Pre-Visit Prioritization for complex patients with diabetes: Randomized trial design and implementation within an integrated health care system

The Alliance for Healthier Communities as a Learning Health System for primary care: A qualitative analysis in Ontario, Canada

RATIONALE, AIMS AND OBJECTIVES

A learning health system model can be used to efficiently evaluate and incorporate evidence-based care into practice. However, there is a paucity of evidence describing key organizational attributes needed to ensure a successful learning health system within primary care. We interviewed stakeholders for a primary care learning health system in Ontario, Canada (the Alliance for Healthier Communities) to identify strengths and areas for improvement.

METHOD

We conducted a qualitative descriptive study using individual semistructured interviews with Alliance stakeholders between December 2019 and March 2020. The Alliance delivers community-governed primary healthcare through 109 organizations including Community Health Centres (CHCs). All CHC staff within the Alliance were invited to participate. Interviews were audio-recorded and transcribed verbatim. We performed a thematic analysis using a team approach.

RESULTS

We interviewed 29 participants across six CHCs, including Executive Directors, managers, healthcare providers and data support staff. We observed three foundational elements necessary for a successful learning health system within primary care: shared organizational goals and culture, data quality and resources. Building on this foundation, people are needed to drive the learning health system, and this is conditional on their level of engagement. The main factors motivating staff member's engagement with the learning health system included their drive to help improve patient care, focusing on initiatives of personal interest and understanding the purpose of different initiatives. Areas for improvement were identified such as the ability to extract and use data to inform changes in real-time, better engagement and protected time for providers to do improvement work, and more staff dedicated to data extraction and analysis.

CONCLUSIONS

We identified key components needed to establish a learning health system in primary care. Similar primary care organizations in Canada and elsewhere can use these insights to guide their development as learning health systems.

Adapting an Interdisciplinary Learning Health System Framework for Academic Health Centers: A Scoping Review

PURPOSE

Learning health systems (LHSs), defined as a systematic process for aligning science, informatics, and clinical practice to integrate providers, researchers, and patients as active participants in an evidence-based care continuum, can provide an ideal environment for academic health centers to rapidly adopt evidence-based guidelines and translate research into practice. However, few LHS frameworks are specifically adapted for academic health centers. The authors wanted to identify the definitions, components, and other features of LHSs to develop an interdisciplinary LHS framework for use within academic health centers.

METHOD

The authors conducted a scoping review of the literature to identify definitions, components, and other features of LHSs that are useful to academic health centers. In January 2021, they searched PubMed, Academic Search Premier, and Scopus databases and identified English-language, peer-reviewed articles pertaining to LHS, LHS frameworks, organization, components, and models. Since the phrase learning health system is relatively new terminology, they conducted a supplemental review with alternative phrases, including embedded research and coordinated or collaborative research network . They used the Knowledge to Action (KTA) Framework to integrate the generation and flow of research into practice.

RESULTS

The primary review retrieved 719 articles and the supplemental review retrieved 209; of these, 49 articles were retained to synthesize common definitions, components, and other features of LHS frameworks. Seven structural components of LHSs were identified: organization and collaborations, performance, ethics and security, scientific approaches, data, information technology, and patient outcomes. An adapted interdisciplinary LHS framework was developed that incorporated research and learning engines derived from the KTA and adaptations of common components and other features within the reviewed articles to fit the interests of providers, researchers, and patients within academic health centers.

CONCLUSIONS

The adapted LHS framework can be used as a dynamic foundation for development and organization of interdisciplinary LHSs within academic health centers.

Establishing priorities for diabetes action goals according to key opinion leaders and health professionals

Background

The ever-increasing burden of diabetes and the limited resources highlight the need for prioritization of national action goals for diabetes management. The Israeli National Diabetes Council (INDC) initiated a prioritization process aiming to set a top list of diabetes related goals, as suggested by decision makers and health professionals.

Methods

A 2-step prioritization process, including a small (n = 32) circle of key opinion leaders of the INDC and a larger (n = 195) nationwide circle of diabetes health professionals consisting of physicians, nurses, and dieticians working in diabetes care centers, hospitals and family practice clinics, was established. An online questionnaire presenting 45 different action areas in diabetes prevention and care was distributed to the INDC members who ranked the 3 top diabetes priorities based on their individual interpretation of importance and applicability. The 7 highest ranking priorities were later presented to hospital-based and community diabetes health professionals. These professionals selected the 3 top priorities, based on their perceived importance.

