1
|
Kilbourne AM, Borsky AE, O'Brien RW, Braganza MZ, Garrido MM. The foundational science of learning health systems. Health Serv Res 2024. [PMID: 39165034 DOI: 10.1111/1475-6773.14374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2024] Open
Affiliation(s)
- Amy M Kilbourne
- Office of Research and Development, Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, DC, USA
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Amanda E Borsky
- Office of Research and Development, Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, DC, USA
| | - Robert W O'Brien
- Office of Research and Development, Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, DC, USA
| | - Melissa Z Braganza
- Office of Research and Development, Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, DC, USA
| | - Melissa M Garrido
- Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Harrison MI, Borsky AE. Funding Learning Health System Research: Challenges and Strategies. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2024; 99:673-682. [PMID: 38363814 DOI: 10.1097/acm.0000000000005661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
PURPOSE A growing number of health systems are establishing learning health system (LHS) programs, where research focuses on rapidly improving the health system's internal operations and performance. The authors examine funding challenges facing such initiatives and identify strategies for managing tensions between reliance on external research funding and directly contributing to improvement and learning within the researchers' own system. METHOD Qualitative case studies of LHS research programs in 5 health systems were performed via 38 semistructured interviews (October 2019-April 2021) with 35 diverse respondents. Inductive and deductive rapid qualitative analysis supported interview, system-level, and cross-system summaries and analysis. RESULTS External funding awards to LHS researchers facilitated some internal improvement and learning, scientific advancements, and the reputation of researchers and their systems, but reliance on external funding also challenged researchers' responsiveness to concerns of system leaders, managers, practitioners, and system needs. Gaps between external funding requirements and internally focused projects arose in objectives, practical applicability, audiences, timetables, routines, skill sets, and researchers' careers. To contribute more directly to system improvement, LHS researchers needed to collaborate with clinicians and other nonresearchers and pivot between long research studies and shorter, dynamic improvement, evaluation, and data analysis projects. With support from system executives, LHS program leaders employed several strategies to enhance researchers' internal contributions. They aligned funded-research topics with long-term system needs, obtained internal funding for implementing and sustaining practice change, and diversified funding sources. CONCLUSIONS To foster LHS research contributions to internal system learning and improvement, LHS program leaders need to manage tensions between concentrating on externally funded research and fulfilling their mission of providing research-based services to their own system. Health system executives can support LHS programs by setting clear goals for them; appropriately staffing, budgeting, and incentivizing LHS researchers; and developing supportive, system-wide teamwork, skill development programs, and data infrastructures.
Collapse
|
3
|
Chiem JL, Hansen EE, Fernandez N, Merguerian PA, Parikh SR, Reece K, Low DK, Martin LD. Transforming into a Learning Health System: A Quality Improvement Initiative. Pediatr Qual Saf 2024; 9:e724. [PMID: 38751896 PMCID: PMC11093568 DOI: 10.1097/pq9.0000000000000724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 02/21/2024] [Indexed: 05/18/2024] Open
Abstract
Background The Institute of Medicine introduced the Learning Healthcare System concept in 2006. The system emphasizes quality, safety, and value to improve patient outcomes. The Bellevue Clinic and Surgical Center is an ambulatory surgical center that embraces continuous quality improvement to provide exceptional patient-centered care to the pediatric surgical population. Methods We used statistical process control charts to study the hospital's electronic health record data. Over the past 7 years, we have focused on the following areas: efficiency (surgical block time use), effectiveness (providing adequate analgesia after transitioning to an opioid-sparing protocol), efficacy (creating a pediatric enhanced recovery program), equity (evaluating for racial disparities in surgical readmission rates), and finally, environmental safety (tracking and reducing our facility's greenhouse gas emissions from inhaled anesthetics). Results We have seen improvement in urology surgery efficiency, resulting in a 37% increase in monthly surgical volume, continued adaptation to our opioid-sparing protocol to further reduce postanesthesia care unit opioid administration for tonsillectomy and adenoidectomy cases, successful implementation of an enhanced recovery program, continued work to ensure equitable healthcare for our patients, and more than 85% reduction in our facility's greenhouse gas emissions from inhaled anesthetics. Conclusions The Bellevue Clinic and Surgical Center facility is a living example of a learning health system, which has evolved over the years through continued patient-centered QI work. Our areas of emphasis, including efficiency, effectiveness, efficacy, equity, and environmental safety, will continue to impact the community we serve positively.
