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Jenssen BP, Kelleher S, Karavite DJ, Nekrasova E, Thayer JG, Ratwani R, Shea JA, Nabi-Burza E, Drehmer JE, Winickoff JP, Grundmeier RW, Schnoll RA, Fiks AG. A Clinical Decision Support System for Motivational Messaging and Tobacco Cessation Treatment for Parents: Pilot Evaluation of Use and Acceptance. Appl Clin Inform 2023; 14:439-447. [PMID: 36972687 PMCID: PMC10247306 DOI: 10.1055/a-2062-9627] [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: 12/19/2022] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Research is needed to identify how clinical decision support (CDS) systems can support communication about and engagement with tobacco use treatment in pediatric settings for parents who smoke. We developed a CDS system that identifies parents who smoke, delivers motivational messages to start treatment, connects parents to treatment, and supports pediatrician-parent discussion. OBJECTIVE The objective of this study is to assess the performance of this system in clinical practice, including receipt of motivational messages and tobacco use treatment acceptance rates. METHODS The system was evaluated at one large pediatric practice through a single-arm pilot study from June to November 2021. We collected data on the performance of the CDS system for all parents. Additionally, we surveyed a sample of parents immediately after the clinical encounter who used the system and reported smoking. Measures were: (1) the parent remembered the motivational message, (2) the pediatrician reinforced the message, and (3) treatment acceptance rates. Treatments included nicotine replacement therapy, quitline referral (phone counseling), and/or SmokefreeTXT referral (text message counseling). We described survey response rates overall and with 95% confidence intervals (CIs). RESULTS During the entire study period, 8,488 parents completed use of the CDS: 9.3% (n = 786) reported smoking and 48.2% (n = 379) accepted at least one treatment. A total of 102 parents who smoke who used the system were approached to survey 100 parents (98% response rate). Most parents self-identified as female (84%), aged 25 to 34 years (56%), and Black/African American (94%), and had children with Medicaid insurance (95%). Of parents surveyed, 54% accepted at least one treatment option. Most parents recalled the motivational message (79%; 95% CI: 71-87%), and 31% (95% CI: 19-44%) reported that the pediatrician reinforced the motivational message. CONCLUSION A CDS system to support parental tobacco use treatment in pediatric primary care enhanced motivational messaging about smoking cessation and evidence-based treatment initiation.
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Affiliation(s)
- Brian P. Jenssen
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
- Clinical Futures, PolicyLab, and The Possibilities Project, Children's Hospital of Philadelphia, Pennsilvania, United States
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Shannon Kelleher
- Clinical Futures, PolicyLab, and The Possibilities Project, Children's Hospital of Philadelphia, Pennsilvania, United States
| | - Dean J. Karavite
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Ekaterina Nekrasova
- Clinical Futures, PolicyLab, and The Possibilities Project, Children's Hospital of Philadelphia, Pennsilvania, United States
| | - Jeritt G. Thayer
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Raj Ratwani
- MedStar Health National Center for Human Factors in Healthcare, Washington, District of Columbia, United States
| | - Judy A. Shea
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Emara Nabi-Burza
- Division of General Academic Pediatrics, Tobacco Research and Treatment Center, Massachusetts General Hospital for Children, Boston, Massachusetts, United States
| | - Jeremy E. Drehmer
- Division of General Academic Pediatrics, Tobacco Research and Treatment Center, Massachusetts General Hospital for Children, Boston, Massachusetts, United States
| | - Jonathan P. Winickoff
- Division of General Academic Pediatrics, Tobacco Research and Treatment Center, Massachusetts General Hospital for Children, Boston, Massachusetts, United States
| | - Robert W. Grundmeier
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Robert A. Schnoll
- Department of Psychiatry, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Alexander G. Fiks
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
- Clinical Futures, PolicyLab, and The Possibilities Project, Children's Hospital of Philadelphia, Pennsilvania, United States
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
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2
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Chang LS, Kuo HC, Suen JJB, Yang PH, Hou CP, Sun HR, Lee ZM, Huang YH. Multimedia Mixed Reality Interactive Shared Decision-Making Game in Children with Moderate to Severe Atopic Dermatitis, a Pilot Study. CHILDREN 2023; 10:children10030574. [PMID: 36980133 PMCID: PMC10047264 DOI: 10.3390/children10030574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/07/2023] [Accepted: 03/15/2023] [Indexed: 03/19/2023]
Abstract
