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Burra TA, Soong C, Wong BM. Taking action on inequities: a structural paradigm for quality and safety. BMJ Qual Saf 2024; 33:351-353. [PMID: 38688709 DOI: 10.1136/bmjqs-2023-017027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2024] [Indexed: 05/02/2024]
Affiliation(s)
- Tara A Burra
- Department of Psychiatry, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Christine Soong
- General Internal Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Brian M Wong
- Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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2
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Drake C, Lewinski AA, Rader A, Schexnayder J, Bosworth HB, Goldstein KM, Gierisch J, White-Clark C, McCant F, Zullig LL. Addressing Hypertension Outcomes Using Telehealth and Population Health Managers: Adaptations and Implementation Considerations. Curr Hypertens Rep 2022; 24:267-284. [PMID: 35536464 PMCID: PMC9087161 DOI: 10.1007/s11906-022-01193-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2022] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW There is a growing evidence base describing population health approaches to improve blood pressure control. We reviewed emerging trends in hypertension population health management and present implementation considerations from an intervention called Team-supported, Electronic health record-leveraged, Active Management (TEAM). By doing so, we highlight the role of population health managers, practitioners who use population level data and to proactively engage at-risk patients, in improving blood pressure control. RECENT FINDINGS Within a population health paradigm, we discuss telehealth-delivered approaches to equitably improve hypertension care delivery. Additionally, we explore implementation considerations and complementary features of team-based, telehealth-delivered, population health management. By leveraging the unique role and expertise of a population health manager as core member of team-based telehealth, health systems can implement a cost-effective and scalable intervention that addresses multi-level barriers to hypertension care delivery. We describe the literature of telehealth-based population health management for patients with hypertension. Using the TEAM intervention as a case study, we then present implementation considerations and intervention adaptations to integrate a population health manager within the health care team and effectively manage hypertension for a defined patient population. We emphasize practical considerations to inform implementation, scaling, and sustainability. We highlight future research directions to advance the field and support translational efforts in diverse clinical and community contexts.
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Affiliation(s)
- Connor Drake
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA.
| | - Allison A Lewinski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- School of Nursing, Duke University, Durham, NC, USA
| | - Abigail Rader
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
| | - Julie Schexnayder
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Hayden B Bosworth
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
- School of Nursing, Duke University, Durham, NC, USA
| | - Karen M Goldstein
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer Gierisch
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Courtney White-Clark
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Felicia McCant
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Leah L Zullig
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
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3
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D’Apice C, Ghirotto L, Bassi MC, Artioli G, Sarli L. A realist synthesis of staff-based primary health care interventions addressing universal health coverage. J Glob Health 2022; 12:04035. [PMID: 35569053 PMCID: PMC9107778 DOI: 10.7189/jogh.12.04035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Methods Results Conclusions
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Affiliation(s)
- Clelia D’Apice
- University of Parma, Department of Medicine and Surgery, Parma, Italy
| | - Luca Ghirotto
- Qualitative Research Unit, Azienda USL – IRCCS, Reggio Emilia, Italy
| | - Maria C Bassi
- Medical Library, Azienda USL – IRCCS, Reggio Emilia, Italy
| | - Giovanna Artioli
- University of Parma, Department of Medicine and Surgery, Parma, Italy
| | - Leopoldo Sarli
- University of Parma, Department of Medicine and Surgery, Parma, Italy
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Addressing ethical clinical dilemmas with quality improvement methodology. Semin Pediatr Surg 2021; 30:151105. [PMID: 34635285 DOI: 10.1016/j.sempedsurg.2021.151105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Application of Quality Improvement methodology to nuanced clinical scenarios may be useful to ensure consistent delivery of equitable and comprehensive care. The purpose of this article is to inform the pediatric surgical readership of opportunities where quality improvement methodology may aid in navigating ethical nuances of complex surgical care. We present three case scenarios and discuss how quality improvement methodology could be utilized to address issues of provider autonomy, patient autonomy, and justice.
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Coury JK, Schneider JL, Green BB, Baldwin LM, Petrik AF, Rivelli JS, Schwartz MR, Coronado GD. Two Medicaid health plans' models and motivations for improving colorectal cancer screening rates. Transl Behav Med 2021; 10:68-77. [PMID: 30445511 DOI: 10.1093/tbm/iby094] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Screening rates for colorectal cancer (CRC) remain low, especially among certain populations. Mailed fecal immunochemical testing (FIT) outreach initiated by U.S. health plans could reach underserved individuals, while solving CRC screening data and implementation challenges faced by health clinics. We report the models and motivations of two health insurance plans implementing a mailed FIT program for age-eligible U.S. Medicaid and Medicare populations. One health plan operates in a single state with ~220,000 enrollees; the other operates in multiple states with ~2 million enrollees. We conducted in-depth qualitative interviews with key stakeholders and observed leadership and clinic staff planning during program development and implementation. Interviews were transcribed and coded using a content analysis approach; coded interview reports and meeting minutes were iteratively reviewed and summarized for themes. Between June and September 2016, nine participants were identified, and all agreed to the interview. Interviews revealed that organizational context was important to both organizations and helped shape program design. Both organizations were hoping this program would address barriers to their prior CRC screening improvement efforts and saw CRC screening as a priority. Despite similar motivations to participate in a mailed FIT intervention, contextual features of the health plans led them to develop distinct implementation models: a collaborative model using some health clinic staffing versus a centralized model operationalizing outreach primarily at the health plan. Data are not yet available on the models' effectiveness. Our findings might help inform the design of programs to deliver mailed FIT outreach.
