1
|
Parchman M, Ike B, Osterhage K, Johnson A, Baldwin LM. Supporting Practice Facilitators in a Learning Health Care System. Perm J 2023; 27:3-6. [PMID: 37537988 PMCID: PMC10502377 DOI: 10.7812/tpp/23.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Affiliation(s)
- Michael Parchman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Brooke Ike
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Katie Osterhage
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Ashley Johnson
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Laura-Mae Baldwin
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
2
|
Lindner SR, Balasubramanian B, Marino M, McConnell KJ, Kottke TE, Edwards ST, Cykert S, Cohen DJ. Estimating the Cardiovascular Disease Risk Reduction of a Quality Improvement Initiative in Primary Care: Findings from EvidenceNOW. J Am Board Fam Med 2023; 36:462-476. [PMID: 37169589 PMCID: PMC10830125 DOI: 10.3122/jabfm.2022.220331r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND This study estimates reductions in 10-year atherosclerotic cardiovascular disease (ASCVD) risk associated with EvidenceNOW, a multi-state initiative that sought to improve cardiovascular preventive care in the form of (A)spirin prescribing for high-risk patients, (B)lood pressure control for people with hypertension, (C)holesterol management, and (S)moking screening and cessation counseling (ABCS) among small primary care practices by providing supportive interventions such as practice facilitation. DESIGN We conducted an analytic modeling study that combined (1) data from 1,278 EvidenceNOW practices collected 2015 to 2017; (2) patient-level information of individuals ages 40 to 79 years who participated in the 2015 to 2016 National Health and Nutrition Examination Survey (n = 1,295); and (3) 10-year ASCVD risk prediction equations. MEASURES The primary outcome measure was 10-year ASCVD risk. RESULTS EvidenceNOW practices cared for an estimated 4 million patients ages 40 to 79 who might benefit from ABCS interventions. The average 10-year ASCVD risk of these patients before intervention was 10.11%. Improvements in ABCS due to EvidenceNOW reduced their 10-year ASCVD risk to 10.03% (absolute risk reduction: -0.08, P ≤ .001). This risk reduction would prevent 3,169 ASCVD events over 10 years and avoid $150 million in 90-day direct medical costs. CONCLUSION Small preventive care improvements and associated reductions in absolute ASCVD risk levels can lead to meaningful life-saving benefits at the population level.
Collapse
Affiliation(s)
- Stephan R Lindner
- From the Center for Health Systems Effectiveness, Oregon Health & Science University (SRL, KJM); OHSU-PSU School of Public Health (SRL, MM, KJM); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas (BB); Department of Family Medicine, Oregon Health & Science University (MM, STE, DJC); HealthPartners Institute, Minneapolis, Minnesota (TEK); Section of General Internal Medicine, Veterans Affairs Portland Health Care System (STE); The Cecil G. Sheps Center for Health Services Research and Division of General Internal Medicine and Clinical Epidemiology, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill (DJC); Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University (DJC).
| | - Bijal Balasubramanian
- From the Center for Health Systems Effectiveness, Oregon Health & Science University (SRL, KJM); OHSU-PSU School of Public Health (SRL, MM, KJM); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas (BB); Department of Family Medicine, Oregon Health & Science University (MM, STE, DJC); HealthPartners Institute, Minneapolis, Minnesota (TEK); Section of General Internal Medicine, Veterans Affairs Portland Health Care System (STE); The Cecil G. Sheps Center for Health Services Research and Division of General Internal Medicine and Clinical Epidemiology, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill (DJC); Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University (DJC)
| | - Miguel Marino
- From the Center for Health Systems Effectiveness, Oregon Health & Science University (SRL, KJM); OHSU-PSU School of Public Health (SRL, MM, KJM); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas (BB); Department of Family Medicine, Oregon Health & Science University (MM, STE, DJC); HealthPartners Institute, Minneapolis, Minnesota (TEK); Section of General Internal Medicine, Veterans Affairs Portland Health Care System (STE); The Cecil G. Sheps Center for Health Services Research and Division of General Internal Medicine and Clinical Epidemiology, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill (DJC); Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University (DJC)
| | - K John McConnell
- From the Center for Health Systems Effectiveness, Oregon Health & Science University (SRL, KJM); OHSU-PSU School of Public Health (SRL, MM, KJM); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas (BB); Department of Family Medicine, Oregon Health & Science University (MM, STE, DJC); HealthPartners Institute, Minneapolis, Minnesota (TEK); Section of General Internal Medicine, Veterans Affairs Portland Health Care System (STE); The Cecil G. Sheps Center for Health Services Research and Division of General Internal Medicine and Clinical Epidemiology, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill (DJC); Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University (DJC)
| | - Thomas E Kottke