Collapse
Affiliation(s)
- Jennifer L. Chiem
- From the Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, Seattle, Wash
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Wash
| | - Elizabeth E. Hansen
- From the Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, Seattle, Wash
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Wash
| | - Nicolas Fernandez
- Department of Urology, Seattle Children’s Hospital, Seattle, Wash
- Department of Urology, University of Washington, Seattle, Wash
| | - Paul A. Merguerian
- Department of Urology, Seattle Children’s Hospital, Seattle, Wash
- Department of Urology, University of Washington, Seattle, Wash
| | - Sanjay R. Parikh
- Seattle Children’s Hospital, Seattle, Wash
- Department of Otolaryngology—Head and Neck Surgery, University of Washington, Seattle, Wash
| | - Kayla Reece
- Department of Perioperative Services, Seattle Children’s Hospital, Seattle, Wash
| | - Daniel K. Low
- From the Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, Seattle, Wash
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Wash
| | - Lynn D. Martin
- From the Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, Seattle, Wash
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Wash
| |
Collapse
|
4
|
Grant RW, Schmittdiel JA, Liu VX, Estacio KR, Chen YI, Lieu TA. Training the next generation of delivery science researchers: 10-year experience of a post-doctoral research fellowship program within an integrated care system. Learn Health Syst 2024; 8:e10361. [PMID: 38249850 PMCID: PMC10797580 DOI: 10.1002/lrh2.10361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 01/25/2023] [Accepted: 01/31/2023] [Indexed: 01/23/2024] Open
Abstract
Introduction Learning health systems require a workforce of researchers trained in the methods of identifying and overcoming barriers to effective, evidence-based care. Most existing postdoctoral training programs, such as NIH-funded postdoctoral T32 awards, support basic and epidemiological science with very limited focus on rigorous delivery science methods for improving care. In this report, we present the 10-year experience of developing and implementing a Delivery Science postdoctoral fellowship embedded within an integrated health care delivery system. Methods In 2012, the Kaiser Permanente Northern California Division of Research designed and implemented a 2-year postdoctoral Delivery Science Fellowship research training program to foster research expertise in identifying and addressing barriers to evidence-based care within health care delivery systems. Results Since 2014, 20 fellows have completed the program. Ten fellows had PhD-level scientific training, and 10 fellows had clinical doctorates (eg, MD, RN/PhD, PharmD). Fellowship alumni have graduated to faculty research positions at academic institutions (9), and research or clinical organizations (4). Seven alumni now hold positions in Kaiser Permanente's clinical operations or medical group (7). Conclusions This delivery science fellowship program has succeeded in training graduates to address delivery science problems from both research and operational perspectives. In the next 10 years, additional goals of the program will be to expand its reach (eg, by developing joint research training models in collaboration with clinical fellowships) and strengthen mechanisms to support transition from fellowship to the workforce, especially for researchers from underrepresented groups.
Collapse
Affiliation(s)
- Richard W Grant
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
- The Permanente Medical GroupOaklandCaliforniaUSA
| | - Julie A Schmittdiel
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
| | - Vincent X Liu
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
- The Permanente Medical GroupOaklandCaliforniaUSA
| | - Karen R Estacio
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
| | | | - Tracy A Lieu
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
- The Permanente Medical GroupOaklandCaliforniaUSA
- Department of Health Systems ScienceKaiser Permanente School of MedicinePasadenaCaliforniaUSA
| |
Collapse
|
5
|
Easterling D, Perry A, Miller D. Implementing the learning health system paradigm within academic health centers. Learn Health Syst 2024; 8:e10367. [PMID: 38249847 PMCID: PMC10797573 DOI: 10.1002/lrh2.10367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/10/2023] [Accepted: 03/29/2023] [Indexed: 01/23/2024] Open
Abstract
Introduction The learning health system (LHS) concept represents a bold innovation that combines organizational learning, strategic analysis of patient data, stakeholder engagement and the systematic translation of research into practice - all in service of improving the quality of health care delivered across the organization. This innovation has been diffused and widely adopted by healthcare organizations over the past 15 years, but academic health centers (AHCs) have been slower on the uptake. The irony is that AHCs have the resources (e.g., trained researchers, sophisticated clinical data systems, informatics infrastructure) that are necessary to do the highest-quality and most impactful LHS work. Methods Based on a review of publications describing how AHCs have implemented LHS work, as well as the authors' direct experience promoting the adoption of the LHS paradigm at Atrium Health Wake Forest Baptist (AHWFB), we:identify a set of factors that have inhibited broader adoption of the LHS paradigm among AHCs; distinguish between the forms of LHS work that are consistent and inconsistent with the mission of AHCs; and offer recommendations for broader adoption and fuller implementation of the LHS paradigm. Results The LHS paradigm represents an expansion of the scientific paradigm which serves as the foundation of research enterprise within AHCs. Both paradigms value rigorous studies of new treatments and practices, including pragmatic clinical trials. The LHS paradigm also places a high value on quality improvement studies, organizational learning, and the translation of research findings into improved patient care and operations within the local health system. The two paradigms differ on the origin of the research question, i.e., a pressing patient-care issue facing the health system versus the investigator's own research interests. Academic researchers have been disincentivized from pursuing at least some forms of LHS research. However, a growing number of AHCs are finding ways to integrate the LHS paradigm into their research enterprise, either by providing research faculty with institutional funding to cover their effort on studies that address the health system's priority issues, or by establishing an institute dedicated to LHS research. Conclusions The LHS paradigm is a disruptive intervention for AHCs, one that was initially resisted but is increasingly being embraced. AHCs are developing strategies for conducting LHS research, typically in parallel to the more traditional biomedical science that is core to academic medicine. Full implementation of the LHS paradigm will require further alignment between LHS and science, including a shift in the criteria for promotion and tenure to support those researchers who choose to focus on the pressing issues facing the health system.