(1) Objective: Atopic dermatitis (AD) is a recurring skin disease that affects children’s daily activities and sleep quality. Due to the limitations of children’s understanding and ability to express themselves, shared decision making (SDM) is often made by guardians, which thus affects the acceptance and effectiveness of children’s treatments. Previous studies have demonstrated that involving both children and parents in decision making may help improve treatment outcomes; thus, we designed a multimedia mixed reality (MR) interactive game of SDM for children with moderate to severe AD. (2) Methods: Research participants included 6–18-year-old patients with moderate to severe AD. This research consisted of the following steps: designing SDM; character setting and visual design; performing games; system modification and optimization; screen editing and dubbing; and user testing and questionnaires by the System Usability Scale (SUS). (3) Results: We completed the SDM design for children with moderate to severe AD. Four different treatments were biologics, oral immune-modulating drugs, phototherapy, and wet wrap. An animated PowerPoint slide showed the AD apple rolling around before treatments and the AD apple sleeping soundly after treatments. Instructions with video teaching for the four different treatments were played, and then, the MR was turned on so that the patients could help the AD apple in the metaverse to undergo these four treatments. A total of 12 moderate to severe AD patients and six control patients used the game, all aged between six and eighteen years old, with an average SUS score of 81.0 and a standard error of 2.1 points. Adjective ratings yielded a rating between good and excellent. The game showed acceptable usability. We found no statistically significant differences in SUS scores between patients with and without moderate to severe AD or between boys and girls nor significant associations between SUS and age or severity. The analysis identified that the two items with the lowest SUS scores were “I think that I would need the support of a technical person to be able to use this product” and “I needed to learn a lot of things before I could get going with this product”. Both of these comments show the limitations of this game. (4) Conclusions: Overall, this study provides the first MR SDM game that has passed the SUS and can be used as an aid in clinical SDM.
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Affiliation(s)
- Ling-Sai Chang
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Correspondence:
| | - Ho-Chang Kuo
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Jason Jyh-Bin Suen
- Department of Digital Media Design, I-Shou University, Kaohsiung 83301, Taiwan
| | - Pei-Hsin Yang
- Department of Nursing and Pediatric Ward, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Kaohsiung 83301, Taiwan
| | - Chiu-Ping Hou
- Department of Nursing and Pediatric Ward, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Kaohsiung 83301, Taiwan
| | - Hui-Ru Sun
- Department of Nursing and Pediatric Ward, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Kaohsiung 83301, Taiwan
| | - Zon-Min Lee
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
| | - Ying-Hsien Huang
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
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3
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Penumalee L, Lambert JO, Gonzalez M, Gray M, Partani E, Wilson C, Etz R, Nelson B. "Why Do They Want to Know?": A Qualitative Assessment of Caregiver Perspectives on Social Drivers of Health Screening in Pediatric Primary Care. Acad Pediatr 2023; 23:329-335. [PMID: 35840084 DOI: 10.1016/j.acap.2022.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 07/01/2022] [Accepted: 07/03/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Despite strong evidence that social factors have a large influence on child health, systematic screening for social needs is not performed universally in pediatric primary care. This is due to multiple barriers, including concerns about acceptability to families. This study sought to assess family acceptability of social needs screening in pediatric primary care. METHODS Eight semi-structured focus groups were performed with English and Spanish-speaking caregivers of pediatric patients from a diverse academic medical center. Focus groups explored the acceptability of social domains including housing, education, finances, food access, and safety. Focus group transcripts were qualitatively analyzed to identify themes. RESULTS Four salient themes emerged: 1) the acceptability of social determinants of health screening questions was tied to participants' understanding of the connection between the topic and child health, 2) families preferred a warm handoff to community services, 3) families feared child protective services intervention as a result of sharing unmet social needs, and 4) positive provider rapport was an important factor in choosing to share social needs. CONCLUSIONS Pediatric primary care providers should feel comfortable implementing social needs screening when they can clearly explain the connection to child health. They should become knowledgeable about organizations and partners within their communities and feel empowered to connect patients to these resources.
