Adaptation of Coping Together - a self-directed coping skills intervention for patients and caregivers in an outpatient hematopoietic stem cell transplantation setting: a study protocol

Background

Despite numerous reports of significant distress and burden for hematopoietic stem cell transplantation (HSCT) patients and caregivers (CGs), HSCT-specific coping interventions remain rare. The few in use lack specificity and are often not easily accessible or cost-effective. Whereas the development of new interventions is resource-intensive, theory-informed adaptation of existing evidence-based interventions is promising. To date, no HSCT-specific intervention has relied on a formal adaptation approach.

Methods

Using the Center for Disease Control and Prevention’s Map of Adaptation, this two-phase qualitative descriptive study seeks to understand the perceptions of HSCT patients, CGs, individually, and in dyads, and clinicians about Coping Together (CT) for the preliminary adaptation (Phase 1), and then explores perceptions of the modified intervention in additional mixed sample (Phase 2). Six to ten participants including outpatients, CGs and dyads and five to seven HSCT clinician participants will be recruited for Phase 1. For Phase 2, 14 to 16 participants including outpatients, CGs and dyads will be recruited. Individual and dyadic semi-structured interviews will take place between 100 and 130 days post-HSCT. Verbatim transcripts will be analyzed using content analysis.

Discussion

It is paramount to have HSCT-specific supportive interventions that address patients’ and CGs’ multidimensional and complex needs. The timely involvement of key stakeholders throughout the adaptation process is likely to optimize the relevance and uptake of such tailored intervention.

Trial registration

This study is registered on October 6, 2016 in ClinicalTrials.gov at (identifier number NCT02928185).

The benefits of respectful interactions: fluid alliancing and inter-occupational information sharing in primary care

Though inter-occupational interactions in health care have been the focus of increasing attention, we still know little about how such interactions shape information sharing in clinical settings. This is particularly true in primary care where research on teams and collaboration has been based on individual perceptions of work (using surveys and interviews) rather than observing the interactions that directly mediate the inter-occupational flow of information. To explore how interactions shape information sharing, we conducted a secondary analysis of ethnographic data from 27 primary care practices. Ease of information sharing among nurses and doctors is linked to the degree to which practices feature respectful interactions, with practices in the sample falling into one of three categories (those with low, uneven, and high degrees of respectful interactions). Those practices with the highest degree of respectful interactions demonstrate what we describe as fluid-alliancing: flexible interactions between individuals from different occupational groups in which bidirectional information sharing occurs for the benefit of patients and the efficacy of the practice community. We conclude by arguing that this process unlocks the strengths of all practice members, and that leadership should encourage respectful interactions to augment organisational efficacy and the ability of individual practice members to provide quality patient care.

Practical Approaches to Developing Cultural Competency

The same demographic trends and cultural changes that have caused government agencies and private sector businesses to train their associates to be culturally competent are affecting the nursing profession. The patient-centered orientation of nurses makes it essential that they also be culturally competent by accessing cultural knowledge and developing cultural skills. What follows are vignettes and personal experiences based on a study by the author in which nurses were observed providing home care to newly admitted, culturally diverse patients. Tools for cultural assessment are described and included, along with recommendations to enhance the cultural competence of home care nurses and home care agencies.

Complex patients and interprofessional relationships: Perceptions of primary care nurse practitioners and primary care physicians

PURPOSE

The literature describing primary care nurse practitioners (PCNPs) and primary care physicians (PCPs) suggests that PCNPs provide care to patients with less complicated diagnoses than their PCP colleagues. However, other literature suggests the contrary. Therefore, the purpose of this qualitative study was to understand how patients are assigned and cared for by primary care clinicians and how these clinicians relate to one another. Additionally we explore how PCNPs relate to physicians outside the practice.

DATA SOURCES

Two nurse investigators conducted in-depth qualitative interviews with a nurse practitioner and a family medicine physician leader in each of 10 primary care practices. A content analysis was used to identify major themes.