Collapse
Affiliation(s)
- Douglas Easterling
- Department of Social Sciences and Health PolicyWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
- Wake Forest Clinical and Translational Science InstituteWinston‐SalemNorth CarolinaUSA
| | - Anna Perry
- Wake Forest Clinical and Translational Science InstituteWinston‐SalemNorth CarolinaUSA
| | - David Miller
- Wake Forest Clinical and Translational Science InstituteWinston‐SalemNorth CarolinaUSA
- Department of Internal MedicineWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
| |
Collapse
|
6
|
Welch LC, Brewer SK, Schleyer T, Daudelin D, Paranal R, Hunt JD, Dozier AM, Perry A, Cabrera AB, Gatto CL. Learning health system benefits: Development and initial validation of a framework. Learn Health Syst 2024; 8:e10380. [PMID: 38249854 PMCID: PMC10797574 DOI: 10.1002/lrh2.10380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/14/2023] [Accepted: 06/22/2023] [Indexed: 01/23/2024] Open
Abstract
Introduction Implementation of research findings in clinical practice often is not realized or only partially achieved, and if so, with a significant delay. Learning health systems (LHSs) hold promise to overcome this problem by embedding clinical research and evidence-based best practices into care delivery, enabling innovation and continuous improvement. Implementing an LHS is a complex process that requires participation and resources of a wide range of stakeholders, including healthcare leaders, clinical providers, patients and families, payers, and researchers. Engaging these stakeholders requires communicating clear, tangible value propositions. Existing models identify broad categories of benefits but do not explicate the full range of benefits or ways they can manifest in different organizations. Methods To develop such a framework, a working group with representatives from six Clinical and Translational Science Award (CTSA) hubs reviewed existing literature on LHS characteristics, models, and goals; solicited expert input; and applied the framework to their local LHS experiences. Results The Framework of LHS Benefits includes six categories of benefits (quality, safety, equity, patient satisfaction, reputation, and value) relevant for a range of stakeholders and defines key concepts within each benefit. Applying the framework to five LHS case examples indicated preliminary face validity across varied LHS approaches and revealed three dimensions in which the framework is relevant: defining goals of individual LHS projects, facilitating collaboration based on shared values, and establishing guiding tenets of an LHS program or mission. Conclusion The framework can be used to communicate the value of an LHS to different stakeholders across varied contexts and purposes, and to identify future organizational priorities. Further validation will contribute to the framework's evolution and support its potential to inform the development of tools to evaluate LHS impact.
