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Griffiths SL, Murray GK, Logeswaran Y, Ainsworth J, Allan SM, Campbell N, Drake RJ, Katshu MZUH, Machin M, Pope MA, Sullivan SA, Waring J, Bogatsu T, Kane J, Weetman T, Johnson S, Kirkbride JB, Upthegrove R. Implementing and Evaluating a National Integrated Digital Registry and Clinical Decision Support System in Early Intervention in Psychosis Services (Early Psychosis Informatics Into Care): Co-Designed Protocol. JMIR Res Protoc 2024; 13:e50177. [PMID: 38502175 PMCID: PMC10988369 DOI: 10.2196/50177] [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: 06/23/2023] [Revised: 01/21/2024] [Accepted: 02/21/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Early intervention in psychosis (EIP) services are nationally mandated in England to provide multidisciplinary care to people experiencing first-episode psychosis, which disproportionately affects deprived and ethnic minority youth. Quality of service provision varies by region, and people from historically underserved populations have unequal access. In other disease areas, including stroke and dementia, national digital registries coupled with clinical decision support systems (CDSSs) have revolutionized the delivery of equitable, evidence-based interventions to transform patient outcomes and reduce population-level disparities in care. Given psychosis is ranked the third most burdensome mental health condition by the World Health Organization, it is essential that we achieve the same parity of health improvements. OBJECTIVE This paper reports the protocol for the program development phase of this study, in which we aimed to co-design and produce an evidence-based, stakeholder-informed framework for the building, implementation, piloting, and evaluation of a national integrated digital registry and CDSS for psychosis, known as EPICare (Early Psychosis Informatics into Care). METHODS We conducted 3 concurrent work packages, with reciprocal knowledge exchange between each. In work package 1, using a participatory co-design framework, key stakeholders (clinicians, academics, policy makers, and patient and public contributors) engaged in 4 workshops to review, refine, and identify a core set of essential and desirable measures and features of the EPICare registry and CDSS. Using a modified Delphi approach, we then developed a consensus of data priorities. In work package 2, we collaborated with National Health Service (NHS) informatics teams to identify relevant data currently captured in electronic health records, understand data retrieval methods, and design the software architecture and data model to inform future implementation. In work package 3, observations of stakeholder workshops and individual interviews with representative stakeholders (n=10) were subject to interpretative qualitative analysis, guided by normalization process theory, to identify factors likely to influence the adoption and implementation of EPICare into routine practice. RESULTS Stage 1 of the EPICare study took place between December 2021 and September 2022. The next steps include stage 2 building, piloting, implementation, and evaluation of EPICare in 5 demonstrator NHS Trusts serving underserved and diverse populations with substantial need for EIP care in England. If successful, this will be followed by stage 3, in which we will seek NHS adoption of EPICare for rollout to all EIP services in England. CONCLUSIONS By establishing a multistakeholder network and engaging them in an iterative co-design process, we have identified essential and desirable elements of the EPICare registry and CDSS; proactively identified and minimized potential challenges and barriers to uptake and implementation; and addressed key questions related to informatics architecture, infrastructure, governance, and integration in diverse NHS Trusts, enabling us to proceed with the building, piloting, implementation, and evaluation of EPICare. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/50177.
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Affiliation(s)
- Siân Lowri Griffiths
- Institute for Mental Health, University of Birmingham, Birmingham, United Kingdom
| | - Graham K Murray
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
- CAMEO, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, United Kingdom
| | - Yanakan Logeswaran
- Division of Psychiatry, University College London, London, United Kingdom
| | - John Ainsworth
- The University of Manchester, Manchester, United Kingdom
- NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Sophie M Allan
- Department of Clinical Psychology and Psychotherapies, Medical School, University of East Anglia, Norwich, United Kingdom
- School of Health Sciences, University of East Anglia, Norwich, United Kingdom
| | - Niyah Campbell
- Institute for Mental Health, University of Birmingham, Birmingham, United Kingdom
| | - Richard J Drake
- The University of Manchester, Manchester, United Kingdom
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
| | - Mohammad Zia Ul Haq Katshu
- Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
- Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, United Kingdom
| | - Matthew Machin
- The University of Manchester, Manchester, United Kingdom
| | - Megan A Pope
- Institute for Mental Health, University of Birmingham, Birmingham, United Kingdom
| | - Sarah A Sullivan
- Centre for Academic Mental Health, University of Bristol, Bristol, United Kingdom
- Biomedical Research Centre, University of Bristol, Bristol, United Kingdom
| | - Justin Waring
- School of Social Policy, University of Birmingham, Birmingham, United Kingdom
| | - Tumelo Bogatsu
- Institute for Mental Health, University of Birmingham, Birmingham, United Kingdom
| | - Julie Kane
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, United Kingdom