- From the Center for Health Systems Effectiveness, Oregon Health & Science University (SRL, KJM); OHSU-PSU School of Public Health (SRL, MM, KJM); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas (BB); Department of Family Medicine, Oregon Health & Science University (MM, STE, DJC); HealthPartners Institute, Minneapolis, Minnesota (TEK); Section of General Internal Medicine, Veterans Affairs Portland Health Care System (STE); The Cecil G. Sheps Center for Health Services Research and Division of General Internal Medicine and Clinical Epidemiology, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill (DJC); Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University (DJC)
| | - Samuel T Edwards
- From the Center for Health Systems Effectiveness, Oregon Health & Science University (SRL, KJM); OHSU-PSU School of Public Health (SRL, MM, KJM); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas (BB); Department of Family Medicine, Oregon Health & Science University (MM, STE, DJC); HealthPartners Institute, Minneapolis, Minnesota (TEK); Section of General Internal Medicine, Veterans Affairs Portland Health Care System (STE); The Cecil G. Sheps Center for Health Services Research and Division of General Internal Medicine and Clinical Epidemiology, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill (DJC); Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University (DJC)
| | - Sam Cykert
- From the Center for Health Systems Effectiveness, Oregon Health & Science University (SRL, KJM); OHSU-PSU School of Public Health (SRL, MM, KJM); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas (BB); Department of Family Medicine, Oregon Health & Science University (MM, STE, DJC); HealthPartners Institute, Minneapolis, Minnesota (TEK); Section of General Internal Medicine, Veterans Affairs Portland Health Care System (STE); The Cecil G. Sheps Center for Health Services Research and Division of General Internal Medicine and Clinical Epidemiology, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill (DJC); Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University (DJC)
| | - Deborah J Cohen
- From the Center for Health Systems Effectiveness, Oregon Health & Science University (SRL, KJM); OHSU-PSU School of Public Health (SRL, MM, KJM); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas (BB); Department of Family Medicine, Oregon Health & Science University (MM, STE, DJC); HealthPartners Institute, Minneapolis, Minnesota (TEK); Section of General Internal Medicine, Veterans Affairs Portland Health Care System (STE); The Cecil G. Sheps Center for Health Services Research and Division of General Internal Medicine and Clinical Epidemiology, The University of North Carolina School of Medicine at Chapel Hill, Chapel Hill (DJC); Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University (DJC)
| |
Collapse
|
3
|
Kroon D, van Dulmen SA, Westert GP, Jeurissen PPT, Kool RB. Development of the SPREAD framework to support the scaling of de-implementation strategies: a mixed-methods study. BMJ Open 2022; 12:e062902. [PMID: 36343997 PMCID: PMC9644331 DOI: 10.1136/bmjopen-2022-062902] [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] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE We aimed to increase the understanding of the scaling of de-implementation strategies by identifying the determinants of the process and developing a determinant framework. DESIGN AND METHODS This study has a mixed-methods design. First, we performed an integrative review to build a literature-based framework describing the determinants of the scaling of healthcare innovations and interventions. PubMed and EMBASE were searched for relevant studies from 1995 to December 2020. We systematically extracted the determinants of the scaling of interventions and developed a literature-based framework. Subsequently, this framework was discussed in four focus groups with national and international de-implementation experts. The literature-based framework was complemented by the findings of the focus group meetings and adapted for the scaling of de-implementation strategies. RESULTS The literature search resulted in 42 articles that discussed the determinants of the scaling of innovations and interventions. No articles described determinants specifically for de-implementation strategies. During the focus groups, all participants agreed on the relevance of the extracted determinants for the scaling of de-implementation strategies. The experts emphasised that while the determinants are relevant for various countries, the implications differ due to different contexts, cultures and histories. The analyses of the focus groups resulted in additional topics and determinants, namely, medical training, professional networks, interests of stakeholders, clinical guidelines and patients' perspectives. The results of the focus group meetings were combined with the literature framework, which together formed the supporting the scaling of de-implementation strategies (SPREAD) framework. The SPREAD framework includes determinants from four domains: (1) scaling plan, (2) external context, (3) de-implementation strategy and (4) adopters. CONCLUSIONS The SPREAD framework describes the determinants of the scaling of de-implementation strategies. These determinants are potential targets for various parties to facilitate the scaling of de-implementation strategies. Future research should validate these determinants of the scaling of de-implementation strategies.