Collapse
Affiliation(s)
- Lisa C. Welch
- Tufts Clinical and Translational Science InstituteTufts UniversityBostonMassachusettsUSA
| | - Sarah K. Brewer
- Tufts Clinical and Translational Science InstituteTufts UniversityBostonMassachusettsUSA
| | - Titus Schleyer
- Center for Biomedical InformaticsRegenstrief InstituteIndianapolisIndianaUSA
- Indiana Clinical and Translational Sciences InstituteIndiana UniversityIndianapolisIndianaUSA
| | - Denise Daudelin
- Tufts Clinical and Translational Science InstituteTufts UniversityBostonMassachusettsUSA
| | - Rechelle Paranal
- South Carolina Clinical and Translational Research Institute, Medical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Joe D. Hunt
- Indiana Clinical and Translational Sciences InstituteIndiana UniversityIndianapolisIndianaUSA
| | - Ann M. Dozier
- University of Rochester Clinical and Translational Science Institute, University of RochesterRochesterNew YorkUSA
| | - Anna Perry
- Wake Forest Clinical and Translational Science Institute, Wake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Alyssa B. Cabrera
- Tufts Clinical and Translational Science InstituteTufts UniversityBostonMassachusettsUSA
| | - Cheryl L. Gatto
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical CenterNashvilleTennesseeUSA
| |
Collapse
|
7
|
Parrott TD, Wallace MD, Niehoff KM, Eble SH, Blumenfeld L, Sevin CM, Choma NN, Gao Y, Choi L, Lindsell CJ, Zuckerman AD. Pharmacist Review of Chronic Inhaler Therapy Appropriateness for Hospitalized Patients with COPD or Asthma. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2023; 6:1304-1312. [PMID: 38352722 PMCID: PMC10861239 DOI: 10.1002/jac5.1862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/06/2023] [Indexed: 02/16/2024]
Abstract
INTRODUCTION Patients with asthma and chronic obstructive pulmonary disease rely on inhaler therapy to reduce disease progression and exacerbation risk. Patients admitted to the hospital are at an increased risk for exacerbations and readmission if their inhaler therapy upon discharge is not aligned with current guidelines and/or affordable. OBJECTIVE Assess the appropriateness of the chronic inhaler regimen for patients admitted to the hospital based on clinical practice guidelines and insurance coverage. METHODS A sub-study was designed to analyze a cohort of a single-center, pragmatic, prospective randomized controlled trial at a large academic medical center. Patients admitted to a medicine service with a pharmacist and prescribed a long-acting inhaler were included. Participants randomized to a pharmacist-led intervention were assessed for inhaler appropriateness based on clinical guidelines and patient insurance. The objective of this sub-study is to assess the number of inhalers identified as inappropriate based on the pharmacist's review. A patient was considered to have an inappropriate inhaler regimen if any of their inhalers were inconsistent with guideline recommendations or not covered by insurance. Descriptive statistics were used to characterize appropriate inhaler use. RESULTS The study pharmacist reviewed 552 unique inhalers for 348 patients. Overall, 42% of inhalers were inappropriate, affecting 50.3% of participants. 20% of inhalers were inappropriate based on insurance, 26% were inappropriate based on guidelines, and 7% were inappropriate based on both criteria. Recommendations were placed via a pharmacy consult for 198 patients (57%), most recommending an inhaler initiation (55%), followed by inhaler discontinuation (38%). CONCLUSION A pharmacist-led review of chronic inhaler therapy for patients admitted to the hospital identified the need for a change in therapy based on financial or clinical guidelines in over half of the patients reviewed. Interventions to increase the appropriateness of prescribed inhalers are needed to reduce disease progression and disease exacerbation.
Collapse
Affiliation(s)
- Tate D Parrott
- Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232; 615-875-1537
| | - Matthew D Wallace
- Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232
| | - Kristina M Niehoff
- Vanderbilt Home Care Services, 2120 Belcourt Avenue, Nashville, TN 37212
| | - Sarah H Eble
- Vanderbilt Complex Care Service, Vanderbilt University Medical Center 1301 Medical Center Drive, Nashville, TN 37232
| | - Lauren Blumenfeld
- PGY-1 Pharmacy Resident, Veterans Affairs Tennessee Valley Healthcare System, 1310 24 Ave S, Nashville, TN 37212
| | - Carla M Sevin
- Pulmonary Patient Care Center, Vanderbilt Lung Institute, Vanderbilt University Medical Center, Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, 1161 21 Avenue S, T-1218 MCN, Nashville, TN 37232
| | - Neesha N Choma
- Vanderbilt University Hospital & Clinics, 2135 Blakemore Avenue, Nashville, TN 37212; 615-343-1203; Department of Medicine, Department of Quality, Safety & Risk Prevention
| | - Yue Gao
- Department of Biostatistics, Vanderbilt University School of Medicine, 2525 West End Ave, Suite 1100, Nashville, TN 37203
| | - Leena Choi
- Department of Biostatistics, Vanderbilt University School of Medicine, 2525 West End Ave, Suite 1100, Nashville, TN 37203
| | | | - Autumn D Zuckerman
- Specialty Pharmacy Services, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232
| |
Collapse
|
8
|
Hirsch G, Velentgas P, Curtis JR, Larholt K, Park JJH, Pashos CL, Trinquart L. Extending the vision of adaptive point-of-care platform trials to improve targeted use of drug therapy regimens: An agile approach in the learning healthcare system toolkit. Contemp Clin Trials 2023; 133:107327. [PMID: 37652359 DOI: 10.1016/j.cct.2023.107327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/24/2023] [Accepted: 08/28/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVES Improving the targeted use of drug regimens requires robust real-world evidence (RWE) to address the uncertainties that remain regarding their real-world performance following market entry. However, challenges in the current state of RWE production limit its impact on clinical decisions, as well as its operational scalability and sustainability. We propose an adaptive point-of-care (APoC) platform trial as an approach to RWE production that improves both clinical and operational efficiencies. METHODS AND FINDINGS We explored design innovations, operational challenges, and infrastructure needs within a multi-stakeholder consortium to evaluate the potential of an APoC platform trial for studying chronic disease treatment regimens using rheumatoid arthritis as a case study. The concept integrates elements from adaptive clinical trials (dynamic treatment regimen strategies) and point-of-care trials (research embedded into routine clinical care) under a perpetual platform infrastructure. The necessary components to implement an APoC platform trial within outpatient settings exist, and present an opportunity for a cross-disciplinary, multi-stakeholder approach. Effective engagement of key stakeholders involved in and impacted by the platform is critical to success. Our collaborative design process identified three high-impact stakeholder-engagement areas: (1) focus on research question(s), (2) design and implementation planning such that it is feasible and fit-for-purpose, and (3) measurement, or meaningful metrics for both clinical (patient outcomes) and system (operational efficiencies) impact. CONCLUSIONS An APoC platform trial for rheumatoid arthritis integrating innovative design elements in a scalable infrastructure has the potential to reduce important uncertainties about the real-world performance of biomedical innovations and improve clinical decisions.