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Affiliation(s)
- Leena Penumalee
- University of Chicago Pritzker School of Medicine (L Penumalee), Chicago, Ill
| | | | - Martha Gonzalez
- Department of Family Medicine and Population Health, Virginia Commonwealth University (M Gonzalez and R Etz), Richmond, Va
| | - Melanie Gray
- Pediatric Residency Program, Medical University of South Carolina (M Gray), Charleston, SC
| | - Ekta Partani
- Obstetrics-Gynecology Residency Program, Kaiser Permanente (E Partani), Santa Clara, Calif
| | - Celia Wilson
- Department of Pediatrics, Children's Hospital of Richmond at VCU (C Wilson and B Nelson), Richmond, Va
| | - Rebecca Etz
- Department of Family Medicine and Population Health, Virginia Commonwealth University (M Gonzalez and R Etz), Richmond, Va
| | - Bergen Nelson
- Department of Pediatrics, Children's Hospital of Richmond at VCU (C Wilson and B Nelson), Richmond, Va.
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4
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Drake LA, Suresh K, Chrastil H, Lewis CL, Altman RL. Improving Tobacco Cessation Rates Using Inline Clinical Decision Support. Appl Clin Inform 2022; 13:1116-1122. [PMID: 36252806 PMCID: PMC9683998 DOI: 10.1055/a-1961-9800] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 09/19/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Tobacco use is a significant cause of morbidity and mortality in the United States. Even brief advice from a clinician can significantly influence cessation rates among tobacco users, but clinicians often miss opportunities to provide this simple intervention. OBJECTIVES The intent of this quality improvement project was to increase tobacco cessation among tobacco users by nudging clinicians using a clinical decision support (CDS) tool. METHODS We developed a CDS tool using principles of user-centered design and the CDS Five Rights to dynamically insert actionable information about current tobacco users into the Assessment and Plan section of clinicians' notes. We conducted a retrospective analysis of patients at four primary care practices in the Denver Metro area evaluating the impact of the CDS tool on time to tobacco cessation. A multivariable Cox proportional-hazards model was used in this determination. Kaplan-Meier curves were used to estimate tobacco cessation probabilities at 90, 180, and 365 days. RESULTS We analyzed 5,644 patients with a median age of 45 years, most of whom lived in an urban location (99.5%) and the majority of whom were males (60%). The median follow-up time for patients was 16 months. After adjustment for age, gender, practice site, and patient location (rural, urban), the intervention group had significantly greater risk of tobacco cessation compared to those in the control group (hazard ratio: 1.22, 95% confidence interval: 1.08-1.36; p = 0.001). CONCLUSION This study suggests a CDS intervention which respects the CDS Five Rights and incorporates user-centered design can affect tobacco use rates. Future work should expand the target population of this CDS tool and continue a user-centered, iterative design process.
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Affiliation(s)
- Lauren A. Drake
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Krithika Suresh
- Department of Biostatistics and Informatics, University of Colorado School of Public Health, Aurora, Colorado, United States
| | - Hillary Chrastil
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Carmen L. Lewis
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Richard L. Altman
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
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5
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Gittelman M, Southworth H, Carle AC, Anzeljc S, Qian X, Wervey Arnold M, Mahabee-Gittens EM. Types of Tobacco Products Used by Caregivers of Newborns in the Primary Care Setting. Clin Pediatr (Phila) 2022; 61:535-541. [PMID: 35484841 PMCID: PMC10134048 DOI: 10.1177/00099228221091030] [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] [Indexed: 11/16/2022]
Abstract
This study determined the types of tobacco products used by caregivers who presented to infant well-child visits (WCVs), tobacco product use by other household members, and caregivers' readiness to quit. The Ohio Chapter of the American Academy of Pediatrics conducted a 10-month quality improvement collaborative to improve providers' tobacco screening and cessation counseling practices. A sub-analysis of the initial screenings was performed to determine types of tobacco products used and caregivers' readiness to quit. Fourteen practices (60 providers) participated, and 3972 initial screens were analyzed; 320 (8.1%) caregivers and 490 (12.4%) household members used tobacco products. Most smoking caregivers and household members exclusively used cigarettes (79% and 72%, respectively). There was no difference in caregiver intention to quit by tobacco type, yet 53% of smoking caregivers were ready to quit. Providers should provide screening and cessation counseling to caregivers of infants at WCVs since many are ready to quit.