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Affiliation(s)
| | - Jennifer L Schneider
- Kaiser Permanente, Center for Health Research, Science Department, Portland, OR, USA
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Science Department, Seattle, WA, USA
| | - Laura-Mae Baldwin
- University of Washington, Department of Family Medicine, Seattle, WA, USA
| | - Amanda F Petrik
- Kaiser Permanente, Center for Health Research, Science Department, Portland, OR, USA
| | - Jennifer S Rivelli
- Kaiser Permanente, Center for Health Research, Science Department, Portland, OR, USA
| | - Malaika R Schwartz
- University of Washington, Department of Family Medicine, Seattle, WA, USA
| | - Gloria D Coronado
- Kaiser Permanente, Center for Health Research, Science Department, Portland, OR, USA
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Sazali MF, Rahim SSSA, Hayati F, Mohd Daud MN, Avoi R, Omar A, Atil A, Abd Rahim MA, Madrim MF, Mokti K, Ramdzan AR, Sidek Ahmad ZN, Zakaria AD, Che Ani MF, Ibrahim AF, Azhar ZI, Jeffree MS, Hassan MR. Colorectal cancer and potential predictors of never screened for faecal occult blood test: a narrative review. J Public Health Res 2021; 11. [PMID: 34351098 PMCID: PMC8859728 DOI: 10.4081/jphr.2021.2377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/08/2021] [Indexed: 11/25/2022] Open
Abstract
Colorectal cancer (CRC) is a major public health threat. Therefore, CRC screening uptake has been a focus with the established precancerous lesion and the strong association of early detection with staging and survival of the disease. However, CRC screening is relatively low in many countries. This article briefly discussed the current situation of CRC, recommendations, and current uptake of CRC screening in various countries. Besides that, this article also highlights the potential factors that help to predict the CRC screening uptake worldwide. Identification of those factors could guide policymakers to develop an effective strategy to improve the CRC screening uptake and ultimately improve the health outcome of the population. Significance for public health This study highlights the public health challenge in early screening for colorectal cancer (CRC). The prevalence of never screened for faecal occult blood test is relatively high. This review dissects the issue and further discuss on the predictors, which could guide policymakers in developing strategy to improve CRC screening uptake.
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Affiliation(s)
- Mohd Fazeli Sazali
- Community and Family Medicine Department, Faculty of Medicine and Health Science, Universiti Malaysia Sabah, Kota Kinabalu, Sabah.
| | - Syed Sharizman Syed Abdul Rahim
- Community and Family Medicine Department, Faculty of Medicine and Health Science, Universiti Malaysia Sabah, Kota Kinabalu, Sabah.
| | - Firdaus Hayati
- Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu.
| | - Mohd Nazri Mohd Daud
- Community and Family Medicine Department, Faculty of Medicine and Health Science, Universiti Malaysia Sabah, Kota Kinabalu, Sabah.
| | - Richard Avoi
- Community and Family Medicine Department, Faculty of Medicine and Health Science, Universiti Malaysia Sabah, Kota Kinabalu, Sabah.
| | - Azizan Omar
- Community and Family Medicine Department, Faculty of Medicine and Health Science, Universiti Malaysia Sabah, Kota Kinabalu, Sabah.
| | - Azman Atil
- Community and Family Medicine Department, Faculty of Medicine and Health Science, Universiti Malaysia Sabah, Kota Kinabalu, Sabah.
| | - Muhammad Aklil Abd Rahim
- Community and Family Medicine Department, Faculty of Medicine and Health Science, Universiti Malaysia Sabah, Kota Kinabalu, Sabah.
| | - Mohd Faizal Madrim
- Community and Family Medicine Department, Faculty of Medicine and Health Science, Universiti Malaysia Sabah, Kota Kinabalu, Sabah.
| | - Khalid Mokti
- Community and Family Medicine Department, Faculty of Medicine and Health Science, Universiti Malaysia Sabah, Kota Kinabalu, Sabah.
| | - Abdul Rahman Ramdzan
- Community and Family Medicine Department, Faculty of Medicine and Health Science, Universiti Malaysia Sabah, Kota Kinabalu, Sabah.
| | - Zulkhairul Naim Sidek Ahmad
- Community and Family Medicine Department, Faculty of Medicine and Health Science, Universiti Malaysia Sabah, Kota Kinabalu, Sabah.
| | - Andee Dzulkarnaen Zakaria
- Department of General Surgery, Hospital Universiti Sains Malaysia, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan.
| | - Mohd Firdaus Che Ani
- Department of Surgery, Faculty of Medicine, Universiti Teknologi MARA, Selangor.
| | - Aini Fahriza Ibrahim
- Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Kota Samarahan, Sarawak.
| | - Zahir Izuan Azhar
- Department of Public Health Medicine, Faculty of Medicine, Universiti Teknologi MARA, Selangor.
| | - Mohammad Saffree Jeffree
- Community and Family Medicine Department, Faculty of Medicine and Health Science, Universiti Malaysia Sabah, Kota Kinabalu, Sabah.
| | - Mohd Rohaizat Hassan
- Faculty of Medicine, Universiti Kebangsaan Malaysia, Bandar Tun Razak, Cheras, Kuala Lumpur.
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Check DK, Zullig LL, Davis MM, Davies L, Chambers D, Fleisher L, Kaplan SJ, Proctor E, Ramanadhan S, Schroeck FR, Stover AM, Koczwara B. Improvement Science and Implementation Science in Cancer Care: Identifying Areas of Synergy and Opportunities for Further Integration. J Gen Intern Med 2021; 36:186-195. [PMID: 32869193 PMCID: PMC7859137 DOI: 10.1007/s11606-020-06138-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 08/11/2020] [Indexed: 12/30/2022]
Abstract
Efforts to improve cancer care primarily come from two fields: improvement science and implementation science. The two fields have developed independently, yet they have potential for synergy. Leveraging that synergy to enhance alignment could both reduce duplication and, more importantly, enhance the potential of both fields to improve care. To better understand potential for alignment, we examined 20 highly cited cancer-related improvement science and implementation science studies published in the past 5 years, characterizing and comparing their objectives, methods, and approaches to practice change. We categorized studies as improvement science or implementation science based on authors' descriptions when possible; otherwise, we categorized studies as improvement science if they evaluated efforts to improve the quality, value, or safety of care, or implementation science if they evaluated efforts to promote the implementation of evidence-based interventions into practice. All implementation studies (10/10) and most improvement science studies (6/10) sought to improve uptake of evidence-based interventions. Improvement science and implementation science studies employed similar approaches to change practice. For example, training was employed in 8/10 implementation science studies and 4/10 improvement science studies. However, improvement science and implementation science studies used different terminology to describe similar concepts and emphasized different methodological aspects in reporting. Only 4/20 studies (2 from each category) described using a formal theory or conceptual framework to guide program development. Most studies were multi-site (10/10 implementation science and 6/10 improvement science) and a minority (2 from each category) used a randomized design. Based on our review, cancer-related improvement science and implementation science studies use different terminology and emphasize different methodological aspects in reporting but share similarities in purpose, scope, and methods, and are at similar levels of scientific development. The fields are well-positioned for alignment. We propose that next steps include harmonizing language and cross-fertilizing methods of program development and evaluation.