Collapse
Affiliation(s)
- Gigi Hirsch
- Center for Biomedical System Design & NEWDIGS, Tufts Medical Center, Boston, MA, USA.
| | | | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Illumination Health, Hoover, AL, USA
| | - Kay Larholt
- Center for Biomedical System Design & NEWDIGS, Tufts Medical Center, Boston, MA, USA
| | - Jay J H Park
- Core Clinical Sciences Inc, Vancouver, BC, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Ludovic Trinquart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA; Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
| |
Collapse
|
9
|
Mezuk B, Zhong C, Firestone M. Integrative approaches to methods training for early-career scientists: Rationale and process evaluation of the first cohort of the Michigan Integrative Well-Being and Inequality Training Program. J Clin Transl Sci 2023; 7:e169. [PMID: 37588674 PMCID: PMC10425869 DOI: 10.1017/cts.2023.595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/10/2023] [Accepted: 07/12/2023] [Indexed: 08/18/2023] Open
Abstract
Background The Michigan Integrative Well-Being and Inequality (MIWI) Training Program aims to provide state-of-the-art, interdisciplinary training to enhance the methodological skills of early-career scientists interested in integrative approaches to understanding health disparities. The goals of this paper are to describe the scientific rationale and core design elements of MIWI, and to conduct a process evaluation of the first cohort of trainees (called "scholars") to complete this program. Methods Mixed methods process evaluation of program components and assessment of trainee skills and network development of the first cohort (n = 15 scholars). Results The program drew 57 applicants from a wide range of disciplines. Of the 15 scholars in the first cohort, 53% (n = 8) identified as an underrepresented minority, 60% (n = 9) were within 2 years of completing their terminal degree, and most (n = 11, 73%) were from a social/behavioral science discipline (e.g., social work, public health). In the post-program evaluation, scholars rated their improvement in a variety of skills on a one (not at all) to five (greatly improved) scale. Areas of greatest growth included being an interdisciplinary researcher (mean = 4.47), developing new research collaborations (mean = 4.53), and designing a research study related to integrative health (mean = 4.27). The qualitative process evaluation indicated that scholars reported a strong sense of community and that the program broadened their research networks. Conclusions These findings have implications for National Institutes of Health (NIH) efforts to train early-career scientists, particularly from underrepresented groups, working at the intersection of multiple disciplines and efforts to support the formation of research networks.