CONCLUSIONS

The participating PCNPs and PCPs have highly collaborative relationships. PCNPs often function independently, engage in reciprocal consultations with PCPs, and provide care to highly complex patients. In contrast to their relationships with practice colleagues, PCNP relationships with physicians outside the practice are disruptive.

IMPLICATIONS FOR PRACTICE

These findings indicate that PCNPs are well positioned to assume responsibility for a diversity of primary care patients, including those with complex diagnoses. To promote the more effective integration of PCNPs, interprofessional barriers must be addressed by healthcare organizations and policy experts.

Complementary and alternative medicine in US family medicine practices: a pilot qualitative study

CONTEXT

The growth of complementary and alternative medicine (CAM) has led some family medicine practices to include CAM. Acupuncture or herbal medicine, for example, may be offered at such practices. When a practice incorporates both CAM and conventional treatments, its goals and values may differ from those found in traditional primary care. Little is known about the development of these integrated practices, which may be expected to become more widespread.

OBJECTIVE

To identify some of the concepts and challenges shaping family medicine practices that incorporate CAM.

DESIGN

Comparative case study.

METHOD

Multi-method assessment process including participant observation, key informant interviews, semi-structured depth interviews, and observation of patient-provider encounters.

SETTING

Four family medicine/CAM practices in the mid-Atlantic region of the United States.

RESULTS

Key themes that influence these practices' organization include dimensions of health, the selection of therapies used, the practices' approach to evidence, their perspective on the amount of time spent with patients, and their adaptations to financial concerns. Each practice emphasized long patient visits. In each, physicians had expertise that enabled them to draw on both conventional medicine and CAM.

CONCLUSION

Successful incorporation of CAM modalities within a family medicine framework requires adaptation not only at the practice level but also by individual physicians.

Variation in electronic prescribing implementation among twelve ambulatory practices

BACKGROUND

Electronic prescribing has been advocated as an important tool for improving the safety and quality of medication use in ambulatory settings. However, widespread adoption of e-prescribing in ambulatory settings has yet to be realized. The determinants of successful implementation and use in these settings are not well understood.

OBJECTIVE

To describe the practice characteristics associated with implementation and use of e-prescribing in ambulatory settings.

DESIGN

Multi-method qualitative case study of ambulatory practices before and after e-prescribing implementation.

PARTICIPANTS

Sixteen physicians and 31 staff members working in 12 practices scheduled for implementation of an e-prescribing program and purposively sampled to ensure a mix of practice size and physician specialty.

MEASUREMENTS

Field researchers used observational and interview techniques to collect data on prescription-related clinical workflow, information technology experience, and expectations.

RESULTS

Five practices fully implemented e-prescribing, 3 installed but with only some prescribers or staff members using the program, 2 installed and then discontinued use, 2 failed to install. Compared to practice members in other groups, members of successful practices exhibited greater familiarity with the capabilities of health information technologies and had more modest expectations about the benefits likely to accrue from e-prescribing. Members of unsuccessful practices reported limited understanding of e-prescribing capabilities, expected that the program would increase the speed of clinical care and reported difficulties with technical aspects of the implementation and insufficient technical support.

CONCLUSIONS

Practice leaders should plan implementation carefully, ensuring that practice members prepare for the effective integration of this technology into clinical workflow.

Developing a model of social capital: relationships in primary care

We have developed a model of social capital to enhance relationships within primary care practices that promote organizational success and improve patient care outcomes. The model extends the meaning and the value of social capital by providing dimensions, attributes, and operational definitions that can be used to measure outcomes and guidelines to develop future interventions. Our model brings new insight and logic to understanding relationships to create resources to improve primary care practices. Furthermore, our model provides a preliminary focus on the value of integrating registered nurses into the work of primary care practices and as facilitators of social capital.

Electronic medical records and diabetes quality of care: results from a sample of family medicine practices

PURPOSE

Care of patients with diabetes requires management of complex clinical information, which may be improved by the use of an electronic medical record (EMR); however, the actual relationship between EMR usage and diabetes care quality in primary care settings is not well understood. We assessed the relationship between EMR usage and diabetes care quality in a sample of family medicine practices.