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Affiliation(s)
- Devon K Check
- Department of Population Health Sciences and Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA.
| | - Leah L Zullig
- Department of Population Health Sciences and Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Melinda M Davis
- Oregon Rural Practice-based Research Network and Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.,School of Public Health, Oregon Health & Science University and Portland State University, Portland, OR, USA
| | - Louise Davies
- The VA Outcomes Group, White River Junction VA Medical Center, Hartford, VT, USA.,The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Hanover, NH, USA.,Department of Surgery - Otolaryngology Head & Neck Surgery, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - David Chambers
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | | | - Samantha J Kaplan
- Duke University Medical Center Library & Archives, Duke University School of Medicine, Durham, NC, USA
| | - Enola Proctor
- The Brown School at Washington University in St. Louis, St. Louis, MO, USA
| | - Shoba Ramanadhan
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Florian R Schroeck
- The VA Outcomes Group, White River Junction VA Medical Center, Hartford, VT, USA.,The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Hanover, NH, USA.,Section of Urology and Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, PA, USA
| | - Angela M Stover
- Department of Health Policy and Management, Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Miguel CA, Paskett ED, Fisher JL, Fickle DK, Washington CM, Degraffinreid C, Tatum C, Gray II DM. Scripted tours through a giant inflatable colon: An innovative and effective educational tool in urban communities. Prev Med Rep 2020; 20:101248. [PMID: 33294315 PMCID: PMC7695982 DOI: 10.1016/j.pmedr.2020.101248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/22/2020] [Accepted: 11/08/2020] [Indexed: 01/05/2023] Open
Abstract
Colorectal cancer (CRC) is the second leading cause of cancer-related death among men and women in the US and mortality rates are increasing among young adults. Although CRC is largely preventable with screening and often curable when detected at an early stage, many age-appropriate individuals remain unscreened or are not currently up-to-date with screening. We aimed to examine the impact of providing guided, scripted tours through an inflatable colon on three domains: CRC knowledge, likelihood of communicating about CRC with others, and the intention to be screened for CRC in a diverse, urban population. The inflatable walk-through colon was exhibited at five community events in Franklin County, Ohio between March 2015 and August 2016. A pre and posttest research design and composite scores were stratified into three age groups (<45 years, 45-49 years and ≥ 50 years of age). Descriptive statistics were used to describe and compare demographic characteristics. Logistic regression was used to examine potential associations between demographic factors and the three outcomes of interest. These tours led to statistically significant increases in CRC knowledge, communication, and intention to undergo CRC screening among participants in all three age cohorts. In addition, the intention of undergo screening after a tour among individuals<45 years of age were nearly three times that of those older than 50 (OR = 2.66; 95%CI = 1.49-4.75). Overall, this study supports the use of scripted tours through an inflatable colon exhibit as a potentially effective intervention to increase age-appropriate CRC screening uptake.
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Affiliation(s)
| | - Electra D. Paskett
- The Ohio State University College of Medicine, Columbus, OH, USA
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - James L. Fisher
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Darla K. Fickle
- The Ohio State University College of Medicine, Columbus, OH, USA
| | | | | | - Cathy Tatum
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Darrell M. Gray II
- The Ohio State University College of Medicine, Columbus, OH, USA
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
- The Division of Gastroenterology, Hepatology and Nutrition. The Ohio State University College of Medicine, Columbus, OH, USA
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Nelson HD, Cantor A, Wagner J, Jungbauer R, Quiñones A, Stillman L, Kondo K. Achieving Health Equity in Preventive Services: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med 2020; 172:258-271. [PMID: 31931527 DOI: 10.7326/m19-3199] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Disadvantaged populations in the United States experience disparities in the use of preventive health services. PURPOSE To examine effects of barriers that create health disparities in 10 recommended preventive services for adults, and to evaluate the effectiveness of interventions to reduce them. DATA SOURCES English-language searches of Ovid MEDLINE, PsycINFO, SocINDEX, and the Veterans Affairs Health Services database (1 January 1996 to 5 July 2019); reference lists. STUDY SELECTION Trials, observational studies with comparison groups, and systematic reviews of populations adversely affected by disparities that reported effects of barriers on use of any of the 10 selected preventive services or that reported the effectiveness of interventions to reduce disparities in use of a preventive service by improving intermediate or clinical outcomes. DATA EXTRACTION Dual extraction and assessment of study quality, strength of evidence, and evidence applicability. DATA SYNTHESIS No studies reported effects of provider-specific barriers on preventive service use. Eighteen studies reporting effects of patient barriers, such as insurance coverage or lack of a regular provider, on preventive service use had mixed and inconclusive findings. Studies of patient-provider interventions (n = 12), health information technologies (n = 11), and health system interventions (n = 88) indicated higher cancer screening rates with patient navigation; telephone calls, prompts, and other outreach methods; reminders involving lay health workers; patient education; risk assessment, counseling, and decision aids; screening checklists; community engagement; and provider training. Single studies showed that clinician-delivered and technology-assisted interventions improved rates of smoking cessation and weight loss, respectively. LIMITATION Insufficient or low strength of evidence and applicability for most interventions except patient navigation, telephone calls and prompts, and reminders involving lay health workers. CONCLUSION In populations adversely affected by disparities, patient navigation, telephone calls and prompts, and reminders involving lay health workers increase cancer screening. PRIMARY FUNDING SOURCE National Institutes of Health Office of Disease Prevention through an interagency agreement with the Agency for Healthcare Research and Quality. (PROSPERO: CRD42018109263).