| | - Tyler Weetman
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, United Kingdom
| | - Sonia Johnson
- Division of Psychiatry, University College London, London, United Kingdom
- Camden and Islington NHS Foundation Trust, London, United Kingdom
| | - James B Kirkbride
- Division of Psychiatry, University College London, London, United Kingdom
| | - Rachel Upthegrove
- Institute for Mental Health, University of Birmingham, Birmingham, United Kingdom
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, United Kingdom
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Carlsson SV, Preston M, Vickers A, Malhotra D, Ehdaie B, Healey M, Kibel AS. Provider Perceptions of an Electronic Health Record Prostate Cancer Screening Tool. Appl Clin Inform 2024; 15:282-294. [PMID: 38599619 PMCID: PMC11006557 DOI: 10.1055/s-0044-1782619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 02/12/2024] [Indexed: 04/12/2024] Open
Abstract
OBJECTIVES We conducted a focus group to assess the attitudes of primary care physicians (PCPs) toward prostate-specific antigen (PSA)-screening algorithms, perceptions of using decision support tools, and features that would make such tools feasible to implement. METHODS A multidisciplinary team (primary care, urology, behavioral sciences, bioinformatics) developed the decision support tool that was presented to a focus group of 10 PCPs who also filled out a survey. Notes and audio-recorded transcripts were analyzed using Thematic Content Analysis. RESULTS The survey showed that PCPs followed different guidelines. In total, 7/10 PCPs agreed that engaging in shared decision-making about PSA screening was burdensome. The majority (9/10) had never used a decision aid for PSA screening. Although 70% of PCPs felt confident about their ability to discuss PSA screening, 90% still felt a need for a provider-facing platform to assist in these discussions. Three major themes emerged: (1) confirmatory reactions regarding the importance, innovation, and unmet need for a decision support tool embedded in the electronic health record; (2) issues around implementation and application of the tool in clinic workflow and PCPs' own clinical bias; and (3) attitudes/reflections regarding discrepant recommendations from various guideline groups that cause confusion. CONCLUSION There was overwhelmingly positive support for the need for a provider-facing decision support tool to assist with PSA-screening decisions in the primary care setting. PCPs appreciated that the tool would allow flexibility for clinical judgment and documentation of shared decision-making. Incorporation of suggestions from this focus group into a second version of the tool will be used in subsequent pilot testing.
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Affiliation(s)
- Sigrid V. Carlsson
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, United States
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, United States
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Division of Urological Cancers, Department of Translational Medicine, Medical Faculty, Lund University, Lund, Sweden
| | - Mark Preston
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Deepak Malhotra
- Organizations, and Markets Unit, Harvard Business School, Boston, Massachusetts, United States
| | - Behfar Ehdaie
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Michael Healey
- Brigham and Women's Hospital Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Adam S. Kibel
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
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Beal EW, Owen M, McNamara M, McAlearney AS, Tsung A. Patient-, Provider-, and System-Level Barriers to Surveillance for Hepatocellular Carcinoma in High-Risk Patients in the USA: a Scoping Review. J Gastrointest Cancer 2023; 54:332-356. [PMID: 35879510 DOI: 10.1007/s12029-022-00851-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Hepatocellular carcinoma has a dismal prognosis, except in patients diagnosed early who are candidates for potentially curative therapies. Most HCC cases develop in patients with chronic liver disease. Therefore, expert society guidelines recommend surveillance every 6 months with ultrasound with or without serum alpha-fetoprotein for high-risk patients. However, fewer than 20% of patients in the USA undergo appropriate surveillance. METHODS A systematic scoping review was performed with the objective of identifying barriers to screening among high-risk patients in the USA including mapping key concepts in the relevant literature, identifying the main sources and types of evidence available, and identifying gaps in the literature. A total of 43 studies published from 2007 to 2021 were included. Data were extracted and a conceptual framework was created. RESULTS Assessment of quantitative studies revealed poor surveillance rates, often below 50%. Three categories of barriers to surveillance were identified: patient-level, provider-level, and system-level barriers. Prevalent patient-level barriers included financial constraints, lack of awareness of surveillance recommendations, and scheduling difficulties. Common provider-level barriers were lack of provider awareness of guidelines for surveillance, difficulty accessing specialty resources, and time constraints in the clinic. System-level barriers included fewer clinic visits and rural/safety-net settings. Proposed interventions include improved patient/provider education, patient navigators, increased community/academic collaboration, and EMR-based reminders. CONCLUSION Based on these findings, there is a crucial need to implement and evaluate proposed interventions to improve HCC surveillance.
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Affiliation(s)
- Eliza W Beal
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, 43210, USA.
