordant delivery of evidence-informed chronic disease care in primary care. METHODS Cross-sectional observational study; purposively selected 22 practices to vary on size, ownership and geographic location, using National Quality Forum metrics to ensure practices had a ≥ 70% quality level for at least 2 of the following: aspirin use in high-risk individuals, blood pressure control, cholesterol and diabetes management. Interviewed 2 professionals (eg, medical director, practice manager) per practice (n = 44) to understand staffing and clinical operations. Analyzed data using an iterative and inductive approach. RESULTS Community Health Centers (CHCs) employed interdisciplinary clinical teams that included a variety of professionals as compared with hospital-health systems (HHS) and clinician-owned practices. Despite this difference, practice members consistently reported a number of functions that may be connected to clinical chronic care quality, including: having engaged leadership; a culture of teamwork; engaging in team-based care; using data to inform quality improvement; empaneling patients; and managing the care of patient panels, with a focus on continuity and comprehensiveness, as well as having a commitment to the community. CONCLUSIONS There are mutable organizational attributes connected-guideline concordant chronic disease care in primary care. Research and policy reform are needed to promote and study how to achieve widespread adoption of these functions and organizational attributes that may be central to achieving equity and improving chronic disease prevention.
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Affiliation(s)
- Deborah J Cohen
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Tamar Wyte-Lake
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Pamela Bonsu
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Stephanie L Albert
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Lorraine Kwok
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Margaret M Paul
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Ann M Nguyen
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Carolyn A Berry
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Donna R Shelley
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
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Massar RE, Berry CA, Paul MM. Social needs screening and referral in pediatric primary care clinics: a multiple case study. BMC Health Serv Res 2022; 22:1369. [DOI: 10.1186/s12913-022-08692-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 10/04/2022] [Accepted: 10/18/2022] [Indexed: 11/18/2022] Open
Abstract
Abstract
Background
Unmet social risks such as housing, food insecurity and safety concerns are associated with adverse health outcomes in adults and children. Experimentation with social needs screening in primary care is currently underway throughout the United States. Pediatric primary care practices are well-positioned to amplify the effects of social needs screening and referral programs because all members of the household have the potential to benefit from connection to needed social services; however, more research is needed to determine effective implementation strategies.
Methods
To describe common implementation barriers and facilitators, we conducted 48 in-depth qualitative interviews with leadership, providers and staff between November 2018 and June 2019 as part of a multiple case study of social needs screening and referral programs based out of four pediatric ambulatory care clinics in New York City. Interviews were recorded, transcribed and coded using a protocol-driven, template-based rapid analysis approach designed for pragmatic health services research. In addition to analyzing content for our study, we delivered timely findings to each site individually in order to facilitate quality improvement changes in close-to-real time.
Results
Effective implementation strategies included tailoring screening tools to meet the needs of families seen at the clinic and reflect the resources available in the community, hiring dedicated staff to manage the program, building strong and lasting partnerships with community-based organizations, establishing shared communication methods between partners, and utilizing technology for efficient tracking of screening data. Respondents were enthusiastic about the value of their programs and the impact on families, but remained concerned about long-term sustainability after the grant period.
Conclusion
Implementation of social needs screening and referral interventions is dependent on contextual factors including the nature of family needs and the availability of intraorganizational and community resources to address those needs. Additional research is needed to prospectively test promising implementation strategies that were found to be effective across sites in this study. Sustainability of programs is challenging, and future research should also explore measurable outcomes and payment structures to support such interventions in pediatric settings, as well as aim to better understand caregiver perspectives to improve engagement.
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Cohen DJ, Wyte-Lake T, Bonsu P, Albert SL, Kwok L, Paul MM, Nguyen AM, Berry CA, Shelley DR. Organizational Factors Associated with Guideline Concordance of Chronic Disease Care and Management Practices. J Am Board Fam Med 2022:jabfm.2022.AP.210502. [PMID: 36113991 PMCID: PMC10515112 DOI: 10.3122/jabfm.2022.ap.210502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/08/2022] [Accepted: 06/27/2022] [Indexed: 03/21/2023] Open
Abstract
BACKGROUND Guidelines for managing and preventing chronic disease tend to be well-known. Yet, translation of this evidence into practice is inconsistent. We identify a combination of factors that are connected to guideline concordant delivery of evidence-informed chronic disease care in primary care. METHODS Cross-sectional observational study; purposively selected 22 practices to vary on size, ownership and geographic location, using National Quality Forum metrics to ensure practices had a ≥ 70% quality level for at least 2 of the following: aspirin use in high-risk individuals, blood pressure control, cholesterol and diabetes management. Interviewed 2 professionals (eg, medical director, practice manager) per practice (n = 44) to understand staffing and clinical operations. Analyzed data using an iterative and inductive approach. RESULTS Community Health Centers (CHCs) employed interdisciplinary clinical teams that included a variety of professionals as compared with hospital-health systems (HHS) and clinician-owned practices. Despite this difference, practice members consistently reported a number of functions that may be connected to clinical chronic care quality, including: having engaged leadership; a culture of teamwork; engaging in team-based care; using data to inform quality improvement; empaneling patients; and managing the care of patient panels, with a focus on continuity and comprehensiveness, as well as having a commitment to the community. CONCLUSIONS There are mutable organizational attributes connected-guideline concordant chronic disease care in primary care. Research and policy reform are needed to promote and study how to achieve widespread adoption of these functions and organizational attributes that may be central to achieving equity and improving chronic disease prevention.
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Affiliation(s)
- Deborah J Cohen
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS).
| | - Tamar Wyte-Lake
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Pamela Bonsu
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Stephanie L Albert
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Lorraine Kwok
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Margaret M Paul
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Ann M Nguyen
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Carolyn A Berry
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Donna R Shelley
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
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Blecker S, Paul MM, Jones S, Billings J, Bouchonville MF, Hager B, Arora S, Berry CA. A Project ECHO and Community Health Worker Intervention for Patients with Diabetes. Am J Med 2022; 135:e95-e103. [PMID: 34973203 DOI: 10.1016/j.amjmed.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 12/01/2021] [Accepted: 12/05/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Both community health workers and the Project ECHO model of specialist telementoring are innovative approaches to support primary care providers in the care of complex patients with diabetes. We studied the effect of an intervention that combined these 2 approaches on glycemic control. METHODS Patients with diabetes were recruited from 10 federally qualified health centers in New Mexico. We used electronic health record (EHR) data to compare HbA1c levels prior to intervention enrollment with HbA1c levels after 3 months (early follow-up) and 12 months (late follow-up) following enrollment. We propensity matched intervention patients to comparison patients from other sites within the same electronic health records databases to estimate the average treatment effect. RESULTS Among 557 intervention patients with HbA1c data, mean HbA1c decreased from 10.5% to 9.3% in the pre- versus postintervention periods (P < .001). As compared to the comparison group, the intervention was associated with a change in HbA1c of -0.2% (95% confidence interval [CI] -0.4%-0.5%) and -0.3 (95% CI -0.5-0.0) in the early and late follow-up cohorts, respectively. The intervention was associated with a significant increase in percentage of patients with HbA1c <8% in the late follow-up cohort (8.1%, 95% CI 2.2%-13.9%) but not the early follow-up cohort (3.6%, 95% CI -1.5% to 8.7%) DISCUSSION: The intervention was associated with a substantial decrease in HbA1c in intervention patients, although this improvement was not different from matched comparison patients in early follow-up. Although combining community health workers with Project ECHO may hold promise for improving glycemic control, particularly in the longer term, further evaluations are needed.
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Affiliation(s)
- Saul Blecker
- Department of Population Health, NYU Grossman School of Medicine, New York, NY; Department of Medicine, NYU Grossman School of Medicine, New York, NY.
| | - Margaret M Paul
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
| | - Simon Jones
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
| | - John Billings
- Wagner School of Public Service, New York University, New York, NY
| | - Matthew F Bouchonville
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque; ECHO Institute, University of New Mexico Health Sciences Center, Albuquerque
| | - Brant Hager
- ECHO Institute, University of New Mexico Health Sciences Center, Albuquerque; Department of Psychiatry and Behavioral Sciences, University of New Mexico School of Medicine, Albuquerque
| | - Sanjeev Arora
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque; ECHO Institute, University of New Mexico Health Sciences Center, Albuquerque
| | - Carolyn A Berry
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
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Nguyen AM, Paul MM, Shelley DR, Albert SL, Cohen DJ, Bonsu P, Wyte-Lake T, Blecker S, Berry CA. Ten Common Structures and Processes of High-Performing Primary Care Practices. J Public Health Manag Pract 2022; 28:E639-E644. [PMID: 34654020 PMCID: PMC8781214 DOI: 10.1097/phh.0000000000001451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Structures (context of care delivery) and processes (actions aimed at delivery care) are posited to drive patient outcomes. Despite decades of primary care research, there remains a lack of evidence connecting specific structures/processes to patient outcomes to determine which of the numerous recommended structures/processes to prioritize for implementation. The objective of this study was to identify structures/processes most commonly present in high-performing primary care practices for chronic care management and prevention. We conducted key informant interviews with a national sample of 22 high-performing primary care practices. We identified the 10 most commonly present structures/processes in these practices, which largely enable 2 core functions: mobilizing staff to conduct patient outreach and helping practices avoid gaps in care. Given the costs of implementing and maintaining numerous structures/processes, our study provides a starting list for providers to prioritize and for researchers to investigate further for specific effects on patient outcomes.