Collapse
Affiliation(s)
| | | | | | | | - Rudolf B Kool
- IQ Healthcare, Radboudumc, Nijmegen, The Netherlands
| |
Collapse
|
4
|
Sweeney SM, Baron A, Hall JD, Ezekiel-Herrera D, Springer R, Ward RL, Marino M, Balasubramanian BA, Cohen DJ. Effective Facilitator Strategies for Supporting Primary Care Practice Change: A Mixed Methods Study. Ann Fam Med 2022; 20:414-422. [PMID: 36228060 PMCID: PMC9512557 DOI: 10.1370/afm.2847] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 03/16/2022] [Accepted: 05/04/2022] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Practice facilitation is an evidence-informed implementation strategy to support quality improvement (QI) and aid practices in aligning with best evidence. Few studies, particularly of this size and scope, identify strategies that contribute to facilitator effectiveness. METHODS We conducted a sequential mixed methods study, analyzing data from EvidenceNOW, a large-scale QI initiative. Seven regional cooperatives employed 162 facilitators to work with 1,630 small or medium-sized primary care practices. Main analyses were based on facilitators who worked with at least 4 practices. Facilitators were defined as more effective if at least 75% of their practices improved on at least 1 outcome measure-aspirin use, blood pressure control, smoking cessation counseling (ABS), or practice change capacity, measured using Change Process Capability Questionnaire-from baseline to follow-up. Facilitators were defined as less effective if less than 50% of their practices improved on these outcomes. Using an immersion crystallization and comparative approach, we analyzed observational and interview data to identify strategies associated with more effective facilitators. RESULTS Practices working with more effective facilitators had a 3.6% greater change in the mean percentage of patients meeting the composite ABS measure compared with practices working with less effective facilitators (P <.001). More effective facilitators cultivated motivation by tailoring QI work and addressing resistance, guided practices to think critically, and provided accountability to support change, using these strategies in combination. They were able to describe their work in detail. In contrast, less effective facilitators seldom used these strategies and described their work in general terms. Facilitator background, experience, and work on documentation did not differentiate between more and less effective facilitators. CONCLUSIONS Facilitation strategies that differentiate more and less effective facilitators have implications for enhancing facilitator development and training, and can assist all facilitators to more effectively support practice changes.
Collapse
Affiliation(s)
- Shannon M Sweeney
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Andrea Baron
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Jennifer D Hall
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | | | - Rachel Springer
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Rikki L Ward
- Department of Epidemiology, Human Genetics, and Environmental Science, UTHealth School of Public Health, Dallas, Texas
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Bijal A Balasubramanian
- Department of Epidemiology, Human Genetics, and Environmental Science, UTHealth School of Public Health, Dallas, Texas
| | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| |
Collapse
|
5
|
Coleman KF, Krakauer C, Anderson M, Michaels L, Dorr DA, Fagnan LJ, Hsu C, Parchman ML. Improving Quality Improvement Capacity and Clinical Performance in Small Primary Care Practices. Ann Fam Med 2021; 19:499-506. [PMID: 34750124 PMCID: PMC8575517 DOI: 10.1370/afm.2733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 02/08/2021] [Accepted: 03/22/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We undertook a study to assess whether implementing 7 evidence-based strategies to build improvement capacity within smaller primary care practices was associated with changes in performance on clinical quality measures (CQMs) for cardiovascular disease. METHODS A total of 209 practices across Washington, Oregon, and Idaho participated in a pragmatic clinical trial that focused on building quality improvement capacity as measured by a validated questionnaire, the 12-point Quality Improvement Capacity Assessment (QICA). Clinics reported performance on 3 cardiovascular CQMs-appropriate aspirin use, blood pressure (BP) control (<140/90 mm Hg), and smoking screening/cessation counseling-at baseline (2015) and follow-up (2017). Regression analyses with change in CQM as the dependent variable allowed for clustering by practice facilitator and adjusted for baseline CQM performance. RESULTS Practices improved QICA scores by 1.44 points (95% CI, 1.20-1.68; P <.001) from an average baseline of 6.45. All 3 CQMs also improved: aspirin use by 3.98% (average baseline = 66.8%; 95% CI for change, 1.17%-6.79%; P = .006); BP control by 3.36% (average baseline = 61.5%; 95% CI for change, 1.44%-5.27%; P = .001); and tobacco screening/cessation counseling by 7.49% (average baseline = 73.8%; 95% CI for change, 4.21%-10.77%; P <.001). Each 1-point increase in QICA score was associated with a 1.25% (95% CI, 0.41%-2.09%, P = .003) improvement in BP control; the estimated likelihood of reaching a 70% BP control performance goal was 1.24 times higher (95% CI, 1.09-1.40; P <.001) for each 1-point increase in QICA. CONCLUSION Improvements in clinic-level performance on BP control may be attributed to implementation of 7 evidence-based strategies to build quality improvement capacity. These strategies were feasible to implement in small practices over 15 months.