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Affiliation(s)
- Heidi D Nelson
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., J.W., R.J., L.S.)
| | - Amy Cantor
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., J.W., R.J., L.S.)
| | - Jesse Wagner
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., J.W., R.J., L.S.)
| | - Rebecca Jungbauer
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., J.W., R.J., L.S.)
| | - Ana Quiñones
- Oregon Health & Science University-Portland State University, Portland, Oregon (A.Q.)
| | - Lucy Stillman
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., J.W., R.J., L.S.)
| | - Karli Kondo
- Portland VA Health Care System and Oregon Health & Science University, Portland, Oregon (K.K.)
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Muthukrishnan M, Arnold LD, James AS. Patients' self-reported barriers to colon cancer screening in federally qualified health center settings. Prev Med Rep 2019; 15:100896. [PMID: 31193550 PMCID: PMC6531912 DOI: 10.1016/j.pmedr.2019.100896] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 05/10/2019] [Accepted: 05/12/2019] [Indexed: 01/06/2023] Open
Abstract
Colorectal cancer (CRC) is a leading cause of cancer-related death in the United States. Despite evidence that screening reduces CRC incidence and mortality, only about 60% of age-eligible adults are up-to-date on CRC screening. This analysis aims to identify self-reported barriers to CRC screening among patients in a safety-net healthcare setting. Participants were recruited from safety-net primary care sites that were participating in a trial to increase CRC screening. At baseline, patients (n = 483) completed self-report surveys that assessed demographics, healthcare and CRC screening. Barriers to CRC screening were assessed through an open-ended question. Using a basic text analysis, data were coded and organized into key topics. Overall, 65.2% ever had CRC screening; 46.4% were up-to-date. Of those who described barriers (n = 198), 22.9% said they were not due for screening or their provider had not recommended it. Other common barriers included fear or worry about the procedure or outcome, financial challenges such as lack of insurance or cost of testing, and logistic challenges such as transportation and time. Fewer said that screening was of low importance or mentioned discomfort with the procedure or colonoscopy preparation. In this safety-net setting, CRC screening rates were lower than national rates. These qualitative results are similar to quantitative findings reported in the literature but the qualitative data add to our understanding of patient-reported concerns and challenges faced by safety-net patients. These results may be applied to developing targeting communication or intervention strategies to improve CRC screening rates within safety-net health centers.
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Affiliation(s)
- Meera Muthukrishnan
- College for Public Health and Social Justice, Saint Louis University, United States of America
- Corresponding author at: Saint Louis University, College of Public Health and Social Justice, 3545 Lafayette Ave., United States of America
| | - Lauren D. Arnold
- College for Public Health and Social Justice, Saint Louis University, United States of America
| | - Aimee S. James
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, United States of America
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11
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Lyles CR, Handley MA, Ackerman SL, Schillinger D, Williams P, Westbrook M, Gourley G, Sarkar U. Innovative Implementation Studies Conducted in US Safety Net Health Care Settings: A Systematic Review. Am J Med Qual 2018; 34:293-306. [PMID: 30198304 PMCID: PMC7243669 DOI: 10.1177/1062860618798469] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Little is known about dissemination and implementation in safety net settings. The authors conducted a literature review of innovation/implementation studies in US safety net health care settings between 2008 and 2017. Each article was coded for (1) intervention characteristics, (2) implementation stage, (3) internal versus external ownership, and (4) prespecified implementation outcomes (eg, acceptability and fidelity). Twenty studies were identified; the majority were implemented within community clinics or integrated safety net systems (15 articles), most involved care process improvements (13 articles), and most were internally developed (13 articles). The internally developed innovations reported fewer barriers to acceptability among staff/providers, higher leadership involvement and organizational alignment, greater amounts of customization to the local setting, and better sustainment. Future work should harness the high levels of alignment and acceptability in implementation research within safety net settings, with an eye toward maintaining fidelity to facilitate dissemination across sites.
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12
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Muthukrishnan M, Sutcliffe S, Hunleth JM, Wang JS, Colditz GA, James AS. Conducting a randomized trial in rural and urban safety-net health centers: Added value of community-based participatory research. Contemp Clin Trials Commun 2018; 10:29-35. [PMID: 29696155 PMCID: PMC5898527 DOI: 10.1016/j.conctc.2018.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 02/15/2018] [Accepted: 02/27/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is the second most common cancer in the US. Despite evidence that screening reduces CRC incidence and mortality, screening rates are sub-optimal with disparities by race/ethnicity, income, and geography. Rural-urban differences in CRC screening are understudied even though approximately one-fifth of the US population lives in rural areas. This focus on urban populations limits the generalizability and dissemination potential of screening interventions. METHODS Using community-based participatory research (CBPR) principles, we designed a cluster-randomized trial, adaptable to a range of settings, including rural and urban health centers. We enrolled 483 participants across 11 health centers representing 2 separate networks. Both networks serve medically-underserved communities; however one is primarily rural and one primarily urban. RESULTS Our goal in this analysis is to describe baseline characteristics of participants and examine setting-level differences. CBPR was a critical for recruiting networks to the trial. Patient respondents were predominately female (61.3%), African-American (66.5%), and earned <$1200 per month (87.1%). The rural network sample was older; more likely to be female, white, disabled or retired, and have a higher income, but fewer years of education. CONCLUSIONS Variation in the samples partly reflects the CBPR process and partly reflects inherent differences in the communities. This confirmed the importance of using CBPR when planning for eventual dissemination, as it enhanced our ability to work within diverse settings. These baseline findings indicate that using a uniform approach to implementing a trial or intervention across diverse settings might not be effective or efficient.