- The Center for the Advancement of Team Science, Systems Thinking in Health Services and Implementation Science Research (CATALYST, The Ohio State University College of Medicine, AnalyticsColumbus, OH, 43210, USA.
| | - Mackenzie Owen
- The Ohio State University College of Medicine, Columbus, OH, 43210, USA
| | - Molly McNamara
- The Ohio State University College of Medicine, Columbus, OH, 43210, USA
| | - Ann Scheck McAlearney
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, 43210, USA
- The Center for the Advancement of Team Science, Systems Thinking in Health Services and Implementation Science Research (CATALYST, The Ohio State University College of Medicine, AnalyticsColumbus, OH, 43210, USA
- The Department of Family and Community Medicine, The Ohio State University College of Medicine, Columbus, OH, 43210, USA
| | - Allan Tsung
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, 43210, USA
- The Center for the Advancement of Team Science, Systems Thinking in Health Services and Implementation Science Research (CATALYST, The Ohio State University College of Medicine, AnalyticsColumbus, OH, 43210, USA
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Perkins R, Mitchell E. Cervical cancer disparities. J Natl Med Assoc 2023; 115:S19-S25. [PMID: 37202000 DOI: 10.1016/j.jnma.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 02/01/2023] [Indexed: 05/20/2023]
Affiliation(s)
- Rebecca Perkins
- Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, United States
| | - Edith Mitchell
- Sidney Kimmel Cancer Center at Jefferson, Philadelphia, PA, United States.
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Harper J, Hunt T, Choudry M, Kapron AL, Cooney KA, Martin C, Ambrose J, O'Neil B. Clinician interest in clinical decision support for PSA-based prostate cancer screening. Urol Oncol 2023; 41:145.e17-145.e23. [PMID: 36610816 PMCID: PMC9992103 DOI: 10.1016/j.urolonc.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 11/13/2022] [Accepted: 11/21/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To evaluate the interest of primary care clinicians in utilizing CDS for PSA screening. Evidence suggests that electronic clinical decision support (CDS) may decrease low-value prostate-specific antigen (PSA) testing. However, physician attitudes towards CDS for PSA screening are largely unknown. METHODS A survey was sent to 201 primary care clinicians, including both physicians and Advanced Practice Providers (APP), within a large academic health system. Eligible clinicians cared for male patients aged 40 to 80 years and ordered ≥5 PSA tests in the past year. Respondents were stratified into 3 groups, appropriate screeners, low-value screeners, or rare-screeners, based on responses to survey questions assessing PSA screening practices. The degree of interest in electronic CDS was determined via a composite Likert score comprising relevant survey items. RESULTS Survey response rate was 29% (59/201) consisting of 85% MD/DO and 15% APP respondents. All clinicians surveyed were interested in CDS (P < 0.001) without significant difference between screener groups. Clinicians agreed most uniformly that CDS be evidence-based. Clinicians disagreed on whether CDS would decrease professional discretion over patient decisions. CONCLUSIONS Primary care clinicians are interested in CDS for PSA screening regardless of their current screening practices. Prioritizing CDS features that clinicians value, such as ensuring CDS recommendations are evidence-based, may increase the likelihood of successful implementation, whereas perceived threat to autonomy may be a hinderance to utilization.
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Affiliation(s)
- Jonathan Harper
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Trevor Hunt
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT; Department of Urology, University of Rochester Medical Center, Rochester, NY
| | - Mouneeb Choudry
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Ashley L Kapron
- Utah Clinical & Translational Science Institute, University of Utah Health, Salt Lake City, UT
| | - Kathleen A Cooney
- Department of Medicine, Duke Cancer Institute, Duke University School of Medicine, Durham, NC
| | - Christopher Martin
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Jacob Ambrose
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Brock O'Neil
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT.