Results

Council members opted mostly for action areas regarding specific populations, such as clinics for adult type-1 diabetes patients, diabetic foot, and pediatric and adolescent patients, while the health professionals’ top priorities were mostly in the general field of prevention, namely high-risk prediabetes population, prevention of obesity, and promotion of healthy life-style. In addition, priorities differed between hospital and community health professionals as well as between different professional groups.

Conclusions

A national prioritization process of action areas in diabetes prevention and care is attainable. The resulting item list is affected by professional considerations. These priorities may direct efforts in the implementation of interventions to improve national-level diabetes management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13584-022-00540-x.

Clarifying the concept of a learning health system for healthcare delivery organizations: Implications from a qualitative analysis of the scientific literature

The "learning health system" (LHS) concept has been defined in broad terms, which makes it challenging for health system leaders to determine exactly what is required to transform their organization into an LHS. This study provides a conceptual map of the LHS landscape by identifying the activities, principles, tools, and conditions that LHS researchers have associated with the concept. Through a multi-step screening process, two researchers identified 79 publications from PubMed (published before January 2020) that contained information relevant to the question, "What work is required of a healthcare organization that is operating as an LHS?" Those publications were coded as to whether or not they referenced each of 94 LHS elements in the taxonomy developed by the study team. This taxonomy, named the Learning Health Systems Consolidated Framework (LHS-CF), organizes the elements into five "bodies of work" (organizational learning, translation of evidence into practice, building knowledge, analyzing clinical data, and engaging stakeholders) and four "enabling conditions" (workforce skilled for LHS work, data systems and informatics technology in place, organization invests resources in LHS work, and supportive organizational culture). We report the frequency that each of the 94 elements was referenced across the 79 publications. The four most referenced elements were: "organization builds knowledge or evidence," "quality improvement practices are standard practice," "patients and family members are actively engaged," and "organizational culture emphasizes and supports learning." By dissecting the LHS construct into its component elements, the LHS-CF taxonomy can serve as a useful tool for LHS researchers and practitioners in defining the aspects of LHS they are addressing. By assessing how often each element is referenced in the literature, the study provides guidance to health system leaders as to how their organization needs to evolve in order to become an LHS - while also recognizing that each organization should emphasize elements that are most aligned with their mission and goals.

Pilot randomized controlled trial Protocol: Life context-informed pre-visit planning to improve care plans for primary care patients with multiple chronic conditions including diabetes

Background

Multimorbidity is common, and care is impacted by patient life context. Effective, efficient interventions to improve patient-centered outcomes such as perceived treatment burden are limited. There is a need for interventions that integrate patient contextual information into primary care encounters to improve such outcomes. Patient life context is a multitude of factors that influence a patient’s life and healthcare, including social determinants of health and broader elements such as family and work demands.

Methods

This pilot randomized controlled trial (RCT) protocol will compare standard pre-visit planning to context-informed pre-visit planning that incorporates the patient’s life context, for patients with diabetes plus other chronic comorbid conditions. Primary outcomes include measures of trial protocol and intervention feasibility and acceptability: physician study and visit perceived burden, patient satisfaction, and patient, physician and staff experience with the trial. Additional measurements of intervention impact include: initial estimates of effect size on patient treatment burden and other patient-oriented outcomes, change in glycemic control, and other intermediate medical outcomes.

Discussion

This intervention is novel as it collects patient life context information using a direct person-to-person approach, allows physicians to review the information prior to patient arrival at the clinic and, where appropriate, incorporate it when negotiating treatment plans, and is longitudinal, summarizing evolving contextual information over time. This pilot RCT has the potential to demonstrate trial protocol and intervention feasibility and acceptability, and estimate effect size on patient and provider outcomes, to inform for a future, definitive RCT.

Trial Registration: This trial was registered at ClinicalTrials.gov prior to patient enrollment: NCT04568382

Technology-Enabled and Artificial Intelligence Support for Pre-Visit Planning in Ambulatory Care: Findings From an Environmental Scan

PURPOSE

Pre-visit planning (PVP) is believed to improve effectiveness, efficiency, and experience of care, yet numerous implementation barriers exist. There are opportunities for technology-enabled and artificial intelligence (AI) support to augment existing human-driven PVP processes-from appointment reminders and pre-visit questionnaires to pre-visit order sets and care gap closures. This study aimed to explore the current state of PVP, barriers to implementation, evidence of impact, and potential use of non-AI and AI tools to support PVP.

