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Kleinman LC, Howell EA. Equity and the Hazard of Veiled Injustice: A Methodological Reflection on Risk Adjustment. Pediatrics 2022; 149:184822. [PMID: 35230433 DOI: 10.1542/peds.2020-045948g] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Lawrence C Kleinman
- Division of Population Health, Quality, and Implementation Sciences, Department of Pediatrics, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey; and
| | - Elizabeth A Howell
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Lee SJC, Jetelina KK, Marks E, Shaw E, Oeffinger K, Cohen D, Santini NO, Cox JV, Balasubramanian BA. Care coordination for complex cancer survivors in an integrated safety-net system: a study protocol. BMC Cancer 2018; 18:1204. [PMID: 30514267 PMCID: PMC6278055 DOI: 10.1186/s12885-018-5118-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 11/20/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The growing numbers of cancer survivors challenge delivery of high-quality survivorship care by healthcare systems. Innovative ways to improve care coordination for patients with cancer and multiple chronic conditions ("complex cancer survivors") are needed to achieve better care outcomes, improve patient experience of care, and lower cost. Our study, Project CONNECT, will adapt and implement three evidence-based care coordination strategies, shown to be effective for primary care conditions, among complex cancer survivors. Specifically, the purpose of this study is to: 1) Implement a system-level EHR-driven intervention for 500 complex cancer survivors at Parkland; 2) Test effectiveness of the strategies on system- and patient-level outcomes measured before and after implementation; and 3) Elucidate system and patient factors that facilitate or hinder implementation and result in differences in experiences of care coordination between complex patients with and without cancer. METHODS Project CONNECT is a quasi-experimental implementation study among 500 breast and colorectal cancer survivors with at least one of the following chronic conditions: diabetes, hypertension, chronic lung disease, chronic kidney disease, or heart disease. We will implement three evidence-based care coordination strategies in a large, county integrated safety-net health system: 1) an EHR-driven registry to facilitate patient transitions between primary and oncology care; 2) co-locating a nurse practitioner trained in care coordination within a complex care team; 3) and enhancing teamwork through coaching. Segmented regression analysis will evaluate change in system-level (i.e. composite care quality score) and patient-level outcomes (i.e. self-reported care coordination). To evaluate implementation, we will merge quantitative findings with structured observations and physician and patient interviews. DISCUSSION This study will result in an evaluation toolkit identifying key model elements, barriers, and facilitators that can be used to guide care coordination interventions in other safety-net settings. Because Parkland is a vanguard of safety-net healthcare nationally, findings will be widely applicable as other safety-nets move toward increased integration, enhanced EHR capability, and experience with growing patient diversity. Our proposal recognizes the complexity of interventions and scaffolds evidence-based strategies together to meet the needs of complex patients, systems of care, and service integration. TRIAL REGISTRATION ClinicalTrials.gov, NCT02943265 . Registered 24 October 2016.
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Affiliation(s)
- Simon J. Craddock Lee
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, E5.506, Dallas, TX 75390-9066 USA
- Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Road, Dallas, TX 75235 USA
| | - Katelyn K. Jetelina
- Department of Epidemiology, University of Texas Health Science Center, School of Public Health, 6011 Harry Hines Blvd, V8.112, Dallas, TX 75235 USA
| | - Emily Marks
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, E5.506, Dallas, TX 75390-9066 USA
| | - Eric Shaw
- Department of Community Medicine, Mercer University, 1250 E. 66th St, Savannah, GA 31404 USA
| | - Kevin Oeffinger
- Department of Medicine, Division of Medical Oncology, Duke Cancer Institute and Duke University Medical Center, 20 Duke Medicine Cir, Durham, NC 27710 USA
| | - Deborah Cohen
- Department of Family Medicine, Oregon Health and Science Center, 3181 SW Sam Jackson Park Rd, Portland, OR 97239-3098 USA
| | - Noel O. Santini
- Parkland Health and Hospital System, 5201 Harry Hines Blvd, Dallas, TX 75235 USA
| | - John V. Cox
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, E5.506, Dallas, TX 75390-9066 USA
- Parkland Health and Hospital System, 5201 Harry Hines Blvd, Dallas, TX 75235 USA
| | - Bijal A. Balasubramanian
- Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Road, Dallas, TX 75235 USA
- Department of Epidemiology, University of Texas Health Science Center, School of Public Health, 6011 Harry Hines Blvd, V8.112, Dallas, TX 75235 USA
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Donnelly T. The red zone. J Perioper Pract 2015; 25:37-38. [PMID: 26016279 DOI: 10.1177/175045891502500301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
This simple quality initiative won the best innovation in clinical practice at the recent CEO healthcare awards gala event in the North West of Ireland. It demonstrated how a simple collaborative idea led to improving the quality and safety of care in the operating room. As practitioners we have a huge contribution to make in providing quality and safe care to our patients. It is crucial that we share knowledge and have our input recognised.