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Affiliation(s)
- Ann M. Nguyen
- Center for State Health Policy, Rutgers University, New Brunswick, New Jersey (Dr Nguyen); Department of Population Health, NYU Langone Health, New York City, New York (Drs Paul, Albert, Blecker, and Berry); Department of Policy and Public Health Management, New York University School of Global Public Health, New York City, New York (Dr Shelley); and Department of Family Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon (Drs Cohen and Wyte-Lake and Ms Bonsu)
| | - Margaret M. Paul
- Center for State Health Policy, Rutgers University, New Brunswick, New Jersey (Dr Nguyen); Department of Population Health, NYU Langone Health, New York City, New York (Drs Paul, Albert, Blecker, and Berry); Department of Policy and Public Health Management, New York University School of Global Public Health, New York City, New York (Dr Shelley); and Department of Family Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon (Drs Cohen and Wyte-Lake and Ms Bonsu)
| | - Donna R. Shelley
- Center for State Health Policy, Rutgers University, New Brunswick, New Jersey (Dr Nguyen); Department of Population Health, NYU Langone Health, New York City, New York (Drs Paul, Albert, Blecker, and Berry); Department of Policy and Public Health Management, New York University School of Global Public Health, New York City, New York (Dr Shelley); and Department of Family Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon (Drs Cohen and Wyte-Lake and Ms Bonsu)
| | - Stephanie L. Albert
- Center for State Health Policy, Rutgers University, New Brunswick, New Jersey (Dr Nguyen); Department of Population Health, NYU Langone Health, New York City, New York (Drs Paul, Albert, Blecker, and Berry); Department of Policy and Public Health Management, New York University School of Global Public Health, New York City, New York (Dr Shelley); and Department of Family Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon (Drs Cohen and Wyte-Lake and Ms Bonsu)
| | - Deborah J. Cohen
- Center for State Health Policy, Rutgers University, New Brunswick, New Jersey (Dr Nguyen); Department of Population Health, NYU Langone Health, New York City, New York (Drs Paul, Albert, Blecker, and Berry); Department of Policy and Public Health Management, New York University School of Global Public Health, New York City, New York (Dr Shelley); and Department of Family Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon (Drs Cohen and Wyte-Lake and Ms Bonsu)
| | - Pam Bonsu
- Center for State Health Policy, Rutgers University, New Brunswick, New Jersey (Dr Nguyen); Department of Population Health, NYU Langone Health, New York City, New York (Drs Paul, Albert, Blecker, and Berry); Department of Policy and Public Health Management, New York University School of Global Public Health, New York City, New York (Dr Shelley); and Department of Family Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon (Drs Cohen and Wyte-Lake and Ms Bonsu)
| | - Tamar Wyte-Lake
- Center for State Health Policy, Rutgers University, New Brunswick, New Jersey (Dr Nguyen); Department of Population Health, NYU Langone Health, New York City, New York (Drs Paul, Albert, Blecker, and Berry); Department of Policy and Public Health Management, New York University School of Global Public Health, New York City, New York (Dr Shelley); and Department of Family Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon (Drs Cohen and Wyte-Lake and Ms Bonsu)
| | - Saul Blecker
- Center for State Health Policy, Rutgers University, New Brunswick, New Jersey (Dr Nguyen); Department of Population Health, NYU Langone Health, New York City, New York (Drs Paul, Albert, Blecker, and Berry); Department of Policy and Public Health Management, New York University School of Global Public Health, New York City, New York (Dr Shelley); and Department of Family Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon (Drs Cohen and Wyte-Lake and Ms Bonsu)
| | - Carolyn A. Berry
- Center for State Health Policy, Rutgers University, New Brunswick, New Jersey (Dr Nguyen); Department of Population Health, NYU Langone Health, New York City, New York (Drs Paul, Albert, Blecker, and Berry); Department of Policy and Public Health Management, New York University School of Global Public Health, New York City, New York (Dr Shelley); and Department of Family Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon (Drs Cohen and Wyte-Lake and Ms Bonsu)
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Albert SL, Paul MM, Nguyen AM, Shelley DR, Berry CA. A qualitative study of high-performing primary care practices during the COVID-19 pandemic. BMC Fam Pract 2021; 22:237. [PMID: 34823495 PMCID: PMC8614080 DOI: 10.1186/s12875-021-01589-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 11/11/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Primary care practices have remained on the frontline of health care service delivery throughout the COVID-19 pandemic. The purpose of our study was to understand the early pandemic experience of primary care practices, how they adapted care processes for chronic disease management and preventive care, and the future potential of these practices' service delivery adaptations. METHODS We interviewed 44 providers and staff at 22 high-performing primary care practices located throughout the United States between March and May 2020. Interviews were transcribed and coded using a modified rapid assessment process due to the time-sensitive nature of the study. RESULTS Practices reported employing a variety of adaptations to care during the COVID-19 pandemic including maintaining safe and socially distanced access through increased use of telehealth visits, using disease registries to identify and proactively outreach to patients, providing remote patient education, and incorporating more home-based monitoring into care. Routine screening and testing slowed considerably, resulting in concerns about delayed detection. Patients with fewer resources, lower health literacy, and older adults were the most difficult to reach and manage during this time. CONCLUSION Our findings indicate that primary care structures and processes developed for remote chronic disease management and preventive care are evolving rapidly. Emerging adapted care processes, most notably remote provision of care, are promising and may endure beyond the pandemic, but issues of equity must be addressed (e.g., through payment reform) to ensure vulnerable populations receive the same benefit.
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Affiliation(s)
- Stephanie L Albert
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, 2nd Floor, New York, NY, 10016, USA.
| | - Margaret M Paul
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, 2nd Floor, New York, NY, 10016, USA
| | - Ann M Nguyen
- Center for State Health Policy, Rutgers, The State University of New Jersey, 112 Paterson Street, New Brunswick, NJ, 08901, USA
| | - Donna R Shelley
- Global Center for Implementation Science, Department of Policy and Public Health Management, New York University School of Global Public Health, 665 Broadway, 8th Floor, New York, NY, 10012, USA
| | - Carolyn A Berry
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, 2nd Floor, New York, NY, 10016, USA
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Chang JE, Lai AY, Gupta A, Nguyen AM, Berry CA, Shelley DR. Rapid Transition to Telehealth and the Digital Divide: Implications for Primary Care Access and Equity in a Post-COVID Era. Milbank Q 2021; 99:340-368. [PMID: 34075622 PMCID: PMC8209855 DOI: 10.1111/1468-0009.12509] [Citation(s) in RCA: 138] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Policy Points Telehealth has many potential advantages during an infectious disease outbreak such as the COVID‐19 pandemic, and the COVID‐19 pandemic has accelerated the shift to telehealth as a prominent care delivery mode. Not all health care providers and patients are equally ready to take part in the telehealth revolution, which raises concerns for health equity during and after the COVID‐19 pandemic. Without proactive efforts to address both patient‐ and provider‐related digital barriers associated with socioeconomic status, the wide‐scale implementation of telehealth amid COVID‐19 may reinforce disparities in health access in already marginalized and underserved communities. To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them.
Context The COVID‐19 pandemic has catalyzed fundamental shifts across the US health care delivery system, including a rapid transition to telehealth. Telehealth has many potential advantages, including maintaining critical access to care while keeping both patients and providers safe from unnecessary exposure to the coronavirus. However, not all health care providers and patients are equally ready to take part in this digital revolution, which raises concerns for health equity during and after the COVID‐19 pandemic. Methods The study analyzed data about small primary care practices’ telehealth use and barriers to telehealth use collected from rapid‐response surveys administered by the New York City Department of Health and Mental Hygiene's Bureau of Equitable Health Systems and New York University from mid‐April through mid‐June 2020 as part of the city's efforts to understand how primary care practices were responding to the COVID‐19 pandemic following New York State's stay‐at‐home order on March 22. We focused on small primary care practices because they represent 40% of primary care providers and are disproportionately located in low‐income, minority or immigrant areas that were more severely impacted by COVID‐19. To examine whether telehealth use and barriers differed based on the socioeconomic characteristics of the communities served by these practices, we used the Centers for Disease Control and Prevention Social Vulnerability Index (SVI) to stratify respondents as being in high‐SVI or low‐SVI areas. We then characterized respondents’ telehealth use and barriers to adoption by using means and proportions with 95% confidence intervals. In addition to a primary analysis using pooled data across the five waves of the survey, we performed sensitivity analyses using data from respondents who only took one survey, first wave only, and the last two waves only. Findings While all providers rapidly shifted to telehealth, there were differences based on community characteristics in both the primary mode of telehealth used and the types of barriers experienced by providers. Providers in high‐SVI areas were almost twice as likely as providers in low‐SVI areas to use telephones as their primary telehealth modality (41.7% vs 23.8%; P <.001). The opposite was true for video, which was used as the primary telehealth modality by 18.7% of providers in high‐SVI areas and 33.7% of providers in low‐SVI areas (P <0.001). Providers in high‐SVI areas also faced more patient‐related barriers and fewer provider‐related barriers than those in low‐SVI areas. Conclusions Between April and June 2020, telehealth became a prominent mode of primary care delivery in New York City. However, the transition to telehealth did not unfold in the same manner across communities. To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them.
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Affiliation(s)
- Ji E Chang
- New York University School of Global Public Health
| | | | - Avni Gupta
- New York University School of Global Public Health
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10
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Gold HT, Siman N, Cuthel AM, Nguyen AM, Pham-Singer H, Berry CA, Shelley DR. A practice facilitation-guided intervention in primary care settings to reduce cardiovascular disease risk: a cost analysis. Implement Sci Commun 2021; 2:15. [PMID: 33549152 PMCID: PMC7868016 DOI: 10.1186/s43058-021-00116-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 01/28/2021] [Indexed: 11/23/2022] Open
Abstract
Background A stepped-wedge, cluster randomized controlled trial assessed the effectiveness of practice facilitation (PF) for adoption of guidelines for prevention and treatment of cardiovascular disease risk factors. This study estimated the associated cost of PF for guideline adoption in small, private primary care practices. Methods The cost analysis included categories for start-up costs, intervention costs, and practice staff costs for the implemented PF-guided intervention. We estimated the total 1-year costs to operate the program and calculated the mean and range of the cost-per-practice by quarter of the intervention. We estimated the lower and upper bounds for all salary expenses, rounding to the nearest $100. Results Total 1-year intervention costs for all 261 practices ranged from $7,900,000 to $10,200,000, with program and practice salaries comprising $6,600,000–$8,400,000 of the total. Start-up costs were a small proportion (3%) of the total 1-year costs. Excluding start-up costs, quarter 1 cost-per-practice was the most expensive at $20,400–$26,700, and quarter 4 was the least expensive at about $10,000. Practice staff time (compared with program staff time) was the majority of the staffing costs at 75–84%. Conclusions The PF strategy costs approximately $10,000 per practice per quarter for program and practice costs, once implemented and running at highest efficiency. Whether this program is “worth it” to the decision-maker depends on the relative costs and effectiveness of their other options for improving cardiovascular risk reduction. Trial registration This study is retrospectively registered on January 5, 2016, at www.clinicaltrials.gov as NCT02646488.