METHODS

We used an environmental scan approach involving: (1) literature review; (2) key informant interviews with PVP experts in ambulatory care; and (3) a search of the public domain for technology-enabled and AI solutions that support PVP. We then synthesized the findings using a qualitative matrix analysis.

RESULTS

We found 26 unique PVP implementations in the literature and conducted 16 key informant interviews. Demonstration of impact is typically limited to process outcomes, with improved patient outcomes remaining elusive. Our key informants reported that many PVP barriers are human effort-related and see potential for non-AI and AI technologies to support certain aspects of PVP. We identified 8 examples of commercially available technology-enabled tools that support PVP, some with AI capabilities; however, few of these have been independently evaluated.

CONCLUSIONS

As health systems transition toward value-based payment models in a world where the coronavirus disease 2019 pandemic has shifted patient care into the virtual space, PVP activities-driven by humans and supported by technology-may become more important and powerful and should be rigorously evaluated.

Learning health systems in primary care: a systematic scoping review

BACKGROUND

Learning health systems have been gaining traction over the past decade. The purpose of this study was to understand the spread of learning health systems in primary care, including where they have been implemented, how they are operating, and potential challenges and solutions.

METHODS

We completed a scoping review by systematically searching OVID Medline®, Embase®, IEEE Xplore®, and reviewing specific journals from 2007 to 2020. We also completed a Google search to identify gray literature.

RESULTS

We reviewed 1924 articles through our database search and 51 articles from other sources, from which we identified 21 unique learning health systems based on 62 data sources. Only one of these learning health systems was implemented exclusively in a primary care setting, where all others were integrated health systems or networks that also included other care settings. Eighteen of the 21 were in the United States. Examples of how these learning health systems were being used included real-time clinical surveillance, quality improvement initiatives, pragmatic trials at the point of care, and decision support. Many challenges and potential solutions were identified regarding data, sustainability, promoting a learning culture, prioritization processes, involvement of community, and balancing quality improvement versus research.

CONCLUSIONS

We identified 21 learning health systems, which all appear at an early stage of development, and only one was primary care only. We summarized and provided examples of integrated health systems and data networks that can be considered early models in the growing global movement to advance learning health systems in primary care.

Applied techniques for putting pre-visit planning in clinical practice to empower patient-centered care in the pandemic era: a systematic review and framework suggestion

Background

One of the main elements of patient-centered care is an enhancement of patient preparedness. Thus, pre-visit planning assessment tools was emerged to prepare and involve patients in their treatment process.

Objective

The main objective of this article was to review the applied tools and techniques for consideration of putting pre-visit planning into practice.

Methods

Web of Science, Scopus, IEEE, and PubMed databases were searched using keywords from January 2001 to November 2020. The review was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Then, qualitative analysis was done to suggest an appropriate framework by mapping the main concepts.

Results

Out of 385 citations were retrieved in initial database searches, 49 studies from ten countries were included. Applied pre-visit techniques can be classified into eight categories. Our results showed that almost 81% of studies were related to procedures that were done between each visit, while 42% of articles were related to before visits. Accordingly, the main approach of included articles was patient preparedness. While 38 studies reported this approach is effective, three studies reported the effectiveness of such tools as moderate, only two articles believed it had a low effect on improving patient-centered care.

Conclusion

This survey summarized the characteristics of published studies on pre-visit planning in the proposed framework. This approach could enhance the quality of patient care alongside enhancement patient-provider communication. However, such an approach can also be helpful to control pandemic diseases by reducing unnecessary referrals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06456-7.

Study protocol: Using peer support to aid in prevention and treatment in prediabetes (UPSTART)

BACKGROUND

There is an urgent need to develop and evaluate effective and scalable interventions to prevent or delay the onset of type 2 diabetes mellitus (T2DM).