Collapse
Affiliation(s)
- Katie F Coleman
- Center for Accelerating Care Transformation (previously MacColl Center), Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Chloe Krakauer
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Melissa Anderson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - LeAnn Michaels
- Oregon Rural Practice Research Network, Oregon Health & Science University, Portland, Oregon
| | - David A Dorr
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Lyle J Fagnan
- Oregon Rural Practice Research Network, Oregon Health & Science University, Portland, Oregon
| | - Clarissa Hsu
- Center for Accelerating Care Transformation (previously MacColl Center), Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Michael L Parchman
- Center for Accelerating Care Transformation (previously MacColl Center), Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| |
Collapse
|
6
|
Leeman J, Boisson A, Go V. Scaling Up Public Health Interventions: Engaging Partners Across Multiple Levels. Annu Rev Public Health 2021; 43:155-171. [PMID: 34724390 DOI: 10.1146/annurev-publhealth-052020-113438] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Advancing the science of intervention scale-up is essential to increasing the impact of effective interventions at the regional and national levels. In contrast with work in high-income countries (HICs), where scale-up research has been limited, researchers in low- and middle-income countries (LMICs) have conducted numerous studies on the regional and national scale-up of interventions. In this article, we review the state of the science on intervention scale-up in both HICs and LMICs. We provide an introduction to the elements of scale-up followed by a description of the scale-up process, with an illustrative case study from our own research. We then present findings from a scoping review comparing scale-up studies in LMIC and HIC settings. We conclude with lessons learned and recommendations for improving scale-up research. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
Collapse
Affiliation(s)
- Jennifer Leeman
- School of Nursing, University of North Carolina, Chapel Hill, North Carolina, USA;
| | - Alix Boisson
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA;
| | - Vivian Go
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA;
| |
Collapse
|
7
|
Edwards ST, Marino M, Solberg LI, Damschroder L, Stange KC, Kottke TE, Balasubramanian BA, Springer R, Perry CK, Cohen DJ. Cultural And Structural Features Of Zero-Burnout Primary Care Practices. Health Aff (Millwood) 2021; 40:928-936. [PMID: 34097508 DOI: 10.1377/hlthaff.2020.02391] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Although much attention has been focused on individual-level drivers of burnout in primary care settings, examining the structural and cultural factors of practice environments with no burnout could identify solutions. In this cross-sectional analysis of survey data from 715 small-to-medium-size primary care practices in the United States participating in the Agency for Healthcare Research and Quality's EvidenceNOW initiative, we found that zero-burnout practices had higher levels of psychological safety and adaptive reserve, a measure of practice capacity for learning and development. Compared with high-burnout practices, zero-burnout practices also reported using more quality improvement strategies, more commonly were solo and clinician owned, and less commonly had participated in accountable care organizations or other demonstration projects. Efforts to prevent burnout in primary care may benefit from focusing on enhancing organization and practice culture, including promoting leadership development and fostering practice agency.
Collapse
Affiliation(s)
- Samuel T Edwards
- Samuel T. Edwards is an assistant professor of medicine at Oregon Health and Science University and a staff physician in the Section of General Internal Medicine, Veterans Affairs Portland Health Care System, both in Portland, Oregon
| | - Miguel Marino
- Miguel Marino is an associate professor of biostatistics in the Department of Family Medicine, Oregon Health and Science University, and at the OHSU-Portland State University School of Public Health, in Portland, Oregon
| | - Leif I Solberg
- Leif I. Solberg is a senior research investigator at HealthPartners Institute, in Minneapolis, Minnesota
| | - Laura Damschroder
- Laura Damschroder is an implementation research consultant through Implementation Pathways, LLC, and a research investigator in the Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, in Ann Arbor, Michigan
| | - Kurt C Stange
- Kurt C. Stange is the Dorothy Jones Weatherhead Professor of Medicine; a professor of family medicine and community health, population and quantitative health sciences, oncology, and sociology; and the director of the Center for Community Health Integration, Case Western Reserve University, in Cleveland, Ohio
| | - Thomas E Kottke
- Thomas E. Kottke is a senior research investigator at HealthPartners Institute
| | - Bijal A Balasubramanian
- Bijal A. Balasubramanian is an associate professor in the Department of Epidemiology, Human Genetics, and Environmental Sciences and regional dean of UTHealth School of Public Health, in Dallas, Texas
| | - Rachel Springer
- Rachel Springer is a biostatistician in the Department of Family Medicine, Oregon Health and Science University
| | - Cynthia K Perry
- Cynthia K. Perry is a professor in the School of Nursing, Oregon Health and Science University
| | - Deborah J Cohen
- Deborah J. Cohen is a professor of family medicine and vice chair of research in the Department of Family Medicine, Oregon Health and Science University
| |
Collapse
|
8
|
Phillips RL. The Need for Coaches in the Clinical World. Ann Fam Med 2021; 19:194-195. [PMID: 34180836 PMCID: PMC8118472 DOI: 10.1370/afm.2700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 03/31/2021] [Indexed: 11/09/2022] Open
|
9
|
Cohen DJ, Sweeney SM, Miller WL, Hall JD, Miech EJ, Springer RJ, Balasubramanian BA, Damschroder L, Marino M. Improving Smoking and Blood Pressure Outcomes: The Interplay Between Operational Changes and Local Context. Ann Fam Med 2021; 19:240-248. [PMID: 34180844 PMCID: PMC8118489 DOI: 10.1370/afm.2668] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 10/23/2020] [Accepted: 10/29/2020] [Indexed: 01/25/2023] Open
Abstract
PURPOSE We undertook a study to identify conditions and operational changes linked to improvements in smoking and blood pressure (BP) outcomes in primary care. METHODS We purposively sampled and interviewed practice staff (eg, office managers, clinicians) from a subset of 104 practices participating in EvidenceNOW-a multisite cardiovascular disease prevention initiative. We calculated Clinical Quality Measure improvements, with targets of 10-point or greater absolute improvements in the proportion of patients with smoking screening and, if relevant, counseling and in the proportion of hypertensive patients with adequately controlled BP. We analyzed interview data to identify operational changes, transforming these into numeric data. We used Configurational Comparative Methods to assess the joint effects of multiple factors on outcomes. RESULTS In clinician-owned practices, implementing a workflow to routinely screen, counsel, and connect patients to smoking cessation resources, or implementing a documentation change or a referral to a resource alone led to an improvement of at least 10 points in the smoking outcome with a moderate level of facilitation support. These patterns did not manifest in health- or hospital system-owned practices or in Federally Qualified Health Centers, however. The BP outcome improved by at least 10 points among solo practices after medical assistants were trained to take an accurate BP. Among larger, clinician-owned practices, BP outcomes improved when practices implemented a second BP measurement when the first was elevated, and when staff learned where to document this information in the electronic health record. With 50 hours or more of facilitation, BP outcomes improved among larger and health- and hospital system-owned practices that implemented these operational changes. CONCLUSIONS There was no magic bullet for improving smoking or BP outcomes. Multiple combinations of operational changes led to improvements, but only in specific contexts of practice size and ownership, or dose of external facilitation.