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Affiliation(s)
- Michael Gittelman
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Ohio Chapter of the American Academy of Pediatrics, Columbus, OH, USA
| | - Hayley Southworth
- Ohio Chapter of the American Academy of Pediatrics, Columbus, OH, USA
| | - Adam C Carle
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Samantha Anzeljc
- Ohio Chapter of the American Academy of Pediatrics, Columbus, OH, USA
| | - Xiaokun Qian
- Ohio Colleges of Medicine, Government Resource Center, Columbus, OH, USA
| | | | - E Melinda Mahabee-Gittens
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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6
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Jenssen BP, Karavite DJ, Kelleher S, Nekrasova E, Thayer JG, Ratwani R, Shea J, Nabi-Burza E, Drehmer JE, Winickoff JP, Grundmeier RW, Schnoll RA, Fiks AG. Electronic Health Record-Embedded, Behavioral Science-Informed System for Smoking Cessation for the Parents of Pediatric Patients. Appl Clin Inform 2022; 13:504-515. [PMID: 35584789 DOI: 10.1055/s-0042-1748148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Helping parents quit smoking is a public health priority. However, parents are rarely, if ever, offered tobacco use treatment through pediatric settings. Clinical decision support (CDS) systems developed for the workflows of pediatric primary care may support consistent screening, treatment, and referral. OBJECTIVES This study aimed to develop a CDS system by using human-centered design (HCD) that identifies parents who smoke, provides motivational messages to quit smoking (informed by behavioral science), and supports delivery of evidence-based tobacco treatment. METHODS Our multidisciplinary team applied a rigorous HCD process involving analysis of the work environment, user involvement in formative design, iterative improvements, and evaluation of the system's use in context with the following three cohorts: (1) parents who smoke, (2) pediatric clinicians, and (3) clinic staff. Participants from each cohort were presented with scenario-based, high-fidelity mockups of system components and then provided input related to their role in using the CDS system. RESULTS We engaged 70 representative participants including 30 parents, 30 clinicians, and 10 clinic staff. A key theme of the design review sessions across all cohorts was the need to automate functions of the system. Parents emphasized a system that presented information in a simple way, highlighted benefits of quitting smoking, and allowed direct connection to treatment. Pediatric clinicians emphasized automating tobacco treatment. Clinical staff emphasized screening for parent smoking via several modalities prior to the patient's visit. Once the system was developed, most parents (80%) reported that it was easy to use, and the majority of pediatricians reported that they would use the system (97%) and were satisfied with it (97%). CONCLUSION A CDS system to support parental tobacco cessation in pediatric primary care, developed through an HCD process, proved easy to use and acceptable to parents, clinicians, and office staff. This preliminary work justifies evaluating the impact of the system on helping parents quit smoking.