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Affiliation(s)
- Heather T Gold
- Department of Population Health, NYU Langone Health, New York, NY, USA.
| | - Nina Siman
- Department of Population Health, NYU Langone Health, New York, NY, USA
| | - Allison M Cuthel
- Ronald O. Perelman Department of Emergency Medicine, NYU Langone Health, New York, NY, USA
| | - Ann M Nguyen
- Rutgers Center for State Health Policy, Rutgers University, New Brunswick, NJ, USA
| | - Hang Pham-Singer
- New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - Carolyn A Berry
- Department of Population Health, NYU Langone Health, New York, NY, USA
| | - Donna R Shelley
- Department of Policy and Public Health Management, School of Global Public Health, New York University, New York, NY, USA
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Paul MM, Saad AD, Billings J, Blecker S, Bouchonville MF, Chavez C, Hager BW, Arora S, Berry CA. A Telementoring Intervention Leads to Improvements in Self-Reported Measures of Health Care Access and Quality among Patients with Complex Diabetes. J Health Care Poor Underserved 2021; 31:1124-1133. [PMID: 33416685 DOI: 10.1353/hpu.2020.0085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Individuals living with complex diabetes experience limited access to endocrine care due to a nationwide shortage of endocrinologists. Project ECHO (Extension for Community Healthcare Outcomes) is an innovative, scalable model of health care that extends specialty care to medically underserved areas through ongoing telementorship of community primary care providers. We evaluated the effects of an endocrine-focused ECHO program (Endo ECHO) on patients with type 1 and complex type 2 diabetes, and report here on changes in patient-reported measures of health care access and quality from baseline to one year aft er program enrollment. Patients were eligible for Endo ECHO if they were 18 years or older with complex diabetes. Aft er participating in Endo ECHO, access to health care and diabetes-related quality of care improved dramatically. Our results suggest that Endo ECHO may be a suitable intervention for extending best practices in diabetes care to medically underserved patients.
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Nguyen AM, Cuthel AM, Rogers ES, Van Devanter N, Pham-Singer H, Shih S, Berry CA, Shelley DR. Attributes of High-Performing Small Practices in a Guideline Implementation: A Multiple-Case Study. J Prim Care Community Health 2020; 11:2150132720984411. [PMID: 33356790 PMCID: PMC7768565 DOI: 10.1177/2150132720984411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objective HealthyHearts NYC was a stepped wedge randomized control trial that tested the effectiveness of practice facilitation on the adoption of cardiovascular disease guidelines in small primary care practices. The objective of this study was to identify was to identify attributes of small practices that signaled they would perform well in a practice facilitation intervention implementation. Methods A mixed methods multiple-case study design was used. Six small practices were selected representing 3 variations in meeting the practice-level benchmark of >70% of hypertensive patients having controlled blood pressure. Inductive and deductive approaches were used to identify themes and assign case ratings. Cross-case rating comparison was used to identify attributes of high performing practices. Results Our first key finding is that the high-performing and improved practices in our study looked and acted similarly during the intervention implementation. The second key finding is that 3 attributes emerged in our analysis of determinants of high performance in small practices: (1) advanced use of the EHR; (2) dedicated resources and commitment to quality improvement; and (3) actively engaged lead clinician and office manager. Conclusions These attributes may be important determinants of high performance, indicating not only a small practice’s capability to engage in an intervention but possibly also its readiness to change. We recommend developing tools to assess readiness to change, specifically for small primary care practices, which may help external agents, like practice facilitators, better translate intervention implementations to context.
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Affiliation(s)
| | | | | | | | - Hang Pham-Singer
- New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - Sarah Shih
- New York City Department of Health and Mental Hygiene, New York, NY, USA
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13
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Blecker S, Lemieux E, Paul MM, Berry CA, Bouchonville MF, Arora S, Billings J. Impact of a Primary Care Provider Tele-Mentoring and Community Health Worker Intervention on Utilization in Medicaid Patients with Diabetes. Endocr Pract 2020; 26:1070-1076. [PMID: 33471708 DOI: 10.4158/ep-2019-0535] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 05/03/2020] [Indexed: 09/16/2023]
Abstract
OBJECTIVE The Endocrinology ECHO intervention utilized a tele-mentoring model that connects primary care providers (PCPs) and community health workers (CHWs) with specialists for training in diabetes care. We evaluated the impact of the Endo ECHO intervention on healthcare utilization and care for Medicaid patients with diabetes in New Mexico. METHODS Between January 2015 and April 2017, patients with complex diabetes from 10 health centers in NM were recruited to receive diabetes care from a PCP and CHW upskilled through Endo ECHO. We matched intervention patients in the NM Medicaid claims database to comparison Medicaid beneficiaries using 5:1 propensity matching. We used a difference-in-difference (DID) approach to compare utilization and processes of care between intervention and comparison patients. RESULTS Of 541 Medicaid patients enrolled in Endo ECHO, 305 met inclusion criteria and were successfully matched. Outpatient visits increased with Endo ECHO for intervention patients as compared to comparison patients (rate ratio, 1.57; 95% confidence interval [CI], 1.43 to 1.72). The intervention was associated with an increase in emergency department (ED) visits (rate ratio, 1.30; 95% CI, 1.04 to 1.63) but no change in hospitalizations (rate ratio, 1.47; 95% CI, 0.95 to 2.23). Among intervention patients, utilization of metformin increased from 57.1% to 60.7%, with a DID between groups of 8.8% (95% CI, 4.0% to 13.6%). We found similar increases in use of statins (DID, 8.5%; 95% CI, 3.2% to 13.8%), angiotensin-converting enzyme inhibitors (DID, 9.5%; 95% CI, 3.5% to 15.4%), or antidepressant therapies (DID, 9.4%; 95% CI, 1.1% to 18.1%). CONCLUSION Patient enrollment in Endo ECHO was associated with increased outpatient and ED utilization and increased uptake of prescription-related quality measures. No impact was observed on hospitalization.
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Affiliation(s)
- Saul Blecker
- Department of Population Health, NYU School of Medicine, New York, New York; Department of Medicine, NYU School of Medicine, New York, New York.
| | | | - Margaret M Paul
- Department of Population Health, NYU School of Medicine, New York, New York
| | - Carolyn A Berry
- Department of Population Health, NYU School of Medicine, New York, New York
| | - Matthew F Bouchonville
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico; ECHO Institute, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Sanjeev Arora
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico; ECHO Institute, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - John Billings
- Wagner School of Public Service, New York University, New York, New York
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Berry CA, Nguyen AM, Cuthel AM, Cleland CM, Siman N, Pham-Singer H, Shelley DR. Measuring Implementation Strategy Fidelity in HealthyHearts NYC: A Complex Intervention Using Practice Facilitation in Primary Care. Am J Med Qual 2020; 36:270-276. [PMID: 32964719 DOI: 10.1177/1062860620959450] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Few studies have assessed the fidelity of practice facilitation (PF) as an implementation strategy, and none have used an a priori definition or conceptual framework of fidelity to guide fidelity assessment. The authors adapted the Conceptual Framework for Implementation Fidelity to guide fidelity assessment in HealthyHearts NYC, an intervention that used PF to improve adoption of cardiovascular disease evidence-based guidelines in primary care practices. Data from a web-based tracking system of 257 practices measured fidelity using 4 categories: frequency, duration, content, and coverage. Almost all (94.2%) practices received at least the required 13 PF visits. Facilitators spent on average 26.3 hours at each site. Most practices (95.7%) completed all Task List items, and 71.2% were educated on all Chronic Care Model strategies. The majority (65.8%) received full coverage. This study provides a model that practice managers and implementers can use to evaluate fidelity of PF, and potentially other implementation strategies.
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Affiliation(s)
- Carolyn A Berry
- NYU Langone Health, New York, NY New York City Department of Health and Mental Hygiene, New York, NY New York University, New York, NY
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15
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Shelley DR, Gepts T, Siman N, Nguyen AM, Cleland C, Cuthel AM, Rogers ES, Ogedegbe O, Pham-Singer H, Wu W, Berry CA. Cardiovascular Disease Guideline Adherence: An RCT Using Practice Facilitation. Am J Prev Med 2020; 58:683-690. [PMID: 32067871 DOI: 10.1016/j.amepre.2019.12.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 12/18/2019] [Accepted: 12/19/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Practice facilitation is a promising practice transformation strategy, but further examination of its effectiveness in improving adoption of guidelines for multiple cardiovascular disease risk factors is needed. The objective of the study is to determine whether practice facilitation is effective in increasing the proportion of patients meeting the Million Hearts ABCS outcomes: (A) aspirin when indicated, (B) blood pressure control, (C) cholesterol management, and (S) smoking screening and cessation intervention. STUDY DESIGN The study used a stepped-wedge cluster RCT design with 4 intervention waves. Data were extracted for 13 quarters between January 1, 2015 and March 31, 2018, which encompassed the control, intervention, and follow-up periods for all waves, and analyzed in 2019. SETTING/PARTICIPANTS A total of 257 small independent primary care practices in New York City were randomized into 1 of 4 waves. INTERVENTION The intervention consisted of practice facilitators conducting at least 13 practice visits over 1 year, focused on capacity building and implementing system and workflow changes to meet cardiovascular disease care guidelines. MAIN OUTCOME MEASURES The main outcomes were the Million Hearts' ABCS measures. Two additional measures were created: (1) proportion of tobacco users who received a cessation intervention (smokers counseled) and (2) a composite measure that assessed the proportion of patients meeting treatment targets for A, B, and C (ABC composite). RESULTS The S measure improved when comparing follow-up with the control period (incidence rate ratio=1.152, 95% CI=1.072, 1.238, p<0.001) and when comparing follow-up with intervention (incidence rate ratio=1.060, 95% CI=1.013, 1.109, p=0.007). Smokers counseled improved when comparing the intervention period with control (incidence rate ratio=1.121, 95% CI=1.037, 1.211, p=0.002). CONCLUSIONS Increasing the impact of practice facilitation programs that target multiple risk factors may require a longer, more intense intervention and greater attention to external policy and practice context. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT02646488.