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Krause J, Van Lieshout J, Klomp R, Huntink E, Aakhus E, Flottorp S, Jaeger C, Steinhaeuser J, Godycki-Cwirko M, Kowalczyk A, Agarwal S, Wensing M, Baker R. Identifying determinants of care for tailoring implementation in chronic diseases: an evaluation of different methods. Implement Sci 2014; 9:102. [PMID: 25112492 PMCID: PMC4243773 DOI: 10.1186/s13012-014-0102-3] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 07/27/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The tailoring of implementation interventions includes the identification of the determinants of, or barriers to, healthcare practice. Different methods for identifying determinants have been used in implementation projects, but which methods are most appropriate to use is unknown. METHODS The study was undertaken in five European countries, recommendations for a different chronic condition being addressed in each country: Germany (polypharmacy in multimorbid patients); the Netherlands (cardiovascular risk management); Norway (depression in the elderly); Poland (chronic obstructive pulmonary disease--COPD); and the United Kingdom (UK) (obesity). Using samples of professionals and patients in each country, three methods were compared directly: brainstorming amongst health professionals, interviews of health professionals, and interviews of patients. The additional value of discussion structured through reference to a checklist of determinants in addition to brainstorming, and determinants identified by open questions in a questionnaire survey, were investigated separately. The questionnaire, which included closed questions derived from a checklist of determinants, was administered to samples of health professionals in each country. Determinants were classified according to whether it was likely that they would inform the design of an implementation intervention (defined as plausibly important determinants). RESULTS A total of 601 determinants judged to be plausibly important were identified. An additional 609 determinants were judged to be unlikely to inform an implementation intervention, and were classified as not plausibly important. Brainstorming identified 194 of the plausibly important determinants, health professional interviews 152, patient interviews 63, and open questions 48. Structured group discussion identified 144 plausibly important determinants in addition to those already identified by brainstorming. CONCLUSIONS Systematic methods can lead to the identification of large numbers of determinants. Tailoring will usually include a process to decide, from all the determinants that are identified, those to be addressed by implementation interventions. There is no best buy of methods to identify determinants, and a combination should be used, depending on the topic and setting. Brainstorming is a simple, low cost method that could be relevant to many tailored implementation projects.
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Meropol SB, Schiltz NK, Sattar A, Stange KC, Nevar AH, Davey C, Ferretti GA, Howell DE, Strosaker R, Vavrek P, Bader S, Ruhe MC, Cuttler L. Practice-tailored facilitation to improve pediatric preventive care delivery: a randomized trial. Pediatrics 2014; 133:e1664-75. [PMID: 24799539 PMCID: PMC4035588 DOI: 10.1542/peds.2013-1578] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE Evolving primary care models require methods to help practices achieve quality standards. This study assessed the effectiveness of a Practice-Tailored Facilitation Intervention for improving delivery of 3 pediatric preventive services. METHODS In this cluster-randomized trial, a practice facilitator implemented practice-tailored rapid-cycle feedback/change strategies for improving obesity screening/counseling, lead screening, and dental fluoride varnish application. Thirty practices were randomized to Early or Late Intervention, and outcomes assessed for 16 419 well-child visits. A multidisciplinary team characterized facilitation processes by using comparative case study methods. RESULTS Baseline performance was as follows: for Obesity: 3.5% successful performance in Early and 6.3% in Late practices, P = .74; Lead: 62.2% and 77.8% success, respectively, P = .11; and Fluoride: <0.1% success for all practices. Four months after randomization, performance rose in Early practices, to 82.8% for Obesity, 86.3% for Lead, and 89.1% for Fluoride, all P < .001 for improvement compared with Late practices' control time. During the full 6-month intervention, care improved versus baseline in all practices, for Obesity for Early practices to 86.5%, and for Late practices 88.9%; for Lead for Early practices to 87.5% and Late practices 94.5%; and for Fluoride, for Early practices to 78.9% and Late practices 81.9%, all P < .001 compared with baseline. Improvements were sustained 2 months after intervention. Successful facilitation involved multidisciplinary support, rapid-cycle problem solving feedback, and ongoing relationship-building, allowing individualizing facilitation approach and intensity based on 3 levels of practice need. CONCLUSIONS Practice-tailored Facilitation Intervention can lead to substantial, simultaneous, and sustained improvements in 3 domains, and holds promise as a broad-based method to advance pediatric preventive care.