Collapse
Affiliation(s)
- Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Shannon M Sweeney
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | | | - Jennifer D Hall
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Edward J Miech
- Regenstrief Institute, Center for Health Services Research, Indianapolis, Indiana
| | - Rachel J Springer
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Bijal A Balasubramanian
- Department of Epidemiology, Human Genetics, and Environmental Science, UTHealth School of Public Health, Dallas, Texas
| | - Laura Damschroder
- Implementation Pathways, LLC and VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| |
Collapse
|
10
|
Ahmed MH, Abdalla ME, Taha MH. Why social accountability of medical schools in Sudan can lead to better primary healthcare and excellence in medical education? J Family Med Prim Care 2020; 9:3820-3825. [PMID: 33110774 PMCID: PMC7586598 DOI: 10.4103/jfmpc.jfmpc_498_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 04/25/2020] [Accepted: 05/21/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction: Medical education in Sudan continues to evolve and progress with proliferation in the number of medical schools after 1990. Social factors and the geographical location of Sudan will increase the opportunity of success of medical schools to be socially accountable. In this analysis, we explained why social accountability is needed in Sudan and how this can enhance both excellence in medical education and primary health care, especially in rural areas. Methodology: PubMed, scopus Medline, and Google Scholar were searched for published-English literature concerning social accountability of medical schools in Sudan and worldwide were reviewed regardless of the time limit. We have also included examples of medical schools from Sudan and the Middle East to reflect on their experience in social accountability. Results: In this critical review, we have shown that social accountability will come with benefits for medical schools and the community. Implementation of social accountability in medical schools in Sudan will increase the effectiveness of medical schools' productivity, research output, and health service in urban and rural areas. There is an urgent need for social accountability alliance in Sudan to increase collaboration between medical schools. This will increase the benefits of social accountability for all stakeholders and also increases the competency in social medicine within the medical school curriculum. Conclusion: Social accountability is regarded as a sign of excellence in medical education. Primary care physicians in Sudan are expected to be the leaders in the implementation of social accountability. This analysis answered two important questions about why medical schools in Sudan should be socially accountable? And do we need a special structure of social accountability in Sudan?
Collapse
Affiliation(s)
- Mohamed H Ahmed
- Department of Medicine and HIV Metabolic Clinic, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes, Buckinghamshire, UK
| | - Mohamed Elhassan Abdalla
- College of Medicine and Medical Education Center, University of Sharjah, Sharjah, United Arab Emirates
| | - Mohamed H Taha
- College of Medicine and Medical Education Center, University of Sharjah, Sharjah, United Arab Emirates
| |
Collapse
|
11
|
RE-AIM Evaluation Plan for Washington State Innovation Models Project. Qual Manag Health Care 2020; 29:81-94. [PMID: 32224792 DOI: 10.1097/qmh.0000000000000246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The State of Washington received a State Innovation Models (SIM) $65 million award from the federal Centers for Medicare & Medicaid Services to improve population health and quality of care and reduce the growth of health care costs in the entire state, which has over 7 million residents. SIM is a "complex intervention" that implements several interacting components in a complex, decentralized health system to achieve goals, which poses challenges for evaluation. Our purpose is to present the state-level evaluation methods for Washington's SIM, a 3-year intervention (2016-2018). We apply the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) evaluation framework to structure our evaluation. We create a conceptual model and a plan to use multiple and mixed methods to study SIM performance in the RE-AIM components from a statewide, population-based perspective.