METHODS

In this randomized controlled pragmatic trial, 296 adults with prediabetes will be randomized to either a peer support arm or enhanced usual care. Participants in the peer support arm meet face-to-face initially with a trained peer coach who also is a patient at the same health center to receive information on locally available wellness and diabetes prevention programs, discuss behavioral goals related to diabetes prevention, and develop an action plan for the next week to meet their goals. Over six months, peer coaches call their assigned participants weekly to provide support for weekly action steps. In the final 6 months, coaches call participants at least once monthly. Participants in the enhanced usual care arm receive information on local resources and periodic updates on available diabetes prevention programs and resources. Changes in A1c, weight, waist circumference and other patient-centered outcomes and mediators and moderators of intervention effects will be assessed.

RESULTS

At least 296 participants and approximately 75 peer supporters will be enrolled.

DISCUSSION

Despite evidence that healthy lifestyle interventions can improve health behaviors and reduce risk for T2DM, engagement in recommended behavior change is low. This is especially true among racial and ethnic minority and low-income adults. Regular outreach and ongoing support from a peer coach may help participants to initiate and sustain healthy behavior changes to reduce their risk of diabetes.

TRIAL REGISTRATION

The ClinicalTrials.gov registration number is NCT03689530.

Patient-Centered Goal Setting in Developmental Therapy: Discordance between Documented Goals and Caregiver-Perceived Goals

INTRODUCTION

Productive interactions between engaged patients and clinical teams are key to effective clinical practice. Accordingly, the identification of needs and priorities through the process of collaborative goal setting is fundamental to patient-centered care. Executing a goal-setting process that is truly collaborative is challenging; many caregivers do not feel that they are adequately involved in the goal-setting process. This study presents the results of an initiative intended to understand goal concordance between therapists and caregivers.

METHODS

We conducted an observational, cross-sectional design study. Twenty-nine pediatric physical and occupational therapists developed and documented collaborative goals for their patients. Over 6 months, 120 randomly selected caregivers from a weekly list of patients scheduled for a follow-up physical or occupational therapy visit participated. Caregivers completed structured interviews related to their children's therapy goals. We calculated agreement coefficients between caregiver-perceived goals and therapist-documented goals.

RESULTS

Overall strength of agreement was poor (M = -0.03, SD = 0.71). There were no significant differences within variables of a goal setter, goal importance, or goal utility. Median agreement coefficients were greatest for goals perceived to be identified solely by the caregiver, perceived as important, and perceived as functionally useful.

CONCLUSIONS

The results of this study underscore the state of discordance in the collaborative goal-setting process in pediatric physical and occupational therapy. Healthcare encounters continue to be framed by provider perspectives and priorities. Developing therapy goals that enhance family involvement, relate to function, and are important to the healthcare consumer may improve the agreement.

Prompting Patients with Poorly Controlled Diabetes to Identify Visit Priorities Before Primary Care Visits: a Pragmatic Cluster Randomized Trial

BACKGROUND

Most patients with diabetes do not meet all evidence-based goals of care, and many patients report poor communication and lack of involvement in decision-making during primary care visits.

OBJECTIVE

To test the hypothesis that a "Pre-Visit Prioritization" secure email message could improve visit communication and glycemic control among patients with type 2 diabetes.

DESIGN

We conducted a pragmatic, provider-randomized, multi-site clinical trial from March 2015 to October 2016 across 30 primary care practices within Kaiser Permanente Northern California (KPNC), a large integrated care delivery system.

PARTICIPANTS

Eligible patients had at least 1 year of KPNC membership, type 2 diabetes with most recently measured hemoglobin A1c (HbA1c) > = 8.0%, and were registered users of the KPNC online patient portal.

INTERVENTIONS

Patients in the intervention arm, upon booking an appointment, received a secure email through the KPNC online portal with a link to the EHR allowing them to submit their top one or two priorities prior to the visit. Control patients received usual care.

MAIN MEASURES

Glycemic control; change in HbA1c 6 and 12 months after the initial visit; patient-reported outcomes related to patient-provider communication and patient care experiences.

KEY RESULTS

During the study period, 1276 patients had at least one eligible visit. In post-visit surveys (n = 457), more intervention arm patients reported preparing questions for their visit (72% vs 63%, p = 0.048) and being given treatment choices to consider (81% vs 73%, p = 0.041). Patients in both arms had similar reductions in HbA1c over the 12-month study period (0.56% ± 1.45%), with no significant differences between arms.

CONCLUSIONS

A "light touch" email-based pre-visit intervention resulted in improved measures of visit interaction but did not significantly improve glycemic control relative to usual care. Improving diabetes clinical outcomes through more effective primary care visits may require more intensive approaches to patient visit preparation.