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Affiliation(s)
- Sharon B. Meropol
- Departments of Pediatrics,,Epidemiology and Biostatistics,,The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Nicholas K. Schiltz
- Epidemiology and Biostatistics,,The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | | | - Kurt C. Stange
- Epidemiology and Biostatistics,,Family Medicine and Community Health,,Oncology,,Sociology
| | - Ann H. Nevar
- The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Christina Davey
- Departments of Pediatrics,,The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | | | - Diana E. Howell
- Departments of Pediatrics,,The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | | | - Pamela Vavrek
- The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Samantha Bader
- The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | | | - Leona Cuttler
- Departments of Pediatrics,,Bioethics, Case Western Reserve University, Cleveland, Ohio; and,The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
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Abstract
PURPOSE The American Board of Medical Specialties' Performance in Practice ("Part IV") portion of Maintenance of Certification (MOC) requirement provides an opportunity for practicing physicians to demonstrate quality improvement (QI) competence. However, specialty boards' certification of one physician at a time does not tap into the potential of collective effort. This article shares learning from a project to help family physicians work in groups to meet their Part IV MOC requirement. METHODS A year-long implementation and evaluation project was conducted. Initially, 348 members of a regional family physician organization were invited to participate. A second path was established through 3 health care systems and a county-wide learning collaborative. Participants were offered (1) a basic introduction to QI methods, (2) the option of an alternative Part IV MOC module using a patient experience survey to guide QI efforts, (3) practice-level improvement coaching, (4) support for collaboration and co-learning, and (5) provision of QI resources. RESULTS More physicians participated through group (66) than individual (12) recruitment, for a total of 78 physicians in 20 practices. Participation occurred at 3 levels: individual, intrapractice, and interpractice. Within the 1-year time frame, intrapractice collaboration occurred most frequently. Interpractice and system-level collaboration has begun and continues to evolve. Physicians felt that they benefited from access to a practice coach and group process. CONCLUSIONS Practice-level collaboration, access to a practice coach, flexibility in choosing and focusing improvement projects, tailored support, and involvement with professional affiliations can enhance the Part IV MOC process. Specialty boards are likely to discover productive opportunities from working with practices, professional organizations, and health care systems to support intra- and interpractice collaborative QI work that uses Part IV MOC requirements to motivate practice improvement.
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Stange KC, Breslau ES, Dietrich AJ, Glasgow RE. State-of-the-art and future directions in multilevel interventions across the cancer control continuum. J Natl Cancer Inst Monogr 2012; 2012:20-31. [PMID: 22623592 DOI: 10.1093/jncimonographs/lgs006] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
We conducted literature searches and analyses to describe the current state of multilevel intervention (MLI) research and to identify opportunities to advance cancer control and prevention. We found single-level studies that considered other contextually important levels, and multilevel health-care systems research and community-wide studies. This literature is characterized by limited reporting of theoretical, contextual, temporal, and implementation factors. Most MLIs focus on prevention and screening, rather than diagnosis, treatment, or survivorship. Opportunities relate to 1) dynamic, adaptive emergent interventions and research designs that evolve over time by attending to contextual factors and interactions across levels; 2) analyses that include simulation modeling, or multimethod approaches that integrate quantitative and qualitative methods; and 3) translation and intervention approaches that locally reinvent MLIs in different contexts. MLIs have great potential to reduce cancer burden by using theory and integrating quantitative, qualitative, participatory, and transdisciplinary methods that continually seek alignment across intervention levels, pay attention to context, and adapt over time.
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Affiliation(s)
- Kurt C Stange
- Department of Family Medicine and Community Health, Case Western Reserve University, 11000 Cedar Ave, Ste 402, Cleveland, OH 44106, USA.
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Abstract
PURPOSE To test the effect of an Appreciative Inquiry (AI) quality improvement strategy on clinical quality management and practice development outcomes. Appreciative inquiry enables the discovery of shared motivations, envisioning a transformed future, and learning around the implementation of a change process. METHODS Thirty diverse primary care practices were randomly assigned to receive an AI-based intervention focused on a practice-chosen topic and on improving preventive service delivery (PSD) rates. Medical-record review assessed change in PSD rates. Ethnographic field notes and observational checklist analysis used editing and immersion/crystallization methods to identify factors affecting intervention implementation and practice development outcomes. RESULTS The PSD rates did not change. Field note analysis suggested that the intervention elicited core motivations, facilitated development of a shared vision, defined change objectives, and fostered respectful interactions. Practices most likely to implement the intervention or develop new practice capacities exhibited 1 or more of the following: support from key leader(s), a sense of urgency for change, a mission focused on serving patients, health care system and practice flexibility, and a history of constructive practice change. CONCLUSIONS An AI approach and enabling practice conditions can lead to intervention implementation and practice development by connecting individual and practice strengths and motivations to the change objective.