Collapse
|
12
|
Dedicated Workforce Required to Support Large-Scale Practice Improvement. J Am Board Fam Med 2020; 33:230-239. [PMID: 32179606 PMCID: PMC7175633 DOI: 10.3122/jabfm.2020.02.190261] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 11/07/2019] [Accepted: 11/19/2019] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Facilitation is an effective approach for helping practices implement sustainable evidence-based practice improvements. Few studies examine the facilitation infrastructure and support needed for large-scale dissemination and implementation initiatives. METHODS The Agency for Health care Research and Quality funded 7 Cooperatives, each of which worked with over 200 primary care practices to rapidly disseminate and implement improvements in cardiovascular preventive care. The intervention target was to improve primary care practice capacity for quality initiative and the ABCS of cardiovascular disease prevention: aspirin in high-risk individuals, blood pressure control, cholesterol management, and smoking cessation. We identified the organizational elements and infrastructures Cooperatives used to support facilitators by reviewing facilitator logs, online diary data, semistructured interviews with facilitators, and fieldnotes from facilitator observations. We analyzed these data using a coding and sorting process. RESULTS Each Cooperative partnered with 2 to 16 organizations, piecing together 16 to 35 facilitators, often from other quality improvement projects. Quality assurance strategies included establishing initial and ongoing training, processes to support facilitators, and monitoring to assure consistency and quality. Cooperatives developed facilitator toolkits, implemented initiative-specific training, and developed processes for peer-to-peer learning and support. CONCLUSIONS Supporting a large-scale facilitation workforce requires creating an infrastructure, including initial training, and ongoing support and monitoring, often borrowing from other ongoing initiatives. Facilitation that recognizes the need to support the vital integrating functions of primary care might be more efficient and effective than this fragmented approach to quality improvement.
Collapse
|
13
|
Khan T, Eschbach C, Cuthbertson CA, Newkirk C, Contreras D, Kirley K. Connecting Primary Care to Community-Based Education: Michigan Physicians' Familiarity With Extension Programs. Health Promot Pract 2019; 21:175-180. [PMID: 31452391 DOI: 10.1177/1524839919868980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Clinical-community linkages enhance health care delivery and enable physician-patient partnerships to achieve better health. The Michigan State University (MSU) Model of Health Extension includes a strategy for forming these linkages by focusing on increasing primary care patient referrals and enrollment in health programs. This article shares the results of a survey of Michigan internal medicine and family medicine physicians (n = 323) to better understand attitudes toward and familiarity with community-based education (CBE) programs and to assess the logistical requirements to make CBE referrals efficient and sustainable. Survey results showed that at most, 55% of respondents were aware of at least one CBE program implemented by Cooperative Extension. Of those who were aware, over 85% agreed that the programs have positive benefits for patients. Thirty-five percent reported at least one referral barrier, and familiarity with the CBE programs was a significant predictor for reporting all referral barriers. The results suggest that increasing physicians' familiarity of CBE health programs is a key first step in identifying ideal strategies to overcome referral barriers. Data from this study may help determine scalable state level models for increasing awareness of chronic disease prevention and other CBE programs in efforts to improve the health of the nation.
Collapse
Affiliation(s)
| | | | | | | | | | - Kate Kirley
- American Medical Association, Chicago, IL, USA
| |
Collapse
|
14
|
Kaufman A, Dickinson WP, Fagnan LJ, Duffy FD, Parchman ML, Rhyne RL. The Role of Health Extension in Practice Transformation and Community Health Improvement: Lessons From 5 Case Studies. Ann Fam Med 2019; 17:S67-S72. [PMID: 31405879 PMCID: PMC6827669 DOI: 10.1370/afm.2409] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 03/06/2019] [Accepted: 04/17/2019] [Indexed: 11/09/2022] Open
Abstract
Passage of the Patient Protection and Affordable Care Act triggered 2 successive grant initiatives from the Agency for Healthcare Research and Quality, allowing for the evolution of health extension models among 20 states, not limited to support for in-clinic primary care practice transformation, but also including a broader concept incorporating technical assistance for practices and their communities to address social determinants of health. Five states stand out in stretching the boundaries of health extension: New Mexico, Oklahoma, Oregon, Colorado, and Washington. Their stories reveal lessons learned regarding the successes and challenges, including the importance of building sustained relationships with practices and community coalitions; of documenting success in broad terms as well as achieving diverse outcomes of meaning to different stakeholders; of understanding that health extension is a function that can be carried out by an individual or group depending on resources; and of being prepared for political struggles over "turf" and ownership of extension. All states saw the need for long-term, sustained fundraising beyond grants in an environment expecting a short-term return on investment, and they were challenged operating in a shifting health system landscape where the creativity and personal relationships built with small primary care practices was hindered when these practices were purchased by larger health delivery systems.