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Affiliation(s)
- Meera Muthukrishnan
- Department of Epidemiology and Biostatistics, Saint Louis University College of Public Health and Social Justice, St. Louis, MO, USA
| | - Siobhan Sutcliffe
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jean M. Hunleth
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jean S. Wang
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Graham A. Colditz
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Aimee S. James
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
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13
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Percac-Lima S, Pace LE, Nguyen KH, Crofton CN, Normandin KA, Singer SJ, Rosenthal MB, Chien AT. Diagnostic Evaluation of Patients Presenting to Primary Care with Rectal Bleeding. J Gen Intern Med 2018; 33:415-422. [PMID: 29302885 PMCID: PMC5880768 DOI: 10.1007/s11606-017-4273-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 10/31/2017] [Accepted: 12/05/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Rectal bleeding is a common, frequently benign problem that can also be an early sign of colorectal cancer. Diagnostic evaluation for rectal bleeding is complex, and clinical practice may deviate from available guidelines. OBJECTIVE To assess the degree to which primary care physicians document risk factors for colorectal cancer among patients with rectal bleeding and order colonoscopies when indicated, and the likelihood of physicians ordering and patients receiving recommended colonoscopies based on demographic characteristics, visit patterns, and clinical presentations. DESIGN Cross-sectional study using explicit chart abstraction methods. PARTICIPANTS Three hundred adults, 40-80 years of age, presenting with rectal bleeding to 15 academically affiliated primary care practices between 2012 and 2016. MAIN MEASURES 1) The frequency at which colorectal cancer risk factors were documented in patients' charts, 2) the frequency at which physicians ordered colonoscopies and patients received them, and 3) the odds of ordering and patients receiving recommended colonoscopies based on patient demographic characteristics, visit patterns, and clinical presentations. KEY RESULTS Risk factors for colorectal cancer were documented between 9% and 66% of the time. Most patients (89%) with rectal bleeding needed a colonoscopy according to a clinical guideline. Physicians placed colonoscopy orders for 74% of these patients, and 56% completed the colonoscopy within a year (36% within 60 days). The odds of physicians ordering recommended colonoscopies were significantly higher in patients aged 50-64 years of age than in those aged 40-50 years (OR = 2.23, 95% CI: 1.04, 4.80), and for patients whose most recent colonoscopy was 5 or more years ago (OR = 4.04, 95% CI: 1.50, 10.83). The odds of physicians ordering and patients receiving recommended colonoscopies were significantly lower for each primary care visit unrelated to rectal bleeding (OR = 0.85, 95% CI: 0.75, 0.96). CONCLUSIONS Diagnostic evaluation of patients presenting to primary care with rectal bleeding may be suboptimal because of inadequate risk factor assessment and prioritization of patients' other concurrent medical problems.
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Affiliation(s)
- Sanja Percac-Lima
- Harvard Medical School, Boston, MA, USA.
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Lydia E Pace
- Harvard Medical School, Boston, MA, USA
- Division of Women's Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Kevin H Nguyen
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Charis N Crofton
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Katharine A Normandin
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Sara J Singer
- Harvard Medical School, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Alyna T Chien
- Harvard Medical School, Boston, MA, USA
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
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14
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James A, Berkowitz SA, Ashburner JM, Chang Y, Horn DM, O'Keefe SM, Atlas SJ. Impact of a Population Health Management Intervention on Disparities in Cardiovascular Disease Control. J Gen Intern Med 2018; 33:463-470. [PMID: 29313223 PMCID: PMC5880754 DOI: 10.1007/s11606-017-4227-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 09/07/2017] [Accepted: 10/26/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Healthcare systems use population health management programs to improve the quality of cardiovascular disease care. Adding a dedicated population health coordinator (PHC) who identifies and reaches out to patients not meeting cardiovascular care goals to these programs may help reduce disparities in cardiovascular care. OBJECTIVE To determine whether a program that used PHCs decreased racial/ethnic disparities in LDL cholesterol and blood pressure (BP) control. DESIGN Retrospective difference-in-difference analysis. PARTICIPANTS Twelve thousdand five hundred fifty-five primary care patients with cardiovascular disease (cohort for LDL analysis) and 41,183 with hypertension (cohort for BP analysis). INTERVENTION From July 1, 2014-December 31, 2014, 18 practices used an information technology (IT) system to identify patients not meeting LDL and BP goals; 8 practices also received a PHC. We examined whether having the PHC plus IT system, compared with having the IT system alone, decreased racial/ethnic disparities, using difference-in-difference analysis of data collected before and after program implementation. MAIN MEASURES Meeting guideline concordant LDL and BP goals. KEY RESULTS At baseline, there were racial/ethnic disparities in meeting LDL (p = 0.007) and BP (p = 0.0003) goals. Comparing practices with and without a PHC, and accounting for pre-intervention LDL control, non-Hispanic white patients in PHC practices had improved odds of LDL control (OR 1.20 95% CI 1.09-1.32) compared with those in non-PHC practices. Non-Hispanic black (OR 1.15 95% CI 0.80-1.65) and Hispanic (OR 1.29 95% CI 0.66-2.53) patients saw similar, but non-significant, improvements in LDL control. For BP control, non-Hispanic white patients in PHC practices (versus non-PHC) improved (OR 1.13 95% CI 1.05-1.22). Non-Hispanic black patients (OR 1.17 95% CI 0.94-1.45) saw similar, but non-statistically significant, improvements in BP control, but Hispanic (OR 0.90 95% CI 0.59-1.36) patients did not. Interaction testing confirmed that disparities did not decrease (p = 0.73 for LDL and p = 0.69 for BP). CONCLUSIONS The population health management intervention did not decrease disparities. Further efforts should explicitly target improving both healthcare equity and quality. Clinical Trials #: NCT02812303 ( ClinicalTrials.gov ).