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Affiliation(s)
- Brian P Jenssen
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States.,Center for Pediatric Clinical Effectiveness, PolicyLab, and The Possibilities Project, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.,Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Dean J Karavite
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Shannon Kelleher
- Center for Pediatric Clinical Effectiveness, PolicyLab, and The Possibilities Project, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Ekaterina Nekrasova
- Center for Pediatric Clinical Effectiveness, PolicyLab, and The Possibilities Project, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Jeritt G Thayer
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Raj Ratwani
- MedStar Health National Center for Human Factors in Healthcare, Washington, Dist. of Columbia, United States
| | - Judy Shea
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Emara Nabi-Burza
- Division of General Academic Pediatrics and Tobacco Research and Treatment Center, Massachusetts General Hospital for Children, Boston, Massachusetts, United States
| | - Jeremy E Drehmer
- Division of General Academic Pediatrics and Tobacco Research and Treatment Center, Massachusetts General Hospital for Children, Boston, Massachusetts, United States
| | - Jonathan P Winickoff
- Division of General Academic Pediatrics and Tobacco Research and Treatment Center, Massachusetts General Hospital for Children, Boston, Massachusetts, United States
| | - Robert W Grundmeier
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States.,Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Robert A Schnoll
- Department of Psychiatry and Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Alexander G Fiks
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States.,Center for Pediatric Clinical Effectiveness, PolicyLab, and The Possibilities Project, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.,Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
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7
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von Sommoggy J, Grepmeier EM, Curbach J. Health Literacy-Sensitive Counselling on Early Childhood Allergy Prevention: Results of a Qualitative Study on German Midwives' Perspectives. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19074182. [PMID: 35409865 PMCID: PMC8998819 DOI: 10.3390/ijerph19074182] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/25/2022] [Accepted: 03/29/2022] [Indexed: 02/06/2023]
Abstract
In Germany, midwives are involved in extensive antenatal and postnatal care. As health professionals, they can play a key role in strengthening health literacy (HL) of parents on how to prevent chronic allergic diseases in their children. The objective of this study is to explore midwives' perspectives regarding HL-sensitive counselling in early childhood allergy prevention (ECAP). Twenty-four qualitative semi-structured interviews were conducted with midwives, and data were analyzed using qualitative content analysis. Only a small number of study participants were aware of HL as a concept. However, most of these use screening and counselling strategies which consider individual information needs and which support parental HL. HL sensitivity in counselling is largely based on the midwives' "gut feelings" and counselling experience, rather than on formal education. The midwives were largely aware of evidence-based ECAP recommendations; however, allergy prevention was not seen as a stand-alone topic but as part of their general counselling on infant feeding and hygiene. They found parents to be more open to receiving complex prevention information during antenatal counselling. In order to strengthen midwives' roles in HL-sensitive ECAP counselling, their formal education should provide them with explicit HL knowledge and counselling skills. ECAP should be an inherent part of antenatal care.
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Affiliation(s)
- Julia von Sommoggy
- Medical Sociology, Department of Epidemiology and Preventive Medicine, University of Regensburg, 93051 Regensburg, Germany
- Correspondence:
| | - Eva-Maria Grepmeier
- Medical Faculty, Institute of Social Medicine & Health Systems Research, Otto von Guericke University Magdeburg, 39120 Magdeburg, Germany;
| | - Janina Curbach
- Department of Business Studies, Ostbayerische Technische Hochschule Regensburg, 93053 Regensburg, Germany;
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8
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Willis VC, Thomas Craig KJ, Jabbarpour Y, Scheufele EL, Arriaga YE, Ajinkya M, Rhee KB, Bazemore A. Digital Health Interventions to Enhance Prevention in Primary Care: Scoping Review. JMIR Med Inform 2022; 10:e33518. [PMID: 35060909 PMCID: PMC8817213 DOI: 10.2196/33518] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/19/2021] [Accepted: 12/04/2021] [Indexed: 12/20/2022] Open
Abstract
Background Disease prevention is a central aspect of primary care practice and is comprised of primary (eg, vaccinations), secondary (eg, screenings), tertiary (eg, chronic condition monitoring), and quaternary (eg, prevention of overmedicalization) levels. Despite rapid digital transformation of primary care practices, digital health interventions (DHIs) in preventive care have yet to be systematically evaluated. Objective This review aimed to identify and describe the scope and use of current DHIs for preventive care in primary care settings. Methods A scoping review to identify literature published from 2014 to 2020 was conducted across multiple databases using keywords and Medical Subject Headings terms covering primary care professionals, prevention and care management, and digital health. A subgroup analysis identified relevant studies conducted in US primary care settings, excluding DHIs that use the electronic health record (EHR) as a retrospective data capture tool. Technology descriptions, outcomes (eg, health care performance and implementation science), and study quality as per Oxford levels of evidence were abstracted. Results The search yielded 5274 citations, of which 1060 full-text articles were identified. Following a subgroup analysis, 241 articles met the inclusion criteria. Studies primarily examined DHIs among health information technologies, including EHRs (166/241, 68.9%), clinical decision support (88/241, 36.5%), telehealth (88/241, 36.5%), and multiple technologies (154/241, 63.9%). DHIs were predominantly used for tertiary prevention (131/241, 54.4%). Of the core primary care functions, comprehensiveness was addressed most frequently (213/241, 88.4%). DHI users were providers (205/241, 85.1%), patients (111/241, 46.1%), or multiple types (89/241, 36.9%). Reported outcomes were primarily clinical (179/241, 70.1%), and statistically significant improvements were common (192/241, 79.7%). Results were summarized across the following 5 topics for the most novel/distinct DHIs: population-centered, patient-centered, care access expansion, panel-centered (dashboarding), and application-driven DHIs. The quality of the included studies was moderate to low. Conclusions Preventive DHIs in primary care settings demonstrated meaningful improvements in both clinical and nonclinical outcomes, and across user types; however, adoption and implementation in the US were limited primarily to EHR platforms, and users were mainly clinicians receiving alerts regarding care management for their patients. Evaluations of negative results, effects on health disparities, and many other gaps remain to be explored.