Collapse
Affiliation(s)
- Arthur Kaufman
- Department of Family and Community Medicine, University of New Mexico, Albuquerque, New Mexico
| | - W Perry Dickinson
- Department of Family Medicine, University of Colorado, Boulder, Colorado
| | - Lyle J Fagnan
- Department of Family Medicine, Oregon Health & Sciences University, Portland, Oregon
| | - F Daniel Duffy
- Office of Health Care Innovation, University of Oklahoma, Norman, Oklahoma
| | - Michael L Parchman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Robert L Rhyne
- Department of Family and Community Medicine, University of New Mexico, Albuquerque, New Mexico
| |
Collapse
|
15
|
Phillips RL, Cohen DJ, Kaufman A, Dickinson WP, Cykert S. Facilitating Practice Transformation in Frontline Health Care. Ann Fam Med 2019; 17:S2-S5. [PMID: 31405869 PMCID: PMC6827672 DOI: 10.1370/afm.2439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 06/18/2019] [Accepted: 07/01/2019] [Indexed: 01/13/2023] Open
Affiliation(s)
- Robert L Phillips
- Center for Professionalism & Value in Health Care, Lexington, Kentucky
| | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Arthur Kaufman
- Office for Community Health, University of New Mexico, Albuquerque, New Mexico
| | - W Perry Dickinson
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Samuel Cykert
- Division of General Medicine and Clinical Epidemiology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| |
Collapse
|
16
|
Perry CK, Damschroder LJ, Hemler JR, Woodson TT, Ono SS, Cohen DJ. Specifying and comparing implementation strategies across seven large implementation interventions: a practical application of theory. Implement Sci 2019. [PMID: 30898133 DOI: 10.1186/s13012‐019‐0876‐4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of implementation strategies is an active and purposive approach to translate research findings into routine clinical care. The Expert Recommendations for Implementing Change (ERIC) identified and defined discrete implementation strategies, and Proctor and colleagues have made recommendations for specifying operationalization of each strategy. We use empirical data to test how the ERIC taxonomy applies to a large dissemination and implementation initiative aimed at taking cardiac prevention to scale in primary care practice. METHODS EvidenceNOW is an Agency for Healthcare Research and Quality initiative that funded seven cooperatives across seven regions in the USA. Cooperatives implemented multi-component interventions to improve heart health and build quality improvement capacity, and used a range of implementation strategies to foster practice change. We used ERIC to identify cooperatives' implementation strategies and specified the actor, action, target, dose, temporality, justification, and expected outcome for each. We mapped and compiled a matrix of the specified ERIC strategies across the cooperatives, and used consensus to resolve mapping differences. We then grouped implementation strategies by outcomes and justifications, which led to insights regarding the use of and linkages between ERIC strategies in real-world scale-up efforts. RESULTS Thirty-three ERIC strategies were used by cooperatives. We identified a range of revisions to the ERIC taxonomy to improve the practical application of these strategies. These proposed changes include revisions to four strategy names and 12 definitions. We suggest adding three new strategies because they encapsulate distinct actions that were not described in the existing ERIC taxonomy. In addition, we organized ERIC implementation strategies into four functional groupings based on the way we observed them being applied in practice. These groupings show how ERIC strategies are, out of necessity, interconnected, to achieve the work involved in rapidly taking evidence to scale. CONCLUSIONS Findings of our work suggest revisions to the ERIC implementation strategies to reflect their utilization in real-work dissemination and implementation efforts. The functional groupings of the ERIC implementation strategies that emerged from on-the-ground implementers will help guide others in choosing among and linking multiple implementation strategies when planning small- and large-scale implementation efforts. TRIAL REGISTRATION Registered as Observational Study at www.clinicaltrials.gov ( NCT02560428 ).
Collapse
Affiliation(s)
- Cynthia K Perry
- School of Nursing, Oregon Health & Science University, 3455 SW US Veterans Hospital Rd, Portland, OR, 97239, USA.