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Affiliation(s)
- Donna R Shelley
- Department of Policy and Public Health Management, College of Global Public Health, New York University, New York, New York.
| | - Thomas Gepts
- University of California Berkeley, Department of Sociology, Berkeley, California
| | - Nina Siman
- Department of Population Health, NYU Langone Health, New York, New York
| | - Ann M Nguyen
- Department of Population Health, NYU Langone Health, New York, New York
| | - Charles Cleland
- Department of Population Health, NYU Langone Health, New York, New York
| | - Allison M Cuthel
- Ronald O. Perelman Department of Emergency Medicine, NYU Langone Health, New York, New York
| | - Erin S Rogers
- Department of Population Health, NYU Langone Health, New York, New York
| | | | - Hang Pham-Singer
- New York City Department of Health and Mental Hygiene, New York, New York
| | - Winfred Wu
- New York City Department of Health and Mental Hygiene, New York, New York
| | - Carolyn A Berry
- Department of Population Health, NYU Langone Health, New York, New York
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16
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Rogers ES, Cuthel AM, Berry CA, Kaplan SA, Shelley DR. Clinician Perspectives on the Benefits of Practice Facilitation for Small Primary Care Practices. Ann Fam Med 2019; 17:S17-S23. [PMID: 31405872 PMCID: PMC6827665 DOI: 10.1370/afm.2427] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 05/20/2019] [Accepted: 05/28/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Small independent primary care practices (SIPs) often lack the resources to implement system changes. HealthyHearts NYC, funded through the EvidenceNOW initiative of the Agency for Healthcare Research and Quality, studied the effectiveness of practice facilitation to improve cardiovascular disease- related care in 257 SIPs. We sought to understand SIP clinicians' perspectives on the benefits of practice facilitation. METHODS We conducted in-depth interviews with 19 SIP clinicians enrolled in HealthyHearts NYC. Interviews were transcribed and coded using deductive and inductive approaches. To understand whether the perceived benefits of practice facilitation differ based on the availability of internal staff for quality improvement (QI), we compared themes pertaining to benefits between practices with 3 or fewer office staff vs more than 3 office staff. RESULTS Clinicians perceived 2 main benefits of practice facilitation. First, facilitators served as a connection to the external health care environment for SIPs, often through teaching and information sharing. Second, facilitators provided electronic health record (EHR)/data expertise, often by teaching functionality and completing technical assistance and tasks. SIPs with more than 3 office staff felt that facilitators provided benefits primarily through teaching, whereas SIPs with 3 or fewer staff felt that facilitators also provided hands-on support. At the intersections of these benefits, there emerged 3 central practice facilitation benefits: (1) creating awareness of quality gaps, (2) connecting practices to information, resources, and strategies, and (3) optimizing the EHR for QI goals. CONCLUSIONS SIP clinicians perceived practice facilitation to be an important resource for connecting their practice to the external health care environment and resources, and helping their practice build QI capacity through teaching, hands-on support, and EHR-driven solutions.
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Affiliation(s)
- Erin S Rogers
- New York University School of Medicine, Department of Population Health, New York, New York .,VA NY Harbor Healthcare System, New York, New York
| | - Allison M Cuthel
- New York University School of Medicine, Department of Population Health, New York, New York
| | - Carolyn A Berry
- New York University School of Medicine, Department of Population Health, New York, New York
| | - Sue A Kaplan
- New York University School of Medicine, Department of Population Health, New York, New York
| | - Donna R Shelley
- New York University School of Medicine, Department of Population Health, New York, New York
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Abstract
An estimated 3 to 5 million Americans are chronically infected with hepatitis C virus (HCV), and approximately 75% of those persons were born between 1945 and 1965 (the so-called baby boomer generation). Because of the largely asymptomatic nature of HCV, up to 50% of those infected are unaware of their disease. Risk-based testing has been largely ineffective. Based on prevalence data, the Centers for Disease Control and Prevention and other organizations recommend a onetime HCV antibody test for all baby boomers. However, uptake of this recommendation requires significant changes in clinical practice for already busy primary care clinicians. We studied the effectiveness of a quality improvement initiative based on continuous audit and feedback combined with education for improving testing in alignment with guidelines; the control group was a cohort of clinicians whose only reminder was an institution-wide electronic health record prompt. Our data show improved testing rates among all clinician groups, but more significant improvement occurred among providers who received continuous feedback about their clinical performance coupled with education.
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18
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Paul MM, Albert SL, Mijanovich T, Shih SC, Berry CA. Patient-Centered Care in Small Primary Care Practices in New York City: Recognition Versus Reality. J Prim Care Community Health 2017; 8:228-232. [PMID: 28553751 PMCID: PMC5932730 DOI: 10.1177/2150131917709404] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The Primary Care Information Project (PCIP) is a program administered by the New York City Department of Health and Mental Hygiene to help primary care providers adopt a fully functional electronic health record (EHR) and focus on population health. PCIP also offers practices assistance with the National Committee for Quality Assurance (NCQA) patient-centered medical home (PCMH) recognition application. The objectives of this study were to assess the presence of key dimensions of PCMH among PCIP practices with 5 or fewer providers and to determine whether and to what extent NCQA recognition was related to the presence of these dimensions. METHODS Analyses relied on data collected from a comprehensive practice assessment survey of PCIP practices administered in summer 2012. The survey was developed to assess discrete dimensions of the PCMH model and other practice characteristics. The study population includes practices for which survey results were available among PCIP practices with 5 or fewer providers (63% response rate; n = 83). RESULTS At the time of survey, 57% of practices had received some level of NCQA recognition (n = 47). Practices with recognition scored significantly higher on several dimensions, including whole person orientation, team-based care, care coordination and integration, and quality and safety. CONCLUSIONS Results indicate that very small urban practices in New York City are implementing many key features of PCMH. In general, practices with NCQA recognition scored higher on PCMH constructs and domains relative to practices without recognition; however, there is room for improvement on construct and domain scores in both groups.
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Affiliation(s)
| | | | | | - Sarah C Shih
- 3 New York City Department of Health and Mental Hygiene, New York, NY, USA
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19
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Tomoaia-Cotisel A, Farrell TW, Solberg LI, Berry CA, Calman NS, Cronholm PF, Donahue KE, Driscoll DL, Hauser D, McAllister JW, Mehta SN, Reid RJ, Tai-Seale M, Wise CG, Fetters MD, Holtrop JS, Rodriguez HP, Brunker CP, McGinley EL, Day RL, Scammon DL, Harrison MI, Genevro JL, Gabbay RA, Magill MK. Implementation of Care Management: An Analysis of Recent AHRQ Research. Med Care Res Rev 2016; 75:46-65. [PMID: 27789628 DOI: 10.1177/1077558716673459] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation.
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Affiliation(s)
- Andrada Tomoaia-Cotisel
- 1 The RAND Corporation, Boston, MA, USA.,2 University of Utah, Salt Lake City, UT, USA.,3 London School of Hygiene and Tropical Medicine, London, UK
| | - Timothy W Farrell
- 2 University of Utah, Salt Lake City, UT, USA.,4 VA Geriatric Research, Education, and Clinical Center, Salt Lake City, UT, USA
| | - Leif I Solberg
- 5 HealthPartners Institute for Education and Research, Minneapolis, MN, USA
| | | | | | | | | | | | - Diane Hauser
- 7 Institute for Family Health, New York, NY, USA
| | | | - Sanjeev N Mehta
- 12 Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA
| | - Robert J Reid
- 13 Group Health Research Institute, Seattle, WA, USA
| | - Ming Tai-Seale
- 14 Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
| | | | | | | | | | | | | | | | | | | | - Janice L Genevro
- 20 Agency for Healthcare Research and Quality, Rockville, MD, USA
| | - Robert A Gabbay
- 12 Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA
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Reid MC, O'Neil KW, Dancy J, Berry CA, Stowell SA. Pain Management in Long-Term Care Communities: A Quality Improvement Initiative. Ann Longterm Care 2015; 23:29-35. [PMID: 25949232 PMCID: PMC4418636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Pain is underrecognized and undertreated in the long-term care (LTC) setting. To improve the management of pain for LTC residents, the authors implemented a quality improvement (QI) initiative at one LTC facility. They conducted a needs assessment to identify areas for improvement and designed a 2-hour educational workshop for facility staff and local clinicians. Participants were asked to complete a survey before and after the workshop, which showed significant improvement in their knowledge of pain management and confidence in their ability to recognize and manage residents' pain. To measure the effectiveness of the QI initiative, the authors performed a chart review at baseline and at 3 and 8 months after the workshop and evaluated relevant indicators of adequate pain assessment and management. The post-workshop chart reviews showed significant improvement in how consistently employees documented pain characteristics (ie, location, intensity, duration) in resident charts and in their use of targeted pain assessments for residents with cognitive dysfunction. The proportion of charts that included a documented plan for pain assessment was high at baseline and remained stable throughout the study. Overall, the findings suggest a QI initiative is an effective way to improve pain care practices in the LTC setting.
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Affiliation(s)
- Manney C Reid
- Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medical College, New York, NY ; New York Presbyterian Hospital, New York, NY
| | | | | | - Carolyn A Berry
- Center for Health Care Strategies, New York University Langone School of Medicine, New York, NY
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Affiliation(s)
| | | | - Vivian Fonseca
- Tulane University Health Sciences Center, Section of Endocrinology, New Orleans, LA
| | - Dace Trence
- University of Washington, Division of Metabolism, Endocrinology, and Nutrition, Seattle, WA
| | - Carolyn A. Berry
- New York University School of Medicine, Department of Population Health, New York
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Baum HBA, Cagliero E, Berry CA, Mencia WA, Stowell SA, Miller SC. Continuing Improvement in Type 2 Diabetes Care Through Performance-Based Evaluations. J Prim Care Community Health 2014; 5:107-11. [DOI: 10.1177/2150131913518438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Aims: The timely evidence-based care of type 2 diabetes mellitus (T2DM) is imperative for achieving and maintaining glycemic control, reducing complications, and changing the paradigm of this epidemic. Based largely on results from earlier performance improvement (PI) activities, we conducted a continuing medical education (CME)–certified PI activity to foster improved adherence to guideline recommendations and current evidence for the care of patients with T2DM. Methods: Participants engaged in a 3-stage process of self-assessment, goal setting, and reassessment. Results: A total of 64 clinicians completed the entire PI process, abstracting data from 1600 patient charts before and after a period of self-improvement. After the intervention, clinicians were more likely to assess patients for disease-related complications and provide counseling on proper nutrition, exercise, and smoking cessation. Patients with A1C, blood pressure (BP), and low-density lipoprotein cholesterol (LDL-C) values above goal (defined as A1C ≥7, BP ≥130/80 mm Hg, and LDL-C >100 g/dL) were more likely to receive treatment modifications compared with baseline clinician performance. Significant changes observed in patient outcomes included improved mean A1C values (baseline 7.5% vs postintervention 7.3%; P = .027), decreased likelihood of BP at or above 130/80 mm Hg (baseline 37% vs postintervention 30%; P < .001), and decreased likelihood of LDL-C above 100 g/dL (baseline 33% vs postintervention, 27%; P < .001). Conclusions: Significant changes in clinician performance of key quality measures were reported in patients with T2DM after a PI CME activity improved adherence to evidence-based recommendations of care.
