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Hwang AS, Chang Y, Matathia S, Brodney S, Barry MJ, Horn DM. Effectiveness of a Population Health Intervention on Disparities in Hypertension Control: A Stepped Wedge Cluster Randomized Clinical Trial. J Gen Intern Med 2024:10.1007/s11606-024-08839-y. [PMID: 38865006 DOI: 10.1007/s11606-024-08839-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 05/20/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Disparities in hypertension control across race, ethnicity, and language have been a long-standing problem in the United States. OBJECTIVE To assess whether a multi-pronged intervention can improve hypertension control for a target population and reduce disparities. DESIGN This stepped wedge cluster randomized trial was conducted at 15 adult primary care clinics affiliated with Massachusetts General Hospital. PCPs were randomized to receive the intervention in twelve groups. PARTICIPANTS The target population was patients who met one of the following criteria based on self-identification: (1) Asian, Black, Indigenous, multi-racial, or other race; (2) Hispanic ethnicity; or (3) preferred language other than English. Reference population was White, English-speaking patients. INTERVENTIONS PCPs were given access to an online equity dashboard that displays disparities in chronic disease management and completed an equity huddle with population health coordinators (PHCs), which involved reviewing target patients whose hypertension was not well controlled. In addition, community health workers (CHWs) were available in some practices to offer additional support. MAIN MEASURES The primary outcome was change in the proportion of target patients meeting the hypertension control goal when comparing intervention and control periods. KEY RESULTS Of the 365 PCPs who were randomized, 311 PCPs and their 10,865 target patients were included in the analysis. The intervention led to an increase in hypertension control in the target population (RD 0.9%; 95% CI [0.3,1.5]) and there was a higher intervention effect in the target population compared to the reference population (DiD 2.1%; 95% CI [1.1, 3.1]). CONCLUSIONS Utilizing data on disparities in quality outcome measures in routine clinical practice augmented by clinical support provided by PHCs and CHWs led to modest, but statistically significant, improvement in hypertension control among BIPOC, Hispanic, and LEP patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05278806.
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Affiliation(s)
- Andrew S Hwang
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah Matathia
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Suzanne Brodney
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael J Barry
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Verbunt EJ, Newman G, Creagh NS, Milley KM, Emery JD, Kelaher MA, Rankin NM, Nightingale CE. Primary care practice-based interventions and their effect on participation in population-based cancer screening programs: a systematic narrative review. Prim Health Care Res Dev 2024; 25:e12. [PMID: 38345096 PMCID: PMC10894721 DOI: 10.1017/s1463423623000713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 11/08/2023] [Accepted: 12/15/2023] [Indexed: 02/15/2024] Open
Abstract
AIM To provide a systematic synthesis of primary care practice-based interventions and their effect on participation in population-based cancer screening programs. BACKGROUND Globally, population-based cancer screening programs (bowel, breast, and cervical) have sub-optimal participation rates. Primary healthcare workers (PHCWs) have an important role in facilitating a patient's decision to screen; however, barriers exist to their engagement. It remains unclear how to best optimize the role of PHCWs to increase screening participation. METHODS A comprehensive search was conducted from January 2010 until November 2023 in the following databases: Medline (OVID), EMBASE, and CINAHL. Data extraction, quality assessment, and synthesis were conducted. Studies were separated by whether they assessed the effect of a single-component or multi-component intervention and study type. FINDINGS Forty-nine studies were identified, of which 36 originated from the USA. Fifteen studies were investigations of single-component interventions, and 34 studies were of multi-component interventions. Interventions with a positive effect on screening participation were predominantly multi-component, and most included combinations of audit and feedback, provider reminders, practice-facilitated assessment and improvement, and patient education across all screening programs. Regarding bowel screening, provision of screening kits at point-of-care was an effective strategy to increase participation. Taking a 'whole-of-practice approach' and identifying a 'practice champion' were found to be contextual factors of effective interventions.The findings suggest that complex interventions comprised of practitioner-focused and patient-focused components are required to increase cancer screening participation in primary care settings. This study provides novel understanding as to what components and contextual factors should be included in primary care practice-based interventions.