Collapse
Affiliation(s)
- Briana Mezuk
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
- Center for Research Group Dynamics, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | - Chuwen Zhong
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Monica Firestone
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
10
|
Kibbons AM, Moore R, Choi L, Zuckerman AD. Patient-Tailored Interventions to Improve Specialty Medication Adherence: Results from a Prospective Randomized Controlled Trial. Am J Med 2023; 136:694-701.e1. [PMID: 37028694 PMCID: PMC10794990 DOI: 10.1016/j.amjmed.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/01/2023] [Accepted: 03/16/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND Specialty medication nonadherence results in poor clinical outcomes and increased costs. This study evaluated the impact of patient-tailored interventions on specialty medication adherence. METHODS A pragmatic, randomized controlled trial was conducted at a single-center health-system specialty pharmacy from May 2019 to August 2021. Participants included recently nonadherent patients prescribed self-administered specialty medications from multiple specialty clinics. Eligible patients were stratified by historical clinic rates of nonadherence and randomized 1:1 to usual care or intervention arms. Intervention patients received patient-tailored interventions and 8 months of follow-up. A Wilcoxon test was used to analyze the difference in 6-, 8-, and 12-month post-enrollment adherence, calculated using proportion of days covered, between the intervention and usual care arms. RESULTS Four hundred and thirty eight patients were randomized. Baseline characteristics were similar between groups: mostly women (68%), white (82%), with a median age of 54 years (interquartile range, 40, 64). The most common reasons for nonadherence in the intervention arm were memory (37%) and unreachability (28%). There was a significant difference in median proportion of days covered between patients in the usual care and intervention arms at 8-months (0.88 vs 0.94, P < .001), 6-months (0.90 vs 0.95, P = .003), and 12-months post-enrollment (0.87 vs 0.93, P < .001). CONCLUSIONS Patient-tailored interventions resulted in significant specialty medication adherence improvement compared with standard of care. Specialty pharmacies should consider targeting nonadherent patients for adherence interventions.
Collapse
Affiliation(s)
| | - Ryan Moore
- Vanderbilt University Medical Center, Nashville, United States
| | - Leena Choi
- Vanderbilt University Medical Center, Nashville, United States
| | | |
Collapse
|
11
|
Burnside ES, Schrager S, DuBenske L, Keevil J, Little T, Trentham-Dietz A, Rolland B, Shah D, Alagoz O. Team Science Principles Enhance Cancer Care Delivery Quality Improvement: Interdisciplinary Implementation of Breast Cancer Screening Shared Decision Making. JCO Oncol Pract 2023; 19:e1-e7. [PMID: 36126243 PMCID: PMC10476722 DOI: 10.1200/op.22.00355] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 07/05/2022] [Accepted: 07/20/2022] [Indexed: 01/14/2023] Open
Abstract
PURPOSE Implementing shared decision making (SDM), recommended in screening mammography by national guidelines for women age 40-49 years, faces challenges that innovations in quality improvement and team science (TS) are poised to address. We aimed to improve the effectiveness, patient-centeredness, and efficiency of SDM in primary care for breast cancer screening. METHODS Our interdisciplinary team included primary and specialty care, psychology, epidemiology, communication science, engineering, and stakeholders (patients and clinicians). Over a 6-year period, we executed two iterative cycles of plan-do-study-act (PDSA) to develop, revise, and implement a SDM tool using TS principles. Patient and physician surveys and retrospective analysis of tool performance informed our first PDSA cycle. Patient and physician surveys, toolkit use, and clinical outcomes in the second PDSA cycle supported SDM implementation. We gathered team member assessments on the importance of individual TS activities. RESULTS Our first PDSA cycle successfully generated a SDM tool called Breast Cancer Risk Estimator, deemed valuable by 87% of patients surveyed. Our second PDSA cycle increased Breast Cancer Risk Estimator utilization, from 2,000 sessions in 2017 to 4,097 sessions in 2019 while maintaining early-stage breast cancer diagnoses. Although TS activities such as culture, trust, and communication needed to be sustained throughout the project, shared goals, research/data infrastructure support, and leadership were more important earlier in the project and persisted in the later stages of the project. CONCLUSION Combining rigorous quality improvement and TS principles can support the complex, interdependent, and interdisciplinary activities necessary to improve cancer care delivery exemplified by our implementation of a breast cancer screening SDM tool.
Collapse
Affiliation(s)
| | - Sarina Schrager
- School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Lori DuBenske
- School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | | | - Terry Little
- School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Amy Trentham-Dietz
- School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Betsy Rolland
- School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Dhavan Shah
- School of Journalism and Mass Communication, University of Wisconsin, Madison, WI
| | - Oguzhan Alagoz
- College of Engineering, University of Wisconsin, Madison, WI
| |
Collapse
|
12
|
Collard HR, Grumbach K. A Call to Improve Health by Achieving the Learning Health Care System. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:29-35. [PMID: 36006840 DOI: 10.1097/acm.0000000000004949] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The learning health care system is an aspirational operational model for improving health care by learning from the care being delivered. The model, which has been endorsed by the National Academy of Medicine, aligns naturally with academic health systems, which have a mission to improve care for their communities through research and education. In this scholarly perspective, the authors define the learning health care system concept and its historical relationship to academic health systems; explore opportunities for and barriers to realizing the learning health care system; and propose actions to achieve the learning health care system at the local, regional, and national levels. The authors argue that the learning health care system model is essential to academic medicine's evolution and to achieving the foundational societal mission of academic health systems to advance health through research and education.