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Affiliation(s)
| | - Enrico Cagliero
- Massachusetts General Hospital Diabetes Center, Boston, MA, USA
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Hirsch FR, Jotte RM, Berry CA, Mencia WA, Stowell SA, Gardner AJ. Quality of Care of Patients with Non–Small-Cell Lung Cancer: A Report of a Performance Improvement Initiative. Cancer Control 2014; 21:90-7. [DOI: 10.1177/107327481402100113] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Stowell SA, Baum HBA, Berry CA, Perri BR, King L, Mijanovich T, Albert S, Miller SC. Impact of Performance-Improvement Strategies on the Clinical Care and Outcomes of Patients With Type 2 Diabetes. Clin Diabetes 2014; 32:18-25. [PMID: 26246674 PMCID: PMC4521425 DOI: 10.2337/diaclin.32.1.18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Bekanich SJ, Wanner N, Junkins S, Mahoney K, Kahn KA, Berry CA, Stowell SA, Gardner AJ. A multifaceted initiative to improve clinician awareness of pain management disparities. Am J Med Qual 2013; 29:388-96. [PMID: 24061868 DOI: 10.1177/1062860613503897] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Patients belonging to some racial, ethnic, and socioeconomic groups are at risk of receiving suboptimal pain management. This study identifies health care provider attitudes, knowledge, and practices regarding the treatment of chronic pain in vulnerable patient populations and assesses whether a certified continuing medical education (CME) intervention can improve knowledge in this area. Survey responses revealed several knowledge gaps, including a lack of knowledge that the undertreatment of pain is more common in minority patients than others. Respondents identified language barriers, miscommunication, fear of medication diversion, and financial barriers as major obstacles to optimal pain management for this patient population. Participants who completed a CME-certified activity on pain management disparities demonstrated increased confidence in caring for disadvantaged patients, but only 1 of 3 knowledge items improved. Understanding clinician factors that underlie suboptimal pain management is necessary to develop effective strategies to overcome disparities and improve quality of care for patients with chronic pain.
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Affiliation(s)
| | - Nathan Wanner
- University of Utah Medical Center, Salt Lake City, UT
| | - Scott Junkins
- University of Utah Medical Center, Salt Lake City, UT
| | - Kim Mahoney
- University of Utah Medical Center, Salt Lake City, UT
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Greenspan SL, Bilezikian JP, Watts NB, Berry CA, Mencia WA, Stowell SA, Karcher RB. A clinician performance initiative to improve quality of care for patients with osteoporosis. J Womens Health (Larchmt) 2013; 22:853-61. [PMID: 24011023 DOI: 10.1089/jwh.2013.4388] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Osteoporosis is a widespread but largely preventable disease. Improved adherence to screening and treatment recommendations is needed to reduce fracture and mortality rates. Additionally, clinicians face increasing demands to demonstrate proficient quality patient care aligning with evidence-based standards. METHODS A three-stage, clinician-focused performance improvement (PI) continuing medical education (CME) initiative was developed to enhance clinician awareness and execution of evidence-based standards of osteoporosis care. Clinician performance was evaluated through a retrospective chart analysis of patients at risk or with a diagnosis of osteoporosis. RESULTS Seventy-five participants reported their patient practices on a total of 1875 patients before and 1875 patients after completing a PI initiative. Significant gains were made in the use of Fracture Risk Assessment Tool (FRAX) (stage A, 26%, n=1769 vs. stage C, 51%, n=1762; p<0.001), assessment of fall risk (stage A, 46%, n=1276 vs. stage C, 89%, n=1190; p<0.001), calcium levels (stage A, 62%, n=1451 vs. stage C, 89%, n=1443; p<0.001), vitamin D levels (stage A, 79%, n=1438 vs. stage C, 93%, n=1439; p<0.001), and medication adherence (stage A, 88%, n=1136 vs. stage C, 96%, n=1106; p<0.001). CONCLUSIONS Gains in patient screening, treatment, and adherence were associated with an initiative promoting self-evaluation and goal setting. Clinicians must assess their performance to improve patient care and maintain certification. PI CME is a valid, useful educational tool for accomplishing these standards.
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Affiliation(s)
- Susan L Greenspan
- 1 Division of Geriatrics, Endocrinology and Metabolism, University of Pittsburgh , Pittsburgh, Pennsylvania
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Goldhaber SZ, Ortel TL, Berry CA, Stowell SA, Gardner AJ. Improving clinician performance of inpatient venous thromboembolism risk assessment and prophylaxis. Hosp Pract (1995) 2013; 41:123-31. [PMID: 23680743 DOI: 10.3810/hp.2013.04.1061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Clinicians are aware of the importance of thromboprophylaxis, and that the application of measures to prevent venous thromboembolism (VTE) occurrence in hospitalized patients must be improved. To enhance clinician execution of appropriate steps to reduce the risk of inpatient VTE, a performance improvement (PI) continuing medical education (CME) initiative consisting of 3 independent tracks for hospitalized patients-patients who are medically ill, patients receiving oncology treatment, and patients undergoing major orthopedic surgery-was designed and implemented. After a baseline chart review of select evidenced-based performance measures for VTE risk stratification and prevention, participants identified ≥ 1 area of personal improvement. Participants then engaged in a period of self-improvement and reassessed their performance with a second chart review. After participating in the PI CME activity, clinician participants in the medically ill track increased their documentation of VTE risk assessments upon patient admission from baseline (56% vs 93%, n = 250; P < 0.001) and their prescription of low-molecular-weight heparin, low-dose unfractionated heparin, or fondaparinux (72% vs 88%, n = 250; P < 0.001). Orthopedic-track participants were significantly more likely to prescribe 15 to 35 days of VTE prophylaxis after total hip arthroplasty or hip fracture surgery upon patient discharge compared with baseline (51%, n = 123 vs 61%, n = 107; P < 0.001). Oncology-track participants demonstrated a nonsignificant trend for assessing and documenting bleeding risk after participation in the PI CME activity (56% vs 68%, n = 80; P = 0.143). Improvements in evidence-based strategies to reduce the risk of inpatient VTE were associated with PI CME participation. Although areas for improvement remain, increased participant identification and use of prophylactic measures can reduce the risk of VTE in hospitalized patients.
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Affiliation(s)
- Samuel Z Goldhaber
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Lavin T, Song Y, Bakker AJ, McLean CJ, Macdonald WA, Noble PB, Berry CA, Pillow JJ, Pinniger GJ. Developmental changes in diaphragm muscle function in the preterm and postnatal lamb. Pediatr Pulmonol 2013; 48:640-8. [PMID: 23401383 DOI: 10.1002/ppul.22762] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 11/27/2012] [Indexed: 11/12/2022]
Abstract
RATIONALE The preterm diaphragm is structurally and functionally immature, potentially contributing to an increased risk of respiratory distress and failure. We investigated developmental changes in contractile function and susceptibility to fatigue of the costal diaphragm in the fetal lamb to understand factors contributing to the risk of developing diaphragm dysfunction and respiratory disorders. We hypothesized that the functional capacity of the diaphragm will vary with maturational stage as will its susceptibility to fatigue. METHODS Lambs were studied at 75, 100, 125, 145, 154, 168, and 200 days postconceptional age (term = 147 days). Lambs were euthanized (sodium pentobarbitone, 100 mg/kg) either at delivery or immediately prior to post-mortem for postnatal lambs. Contractile function was assessed on longitudinal strips of intact muscle fibers and the remaining tissue frozen in liquid nitrogen for analysis of myosin heavy chain (MHC) mRNA expression and protein content. RESULTS Fetal development of diaphragm function was characterized by a significant increase in maximum specific force, increased susceptibility to fatigue, reduced twitch contraction times, and a progressive increase in MHCI and MHCII protein content. Postnatally, there was a progressive decrease in the susceptibility to fatigue that coincided with an increase in the MHC I:II protein ratio. CONCLUSION These data indicate that the functional capacity of the diaphragm varies with maturational age and may be an important determinant of the susceptibility to preterm respiratory failure.
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Affiliation(s)
- T Lavin
- School of Anatomy, Physiology, and Human Biology, The University of Western Australia, Crawley, Western Australia, Australia
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Berry CA, Mijanovich T, Albert S, Winther CH, Paul MM, Ryan MS, McCullough C, Shih SC. Patient-centered medical home among small urban practices serving low-income and disadvantaged patients. Ann Fam Med 2013; 11 Suppl 1:S82-9. [PMID: 23690391 PMCID: PMC3707251 DOI: 10.1370/afm.1491] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Research on the patient-centered medical home (PCMH) model and practice redesign has not focused on the unique challenges and strengths of very small primary care practices serving disadvantaged patient populations. We analyzed the practice characteristics, prior experiences, and dimensions of the PCMH model that exist in such practices participating in the Primary Care Information Project (PCIP) of the New York City Department of Mental Health and Hygiene. METHODS We obtained descriptive data, focusing on PCMH, for 94 primary care practices with 5 or fewer clinicians serving high volumes of Medicaid and minority patient populations in New York City. Data included information extracted from PCIP administrative data and survey data collected specifically for this study. RESULTS Survey results indicated substantial implementation of key aspects of the PCMH among small practices serving disadvantaged patient populations, despite considerable potential challenges to achieving PCMH implementation. Practices tended to use few formal mechanisms, such as formal care teams and designated care or case managers, but there was considerable evidence of use of informal team-based care and care coordination nonetheless. It appears that many of these practices achieved the spirit, if not the letter, of the law in terms of key dimensions of PCMH. CONCLUSIONS Small practices can achieve important aspects of the PCMH model of primary care, often with informal rather than formal mechanisms and strategies. The use of flexible, less formal strategies is important to keep in mind when considering implementation and assessment of PCMH-like initiatives in small practices.