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Affiliation(s)
- Ebony J Verbunt
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Grace Newman
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Nicola S Creagh
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Kristi M Milley
- Centre for Cancer Research and Department of General Practice, Victorian Comprehensive Cancer Centre, University of Melbourne, Melbourne, VIC, Australia
| | - Jon D Emery
- Centre for Cancer Research and Department of General Practice, Victorian Comprehensive Cancer Centre, University of Melbourne, Melbourne, VIC, Australia
| | - Margaret A Kelaher
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Nicole M Rankin
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Claire E Nightingale
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
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Paladino J, Fromme EK, Kilpatrick L, Dingfield L, Teuteberg W, Bernacki R, Jackson V, Sanders JJ, Jacobsen J, Ritchie C, Mitchell S. Lessons Learned About System-Level Improvement in Serious Illness Communication: A Qualitative Study of Serious Illness Care Program Implementation in Five Health Systems. Jt Comm J Qual Patient Saf 2023; 49:620-633. [PMID: 37537096 DOI: 10.1016/j.jcjq.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/26/2023] [Accepted: 06/26/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Serious illness communication is a key element of high-quality care, but it is difficult to implement in practice. The Serious Illness Care Program (SICP) is a multifaceted intervention that contributes to more, earlier, and better serious illness conversations and improved patient outcomes. This qualitative study examined the organizational and implementation factors that influenced improvement in real-world contexts. METHODS The authors performed semistructured interviews of 30 health professionals at five health systems that adopted SICP as quality improvement initiatives to investigate the organizational and implementation factors that appeared to influence improvement. RESULTS After SICP implementation across the organizations studied, approximately 4,661 clinicians have been trained in serious illness communication and 56,712 patients had had an electronic health record (EHR)-documented serious illness conversation. Facilitators included (1) visible support from leaders, who financially invested in an implementation team and champions, expressed the importance of serious illness communication as an institutional priority, and created incentives for training and documenting serious illness conversations; (2) EHR and data infrastructure to foster performance improvement and accountability, including an accessible documentation template, a reporting system, and customized data feedback for clinicians; and (3) communication skills training and sustained support for clinicians to problem-solve communication challenges, reflect on communication experiences, and adapt the intervention. Inhibitors included leadership inaction, competing priorities and incentives, variable clinician acceptance of EHR and data tools, and inadequate support for clinicians after training. CONCLUSION Successful implementation appeared to rely on multilevel organizational strategies to prioritize, reward, and reinforce serious illness communication. The insights derived from this research may function as an organizational road map to guide implementation of SICP or related quality initiatives.
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Konnyu KJ, Yogasingam S, Lépine J, Sullivan K, Alabousi M, Edwards A, Hillmer M, Karunananthan S, Lavis JN, Linklater S, Manns BJ, Moher D, Mortazhejri S, Nazarali S, Paprica PA, Ramsay T, Ryan PM, Sargious P, Shojania KG, Straus SE, Tonelli M, Tricco A, Vachon B, Yu CH, Zahradnik M, Trikalinos TA, Grimshaw JM, Ivers N. Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes. Cochrane Database Syst Rev 2023; 5:CD014513. [PMID: 37254718 PMCID: PMC10233616 DOI: 10.1002/14651858.cd014513] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations. OBJECTIVES To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care. SEARCH METHODS We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section. SELECTION CRITERIA We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy. DATA COLLECTION AND ANALYSIS We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors. Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available. MAIN RESULTS We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted. Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three. Combinations of the three most effective QI strategies were estimated to lead to the below effects: - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%; - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg; - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other). AUTHORS' CONCLUSIONS There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review.