METHODS

We conducted cross-sectional analyses of baseline data from 50 practices participating in a practice improvement study. Between April 2003 and December 2004 chart auditors reviewed a random sample of medical records from patients with diabetes in each practice for adherence to guidelines for diabetes processes of care, treatment, and achievement of intermediate outcomes. Practice leaders provided medical record system information. We conducted multivariate analyses of the relationship between EMR usage and diabetes care adjusting for potential practice- and patient-level confounders and practice-level clustering.

RESULTS

Diabetes care quality in all practices showed room for improvement; however, after adjustment, patient care in the 37 practices not using an EMR was more likely to meet guidelines for process (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.42-3.57) treatment (OR, 1.67; 95% CI, 1.07-2.60), and intermediate outcomes (OR, 2.68; 95% CI, 1.49-4.82) than in the 13 practices using an EMR.

CONCLUSIONS

The use of an EMR in primary care practices is insufficient for insuring high-quality diabetes care. Efforts to expand EMR use should focus not only on improving technology but also on developing methods for implementing and integrating this technology into practice reality.

Delivery of clinical preventive services in family medicine offices

BACKGROUND

This study aimed to elucidate how clinical preventive services are delivered in family practices and how this information might inform improvement efforts.

METHODS

We used a comparative case study design to observe clinical preventive service delivery in 18 purposefully selected Midwestern family medicine offices from 1997 to 1999. Medical records, observation of outpatient encounters, and patient exit cards were used to calculate practice-level rates of delivery of clinical preventive services. Field notes from direct observation of clinical encounters and prolonged observation of the practice and transcripts from in-depth interviews of practice staff and physicians were systematically examined to identify approaches to delivering clinical preventive services recommended by the US Preventive Services Task Force.

RESULTS

Practices developed individualized approaches for delivering clinical preventive services, with no one approach being successful across practices. Clinicians acknowledged a 3-fold mission of providing acute care, managing chronic problems, and prevention, but only some made prevention a priority. The clinical encounter was a central focus for preventive service delivery in all practices. Preventive services delivery rates often appeared to be influenced by competing demands within the clinical encounter (including between different preventive services), having a physician champion who prioritized prevention, and economic concerns.

CONCLUSIONS

Practice quality improvement efforts that assume there is an optimal approach for delivering clinical preventive services fail to account for practices' propensity to optimize care processes to meet local contexts. Interventions to enhance clinical preventive service delivery should be tailored to meet the local needs of practices and their patient populations.

Social network analysis as an analytic tool for interaction patterns in primary care practices

PURPOSE

Social network analysis (SNA) provides a way of quantitatively analyzing relationships among people or other information-processing agents. Using 2 practices as illustrations, we describe how SNA can be used to characterize and compare communication patterns in primary care practices.

METHODS

Based on data from ethnographic field notes, we constructed matrices identifying how practice members interact when practice-level decisions are made. SNA software (UCINet and KrackPlot) calculates quantitative measures of network structure including density, centralization, hierarchy and clustering coefficient. The software also generates a visual representation of networks through network diagrams.

RESULTS

The 2 examples show clear distinctions between practices for all the SNA measures. Potential uses of these measures for analysis of primary care practices are described.

CONCLUSIONS

SNA can be useful for quantitative analysis of interaction patterns that can distinguish differences among primary care practices.

Speaking of weight: how patients and primary care clinicians initiate weight loss counseling

BACKGROUND

Obesity is epidemic in the US and other industrialized countries and contributes significantly to population morbidity and mortality. Primary care physicians see a substantial portion of the obese population, yet rarely counsel patients to lose weight.

METHODS

Descriptive field notes of outpatient visits collected as part of a multimethod comparative case study were used to study patterns of physician-patient communication around weight control in 633 encounters in family practices in a Midwestern state.

RESULTS

Sixty-eight percent of adults and 35% of children were overweight. Excess weight was mentioned in 17% of encounters with overweight patients, while weight loss counseling occurred with 11% of overweight adults and 8% of overweight children. In weight loss counseling encounters, patients formulated weight as a problem by making it a reason for visit or explicitly or implicitly asking for help with weight loss. Clinicians did so by framing weight as a medical problem in itself or as an exacerbating factor for another medical problem.

