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Halm EA, Nair RG, Hu E, Wang L, Lykken JM, Ortiz C, Kim EJ, Santini NO, Moran B, Skinner CS. Improving Colorectal Cancer Screening in a Regional Safety-Net Health System over a 10-Year Period: Lessons for Population Health. J Gen Intern Med 2024; 39:978-984. [PMID: 37932541 PMCID: PMC11074086 DOI: 10.1007/s11606-023-08477-w] [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: 05/08/2023] [Accepted: 10/11/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Despite national policy efforts to increase colorectal cancer (CRC) screening, rates in vulnerable populations remain suboptimal. Many types of interventions have been employed, but their impact on improving population-level rates of CRC screening over time is uncertain. OBJECTIVE Assess the impact of 10 years of different in-reach and outreach strategies to improve CRC screening and identify factors associated with being screen up-to-date (SUTD). DESIGN Observational cohort study. PARTICIPANTS Patients aged 50-74 years from 12 community-based primary care clinics in an integrated, regional safety-net health system. INTERVENTIONS Multiple system-level interventions were implemented over time (visit-based electronic health record [EHR] reminders, quality measurement, annual preventive service letters, and mailed fecal immunohistochemical stool tests [FIT]). MAIN MEASURES CRC SUTD rates by calendar year among those with a primary care (PC) visit in the prior 1 and 3 years and their multivariable correlates. KEY RESULTS The sample included 31,786-40,405 patients/year. In 2011, mean age was 58.9, 63.9% were women, 37.0% were Hispanic, 39.3% Black, 16.8% White, and 6.6% Asian/Other, and 60.5% were uninsured/Medicaid. Three-quarters of patients had ≥ 1 PC visit in the prior year. Lower-intensity interventions (EHR reminders, quality measurement, annual prevention letters) had limited impact on SUTD rates (2-3% rise). Implementing system-wide mailed FIT increased rates from 51.2 to 61.9% among those with a PC visit in the past year (40.5 to 46.8% with a PC visit ≤ 3 years). Stopping mailed FIT due to COVID wiped out these gains. Higher screening rates were associated with the following: older age; female; more comorbidities, PC clinic visits, and prior FITs; and better insurance coverage. Hispanics had the highest SUTD rates followed by Asians, Blacks, and Whites (p < 0.05). CONCLUSIONS Implementation of a system-wide mailed FIT program had the greatest impact on SUTD rates. Lower-intensity interventions (EHR reminders, quality measurement, and patient letters) had limited effects.
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Affiliation(s)
- Ethan A Halm
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Rasmi G Nair
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ellen Hu
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lei Wang
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jacquelyn M Lykken
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Cynthia Ortiz
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Eric J Kim
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Celette Sugg Skinner
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Friedel JE, Cox AD, Davis S. Further Progress Toward Automating Functional Analysis Interpretation. Behav Modif 2024; 48:75-106. [PMID: 37688442 DOI: 10.1177/01454455231195825] [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] [Indexed: 09/10/2023]
Abstract
It is considered best practice to conduct a functional analysis and visually inspect data collected to determine the function of problem behavior, which then informs the intervention approaches applied. Visual inspection has been described as a "subjective" process that may be affected by factors unrelated to the data. Structured decision-making guidelines have been established to address some of these shortcomings. The current paper is a follow-up to earlier work describing positive outcomes related to the viability of a decision support system based on structured criteria from Roane et al. Here, we demonstrate important improvements in a computer script's interpretation of functional analysis data, including improvement in agreement between the updated computer script version and experienced human raters (89%) compared to our original agreement outcomes (81%). This paper further supports the use of decision support systems for functional analysis interpretation.