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Affiliation(s)
- Carolyn A Berry
- Department of Population Health, New York University School of Medicine, New York, New York 10016, USA.
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Boyle PJ, O’Neil KW, Berry CA, Stowell SA, Miller SC. Improving Diabetes Care and Patient Outcomes in Skilled-Care Communities: Successes and Lessons From a Quality Improvement Initiative. J Am Med Dir Assoc 2013; 14:340-4. [DOI: 10.1016/j.jamda.2012.11.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 11/26/2012] [Indexed: 10/27/2022]
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Sekeres MA, Stowell SA, Berry CA, Mencia WM, Dancy JN. Improving the diagnosis and treatment of patients with myelodysplastic syndromes through a performance improvement initiative. Leuk Res 2013; 37:422-6. [DOI: 10.1016/j.leukres.2012.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 11/29/2012] [Accepted: 12/15/2012] [Indexed: 01/30/2023]
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Marshall JL, Cartwright TH, Berry CA, Stowell SA, Miller SC. Implementation of a performance improvement initiative in colorectal cancer care. J Oncol Pract 2012; 8:309-14. [PMID: 23277769 PMCID: PMC3439232 DOI: 10.1200/jop.2011.000461] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2012] [Indexed: 11/20/2022] Open
Abstract
PURPOSE In the United States, colorectal cancer (CRC) is the third leading cause of cancer after breast and prostate cancer. Numerous improvement programs have been implemented to increase CRC screening rates, but few have focused on improving the care and management of patients with a diagnosis of this malignancy. As national medical organizations focus on quality of care, efforts are necessary to provide clinicians the opportunity for self-assessment and methods for practice improvement. With this goal in mind, a national continuing medical education-certified performance improvement initiative was conceived. METHODS THE INITIATIVE CONSISTED OF THREE STAGES: First, participants self-assessed their performance of predetermined topic measures through a review of patient charts. The topic areas included patient safety and supportive care, evidence-based surveillance, and evidenced-based treatment and were derived from current guidelines and other successful quality-improvement initiatives. Second, an actionable plan for practice improvement was developed in at least one of the three topic areas. Third, after a period of self-improvement, participants reassessed their performance of the same topic measures to determine tangible changes in patient care. RESULTS A total of 540 patient charts were reviewed by 27 clinicians. Notable results showed large gains in areas of supportive care, such as quantitative pain assessments and emotional well-being evaluations, which traditionally have been a minor focus of other quality-improvement initiatives. Participants also showed tangible improvements in the performance of leading measures of quality care. CONCLUSION These findings support the need for continued efforts toward performance improvement in both established and emerging areas of CRC patient care.
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Affiliation(s)
- John L. Marshall
- Georgetown University Hospital, Washington, DC; Ocala Oncology Center, Ocala, FL; New York University, New York, NY; and Med-IQ, Baltimore, MD
| | - Thomas H. Cartwright
- Georgetown University Hospital, Washington, DC; Ocala Oncology Center, Ocala, FL; New York University, New York, NY; and Med-IQ, Baltimore, MD
| | - Carolyn A. Berry
- Georgetown University Hospital, Washington, DC; Ocala Oncology Center, Ocala, FL; New York University, New York, NY; and Med-IQ, Baltimore, MD
| | - Stephanie A. Stowell
- Georgetown University Hospital, Washington, DC; Ocala Oncology Center, Ocala, FL; New York University, New York, NY; and Med-IQ, Baltimore, MD
| | - Sara C. Miller
- Georgetown University Hospital, Washington, DC; Ocala Oncology Center, Ocala, FL; New York University, New York, NY; and Med-IQ, Baltimore, MD
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Cannon CP, Hoekstra JW, Larson DM, Karcher RB, Mencia WA, Berry CA, Stowell SA. A report of quality improvement in the care of patients with acute coronary syndromes. Crit Pathw Cardiol 2011; 10:29-34. [PMID: 21562372 DOI: 10.1097/hpc.0b013e318204eb8b] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Despite the existence and wide acceptance of guidelines for the treatment of patients with acute coronary syndromes, gaps in patient care still remain. To improve clinical processes of acute coronary syndromes care, a performance improvement (PI) continuing medical education (CME) program, a CME format approved by the American Medical Association, was developed. Clinician participants underwent a 3-stage process: (1) an initial patient chart review for self-assessment purposes, (2) the development and implementation of a personalized PI plan focusing on strategies to enhance processes of care, and (3) a second patient chart review to assess the changes in practice. Although participants provided a high baseline level of guideline-recommended care, there was an improvement in the documentation of the use of risk scores and a trend towards improved treatment times including many participants reaching a door-to-needle time of within 30 minutes. Participants were also more likely to measure cardiac biomarkers and document electrocardiogram performance times. These results demonstrate that PI is a valid and effective means of CME that has the potential to positively affect patient outcomes.
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Arepally G, Bauer KA, Bhatt DL, Merli GJ, Naccarelli GV, Carter RD, Karcher RB, Berry CA, Keaton KL, Stowell SA. The use of antithrombotic therapies in the prevention and treatment of arterial and venous thrombosis: a survey of current knowledge and practice supporting the need for clinical education. Crit Pathw Cardiol 2010; 9:41-48. [PMID: 20215910 DOI: 10.1097/hpc.0b013e3181d24562] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Arterial and venous thrombosis are serious health threats. Patients with atrial fibrillation (AF), acute coronary syndromes (ACS), and venous thromboembolism (VTE) can reduce their risk of thrombosis through proper anticoagulation. Multiple evidence-based guidelines exist regarding the proper use of antithrombotic therapy, yet previous studies have shown the prevalence of inconsistent practices with respect to guideline recommendations. Here, we describe a survey of 647 practicing physicians and their current beliefs, behaviors, and knowledge surrounding the use of antithrombotic therapies in the treatment of their patients with AF, ACS, and VTE. Results show that while most physicians are confident in their abilities to treat patients with these conditions, specific knowledge of guideline recommendations for the optimal use of antithrombotic agents use is low. In addition, physician concerns over bleeding risks and complicated monitoring procedures associated with antithrombotic use were reported as barriers to their use in patients. Survey results also demonstrated that physicians have little knowledge of investigational antithrombotic agents, but would like education about them. These data suggest a need for education on guideline recommendations regarding the appropriate use of current antithrombotic therapies, as well as a need for information on the potential benefits and limitations of investigational drugs that may be used in the future to manage thrombosis in patients with AF, ACS, and VTE.
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Cannon CP, Hoekstra JW, Larson DM, Carter RD, Cornish J, Karcher RB, Mencia WA, Berry CA, Stowell SA. Physician practice patterns in acute coronary syndromes: an initial report of an individual quality improvement program. Crit Pathw Cardiol 2010; 9:23-29. [PMID: 20215907 DOI: 10.1097/hpc.0b013e3181d09d2d] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The American College of Cardiology and the American Heart Association guidelines are the nationally accepted standards for the treatment of patients with acute coronary syndromes. Despite this recognition, adherence to guideline recommendations remains suboptimal with 25% of opportunities to provide guideline appropriate care missed. To address performance gaps related to acute coronary syndrome care and improve patient outcomes, a performance improvement (PI) initiative was designed for cardiologists and emergency department physicians. As an American Medical Association-approved, standardized continuing medical education initiative, participating physicians can earn up to 20 American Medical Association-PRA Category 1 Credits by completing 2 phases of self-assessment in addition to developing and implementing a PI plan to address self-identified areas where improvement in patient care is needed. As the second in a series of 3 articles, this article describes the initial data submitted by 101 participating physicians and how their treatment practices compared with American College of Cardiology/American Heart Association guidelines as well as with current national standards. Overall, participating physicians meet guideline expectations with performance and documentation of a 12-lead electrocardiography, measurement of cardiac biomarkers, and administration of aspirin. Identified areas of improvement were the standardization of treatment protocols, use of risk assessment scores, appropriate dosing of anticoagulants, and improvement in patient treatment times. A noted challenge of this PI initiative is the low rate of physician participation, with fewer than 10% of registered physicians actively submitting patient data. This fact may reflect several barriers to PI, such as: (1) lack of time to collect and submit data, (2) the belief that current practices do not need to be improved, and (3) the need for system-based improvements.
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Cannon CP, Hoekstra JW, Larson DM, Mencia WA, Cornish J, Carter RD, Berry CA, Karcher RB. Individual quality improvement in acute coronary syndromes: a performance improvement initiative. Crit Pathw Cardiol 2009; 8:43-48. [PMID: 19258838 DOI: 10.1097/hpc.0b013e3181980f75] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Although treatment guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) have been published and widely accepted, barriers to the optimal management of patients with acute coronary syndromes (ACS) still exist. Adherence to guidelines has been correlated with improvements in patient outcomes in ACS, including reduced mortality, yet data demonstrate that 25% of opportunities to provide guideline-recommended care are missed. This article describes a performance improvement (PI) initiative designed to address gaps in process-related ACS care and improve patient outcomes. PI is an American Medical Association-approved, standardized continuing medical education format in which physicians can earn up to 20 American Medical Association PRA category 1 credits by completing 2 phases of self-assessment and developing and implementing a PI plan to address self-identified areas in which patient care can be improved. In this ACS PI initiative, physicians will assess their practice using performance measures defined by the 2007 ACC/AHA ST-segment elevation myocardial infarction and unstable angina or non-ST-segment elevation myocardial infarction guideline updates within 3 general benchmark areas: (1) patient risk assessment, (2) initial pharmacologic management, and (3) time-to-treatment (ie, "door-to-needle," "door-to-balloon," and "door-in-door-out" times). After completing a self-assessment and identifying 1 or more areas of improvement, participants can complete educational interventions and access benchmark-specific tools that provide guidance on improving adherence with the ACC/AHA guidelines. This PI initiative supplements other ongoing quality improvement initiatives in ACS, but is unique in that it is the first to use individual physician self-assessment, benchmark-focused continuing medical education, and self-developed PI plans to improve process-related ACS care.