CONCLUSIONS

Strategies that increase the likelihood of patients identifying weight as a problem, or that provide clinicians with a way to "medicalize" the patient's obesity, are likely to increase the frequency of weight loss counseling in primary care visits.

Opportunistic approaches for delivering preventive care in illness visits

OBJECTIVE

To describe how clinicians create opportunities to deliver preventive care in illness visits and assess the impact this has on preventive service delivery.

METHOD

Detailed and descriptive fieldnotes were collected from 18 purposefully selected family practices, including direct observations of 53 primary care clinicians and 1620 patient encounters. Conversation analysis was used to examine the conversational techniques employed to deliver four preventive services (smoking counseling, immunization delivery, mammography, and cervical cancer screening) in illness visits. Qualitative data was coded and analyzed to assess impact on preventive service delivery rates.

RESULTS

Two methods for opportunistic preventive service delivery were observed. In the first, clinicians used the close of the medical encounter to make arrangement for follow-up preventive care. In the second approach, clinicians use a stepwise conversational device to exit talk about the patient's presenting problem and enter into relevant health habit advice. Quantitative analyses show that opportunistic methods are rarely used to deliver preventive services in illness visits. The stepwise technique was the most frequently used method. Patients treated by clinicians who used opportunistic techniques to deliver preventive care in illness visits were more likely to be up-to-date on smoking counseling and cervical cancer screening than those patients who were treated by clinicians who did not use opportunistic approaches.

CONCLUSIONS

Opportunistic preventive service delivery in illness visits can be an efficient and effective way to deliver preventive care. Although infrequently used, quantitative data suggest that the use of opportunistic approaches to deliver preventive services during illness visits can enhance preventive care rates. Interventions aimed at helping clinicians develop effective strategies for offering preventive care during illness visits may be an important complement to existing mechanical interventions that might, by themselves, be insufficient to improve preventive care.

Assessing diversity and quality in primary care through the multimethod assessment process (MAP)

The U.S. health care system serves a diverse population, often resulting in significant disparities in delivery and quality of care. Nevertheless, most quality improvement efforts fail to systematically assess diversity and associated disparities. This article describes application of the multimethod assessment process (MAP) for understanding disparities in relation to diversity, cultural competence, and quality improvement in clinical practice. MAP is an innovative quality improvement methodology that integrates quantitative and qualitative techniques and produces a system level understanding of organizations to guide quality improvement interventions. A demonstration project in a primary care practice illustrates the utility of MAP for assessing diversity.

Antibiotic use in acute respiratory infections and the ways patients pressure physicians for a prescription

OBJECTIVE

We identified those aspects of physician-patient communication that influence physicians to prescribe antibiotics for respiratory infections.

STUDY DESIGN

A multimethod comparative case study was performed including descriptive field notes of outpatient visits.

POPULATION

We included patients (children and adults) and clinicians in 18 purposefully selected family practices in a midwestern state. A total of 298 outpatient visits for acute respiratory tract (ART) infections were selected for analysis from more than 1600 encounters observed.

OUTCOMES MEASURED

Unnecessary antibiotic use and patterns of physician-patient communication were measured.

RESULTS

Antibiotics were prescribed in 68% of the ART infection visits, and of those, 79% were determined to be unnecessary according to Centers for Disease Control and Prevention guidelines. Patients were observed to pressure physicians for medication. The types of patterns identified were direct request, candidate diagnosis (a diagnosis suggested by the patient), implied candidate diagnosis (a set of symptoms specifically indexing a particular diagnosis), portraying severity of illness, appealing to life-world circumstances, and previous use of antibiotics. Also, clinicians were observed to rationalize their antibiotic prescriptions by reporting medically acceptable reasons and diagnoses to patients.

CONCLUSIONS

Patients strongly influence the antibiotic prescribing of physicians by using a number of different behaviors. To decrease antibiotic use for ART infections, patients should be educated about the dangers and limited benefits of such use, and clinicians should consider appropriate responses to these different patient pressures to prescribe antibiotics.