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Affiliation(s)
| | | | - Sarah Davis
- Brock University, St. Catharines, ON, Canada
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Kirubarajan A, Lynch M, Nasreen S, Gebretekle GB, Fadel SA, Crowcroft NS, Allin S. Increasing pneumococcal vaccine uptake in older adults: a scoping review of interventions in high-income countries. BMC Geriatr 2023; 23:2. [PMID: 36593474 PMCID: PMC9807101 DOI: 10.1186/s12877-022-03653-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 11/25/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND There is low uptake of the pneumococcal vaccination in eligible older adults, even in high-income countries that offer routine and universal vaccination programs. OBJECTIVE To systematically characterize interventions aimed at improving pneumococcal vaccine uptake in older adults. DESIGN We conducted a scoping review following PRISMA-SCr guidelines of five interdisciplinary databases: Medline-Ovid, Embase, CINAHL, PsychInfo, and Cochrane Library. Databases were searched from January 2015 until April 2020. The interventions were summarized into three pillars according to the European Union Conceptional Framework for Action: information campaigns, prioritization of vaccination schemes, and primary care interventions. RESULTS Our scoping review included 39 studies that summarized interventions related to pneumococcal vaccine uptake for older adults, encompassing 2,481,887 study participants (945 healthcare providers and 2,480,942 older adults) across seven countries. Examples of interventions that were associated with increased pneumococcal vaccination rate included periodic health examinations, reminders and decision-making tools built into electronic medical records, inpatient vaccination protocols, preventative health checklists, and multimodal educational interventions. When comparing the three pillars, prioiritization of vaccination schemes had the highest evidence for improved rates of vaccination (n = 14 studies), followed by primary care interventions (n = 8 studies), then information campaigns (n = 5 studies). CONCLUSION Several promising interventions were associated with improved outcomes related to vaccine uptake, although controlled study designs are needed to determine which interventions are most effective.
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Affiliation(s)
- Abirami Kirubarajan
- grid.17063.330000 0001 2157 2938Temerty Faculty of Medicine, University of Toronto, Toronto, Canada ,grid.17063.330000 0001 2157 2938Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada
| | - Meghan Lynch
- grid.17063.330000 0001 2157 2938Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada
| | - Sharifa Nasreen
- grid.17063.330000 0001 2157 2938 Centre for Vaccine Preventable Diseases, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Gebremedhin B. Gebretekle
- grid.17063.330000 0001 2157 2938Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada ,grid.231844.80000 0004 0474 0428 Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Canada
| | - Shaza A. Fadel
- grid.17063.330000 0001 2157 2938 Centre for Vaccine Preventable Diseases, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Natasha S. Crowcroft
- grid.17063.330000 0001 2157 2938 Centre for Vaccine Preventable Diseases, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Sara Allin
- grid.17063.330000 0001 2157 2938Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada
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Measured Performance and Vaccine Administration After Decision Support and Office Workflow Changes for Influenza Vaccination. J Healthc Qual 2021; 42:333-340. [PMID: 31917713 DOI: 10.1097/jhq.0000000000000243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Influenza vaccination is underused. We examined changes in vaccination following decision support and workflow changes in a cross-sectional analysis of three vaccination seasons among adult primary care patients from 21 practices. Interventions included clinical decision support changes to facilitate documentation; changes to rooming workflow for medical assistants and licensed practical nurses to promote vaccination, prepare orders, document care done elsewhere; and record patient refusals. We measured rates for a national vaccination performance measure and receipt of onsite vaccination. Approximately 120,000 patients were eligible each season. Performance on the quality measure increased each year (40.6% to 62.5% to 76.4%). Corresponding rates of onsite vaccination were 27.7%, 28.8%, and 31.5%. The adjusted odds ratio for onsite vaccination in the second season compared with the first was 0.94 (95% confidence interval [CI] 0.92, 0.96). Onsite vaccination was more likely in the third season compared with either previous season-adjusted odds ratio for third versus second 1.14 (95% CI, 1.12, 1.16) or adjusted odds ratio for third versus first 1.07 (95% CI 1.05-1.09). Sequential changes in decision support and patient rooming process workflows were associated with large improvements in measured performance and with a significant increase in clinic-administered influenza vaccination by the third season.
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Bach AT, Kang AY, Lewis J, Xavioer S, Portillo I, Goad JA. Addressing common barriers in adult immunizations: a review of interventions. Expert Rev Vaccines 2019; 18:1167-1185. [PMID: 31791159 DOI: 10.1080/14760584.2019.1698955] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Introduction: Low levels of adult vaccination have been documented in the United States and globally. Research has been conducted to identify reasons for low immunization rates; however, the most useful studies are those that implemented interventions for identified barriers to evaluate their impact on rates of immunization. Identifying successful interventions provides immunization providers with evidence-based methods that can be utilized to increase the uptake of recommended vaccines.Areas covered: This review focuses on known barriers to adult immunizations and the interventions available in the literature to overcome these barriers. It outlines interventions that may increase vaccine uptake in the adult population through addressing barriers related to lack of vaccine knowledge, cost, access, provider and practice-based challenges, and racial and ethnic disparities.Expert opinion: Improving adult immunization rates is critical to protecting a population against vaccine-preventable diseases. Those interventions that appeared to increase immunization rates in the adult population included education and reminders about vaccination using text and telephone calls, low-cost or subsidized vaccines, easy access to immunization services, and understanding the cultural and social needs of different racial and ethnic populations. It is likely that an evidence-based multimodal approach using different categories of interventions is necessary to significantly improve adult immunization rates.