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Affiliation(s)
- Aisha James
- Harvard/Massachusetts General Hospital Medicine-Pediatrics Residency Program, Boston, MA, USA
| | - Seth A Berkowitz
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Jeffrey M Ashburner
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Daniel M Horn
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Boston, MA, USA
| | - Sandra M O'Keefe
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Boston, MA, USA
| | - Steven J Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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15
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Kiran T, Glazier RH, Moineddin R, Gu S, Wilton AS, Paszat L. The Impact of a Population-Based Screening Program on Income- and Immigration-Related Disparities in Colorectal Cancer Screening. Cancer Epidemiol Biomarkers Prev 2017. [DOI: 10.1158/1055-9965.epi-17-0301] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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16
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Hofmann B. Ethical issues with colorectal cancer screening-a systematic review. J Eval Clin Pract 2017; 23:631-641. [PMID: 28026076 DOI: 10.1111/jep.12690] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 11/16/2016] [Accepted: 11/16/2016] [Indexed: 12/26/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Colorectal cancer (CRC) screening is widely recommended and implemented. However, sometimes CRC screening is not implemented despite good evidence, and some types of CRC screening are implemented despite lack of evidence. The objective of this article is to expose and elucidate relevant ethical issues in the literature on CRC screening that are important for open and transparent deliberation on CRC screening. METHODS An axiological question-based method is used for exposing and elucidating ethical issues relevant in HTA. A literature search in MEDLINE, Embase, PsycINFO, PubMed Bioethics subset, ISI Web of Knowledge, Bioethics Literature Database (BELIT), Ethics in Medicine (ETHMED), SIBIL Base dati di bioetica, LEWI Bibliographic Database on Ethics in the Sciences and Humanities, and EUROETHICS identified 870 references of which 114 were found relevant according to title and abstract. The content of the included papers were subject to ethical analysis to highlight the ethical issues, concerns, and arguments. RESULTS A wide range of important ethical issues were identified. The main benefits are reduced relative CRC mortality rate, and potentially incidence rate, but there is no evidence of reduced absolute mortality rate. Potential harms are bleeding, perforation, false test results, overdetection, overdiagnosis, overtreatment (including unnecessary removal of polyps), and (rarely) death. Other important issues are related to autonomy and informed choice equity, justice, medicalization, and expanding disease. CONCLUSION A series of important ethical issues have been identified and need to be addressed in open and transparent deliberation on CRC screening.
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Affiliation(s)
- Bjørn Hofmann
- Department of Health Science, the Norwegian University for Science and Technology, Gjøvik, Norway.,The Centre of Medical Ethics at the University of Oslo, Norway
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17
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Schmittdiel JA, Gopalan A, Lin MW, Banerjee S, Chau CV, Adams AS. Population Health Management for Diabetes: Health Care System-Level Approaches for Improving Quality and Addressing Disparities. Curr Diab Rep 2017; 17:31. [PMID: 28364355 PMCID: PMC5536329 DOI: 10.1007/s11892-017-0858-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE OF REVIEW Population care approaches for diabetes have the potential to improve the quality of care and decrease diabetes-related mortality and morbidity. Population care strategies are particularly relevant as accountable care organizations (ACOs), patient-centered medical homes (PCMH), and integrated delivery systems are increasingly focused on managing chronic disease care at the health system level. This review outlines the key elements of population care approaches for diabetes in the current health care environment. RECENT FINDINGS Population care approaches proactively identify diabetes patients through disease registries and electronic health record data and utilize multidisciplinary care teams, personalized provider feedback, and decision support tools to target and care for patients at risk for poor outcomes. Existing evidence suggests that these strategies can improve care outcomes and potentially ameliorate existing race/ethnic disparities in health care. However, such strategies may be less effective for patients who are disengaged from the health care system. As population care for diabetes continues to evolve, future initiatives should consider ways to tailor population care to meet individual patient needs, while leveraging improvements in clinical information systems and care integration to optimally manage and prevent diabetes in the future.
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Affiliation(s)
- Julie A Schmittdiel
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
| | - Anjali Gopalan
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Mark W Lin
- Kaiser Permanente Northern California Oakland Medical Center, Oakland, CA, USA
| | - Somalee Banerjee
- Kaiser Permanente Northern California Oakland Medical Center, Oakland, CA, USA
| | - Christopher V Chau
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
- University of California at Berkeley School of Public Health, Berkeley, CA, USA
| | - Alyce S Adams
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
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18
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Ellner AL, Phillips RS. The Coming Primary Care Revolution. J Gen Intern Med 2017; 32:380-386. [PMID: 28243869 PMCID: PMC5377886 DOI: 10.1007/s11606-016-3944-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 10/27/2016] [Accepted: 11/16/2016] [Indexed: 01/08/2023]
Abstract
The United States has the most expensive, technologically advanced, and sub-specialized healthcare system in the world, yet it has worse population health status than any other high-income country. Rising healthcare costs, high rates of waste, the continued trend towards chronic non-communicable disease, and the growth of new market entrants that compete with primary care services have set the stage for fundamental change in all of healthcare, driven by a revolution in primary care. We believe that the coming primary care revolution ought to be guided by the following design principles: 1) Payment must adequately support primary care and reward value, including non-visit-based care. 2) Relationships will serve as the bedrock of value in primary care, and will increasingly be fostered by teams, improved clinical operations, and technology, with patients and non-physicians assuming an ever-increasing role in most aspects of healthcare. 3) Generalist physicians will increasingly focus on high-acuity and high-complexity presentations, and primary care teams will increasingly manage conditions that specialists managed in the past. 4) Primary care will refocus on whole-person care, and address health behaviors as well as vision, hearing, dental, and social services. Design based on these principles should lead to higher-value healthcare, but will require new approaches to workforce training.
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Affiliation(s)
- Andrew L Ellner
- Center for Primary Care, Harvard Medical School, 635 Huntington Avenue, Boston, MA, 02115, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Russell S Phillips
- Center for Primary Care, Harvard Medical School, 635 Huntington Avenue, Boston, MA, 02115, USA.
- Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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19
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Lofters AK, Schuler A, Slater M, Baxter NN, Persaud N, Pinto AD, Kucharski E, Davie S, Nisenbaum R, Kiran T. Using self-reported data on the social determinants of health in primary care to identify cancer screening disparities: opportunities and challenges. BMC FAMILY PRACTICE 2017; 18:31. [PMID: 28241787 PMCID: PMC5330155 DOI: 10.1186/s12875-017-0599-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 02/09/2017] [Indexed: 12/13/2022]
Abstract
Background Data on the social determinants of health can help primary care practices target improvement efforts, yet relevant data are rarely available. Our family practice located in Toronto, Ontario routinely collects patient-level sociodemographic data via a pilot-tested survey developed by a multi-organizational steering committee. We sought to use these data to assess the relationship between the social determinants and colorectal, cervical and breast cancer screening, and to describe the opportunities and challenges of using data on social determinants from a self-administered patient survey. Methods Patients of the family practice eligible for at least one of the three cancer screening types, based on age and screening guidelines as of June 30, 2015 and who had answered at least one question on a socio-demographic survey were included in the study. We linked self-reported data from the sociodemographic survey conducted in the waiting room with patients’ electronic medical record data and cancer screening records. We created an individual-level income variable (low-income cut-off) that defined a poverty threshold and took household size into account. The sociodemographic characteristics of patients who were overdue for screening were compared to those who were up-to-date for screening for each cancer type using chi-squared tests. Results We analysed data for 5766 patients for whom we had survey data. Survey participants had significantly higher screening rates (72.9, 78.7, 74.4% for colorectal, cervical and breast cancer screening respectively) than the 13, 036 patients for whom we did not have survey data (59.2, 65.3, 58.9% respectively). Foreign-born patients were significantly more likely to be up-to-date on colorectal screening than their Canadian-born peers but showed no significant differences in breast or cervical cancer screening. We found a significant association between the low-income cut-off variable and cancer screening; neighbourhood income quintile was not significantly associated with cancer screening. Housing status was also significantly associated with colorectal, cervical and breast cancer screening. There was a large amount of missing data for the low-income cut-off variable, approximately 25% across the three cohorts. Conclusion While we were able to show that neighbourhood income might under-estimate income-related disparities in screening, individual-level income was also the most challenging variable to collect. Future work in this area should target the income disparity in cancer screening and simultaneously explore how best to collect measures of poverty. Electronic supplementary material The online version of this article (doi:10.1186/s12875-017-0599-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A K Lofters
- Department of Family & Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. .,Department of Family & Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada. .,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. .,Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada. .,Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.
| | - A Schuler
- Department of Family & Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - M Slater
- Department of Family & Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - N N Baxter
- Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada.,Department of Surgery, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - N Persaud
- Department of Family & Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Department of Family & Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - A D Pinto
- Department of Family & Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Department of Family & Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada
| | - E Kucharski
- Cancer Care Ontario, 620 University Avenue, Toronto, ON, M5G 2L7, Canada
| | - S Davie
- Department of Family & Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - R Nisenbaum
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada
| | - T Kiran
- Department of Family & Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Department of Family & Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
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20
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Alcaraz KI, Sly J, Ashing K, Fleisher L, Gil-Rivas V, Ford S, Yi JC, Lu Q, Meade CD, Menon U, Gwede CK. The ConNECT Framework: a model for advancing behavioral medicine science and practice to foster health equity. J Behav Med 2017; 40:23-38. [PMID: 27509892 PMCID: PMC5296246 DOI: 10.1007/s10865-016-9780-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 08/02/2016] [Indexed: 12/23/2022]
Abstract
Health disparities persist despite ongoing efforts. Given the United States' rapidly changing demography and socio-cultural diversity, a paradigm shift in behavioral medicine is needed to advance research and interventions focused on health equity. This paper introduces the ConNECT Framework as a model to link the sciences of behavioral medicine and health equity with the goal of achieving equitable health and outcomes in the twenty-first century. We first evaluate the state of health equity efforts in behavioral medicine science and identify key opportunities to advance the field. We then discuss and present actionable recommendations related to ConNECT's five broad and synergistic principles: (1) Integrating Context; (2) Fostering a Norm of Inclusion; (3) Ensuring Equitable Diffusion of Innovations; (4) Harnessing Communication Technology; and (5) Prioritizing Specialized Training. The framework holds significant promise for furthering health equity and ushering in a new and refreshing era of behavioral medicine science and practice.
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Affiliation(s)
- Kassandra I Alcaraz
- Behavioral Research Center, American Cancer Society, 250 Williams Street NW, Atlanta, GA, 30303, USA.
| | - Jamilia Sly
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kimlin Ashing
- Beckman Research Institute, City of Hope Medical Center, Duarte, CA, USA
| | - Linda Fleisher
- Center for Injury Research and Prevention, Fox Chase Cancer Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Virginia Gil-Rivas
- Department of Psychology, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Sabrina Ford
- College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - Jean C Yi
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Qian Lu
- Department of Psychology, University of Houston, Houston, TX, USA
| | - Cathy D Meade
- Moffitt Cancer Center, Population Science, Health Outcomes and Behavior, Department of Oncologic Sciences, University of South Florida, Tampa, FL, USA
| | - Usha Menon
- The University of Arizona College of Nursing, Tucson, AZ, USA
| | - Clement K Gwede
- Moffitt Cancer Center, Population Science, Health Outcomes and Behavior, Department of Oncologic Sciences, University of South Florida, Tampa, FL, USA
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21
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Coughlin SS, Blumenthal DS, Seay SJ, Smith SA. Toward the Elimination of Colorectal Cancer Disparities Among African Americans. J Racial Ethn Health Disparities 2016; 3:555-564. [PMID: 27294749 PMCID: PMC4911324 DOI: 10.1007/s40615-015-0174-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 10/01/2015] [Accepted: 10/05/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND In the USA, race and socioeconomic status are well-known factors associated with colorectal cancer incidence and mortality rates. These are higher among blacks than whites and other racial/ethnic groups. METHODS In this article, we review opportunities to address disparities in colorectal cancer incidence, mortality, and survivorship among African Americans. RESULTS First, we summarize the primary prevention of colorectal cancer and recent advances in the early detection of the disease and disparities in screening. Then, we consider black-white disparities in colorectal cancer treatment and survival including factors that may contribute to such disparities and the important roles played by cultural competency, patient trust in one's physician, and health literacy in addressing colorectal cancer disparities, including the need for studies involving the use of colorectal cancer patient navigators who are culturally competent. CONCLUSION To reduce these disparities, intervention efforts should focus on providing high-quality screening and treatment for colorectal cancer and on educating African Americans about the value of diet, weight control, screening, and treatment. Organized approaches for delivering colorectal cancer screening should be accompanied by programs and policies that provide access to diagnostic follow-up and treatment for underserved populations.