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Affiliation(s)
- Kristin J Konnyu
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sharlini Yogasingam
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Johanie Lépine
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Katrina Sullivan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Alun Edwards
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Michael Hillmer
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Sathya Karunananthan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Canada
| | - John N Lavis
- McMaster Health Forum, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Stefanie Linklater
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Braden J Manns
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Canada
| | - David Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sameh Mortazhejri
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Samir Nazarali
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Canada
| | - P Alison Paprica
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Timothy Ramsay
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Peter Sargious
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Kaveh G Shojania
- University of Toronto Centre for Patient Safety, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Sharon E Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital and University of Toronto, Toronto, Canada
| | - Marcello Tonelli
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Canada
| | - Andrea Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital and University of Toronto, Toronto, Canada
- Epidemiology Division and Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Queen's Collaboration for Health Care Quality: A JBI Centre of Excellence, Queen's University, Kingston, Canada
| | - Brigitte Vachon
- School of Rehabilitation, Occupational Therapy Program, University of Montreal, Montreal, Canada
| | - Catherine Hy Yu
- Department of Medicine, St. Michael's Hospital, Toronto, Canada
| | - Michael Zahradnik
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Thomas A Trikalinos
- Departments of Health Services, Policy, and Practice and Biostatistics, Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Noah Ivers
- Department of Family and Community Medicine, Women's College Hospital, Toronto, Canada
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Bonuck KJ, Angier H, McCrimmon S, Holderness H, Erroba J, Huguet N, DeVoe JE, Carney PA. A Scoping Literature Review on Evidence-Based Strategies to Increase Cervical Cancer Screening. J Prim Care Community Health 2023; 14:21501319231220994. [PMID: 38131106 DOI: 10.1177/21501319231220994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
Previous reviews of strategies to increase cervical cancer screening are more than 10 years old, the U.S. continues to fall short of the Healthy People 2030 cervical cancer screening goal, and guidelines were revised in 2018, therefore an updated review of the existing literature is needed. We conducted a scoping review using electronic databases PubMed, Scopus, and Ovid Medline that included publication dates between 2012 and 2021 to answer the question, "Which strategies implemented in U.S. primary care settings have been most successful in increasing rates of cervical cancer screening since the 2012 US Preventative Services Task Force cervical cancer screening guidelines were published?" We mapped findings to pre-specified implementation strategy categories. After initially identifying 399 articles, we excluded 350 due to duplicates or not meeting review criteria, leaving 49 articles for full review. We excluded 37 of these during full-text review and identified 2 additional articles from the manual search of reference lists for a total of 14 studies for abstraction. Eleven articles reported on strategies resulting in increased cervical cancer screening, and 3 did not. Clinic workflow re-design strategies showed the greatest promise in improving cervical cancer screening rates, education strategies for patients had mixed results, and quality management strategies were not effective. These findings suggest clinical workflow re-structures and patient education strategies can increase cervical cancer screening in primary care settings. Results are particularly important in settings that care for underserved populations, as these settings may need additional implementation strategies to decrease cervical cancer screening disparities.
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Affiliation(s)
| | | | | | | | - Jeremy Erroba
- Oregon Health & Science University, Portland, OR, USA
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Paladino J, Sanders J, Kilpatrick LB, Prabhakar R, Kumar P, O'Connor N, Durieux B, Fromme EK, Benjamin E, Mitchell S. Serious Illness Care Programme-contextual factors and implementation strategies: a qualitative study. BMJ Support Palliat Care 2022:bmjspcare-2021-003401. [PMID: 35168931 DOI: 10.1136/bmjspcare-2021-003401] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/24/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES The Serious Illness Care Programme (SICP) is a multicomponent evidence-based intervention that improves communication about patients' values and goals in serious illness. We aim to characterise implementation strategies for programme delivery and the contextual factors that influence implementation in three 'real-world' health system SICP initiatives. METHODS We employed a qualitative thematic framework analysis of field notes collected during the first 1.5 years of implementation and a fidelity survey. RESULTS Analysis revealed empiric evidence about implementation and institutional context. All teams successfully implemented clinician training and an electronic health record (EHR) template for documentation of serious illness conversations. When training was used as the primary strategy to engage clinicians, however, clinician receptivity to the programme and adoption of conversations remained limited due to clinical culture-related barriers (eg, clinicians' attitudes, motivations and practice environment). Visible leadership involvement, champion facilitation and automated EHR-based data feedback on documented conversations appeared to improve adoption. Implementing these strategies depended on contextual factors, including leadership support at the specialty level, champion resources and capacity, and EHR capabilities. CONCLUSIONS Health systems need multifaceted implementation strategies to move beyond the limited impact of clinician training in driving improvement in serious illness conversations. These include EHR-based data feedback, involvement of specialty leaders to message the programme and align incentives, and local champions to problem-solve frontline challenges longitudinally. Implementation of these strategies depended on a favourable institutional context. Greater attention to the influence of contextual factors and implementation strategies may enable sustained improvements in serious illness conversations at scale.