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MESH Headings
- Acute Coronary Syndrome/diagnosis
- Acute Coronary Syndrome/mortality
- Acute Coronary Syndrome/therapy
- Angioplasty, Balloon, Coronary/standards
- Angioplasty, Balloon, Coronary/trends
- Attitude of Health Personnel
- Benchmarking
- Clinical Competence
- Education, Medical, Continuing
- Emergency Service, Hospital/standards
- Emergency Service, Hospital/trends
- Evidence-Based Medicine
- Female
- Guideline Adherence
- Hospital Mortality/trends
- Humans
- Male
- Outcome Assessment, Health Care
- Platelet Aggregation Inhibitors/therapeutic use
- Practice Guidelines as Topic
- Practice Patterns, Physicians'/standards
- Practice Patterns, Physicians'/trends
- Risk Assessment
- Sensitivity and Specificity
- Survival Analysis
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Martin MA, Shalowitz MU, Mijanovich T, Clark-Kauffman E, Perez E, Berry CA. The effects of acculturation on asthma burden in a community sample of Mexican American schoolchildren. Am J Public Health 2007; 97:1290-6. [PMID: 17538053 PMCID: PMC1913078 DOI: 10.2105/ajph.2006.092239] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We sought to determine whether low acculturation among Mexican American caregivers protects their children against asthma. METHODS Data were obtained from an observational study of urban pediatric asthma. Dependent variables were children's diagnosed asthma and total (diagnosed plus possible) asthma. Regression models were controlled for caregivers' level of acculturation, education, marital status, depression, life stress, and social support and children's insurance. RESULTS Caregivers' level of acculturation was associated with children's diagnosed asthma (P = .025) and total asthma (P = .078) in bivariate analyses. In multivariate models, protective effects of caregivers' level of acculturation were mediated by the other covariates. Independent predictors of increased diagnosed asthma included caregivers' life stress (odds ratio [OR] = 1.12, P= .005) and children's insurance, both public (OR = 4.71, P= .009) and private (OR = 2.87, P= .071). Only caregiver's life stress predicted increased total asthma (OR = 1.21, P= .001). CONCLUSIONS The protective effect of caregivers' level of acculturation on diagnosed and total asthma for Mexican American children was mediated by social factors, especially caregivers' life stress. Among acculturation measures, foreign birth was more predictive of disease status than was language use or years in country. Increased acculturation among immigrant groups does not appear to lead to greater asthma risk.
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Affiliation(s)
- Molly A Martin
- Department of Preventive Medicine, Rush University Medical Center, Chicago, Ill 60612, USA.
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Abstract
Increasing the representation of Spanish-speaking study participants requires development and dissemination of reliable and valid translated scales. In the urrent study the construct validity was assessed of the Spanish version of the Crisis n Family Systems-Revised, a measure of contemporary life stressors, with a convenience sample of 377 parents interviewed in a study of childhood asthma, although over half of the respondents did not have children with asthma. Most respondents were foreign-born women between 20 to 60 years old (M=35, SD=7). 52% had not completed high school or its equivalent, and 55% reported a household income of dollar 15,000 or less. For a subsample of 25 respondents test-retest reliability was .86 over 2 wk. Reporting more life stressors was associated with greater depressive symptomatology, poorer physical and mental health function, and lower household income. These relationships support the construct validity of the test in Spanish. This study provided strong evidence that this version is a valid and reliable measure of life stressors for a Spanish-speaking population living in the United States.
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Affiliation(s)
- Carolyn A Berry
- Center for Health and Public Service Research, Robert F. Wagner Graduate School of Public Service, New York University, 295 Lafayette Street, Second Floor, New York, NY 10012, USA.
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Shalowitz MU, Mijanovich T, Berry CA, Clark-Kauffman E, Quinn KA, Perez EL. Context matters: a community-based study of maternal mental health, life stressors, social support, and children's asthma. Pediatrics 2006; 117:e940-8. [PMID: 16651297 DOI: 10.1542/peds.2005-2446] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Recent national survey data indicate an overall asthma prevalence of 12.2% for children who are younger than 18 years. Previous research in clinical samples of children with asthma suggests that their mothers are at greater risk for symptoms of depression. We describe the relationship between maternal symptoms of depression and having a child with asthma in a community-based sample. METHODS After a school-based ascertainment of asthma and asthma symptoms in 15 low-income, racially/ethnically diverse public elementary schools, 1149 eligible mothers agreed to participate in a longitudinal study. Mothers either had a child with previously diagnosed asthma or a child with symptoms consistent with possible asthma or were in the randomly selected comparison group in which no child in the household had asthma. During the first interview, mothers responded to questions about their own life stressors, supports and mental health, and their children's health. RESULTS In bivariate analyses of a community-based sample of children who share low-income neighborhoods, mothers of children with diagnosed or with possible undiagnosed asthma had more symptoms of depression than did mothers of children who have no asthma. Mothers of children with diagnosed or with possible undiagnosed asthma also experienced more life stressors than did mothers of children without asthma. Using nested linear regression, we estimated a model of maternal symptoms of depression. Most of the variation in Center for Epidemiologic Studies-Depression score was accounted for by life stressors and social support. There were no independent effects of either asthma status or asthma status-specific child health status on maternal symptoms of depression. CONCLUSION Children who are under care for chronic conditions such as asthma live and manage their illness outside the clinical setting. Their social context matters, and maternal mental health is related to their children's physical health. Although having a child with asthma may be "just" another stressor in the mother's social context, complex treatment plans must be followed despite the many other pressures of neighborhood and family lives.
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Affiliation(s)
- Madeleine U Shalowitz
- Section for Child and Family Health Studies, Evanston Northwestern Healthcare, Evanston, Illinois, USA.
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Quinn K, Shalowitz MU, Berry CA, Mijanovich T, Wolf RL. Racial and ethnic disparities in diagnosed and possible undiagnosed asthma among public-school children in Chicago. Am J Public Health 2006; 96:1599-603. [PMID: 16507720 PMCID: PMC1551939 DOI: 10.2105/ajph.2005.071514] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined racial and ethnic disparities in the total potential burden of asthma in low-income, racially/ethnically heterogeneous Chicago schools. METHODS We used the Brief Pediatric Asthma Screen Plus (BPAS+) and the Spanish BPAS+, validated, caregiver-completed respiratory questionnaires, to identify asthma and possible asthma among students in 14 racially/ethnically diverse public elementary schools. RESULTS Among 11490 children, we demonstrated a high lifetime prevalence (12.2%) as well as racial and ethnic disparities in diagnosed asthma, but no disparities in prevalences of possible undiagnosed asthma. Possible asthma cases boost the total potential burden of asthma to more than 1 in 3 non-Hispanic Black and Puerto Rican children. CONCLUSIONS There are significant racial and ethnic disparities in diagnosed asthma among inner-city schoolchildren in Chicago. However, possible undiagnosed asthma appears to have similar prevalences across racial/ethnic groups and contributes to a high total potential asthma burden in each group studied. A better understanding of underdiagnosis is needed to address gaps in asthma care and intervention for low-income communities.
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Affiliation(s)
- Kelly Quinn
- Department of Child and Family Health Studies, Evanston Northwestern Healthcare, Evanston, Ill, USA.
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Berry CA, Quinn K, Wolf R, Mosnaim G, Shalowitz M. Validation of the Spanish and English versions of the asthma portion of the Brief Pediatric Asthma Screen Plus among Hispanics. Ann Allergy Asthma Immunol 2005; 95:53-60. [PMID: 16095142 DOI: 10.1016/s1081-1206(10)61188-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The health and health care needs of non-English-speaking Hispanic families with children are poorly understood, in part because they are often excluded from research owing to language barriers. Instruments that are valid in English and Spanish are necessary to accurately evaluate the magnitude of asthma prevalence and morbidity among Hispanics. OBJECTIVE To establish the sensitivity and specificity of the English and Spanish versions of the asthma portion of the Brief Pediatric Asthma Screen Plus (BPAS+) in a low-income Hispanic population. METHODS The validation sample consisted of 145 children whose parents completed the BPAS+ in Spanish and 78 whose parents completed it in English. Bilingual clinicians conducted the examinations on which the clinical assessments were based. We compared the BPAS+ results with the clinical assessment findings to determine the sensitivity and specificity of the BPAS + among Hispanics in terms of identifying children who warrant further medical evaluation for asthma. RESULTS The sensitivity and specificity of the asthma portion of the Spanish BPAS+ were 74% and 86%, respectively. The sensitivity and specificity of the asthma portion of the English BPAS+ were 61% and 83%, respectively. CONCLUSIONS The asthma portion of the BPAS+, a valid screen for identifying children who are in need of further evaluation for potentially undiagnosed asthma, is valid for low-income Hispanics in Spanish and English. As the Hispanic population continues to grow, it is imperative that researchers have English and Spanish instruments that are valid for this population.
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Affiliation(s)
- Carolyn A Berry
- Center for Health and Public Service Research, Robert F. Wagner Graduate School of Public Service, New York University, New York, New York 10012, USA.
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Abstract
BACKGROUND Asthma is the most common disease of childhood, but the recognition and detection remain poor, especially among schoolchildren. There has been an increase in the number of instruments available to detect the risk of asthma earlier in children. We have previously validated a simple, self-reported screen, the Brief Pediatric Asthma Screen (BPAS). OBJECTIVE To develop a new screen for asthma and allergies based on the BPAS (BPAS+) with the intent of keeping the screen brief and simple, while including allergy detection. METHODS Questions from the BPAS were extensively revised, and questions regarding allergic rhinitis were added. A panel of parents of asthmatic children reviewed and critiqued the questions. The final BPAS + was distributed in elementary schools, and a cohort of 129 participated in a validation against the gold standard of evaluation by an expert in asthma. RESULTS For asthma the best items were wheeze, persistent cough, night cough, and response to change in air temperature. The simplest scoring, any 1 of the 4 items, yielded the best balance of specificity (73.6%) and sensitivity (73.3%). For allergy, using all six items, having any one or any two of the items had sensitivity of 71.4% and specificity of 77.3%. CONCLUSIONS The BPAS+ provides a rapid and valid method for the detection of potential allergy and asthma in schoolchildren. Sensitivity and specificity are acceptable for both asthma and allergies.
