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Kelley AT, Weiner SJ, Francis J. Directly Observed Care: Crossing the Chasm of Quality Measurement. J Gen Intern Med 2023; 38:203-207. [PMID: 36127536 PMCID: PMC9849645 DOI: 10.1007/s11606-022-07781-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 08/31/2022] [Indexed: 01/22/2023]
Abstract
After more than two decades of national attention to quality improvement in US healthcare, significant gaps in quality remain. A fundamental problem is that current approaches to measure quality are indirect and therefore imprecise, focusing on clinical documentation of care rather than the actual delivery of care. The National Academy of Medicine (NAM) has identified six domains of quality that are essential to address to improve quality: patient-centeredness, equity, timeliness, efficiency, effectiveness, and safety. In this perspective, we describe how directly observed care-a recorded audit of clinical care delivery-may address problems with current quality measurement, providing a more holistic assessment of healthcare delivery. We further show how directly observed care has the potential to improve each NAM domain of quality.
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Affiliation(s)
- A Taylor Kelley
- Vulnerable Veteran Innovative Patient Aligned Care Team (VIP) Initiative, Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA. .,Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 North 1900 East, Room 5R218, Salt Lake City, UT, 84132, USA. .,Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Saul J Weiner
- Center of Innovation for Complex Chronic Healthcare, Jesse Brown VA Medical Center, Chicago, IL, USA.,Division of Academic Internal Medicine and Geriatrics, Department of Medicine, University of Illinois-Chicago, Chicago, IL, USA
| | - Joseph Francis
- Office of Analytics and Performance Integration, Veterans Health Administration, Washington, DC, USA
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Baylis JD, Charron E, Archer S, Garets M, Bryan MA, Foringer J, Kelley AT, Smid MC, Cochran G. Attitudes, self-efficacy, and practices related to opioid risk assessment and mitigation: A comparison of health care professionals in rural communities. Subst Abus 2022; 43:1163-1171. [PMID: 35617634 DOI: 10.1080/08897077.2022.2074593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background: Health care professionals (HCPs) play an important role in opioid misuse and opioid use disorder (OUD) screening/identification, mitigation, and referral to treatment. This study compared attitudes, self-efficacy, and practices related to opioid risk assessment and mitigation among pregnancy and non-pregnancy HCPs in rural communities. Methods: We conducted a secondary analysis of cross-sectional, self-report survey data of HCPs in two rural counties in southern Utah. Pregnancy HCPs were identified by a question asking whether they provide care to pregnant patients. HCPs' attitudes toward their patients with opioid misuse/OUD were measured using the Survey of Attitudes and Perceptions questionnaire. Self-efficacy and practices related to opioid risk assessment and mitigation were captured with questions asking about assessment and screening of opioid use, advisement to change opioid use behavior, and referral to treatment for OUD. We used linear regression analyses to estimate associations between HCPs' attitudes toward patients with opioid misuse/OUD and their self-efficacy and use of opioid risk assessment and mitigation practices. Results: This sample included a total of 132 HCPs, including 82 pregnancy HCPs and 50 non-pregnancy HCPs. Attitudes domains were similar among pregnancy and non-pregnancy HCPs. Among pregnancy HCPs, role adequacy (β = .48, 95% CI = .16-.80), role legitimacy (β = .72, 95% CI = .21-1.22), motivation (β = .68, 95% CI = .14-1.21), and positive task-specific self-esteem (β = 1.52, 95% CI = .70-2.35) were positively associated with more frequent use of opioid risk assessment and mitigation practices, while attitudes were not associated with these practices among non-pregnancy HCPs. Conclusions: Training initiatives that lead to improved HCP attitudes could improve opioid care management among rural pregnancy HCPs. More research is needed to determine approaches to increase the use of opioid risk assessment and mitigation practices among rural non-pregnancy HCPs.
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Affiliation(s)
- Jacob D Baylis
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Elizabeth Charron
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Shayla Archer
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Mitchell Garets
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - M Aryana Bryan
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jacob Foringer
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - A Taylor Kelley
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Marcela C Smid
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Gerald Cochran
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Greater Intermountain Node (GIN), NIH NIDA Clinical Trials Network, University of Utah, Salt Lake City, UT, USA
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Kelley AT, Smid MC, Baylis JD, Charron E, Begaye LJ, Binns-Calvey A, Archer S, Weiner S, Pettey W, Cochran G. Treatment access for opioid use disorder in pregnancy among rural and American Indian communities. J Subst Abuse Treat 2021; 136:108685. [PMID: 34953636 DOI: 10.1016/j.jsat.2021.108685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 07/28/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Opioid use disorder (OUD) in pregnancy disproportionately impacts rural and American Indian (AI) communities. With limited data available about access to care for these populations, this study's objective was to assess clinic knowledge and new patient access for OUD treatment in three rural U.S. counties. MATERIAL AND METHODS The research team used unannounced standardized patients (USPs) to request new patient appointments by phone for white and AI pregnant individuals with OUD at primary care and OB/GYN clinics that provide prenatal care in three rural Utah counties. We assessed a) clinic familiarity with buprenorphine for OUD; b) appointment availability for buprenorphine treatment; c) appointment wait times; d) referral provision when care was unavailable; and e) availability of OUD care at referral locations. We compared outcomes for AI and white USP profiles using descriptive statistics. RESULTS The USPs made 34 calls to 17 clinics, including 4 with publicly listed buprenorphine prescribers on the Substance Abuse and Mental Health Services Administration website. Among clinical staff answering calls, 16 (47%) were unfamiliar with buprenorphine. OUD treatment was offered when requested in 6 calls (17.6%), with a median appointment wait time of 2.5 days (IQR 1-5). Among clinics with a listed buprenorphine prescriber, 2 of 4 (50%) offered OUD treatment. Most clinics (n = 24/28, 85.7%) not offering OUD treatment provided a referral; however, a buprenorphine provider was unavailable/unreachable 67% of the time. The study observed no differences in appointment availability between AI and white individuals. CONCLUSIONS Rural-dwelling AI and white pregnant individuals with OUD experience significant barriers to accessing care. Improving OUD knowledge and referral practices among rural clinics may increase access to care for this high-risk population.
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Affiliation(s)
- A Taylor Kelley
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132, United States of America; Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, 500 Foothill Drive, Building 2, Salt Lake City, UT 84148, United States of America; Department of Internal Medicine, Division of General Internal Medicine, University of Utah School of Medicine, 30 N 1900 E 5R341, Salt Lake City, UT 84132, United States of America.
| | - Marcela C Smid
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132, United States of America; Department of Obstetrics and Gynecology, University of Utah School of Medicine, 30 N 1900 E 2B300, Salt Lake City, UT 84132, United States of America
| | - Jacob D Baylis
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132, United States of America
| | - Elizabeth Charron
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132, United States of America
| | - Lori Jo Begaye
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132, United States of America
| | - Amy Binns-Calvey
- Department of Medicine, Division of Academic Internal Medicine and Geriatrics, University of Illinois at Chicago, 840 South Wood Street, CSN 440, Chicago, IL 60612, United States of America
| | - Shayla Archer
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132, United States of America
| | - Saul Weiner
- Jesse Brown VA Medical Center, Medical Services, 820 S Damen Ave, Chicago, IL 60612, United States of America; Department of Medicine, Division of Academic Internal Medicine and Geriatrics, University of Illinois at Chicago, 840 South Wood Street, CSN 440, Chicago, IL 60612, United States of America
| | - Warren Pettey
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132, United States of America
| | - Gerald Cochran
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132, United States of America
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