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Harry ML, Chrenka EA, Freitag LA, Saman DM, Allen CI, Asche SE, Truitt AR, Ekstrom HL, O'Connor PJ, Sperl-Hillen JAM, Ziegenfuss JY, Elliott TE. Primary care clinicians' opinions before and after implementation of cancer screening and prevention clinical decision support in a clinic cluster-randomized control trial: a survey research study. BMC Health Serv Res 2022; 22:38. [PMID: 34991570 PMCID: PMC8739981 DOI: 10.1186/s12913-021-07421-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 12/14/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Electronic health record (EHR)-linked clinical decision support (CDS) may impact primary care clinicians' (PCCs') clinical care opinions. As part of a clinic cluster-randomized control trial (RCT) testing a cancer prevention and screening CDS system with patient and PCC printouts (with or without shared decision-making tools [SDMT]) for patients due for breast, cervical, colorectal, and lung cancer screening and/or human papillomavirus (HPV) vaccination compared to usual care (UC), we surveyed PCCs at study clinics pre- and post-CDS implementation. Our primary aim was to learn if PCCs' opinions changed over time within study arms. Secondary aims including examining whether PCCs' opinions in study arms differed both pre- and post-implementation, and gauging PCCs' opinions on the CDS in the two intervention arms. METHODS This study was conducted within a healthcare system serving an upper Midwestern population. We administered pre-implementation (11/2/2017-1/24/2018) and post-implementation (2/2/2020-4/9/2020) cross-sectional electronic surveys to PCCs practicing within a RCT arm: UC; CDS; or CDS + SDMT. Bivariate analyses compared responses between study arms at both time periods and longitudinally within study arms. RESULTS Pre-implementation (53%, n = 166) and post-implementation (57%, n = 172) response rates were similar. No significant differences in PCC responses were seen between study arms on cancer prevention and screening questions pre-implementation, with few significant differences found between study arms post-implementation. However, significantly fewer intervention arm clinic PCCs reported being very comfortable with discussing breast cancer screening options with patients compared to UC post-implementation, as well as compared to the same intervention arms pre-implementation. Other significant differences were noted within arms longitudinally. For intervention arms, these differences related to CDS areas like EHR alerts, risk calculators, and ordering screening. Most intervention arm PCCs noted the CDS provided overdue screening alerts to which they were unaware. Few PCCs reported using the CDS, but most would recommend it to colleagues, expressed high CDS satisfaction rates, and thought patients liked the CDS's information and utility. CONCLUSIONS While appreciated by PCCs with high satisfaction rates, the CDS may lower PCCs' confidence regarding discussing patients' breast cancer screening options and may be used irregularly. Future research will evaluate the impact of the CDS on cancer prevention and screening rates. TRIAL REGISTRATION clinicaltrials.gov , NCT02986230, December 6, 2016.
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Affiliation(s)
- Melissa L Harry
- Essentia Institute of Rural Health, 502 E. Second Street, Duluth, MN, 55805, USA.
| | - Ella A Chrenka
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - Laura A Freitag
- Essentia Institute of Rural Health, 502 E. Second Street, Duluth, MN, 55805, USA
| | - Daniel M Saman
- Essentia Institute of Rural Health, 502 E. Second Street, Duluth, MN, 55805, USA
- Carle Foundation Hospital, Clinical Business and Intelligence, 611 W Park St, Urbana, IL, 61801, USA
| | - Clayton I Allen
- Essentia Institute of Rural Health, 502 E. Second Street, Duluth, MN, 55805, USA
| | - Stephen E Asche
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - Anjali R Truitt
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - Heidi L Ekstrom
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - Patrick J O'Connor
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | | | | | - Thomas E Elliott
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
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Mills JM, Morgan JR, Dhaliwal A, Perkins RB. Eligibility for cervical cancer screening exit: Comparison of a national and safety net cohort. Gynecol Oncol 2021; 162:308-314. [PMID: 34090706 DOI: 10.1016/j.ygyno.2021.05.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To determine eligibility for discontinuation of cervical cancer screening. METHODS Women aged 64 with employer-sponsored insurance enrolled in a national database between 2016 and 2018, and those aged 64-66 receiving primary care at a safety net health center in 2019 were included. Patients were evaluated for screening exit eligibility by current guidelines: no evidence of cervical cancer or HIV-positive status and no evidence of cervical precancer in the past 25 years, and had evidence of either hysterectomy with removal of the cervix or evidence of fulfilling screening exit criteria, defined as two HPV screening tests or HPV plus Pap co-tests or three Pap tests within the past 10 years without evidence of an abnormal result. RESULTS Of the 590,901 women in the national claims database, 131,059 (22.2%) were eligible to exit due to hysterectomy (1.6%) or negative screening (20.6%). Of the 1544 women from the safety net health center, 528 (34.2%) were eligible to exit due to hysterectomy (9.3%) or negative screening (24.9%). Most women did not have sufficient data available to fulfill exit criteria: 382,509 (64.7%) in the national database and 875 (56.7%) in the safety net hospital system. Even among women with 10 years of insurance claims data, only 41.5% qualified to discontinue screening. CONCLUSIONS Examining insurance claims in a national database and electronic medical records at a safety net institution led to remarkably similar findings: two thirds of women fail to qualify for screening exit. Additional steps to ensure eligibility prior to screening exit may be necessary to decrease preventable cervical cancers among women aged >65. CLINICAL TRIAL REGISTRATION N/A.
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Affiliation(s)
- Jacqueline M Mills
- Department of Obstetrics and Gynecology, Boston University School of Medicine/ Boston Medical Center, Boston, MA, United States of America.
| | - Jake R Morgan
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, United States of America.
| | - Amareen Dhaliwal
- Boston University School of Medicine, Boston, MA, United States of America.
| | - Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston University School of Medicine/ Boston Medical Center, Boston, MA, United States of America.
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