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Affiliation(s)
- Steven S Coughlin
- Department of Community Health and Sustainability, Division of Public Health, University of Massachusetts, One University Avenue, Kitson Hall 311A, Lowell, MA, 01854, USA.
| | - Daniel S Blumenthal
- Department of Community Health and Preventive Medicine, Morehouse School of Medicine, Atlanta, GA, USA
| | | | - Selina A Smith
- Department of Community Health and Preventive Medicine, Morehouse School of Medicine, Atlanta, GA, USA
- Institute of Public and Preventive Health, and Department of Family Medicine, Medical College of Georgia, Georgia Regents University, Augusta, GA, USA
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22
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Eisenstat SA, Chang Y, Porneala BC, Geagan E, Wilkins G, Chase B, O’Keefe SM, Delahanty LM, Atlas SJ, Zai AH, Finn D, Weil E, Wexler DJ. Development and Implementation of a Collaborative Team Care Model for Effective Insulin Use in an Academic Medical Center Primary Care Network. Am J Med Qual 2016; 32:397-405. [DOI: 10.1177/1062860616651715] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Improving glycemic control across a primary care diabetes population is challenging. This article describes the development, implementation, and outcomes of the Diabetes Care Collaborative Model (DCCM), a collaborative team care process focused on promoting effective insulin use targeting patients with hyperglycemia in a patient-centered medical home model. After a pilot, the DCCM was implemented in 18 primary care practices affiliated with an academic medical center. Its implementation was associated with improvements in glycemic control and increase in insulin prescription longitudinally and across the entire population, with a >1% reduction in the proportion of glycated hemoglobin >9% at 2 years after the implementation compared with the 2 years prior ( P < .001). Facilitating factors included diverse stakeholder engagement, institutional alignment of priorities, awarding various types of credits for participation and implementation to providers, and a strong theoretical foundation using the principles of the collaborative care model.
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Affiliation(s)
| | - Yuchiao Chang
- Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | | | | | | | | | | | - Linda M. Delahanty
- Harvard Medical School, Boston, MA
- MGH Diabetes Center and Center for Diabetes Population Health, Boston, MA
| | - Steven J. Atlas
- Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Adrian H. Zai
- Harvard Medical School, Boston, MA
- MGH Laboratory of Computer Science, Boston, MA
| | - David Finn
- Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Eric Weil
- Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Deborah J. Wexler
- Harvard Medical School, Boston, MA
- MGH Diabetes Center and Center for Diabetes Population Health, Boston, MA
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Rust G, Zhang S, Yu Z, Caplan L, Jain S, Ayer T, McRoy L, Levine RS. Counties eliminating racial disparities in colorectal cancer mortality. Cancer 2016; 122:1735-48. [PMID: 26969874 DOI: 10.1002/cncr.29958] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/31/2015] [Accepted: 01/25/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND Although colorectal cancer (CRC) mortality rates are declining, racial-ethnic disparities in CRC mortality nationally are widening. Herein, the authors attempted to identify county-level variations in this pattern, and to characterize counties with improving disparity trends. METHODS The authors examined 20-year trends in US county-level black-white disparities in CRC age-adjusted mortality rates during the study period between 1989 and 2010. Using a mixed linear model, counties were grouped into mutually exclusive patterns of black-white racial disparity trends in age-adjusted CRC mortality across 20 three-year rolling average data points. County-level characteristics from census data and from the Area Health Resources File were normalized and entered into a principal component analysis. Multinomial logistic regression models were used to test the relation between these factors (clusters of related contextual variables) and the disparity trend pattern group for each county. RESULTS Counties were grouped into 4 disparity trend pattern groups: 1) persistent disparity (parallel black and white trend lines); 2) diverging (widening disparity); 3) sustained equality; and 4) converging (moving from disparate outcomes toward equality). The initial principal component analysis clustered the 82 independent variables into a smaller number of components, 6 of which explained 47% of the county-level variation in disparity trend patterns. CONCLUSIONS County-level variation in social determinants, health care workforce, and health systems all were found to contribute to variations in cancer mortality disparity trend patterns from 1990 through 2010. Counties sustaining equality over time or moving from disparities to equality in cancer mortality suggest that disparities are not inevitable, and provide hope that more communities can achieve optimal and equitable cancer outcomes for all. Cancer 2016;122:1735-48. © 2016 American Cancer Society.
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Affiliation(s)
- George Rust
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, FL.,Department of Community Health And Preventive Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Shun Zhang
- Statistics and Methodology Department, NORC at the University of Chicago, Chicago, Illinois
| | - Zhongyuan Yu
- School of Systems and Enterprises, Stevens Institute of Technology, Hoboken, New Jersey
| | - Lee Caplan
- Deparment of Community Health and Preventive Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Sanjay Jain
- Department of Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Turgay Ayer
- Department of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Luceta McRoy
- School of Business and Management, Southern Adventist University, Collegedale, Tennessee
| | - Robert S Levine
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas
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Kiran T, Pinto AD. Swimming 'upstream' to tackle the social determinants of health. BMJ Qual Saf 2016; 25:138-40. [PMID: 26744423 DOI: 10.1136/bmjqs-2015-005008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2015] [Indexed: 11/04/2022]
Affiliation(s)
- Tara Kiran
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Andrew D Pinto
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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25
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Lee Smith J, Hall IJ. Advancing Health Equity in Cancer Survivorship: Opportunities for Public Health. Am J Prev Med 2015; 49:S477-82. [PMID: 26590642 PMCID: PMC4658651 DOI: 10.1016/j.amepre.2015.08.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 08/03/2015] [Accepted: 08/13/2015] [Indexed: 01/18/2023]
Affiliation(s)
- Judith Lee Smith
- Epidemiology and Applied Research Branch, Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia.
| | - Ingrid J Hall
- Epidemiology and Applied Research Branch, Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
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Addressing basic resource needs to improve primary care quality: a community collaboration programme. BMJ Qual Saf 2015; 25:164-72. [DOI: 10.1136/bmjqs-2015-004521] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 11/03/2015] [Indexed: 01/30/2023]
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27
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Paluri R. Capsule Commentary on Berkowitz et al., Building Equity Improvement into Quality Improvement: Reducing Socioeconomic Disparities in Colorectal Cancer Screening as Part of Population Health Management. J Gen Intern Med 2015; 30:1001. [PMID: 25722092 PMCID: PMC4471012 DOI: 10.1007/s11606-015-3244-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Ravikumar Paluri
- Division of Hematology and Oncology, Comprehensive Cancer Center, University of Alabama at Birmingham (UAB), Birmingham, AL, USA,
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