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Affiliation(s)
- Raoul L Wolf
- LaRabida Children's Hospital, University of Chicago, Chicago, Illinois 60649, USA.
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Berry CA. Effects of weightlessness in man. Life Sci Space Res 2002; 11:187-99. [PMID: 12001951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
The program for the Apollo 16 flight was designed to include both safeguards against and investigations of the physiological problems arising from increase in the period of manned space flight. Precautions included the provision of a controlled diet with high potassium content, carefully controlled work loads and work-rest cycles and an emergency cardiology consultation service, and investigations were made to enable pre-flight-post-flight comparisons of metabolic, cardiovascular and central nervous system data. Results of these investigations indicate that adjustment to weightlessness can be satisfactorily assisted by appropriate countermeasures including attention to diet.
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Affiliation(s)
- C A Berry
- NASA Life Sciences, NASA, Washington, D.C., USA
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White SC, Berry CA, Hessberg RR. Effects of weightlessness on astronauts--a summary. Life Sci Space Res 2002; 10:47-55. [PMID: 11898841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
This paper reviews the adaptive changes observed in the United States astronauts during flight programs to this date. A series of postulates are offered as to what is happening in these adaptive events. A hypothesis is proposed as to the interrelationship of events observed in the body systems and functions involved. The importance of undertaking an extensive life sciences program. including an on-orbit phase of study as well as pre- and post-flight studies is discussed. Finally, the role the Skylab flight plays in the United States Space Program in achieving the future requirements for more extensive life sciences data is summarized.
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Affiliation(s)
- S C White
- Office of Manned Spaceflight, Headquarters NASA, Washington, DC, USA
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Affiliation(s)
- Sandy Cook
- University of Chicago, Chicago Diabetes Research and Training Center, Illinois
| | - Maria C Solomon
- University of Chicago, Chicago Diabetes Research and Training Center, Illinois
| | - Carolyn A Berry
- New York University, Center for Health and Public Service Research, New York
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Abstract
PURPOSE This paper describes the development and psychometric properties of the Diabetes Problem-Solving Measure for Adolescents (DPSMA). METHODS The DPSMA is a structured, interview-based questionnaire that examines how adolescents with type 1 diabetes solve diabetes-related self-management problems. Seventeen diabetes-related self-management problem vignettes were derived from a survey of adolescents and their parents. The vignettes were reviewed and finalized by a multidisciplinary team of diabetes experts. A sample of 43 adolescents, 13 to 17 years old, with type 1 diabetes, was used to establish the psychometric properties of the instrument. RESULTS The scale demonstrated acceptable internal consistency and interrater reliability. Predicted relationships with scores on concurrently administered measures of adherence, diabetes quality of life, and metabolic control provided support for construct validity. CONCLUSIONS The results suggest that the DPSMA has acceptable internal consistency, interrater reliability, and construct validity. It may be a useful tool to help healthcare providers understand the diabetes-related problem-solving abilities of their adolescent patients.
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Affiliation(s)
- S Cook
- The University of Chicago, Department of Medicine, Chicago, Illinois (Drs Cook and McNabb)
| | - J E Aikens
- The University of Michigan, Department of Family Medicine, AnnArbor, Michigan (Dr Aikens)
| | - C A Berry
- New York University, Center for Health and Public Service Research, New York, New York (Dr Berry)
| | - W L McNabb
- The University of Chicago, Department of Medicine, Chicago, Illinois (Drs Cook and McNabb)
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Shalowitz MU, Berry CA, Quinn KA, Wolf RL. The relationship of life stressors and maternal depression to pediatric asthma morbidity in a subspecialty practice. Ambul Pediatr 2001; 1:185-93. [PMID: 11888399 DOI: 10.1367/1539-4409(2001)001<0185:trolsa>2.0.co;2] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To examine the relationships among demographic characteristics, caregiver life stressors, and depressive symptoms of mothers and their children's asthma morbidity. SETTING Three pediatric asthma subspecialty programs, 2 in the inner city and 1 in the suburbs. DESIGN Cross-sectional census sample of caregivers of children with asthma: interviews mostly with mothers (N = 123) regarding their children's asthma symptoms and health care utilization. Information collected on demographics and caregivers' own recent life stressors and depressive symptoms. SUBJECTS Caregivers of children ages 18 months to 12 years with asthma at their subspecialty visit. MEASURES Structured interviews: a survey instrument prepared for this study and standardized instruments for depression (Center for Epidemiologic Studies--Depression) and life stressors (Crisis in Family Systems). RESULTS A total of 32% of respondents' children had high asthma morbidity, 28% intermediate, and 40% low. Caregiver life stressors and depression and the children's sex showed the strongest relationships to asthma morbidity in a model that also included race, residence, and Medicaid status. Children were more likely to have high morbidity if they had caregivers with more depressive symptoms and negative life stressors and if they were female. CONCLUSIONS Respondents experienced many life stressors and symptoms of depression while managing their children's illness. Caregivers' lives may affect their children's asthma morbidity, offering empirical evidence for the potential value of targeted case management for children in subspecialty care.
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Affiliation(s)
- M U Shalowitz
- Department of Pediatrics, Northwestern University Medical School, Chicago, IL 60201, USA.
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Abstract
STUDY OBJECTIVES The purpose of this study was to confirm the validity of a brief screen for pediatric asthma in schools. BACKGROUND Asthma is the most common chronic disease of childhood, yet the frequency with which this condition is recognized among school-aged children varies widely. Several methods are used to increase the accuracy of detection of asthma, but many are cumbersome and difficult to apply on a large scale. DESIGN We elected to validate a five-question instrument, the Brief Pediatric Asthma Screen (BPAS), to screen for the presence of asthma among children attending school in Region 5 of the Chicago school district, where the schools report a 2.7% frequency of asthma. The questionnaire was distributed to the parents of grade-school children at the time of report-card pick-up. SETTING A clinical assessment was performed on a selected group of children whose parents completed the questionnaire in a school and in a hospital outpatient clinic. PARTICIPANTS Of 4,147 questionnaires that we distributed, 1,796 (43%) were returned. We excluded 341 children (19% of the total sample) whose parents reported that they had been diagnosed with asthma. The remaining pool indicated that the children of 183 responders (10%) had symptoms suggestive of asthma, while 1,272 parents (71%) indicated that their children did not have symptoms of asthma. MEASUREMENTS AND RESULTS We selected 90 of the respondents who did not indicate that their children had a diagnosis of asthma. Of this group, 81 completed the validation, in which their responses suggested symptoms of asthma (n = 34) or no asthma symptoms (n = 47). The children of these respondents were given a blinded clinical evaluation consisting of history, physical examination, and spirometry. The survey demonstrated a sensitivity of 75% and a specificity of 81.2% for the presence of asthma among those who were unaware of the diagnosis. CONCLUSIONS The BPAS is brief, can be filled out by parents, and appears accurate in detecting asthma.
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Affiliation(s)
- R L Wolf
- La Rabida Children's Hospital and Research Center, Chicago, IL 60649, USA.
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Abstract
OBJECTIVE To assess the extent of physical disability in juvenile rheumatoid arthritis (JRA), classified according to subtype, and whether synovitis or flexion contractures are present on examination. METHODS This retrospective study included 88 JRA patients and 50 controls without musculoskeletal disease. The outcome measure was the disability index (DI) derived from the Childhood Health Assessment Questionnaire (CHAQ). RESULTS DI scores for JRA patients with synovitis (mean 0.49, range 0-1.88) and without synovitis (mean 0.37, range 0-1.75) were significantly higher (P < 0.001 for both groups) than for controls (mean 0.06, range 0-0.75, P < 0.001), but not significantly different from one another. Similarly, DI scores for JRA patients with and without any flexion contractures were higher than for controls, but not significantly different from one another. DI scores for JRA patients with both synovitis and flexion contractures were significantly higher than DI scores for JRA patients with neither, but were not distinguishable from JRA patients with synovitis only or flexion contractures only. Likewise, DI scores for JRA patients lacking synovitis and flexion contractures were not significantly different than those for JRA patients with one or the other. DI scores for systemic and polyarticular patients were higher than for pauciarticular patients, and DI scores for all 3 subtypes were higher than for controls. CONCLUSION Our findings suggest that many JRA patients, including those with pauciarticular JRA, have problems with physical function, even when synovitis and flexion contractures are not present. Further attention and research is needed to elucidate the causes or origins of disability in JRA patients with seemingly well-controlled disease. We recommend that health status instruments like the CHAQ be more widely used for JRA patients to complement other assessments, especially in planning occupational and physical therapy.
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Affiliation(s)
- M L Miller
- Department of Pediatrics, Northwestern University Medical School, Chicago, Illinois, USA
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Abstract
PURPOSE To determine the effects of aspects of residency training on AIDS-related treatment practices. METHOD The authors conducted a nationwide longitudinal panel study of 394 physicians who graduated in 1989 from six medical schools in New York State. Data were collected during the participants' fourth year of medical school, their third year of residency training, and six years after they had graduated from medical school. Questionnaires sought information about AIDS-related practice behaviors, including avoiding invasive procedures, minimizing contact, emphasizing AIDS prevention and education, and volume of people with AIDS treated. RESULTS Aspects of residency training had a sustained impact on how the physicians cared for patients with AIDS but not on the numbers of patients they treated. Determinants of treatment practices included aspects of the residency environment (e.g., emphasis on problem solving, student orientation; p < .01), characteristics of the faculty (e.g., commitment to teaching, tolerance of varied viewpoints), cynicism about patient care (p < .001), social biases (homophobia and aversion to intravenous drug users; p < .001), and AIDS-related attitudes (p < .01). CONCLUSIONS Fundamental changes to residency training, all of which are associated with learner-centered education, can improve physicians' treatment of their patients with HIV and AIDS.
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Affiliation(s)
- M J Yedidia
- Wagner Graduate School of Public Service, New York University, New York 10003, USA.
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