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Greenfield DR, Nugus P, Travaglia JF, Braithwaite J. Interprofessional learning and practice can make a difference. Med J Aust 2011; 194:364-5. [DOI: 10.5694/j.1326-5377.2011.tb03008.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2010] [Accepted: 11/07/2010] [Indexed: 11/17/2022]
Affiliation(s)
- David R Greenfield
- Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW
| | - Peter Nugus
- Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW
| | - Joanne F Travaglia
- Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW
| | - Jeffrey Braithwaite
- Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW
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THURGATE CLAIRE, MACGREGOR JANET, O'KEEFE HELEN. Meeting changing service need through role development: a case study for Band 4 assistant practitioners. J Nurs Manag 2010; 18:654-61. [DOI: 10.1111/j.1365-2834.2010.01142.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hade EM, Murray DM, Pennell ML, Rhoda D, Paskett ED, Champion VL, Crabtree BF, Dietrich A, Dignan MB, Farmer M, Fenton JJ, Flocke S, Hiatt RA, Hudson SV, Mitchell M, Monahan P, Shariff-Marco S, Slone SL, Stange K, Stewart SL, Strickland PAO. Intraclass correlation estimates for cancer screening outcomes: estimates and applications in the design of group-randomized cancer screening studies. J Natl Cancer Inst Monogr 2010; 2010:97-103. [PMID: 20386058 DOI: 10.1093/jncimonographs/lgq011] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Screening has become one of our best tools for early detection and prevention of cancer. The group-randomized trial is the most rigorous experimental design for evaluating multilevel interventions. However, identifying the proper sample size for a group-randomized trial requires reliable estimates of intraclass correlation (ICC) for screening outcomes, which are not available to researchers. We present crude and adjusted ICC estimates for cancer screening outcomes for various levels of aggregation (physician, clinic, and county) and provide an example of how these ICC estimates may be used in the design of a future trial. METHODS Investigators working in the area of cancer screening were contacted and asked to provide crude and adjusted ICC estimates using the analysis of variance method estimator. RESULTS Of the 29 investigators identified, estimates were obtained from 10 investigators who had relevant data. ICC estimates were calculated from 13 different studies, with more than half of the studies collecting information on colorectal screening. In the majority of cases, ICC estimates could be adjusted for age, education, and other demographic characteristics, leading to a reduction in the ICC. ICC estimates varied considerably by cancer site and level of aggregation of the groups. CONCLUSIONS Previously, only two articles had published ICCs for cancer screening outcomes. We have complied more than 130 crude and adjusted ICC estimates covering breast, cervical, colon, and prostate screening and have detailed them by level of aggregation, screening measure, and study characteristics. We have also demonstrated their use in planning a future trial and the need for the evaluation of the proposed interval estimator for binary outcomes under conditions typically seen in GRTs.
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Affiliation(s)
- Erinn M Hade
- Center for Biostatistics, The Ohio State University, 2012 Kenny Rd, Columbus, OH 43221, USA.
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Miller WL, Crabtree BF, Nutting PA, Stange KC, Jaén CR. Primary care practice development: a relationship-centered approach. Ann Fam Med 2010; 8 Suppl 1:S68-79; S92. [PMID: 20530396 PMCID: PMC2885724 DOI: 10.1370/afm.1089] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Numerous primary care practice development efforts, many related to the patient-centered medical home (PCMH), are emerging across the United States with few guides available to inform them. This article presents a relationship-centered practice development approach to understand practice and to aid in fostering practice development to advance key attributes of primary care that include access to first-contact care, comprehensive care, coordination of care, and a personal relationship over time. METHODS Informed by complexity theory and relational theories of organizational learning, we built on discoveries from the American Academy of Family Physicians' National Demonstration Project (NDP) and 15 years of research to understand and improve primary care practice. RESULTS Primary care practices can fruitfully be understood as complex adaptive systems consisting of a core (a practice's key resources, organizational structure, and functional processes), adaptive reserve (practice features that enhance resilience, such as relationships), and attentiveness to the local environment. The effectiveness of these attributes represents the practice's internal capability. With adequate motivation, healthy, thriving practices advance along a pathway of slow, continuous developmental change with occasional rapid periods of transformation as they evolve better fits with their environment. Practice development is enhanced through systematically using strategies that involve setting direction and boundaries, implementing sensing systems, focusing on creative tensions, and fostering learning conversations. CONCLUSIONS Successful practice development begins with changes that strengthen practices' core, build adaptive reserve, and expand attentiveness to the local environment. Development progresses toward transformation through enhancing primary care attributes.
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Affiliation(s)
- William L Miller
- Department of Family Medicine, Lehigh Valley Health Network, 17th and Chew Streets, Allentown, PA 18105-7017, USA.
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