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Affiliation(s)
- Joanna Paladino
- Ariadne Labs, Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Justin Sanders
- Ariadne Labs, Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Family Medicine, Palliative Care, McGill University, Montreal, Québec, Canada
| | - Laurel B Kilpatrick
- Division of Supportive and Palliative Care, Baylor Scott and White Health, Temple, Texas, USA
| | | | | | | | | | - Erik K Fromme
- Ariadne Labs, Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Evan Benjamin
- Ariadne Labs, Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Suzanne Mitchell
- Ariadne Labs, Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
- UMass Memorial Health Care, Worcester, Massachusetts, USA
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Heidemann DL, Adhami A, Nair A, Haftka-George A, Zaidan M, Seshadri V, Tang A, Willens DE. Using a Frontline Staff Intervention to Improve Cervical Cancer Screening in a Large Academic Internal Medicine Clinic. J Gen Intern Med 2021; 36:2608-2614. [PMID: 33987788 PMCID: PMC8390589 DOI: 10.1007/s11606-021-06865-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 04/27/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Cervical cancer is the third most common malignancy affecting women. Screening with Papanicolaou (Pap) tests effectively identifies precancerous lesions and early-stage cervical cancer. While the nationwide rate of cervical cancer screening (CCS) is 84%, our urban general internal medicine (GIM) clinic population had a CCS rate of 70% in 2016. OBJECTIVE To improve our clinic's CCS rate to match or exceed the national average within 18 months by identifying barriers and testing solutions. DESIGN A quality improvement project led by a multidisciplinary group of healthcare providers. PARTICIPANTS Our GIM clinic includes 16 attending physicians, 116 resident physicians, and 20 medical assistants (MAs) with an insured and underserved patient population. INTERVENTION Phase 1 lasted 9 months and implemented CCS patient outreach, patient financial incentives, and clinic staff education. Phase 2 lasted 9 months and involved a workflow change in which MAs identified candidates for CCS during patient check-in. Feedback spanned the entire study period. MAIN MEASURES Our primary outcome was the number of Pap tests completed per month during the 2 study phases. Our secondary outcome was the clinic population's CCS rate for all eligible clinic patients. KEY RESULTS After interventions, the average number of monthly Pap tests increased from 35 to 56 in phase 1 and to 75 in phase 2. Of 385 patients contacted in phase 1, 283 scheduled a Pap test and 115 (41%) completed it. Compared to baseline, both interventions improved cervical cancer screening (phase 1 relative risk, 1.86; 95% CI, 1.64-2.10; P < 0.001; phase 2 relative risk, 2.70; 95% CI, 2.40-3.02; P < 0.001). Our clinic's CCS rate improved from 70% to 75% after the 18-month intervention. CONCLUSIONS The rate of CCS increased by 5% after a systematic 2-phase organizational intervention that empowered MAs to remind, identify, and prepare candidates during check-in for CCS.
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Affiliation(s)
- Danielle L Heidemann
- Department of Internal Medicine, Henry Ford Hospital, Henry Ford Health System, Detroit, MI, USA.
| | - Angie Adhami
- Department of Primary Care, Dedicated Senior Medical Center, St. Petersburg, FL, USA
| | - Anupama Nair
- Department of Internal Medicine, Henry Ford Hospital, Henry Ford Health System, Detroit, MI, USA
| | - Alexis Haftka-George
- Department of Internal Medicine, Henry Ford Hospital, Henry Ford Health System, Detroit, MI, USA
| | - Mariam Zaidan
- Department of Internal Medicine, Henry Ford Hospital, Henry Ford Health System, Detroit, MI, USA
| | - Vaidehi Seshadri
- Department of Internal Medicine, Henry Ford Hospital, Henry Ford Health System, Detroit, MI, USA
| | - Amy Tang
- Department of Public Health Sciences, Detroit, MI, USA
| | - David E Willens
- Department of Internal Medicine, Henry Ford Hospital, Henry Ford Health System, Detroit, MI, USA
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