Collapse
Affiliation(s)
- Harold R Collard
- H.R. Collard is professor of medicine and health policy, Department of Medicine, director, Clinical and Translational Science Institute, and associate vice chancellor, Clinical Research, University of California, San Francisco, San Francisco, California; ORCID: https://orcid.org/0000-0002-8384-9506
| | - Kevin Grumbach
- K. Grumbach is professor and chair, Department of Family and Community Medicine, director, Community Engagement Program, Clinical and Translational Science Institute, and senior medical director, Office of Population Health, University of California, San Francisco, San Francisco, California; ORCID: https://orcid.org/0000-0002-7809-214X
| |
Collapse
|
13
|
Hollenberg SM, Janz DR, Hua M, Malesker M, Qadir N, Rochwerg B, Sessler CN, Tatem G, Rice TW. COVID-19: Lessons Learned, Lessons Unlearned, Lessons for the Future. Chest 2022; 162:1297-1305. [PMID: 35952767 PMCID: PMC9512535 DOI: 10.1016/j.chest.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 07/10/2022] [Accepted: 08/02/2022] [Indexed: 12/15/2022] Open
Abstract
The COVID-19 pandemic has affected clinicians in many different ways. Clinicians have their own experiences and lessons that they have learned from their work in the pandemic. This article outlines a few lessons learned from the eyes of CHEST Critical Care Editorial Board members, namely practices which will be abandoned, novel practices to be adopted moving forward, and proposed changes to the health care system in general. In an attempt to start the discussion of how health care can grow from the pandemic, the editorial board members outline their thoughts on these lessons learned.
Collapse
Affiliation(s)
- Steven M Hollenberg
- Emory Heart & Vascular Institute, Emory University School of Medicine, Atlanta, GA
| | - David R Janz
- Medical Critical Care Services, University Medical Center New Orleans, Louisiana State University School of Medicine New Orleans, New Orleans, LA
| | - May Hua
- Mailman School of Public Health, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Mark Malesker
- Department of Pharmacy Practice, School of Pharmacy and Health Professions, Creighton University, Omaha, NE
| | - Nida Qadir
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, Los Angeles, CA
| | | | - Curtis N Sessler
- Center for Adult Critical Care, Virginia Commonwealth University Health System, Richmond, VA
| | - Geneva Tatem
- Pulmonary and Critical Care Medicine Fellowship Program, Henry Ford Health, Detroit, MI
| | - Todd W Rice
- Vanderbilt University Medical Center, Nashville, TN.
| |
Collapse
|
14
|
Trinkley KE, Ho PM, Glasgow RE, Huebschmann AG. How Dissemination and Implementation Science Can Contribute to the Advancement of Learning Health Systems. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:1447-1458. [PMID: 35796045 PMCID: PMC9547828 DOI: 10.1097/acm.0000000000004801] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Many health systems are working to become learning health systems (LHSs), which aim to improve the value of health care by rapidly, continuously generating evidence to apply to practice. However, challenges remain to advance toward the aspirational goal of becoming a fully mature LHS. While some important challenges have been well described (i.e., building system-level supporting infrastructure and the accessibility of inclusive, integrated, and actionable data), other key challenges are underrecognized, including balancing evaluation rapidity with rigor, applying principles of health equity and classic ethics, focusing on external validity and reproducibility (generalizability), and designing for sustainability. Many LHSs focus on continuous learning cycles, but with limited consideration of issues related to the rapidity of these learning cycles, as well as the sustainability or generalizability of solutions. Some types of data have been consistently underrepresented, including patient-reported outcomes and preferences, social determinants, and behavioral and environmental data, the absence of which can exacerbate health disparities. A promising approach to addressing many challenges that LHSs face may be found in dissemination and implementation (D&I) science. With an emphasis on multilevel dynamic contextual factors, representation of implementation partner engagement, pragmatic research, sustainability, and generalizability, D&I science methods can assist in overcoming many of the challenges facing LHSs. In this article, the authors describe the current state of LHSs and challenges to becoming a mature LHS, propose solutions to current challenges, focusing on the contributions of D&I science with other methods, and propose key components and characteristics of a mature LHS model that others can use to plan and develop their LHSs.