| | - Laura J Damschroder
- Implementation Pathways, LLC, Ann Arbor, MI, USA.,VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Jennifer R Hemler
- Department of Family Medicine and Community Health, Rutgers University--Robert Wood Johnson Medical School, 112 Paterson Street, New Brunswick, NJ, 08901, USA
| | - Tanisha T Woodson
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Sarah S Ono
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| |
Collapse
|
17
|
Perry CK, Damschroder LJ, Hemler JR, Woodson TT, Ono SS, Cohen DJ. Specifying and comparing implementation strategies across seven large implementation interventions: a practical application of theory. Implement Sci 2019; 14:32. [PMID: 30898133 PMCID: PMC6429753 DOI: 10.1186/s13012-019-0876-4] [Citation(s) in RCA: 123] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 02/28/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of implementation strategies is an active and purposive approach to translate research findings into routine clinical care. The Expert Recommendations for Implementing Change (ERIC) identified and defined discrete implementation strategies, and Proctor and colleagues have made recommendations for specifying operationalization of each strategy. We use empirical data to test how the ERIC taxonomy applies to a large dissemination and implementation initiative aimed at taking cardiac prevention to scale in primary care practice. METHODS EvidenceNOW is an Agency for Healthcare Research and Quality initiative that funded seven cooperatives across seven regions in the USA. Cooperatives implemented multi-component interventions to improve heart health and build quality improvement capacity, and used a range of implementation strategies to foster practice change. We used ERIC to identify cooperatives' implementation strategies and specified the actor, action, target, dose, temporality, justification, and expected outcome for each. We mapped and compiled a matrix of the specified ERIC strategies across the cooperatives, and used consensus to resolve mapping differences. We then grouped implementation strategies by outcomes and justifications, which led to insights regarding the use of and linkages between ERIC strategies in real-world scale-up efforts. RESULTS Thirty-three ERIC strategies were used by cooperatives. We identified a range of revisions to the ERIC taxonomy to improve the practical application of these strategies. These proposed changes include revisions to four strategy names and 12 definitions. We suggest adding three new strategies because they encapsulate distinct actions that were not described in the existing ERIC taxonomy. In addition, we organized ERIC implementation strategies into four functional groupings based on the way we observed them being applied in practice. These groupings show how ERIC strategies are, out of necessity, interconnected, to achieve the work involved in rapidly taking evidence to scale. CONCLUSIONS Findings of our work suggest revisions to the ERIC implementation strategies to reflect their utilization in real-work dissemination and implementation efforts. The functional groupings of the ERIC implementation strategies that emerged from on-the-ground implementers will help guide others in choosing among and linking multiple implementation strategies when planning small- and large-scale implementation efforts. TRIAL REGISTRATION Registered as Observational Study at www.clinicaltrials.gov ( NCT02560428 ).
Collapse
Affiliation(s)
- Cynthia K Perry
- School of Nursing, Oregon Health & Science University, 3455 SW US Veterans Hospital Rd, Portland, OR, 97239, USA.
| | - Laura J Damschroder
- Implementation Pathways, LLC, Ann Arbor, MI, USA.,VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Jennifer R Hemler
- Department of Family Medicine and Community Health, Rutgers University--Robert Wood Johnson Medical School, 112 Paterson Street, New Brunswick, NJ, 08901, USA
| | - Tanisha T Woodson
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Sarah S Ono
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| |
Collapse
|
18
|
Bryce C, Russell R, Dale J. Learning from the transfer of a fellowship programme to support primary care workforce needs in the UK: a qualitative study. BMJ Open 2019; 9:e023384. [PMID: 30782705 PMCID: PMC6347891 DOI: 10.1136/bmjopen-2018-023384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 11/22/2018] [Accepted: 11/26/2018] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES Service redesign, including workforce development, is being championed by UK health service policy. It is allowing new opportunities to enhance the roles of staff and encourage multiprofessional portfolio working. New models of working are emerging, but there has been little research into how innovative programmes are transferred to and taken up by different areas. This study investigates the transferability of a 1-year post-Certification of Completion of Training fellowship in urgent and acute care from a pilot in the West Midlands region of England to London and the South East. DESIGN A qualitative study using semistructured interviews supplemented by observational data of fellows' clinical and academic activities. Data were analysed using a thematic framework approach. SETTING AND PARTICIPANTS Two cohorts of fellows (15 in total) along with key stakeholders, mentors, tutors and host organisations in London and the South East (LaSE). Fellows had placements in primary and secondary care settings (general practice, emergency department, ambulatory care, urgent care and rapid response teams), together with academic training. RESULTS Seventy-six interviews were completed with 50 participants, with observations in eight clinical placements and two academic sessions. The overall structure of the West Midlands programme was retained and the core learning outcomes adopted in LaSE. Three fundamental adaptations were evident: broadening the programme to include multiprofessional fellows, changes to the funding model and the impact that had on clinical placements. These were felt to be key to its adoption and longer-term sustainability. CONCLUSION The evaluation demonstrates a model of training that is adaptable and transferable between National Health Service regions, taking account of changing national and regional circumstances, and has the potential to be rolled out widely.
Collapse
Affiliation(s)
- Carol Bryce
- Unit of Academic Primary Care, University of Warwick, Warwick Medical School, Coventry, UK
| | - Rachel Russell
- Unit of Academic Primary Care, University of Warwick, Warwick Medical School, Coventry, UK
| | - Jeremy Dale
- Unit of Academic Primary Care, University of Warwick, Warwick Medical School, Coventry, UK
| |
Collapse
|
19
|
Shoemaker SJ, McNellis RJ, DeWalt DA. The Capacity of Primary Care for Improving Evidence-Based Care: Early Findings From AHRQ's EvidenceNOW. Ann Fam Med 2018; 16:S2-S4. [PMID: 29632218 PMCID: PMC5891306 DOI: 10.1370/afm.2227] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 02/20/2018] [Indexed: 01/17/2023] Open
Affiliation(s)
- Sarah J Shoemaker
- Health Policy Practice, Abt Associates, Inc, Cambridge, Massachusetts
| | - Robert J McNellis
- Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, Maryland
| | - Darren A DeWalt
- Division of General Medicine and Clinical Epidemiology, Department of Medicine University of North Carolina School of Medicine, Chapel Hill, North Carolina
| |
Collapse
|