TRIAL REGISTRY

NCT02375932.

Validation of a Novel Electronic Health Record Patient Portal Advance Care Planning Delivery System

BACKGROUND

Advance care planning allows patients to articulate their future care preferences should they no longer be able to make decisions on their own. Early advance care planning in outpatient settings provides benefits such as less aggressive care and fewer hospitalizations, yet it is underutilized due to barriers such as provider time constraints and communication complexity. Novel methods, such as patient portals, provide a unique opportunity to conduct advance care planning previsit planning for outpatient care. This follow-up to our pilot study aimed to conduct pragmatic testing of a novel electronic health record-tethered framework and its effects on advance care planning delivery in a real-world primary care setting.

OBJECTIVE

Our intervention tested a previsit advance care planning workflow centered around a framework sent via secure electronic health record-linked patient portal in a real-world clinical setting. The primary objective of this study was to determine its impact on frequency and quality of advance care planning documentation.

METHODS

We conducted a pragmatic trial including 2 sister clinical sites, one site implementing the intervention and the other continuing standard care. A total of 419 patients aged between 50 and 93 years with active portal accounts received intervention (n=200) or standard care (n=219). Chart review analyzed the presence of advance care planning and its quality and was graded with previously established scoring criteria based on advance care planning best practice guidelines from multiple nations.

RESULTS

A total of 19.5% (39/200) of patients who received previsit planning responded to the framework. We found that the intervention site had statistically significant improvement in new advance care planning documentation rates (P<.01) and quality (P<.01) among all eligible patients. Advance care planning documentation rates increased by 105% (19/39 to 39/39) and quality improved among all patients who engaged in the previsit planning framework (n=39). Among eligible patients aged between 50 and 60 years at the intervention site, advance care planning documentation rates increased by 37% (27/96 to 37/96). Advance care planning documentation rates increased 34% among high users (27/67 to 36/67).

CONCLUSIONS

Advance care planning previsit planning using a secure electronic health record-supported patient portal framework yielded improvement in the presence of advance care planning documentation, with highest improvement in active patient portal users and patients aged between 50 and 60 years. Targeted previsit patient portal advance care planning delivery in these populations can potentially improve the quality of care in these populations.

A preconsultation web-based tool to generate an agenda for discussion in diabetes outpatient clinics to improve patient outcomes (DIAT): a feasibility study

OBJECTIVE

To test the feasibility of running a randomised controlled trial of a preconsultation web-based intervention (Presenting Asking Checking Expressing (PACE-D)) to improve the quality of care and clinical outcomes in patients with diabetes.

DESIGN AND SETTING

A feasibility study (with randomisation) conducted at outpatient diabetes clinics at two secondary care hospitals in Devon, UK.

PARTICIPANTS

People with diabetes (type 1 and type 2) attending secondary care general diabetes outpatient clinics.

INTERVENTION

The PACE-D, a web-based tool adapted for patients with diabetes to use before their consultation to generate an agenda of topics to discuss with their diabetologist.

OUTCOMES

The percentage of eligible patients who were recruited and the percentage of participants for whom routine glycosylated haemoglobin (HbA1c) data (the putative primary outcome) could be extracted from medical notes and who completed secondary outcome assessments via questionnaire at follow-up were reported.

RESULTS

In contrast with the planned recruitment of 120 participants, only 71 participants were randomised during the 7-month recruitment period. This comprised 18.7% (95% CI 14.9% to 23.0%) of those who were eligible. Mean (SD) age of the participants was 56.5 (12.4) years and 66.2% had type 1 diabetes. Thirty-eight patients were randomised to the intervention arm and 33 to the control arm. HbA1c data were available for only 73% (95% CI 61% to 83%) of participants at the 6 months follow-up. The questionnaire-based data were collected for 66% (95% CI 54% to 77%) of the participants at 6 months follow-up. Participants reported that the PACE-D tool was easy to use.

CONCLUSIONS

A randomised controlled trial of the preconsultation web-based intervention as set out in our current protocol is not feasible without significant modification to improve recruitment and follow-up of participants. The study also provides insights into the feasibility and challenges of conducting complex intervention trials in everyday clinical practice.

TRIAL REGISTRATION

ISRCTN75070242.