Collapse
Affiliation(s)
- Katy E Trinkley
- K.E. Trinkley is associate professor, Departments of Clinical Pharmacy and Medicine and Adult and Child Consortium for Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Center, and clinical informaticist, Department of Clinical Informatics, UCHealth, Aurora, Colorado; ORCID: http://orcid.org/0000-0003-2041-7404
| | - P Michael Ho
- P.M. Ho is professor, Department of Medicine, University of Colorado Anschutz Medical Campus, and professor, VA Eastern Colorado Health Care System, Aurora, Colorado; ORCID: http://orcid.org/0000-0002-7775-6266
| | - Russell E Glasgow
- R.E. Glasgow is research professor, Department of Family Medicine, and director, Dissemination and Implementation Science Program, ACCORDS, University of Colorado Anschutz Medical Center, Aurora, Colorado; ORCID: http://orcid.org/0000-0003-4218-3231
| | - Amy G Huebschmann
- A.G. Huebschmann is associate professor, Division of General Internal Medicine, ACCORDS and Ludeman Family Center for Women's Health Research, University of Colorado Anschutz Medical Center, Aurora, Colorado; ORCID: http://orcid.org/0000-0002-9329-3142
| |
Collapse
|
15
|
McEvoy MD, Dear ML, Buie R, Edwards DA, Barrett TW, Allen B, Robertson AC, Fowler LC, Hennessy C, Miller BM, Garvey KV, Bland RP, Fleming GM, Moore D, Rice TW, Bernard GR, Lindsell CJ. Effect of Smartphone App-Based Education on Clinician Prescribing Habits in a Learning Health Care System: A Randomized Cluster Crossover Trial. JAMA Netw Open 2022; 5:e2223099. [PMID: 35881398 PMCID: PMC9327570 DOI: 10.1001/jamanetworkopen.2022.23099] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Effective methods for engaging clinicians in continuing education for learning-based practice improvement remain unknown. OBJECTIVE To determine whether a smartphone-based app using spaced education with retrieval practice is an effective method to increase evidence-based practice. DESIGN, SETTING, AND PARTICIPANTS A prospective, unblinded, single-center, crossover randomized clinical trial was conducted at a single academic medical center from January 6 to April 24, 2020. Vanderbilt University Medical Center clinicians prescribing intravenous fluids were invited to participate in this study. INTERVENTIONS All clinicians received two 4-week education modules: 1 on prescribing intravenous fluids and 1 on prescribing opioid and nonopioid medications (counterbalancing measure), over a 12-week period. The order of delivery was randomized 1:1 such that 1 group received the fluid management module first, followed by the pain management module after a 4-week break, and the other group received the pain management module first, followed by the fluid management module after a 4-week break. MAIN OUTCOMES AND MEASURES The primary outcome was evidence-based clinician prescribing behavior concerning intravenous fluids in the inpatient setting and pain medication prescribing on discharge from the hospital. RESULTS A total of 354 participants were enrolled and randomized, with 177 in group 1 (fluid then pain management education) and 177 in group 2 (pain management then fluid education). During the overall study period, 16 868 questions were sent to 349 learners, with 11 783 (70.0%) being opened: 10 885 (92.4%) of those opened were answered and 7175 (65.9%) of those answered were answered correctly. The differences between groups changed significantly over time, indicated by the significant interaction between educational intervention and time (P = .002). Briefly, at baseline evidence-concordant IV fluid ordered 7.2% less frequently in group 1 than group 2 (95% CI, -19.2% to 4.9%). This was reversed after training at 4% higher (95% CI, -8.2% to 16.0%) in group 1 than group 2, a more than doubling in the odds of evidence-concordant ordering (OR, 2.56, 95% CI, 0.80-8.21). Postintervention, all gains had been reversed with less frequent ordering in group 1 than group 2 (-9.5%, 95% CI, -21.6% to 2.7%). There was no measurable change in opioid prescribing behaviors at any time point. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, use of smartphone app learning modules resulted in statistically significant short-term improvement in some prescribing behaviors. However, this effect was not sustained over the long-term. Additional research is needed to understand how to sustain improvements in care delivery as a result of continuous professional development at the institutional level. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03771482.
Collapse
Affiliation(s)
- Matthew D. McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mary Lynn Dear
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Reagan Buie
- Episodes of Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David A. Edwards
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tyler W. Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brian Allen
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amy C. Robertson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Leslie C. Fowler
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cassandra Hennessy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bonnie M. Miller
- Department of the Office of Health Sciences Education, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kim V. Garvey
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert P. Bland
- Department of HealthIT Architecture and Integration, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Geoffrey M. Fleming
- Department of Pediatrics, Vanderbilt Children’s Hospital, Nashville, Tennessee
| | - Don Moore
- Professor of Medical Education and Administration, Emeritus, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Todd W. Rice
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gordon R. Bernard
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | |
Collapse
|
16
|
Rice TW. Forty-fifth ASPEN Presidential Address: Research in a pandemic-Why, what, how? JPEN J Parenter Enteral Nutr 2021; 45:1690-1702. [PMID: 34477226 PMCID: PMC8646289 DOI: 10.1002/jpen.2261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|