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Affiliation(s)
- Albert T Bach
- Assistant Professor of Pharmacy Practice, School of Pharmacy, Chapman University, Irvine, CA, USA
| | - Amy Y Kang
- Assistant Professor of Pharmacy Practice, School of Pharmacy, Chapman University, Irvine, CA, USA
| | - Jelena Lewis
- Assistant Professor of Pharmacy Practice, School of Pharmacy, Chapman University, Irvine, CA, USA
| | - Sharon Xavioer
- Assistant Professor of Pharmacy Practice, School of Pharmacy, Chapman University, Irvine, CA, USA
| | - Ivan Portillo
- AHIP Health Sciences Librarian, Leathery Libraries, Chapman University, Irvine, CA, USA
| | - Jeffery A Goad
- Chair of the Department of Pharmacy Practice, School of Pharmacy, Chapman University, Irvine, CA, USA
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Ganguli I, Souza J, McWilliams JM, Mehrotra A. Association Of Medicare's Annual Wellness Visit With Cancer Screening, Referrals, Utilization, And Spending. Health Aff (Millwood) 2019; 38:1927-1935. [PMID: 31682513 PMCID: PMC6903905 DOI: 10.1377/hlthaff.2019.00304] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Medicare's annual wellness visit was introduced in 2011 to promote evidence-based preventive care and identify risk factors and undiagnosed conditions in aging adults. Use of the visit has risen steadily since then, yet its benefits remain unclear. Using national Medicare data for 2008-15, we examined claims from fee-for-service Medicare beneficiaries attributed to practices that did or did not adopt the visit. We performed difference-in-differences analysis to compare differential changes in appropriate and low-value cancer screening, functional and neuropsychiatric care, emergency department visits, hospitalizations, and total spending. Examining 17.8 million beneficiary-years, we found modest differential improvements in rates of evidence-based screening and declines in emergency department visits. However, when we accounted for trends that predated the introduction of the visit, none of these benefits persisted. In sum, we found no substantive association between annual wellness visits and improvements in care.
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Affiliation(s)
- Ishani Ganguli
- Ishani Ganguli ( iganguli@bwh. harvard. edu ) is an assistant professor of medicine in the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital and Harvard Medical School, both in Boston, Massachusetts
| | - Jeffrey Souza
- Jeffrey Souza is a programmer in the Department of Health Care Policy, Harvard Medical School
| | - J Michael McWilliams
- J. Michael McWilliams is the Warren Alpert Foundation Professor of Health Care Policy in the Department of Health Care Policy, Harvard Medical School
| | - Ateev Mehrotra
- Ateev Mehrotra is an associate professor of health care policy and medicine in the Department of Health Care Policy, Harvard Medical School
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Kolff CA, Scott VP, Stockwell MS. The use of technology to promote vaccination: A social ecological model based framework. Hum Vaccin Immunother 2018; 14:1636-1646. [PMID: 29781750 PMCID: PMC6067841 DOI: 10.1080/21645515.2018.1477458] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Vaccinations are an important and effective cornerstone of preventive medical care. Growing technologic capabilities and use by both patients and providers present critical opportunities to leverage these tools to improve vaccination rates and public health. We propose the Social Ecological Model as a useful theoretical framework to identify areas in which technology has been or may be leveraged to target undervaccination across the individual, interpersonal, organizational, community, and society levels and the ways in which these levels interact.
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Affiliation(s)
- Chelsea A Kolff
- a Department of Pediatrics , Columbia University , New York , NY , USA.,b Department of Population and Family Health , Mailman School of Public Health, Columbia University , New York , NY , USA
| | - Vanessa P Scott
- a Department of Pediatrics , Columbia University , New York , NY , USA.,c NewYork-Presbyterian Hospital , New York , NY , USA
| | - Melissa S Stockwell
- a Department of Pediatrics , Columbia University , New York , NY , USA.,b Department of Population and Family Health , Mailman School of Public Health, Columbia University , New York , NY , USA.,c NewYork-Presbyterian Hospital , New York , NY , USA
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