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Affiliation(s)
- Van C Willis
- Center for Artificial Intelligence, Research, and Evaluation, IBM Watson Health, Cambridge, MA, United States
| | - Kelly Jean Thomas Craig
- Center for Artificial Intelligence, Research, and Evaluation, IBM Watson Health, Cambridge, MA, United States
| | - Yalda Jabbarpour
- Policy Studies in Family Medicine and Primary Care, The Robert Graham Center, American Academy of Family Physicians, Washington, DC, United States
| | - Elisabeth L Scheufele
- Center for Artificial Intelligence, Research, and Evaluation, IBM Watson Health, Cambridge, MA, United States
| | - Yull E Arriaga
- Center for Artificial Intelligence, Research, and Evaluation, IBM Watson Health, Cambridge, MA, United States
| | - Monica Ajinkya
- Policy Studies in Family Medicine and Primary Care, The Robert Graham Center, American Academy of Family Physicians, Washington, DC, United States
| | - Kyu B Rhee
- Center for Artificial Intelligence, Research, and Evaluation, IBM Watson Health, Cambridge, MA, United States
| | - Andrew Bazemore
- The American Board of Family Medicine, Lexington, KY, United States
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9
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Jenssen BP, Thayer J, Nekrasova E, Grundmeier RW, Fiks AG. Innovation in the pediatric electronic health record to realize a more effective platform. Curr Probl Pediatr Adolesc Health Care 2022; 52:101109. [PMID: 34895836 DOI: 10.1016/j.cppeds.2021.101109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Commercial electronic health records (EHRs) were first developed to automate business processes. As EHRs developed, design principles focused on transferring existing paper-based documentation to comparable electronic forms. In addition, a strong industry focus on adult healthcare settings and quality measures has limited attention and resources for high priority EHR functionality needed for the unique health care of children. The objective of this paper is to provide a review of innovation in the EHR, that includes a variety of established and emerging technologies that may help realize a more effective EHR in child health settings. A more effective EHR would serve as an electronic hub. Existing EHR infrastructure could provide the foundation upon which new technologies and approaches branch and extend, enabling more rapid and customizable innovation to better meet shifting stakeholder and end-user needs. Among many areas for improvement, key goals of innovation could include technology that relieves ambulatory primary care clinician documentation burden, identifies needs, and supports improved care coordination and outcomes, focused on the following key areas: identification of child and family care needs, decision support, documentation, care coordination, and family communication.
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Affiliation(s)
- Brian P Jenssen
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; The Possibilities Project, Center for Pediatric Clinical Effectiveness and PolicyLab, Children's Hospital of Philadelphia (CHOP), USA; Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
| | - Jeritt Thayer
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ekaterina Nekrasova
- The Possibilities Project, Center for Pediatric Clinical Effectiveness and PolicyLab, Children's Hospital of Philadelphia (CHOP), USA
| | - Robert W Grundmeier
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; The Possibilities Project, Center for Pediatric Clinical Effectiveness and PolicyLab, Children's Hospital of Philadelphia (CHOP), USA; Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alexander G Fiks
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; The Possibilities Project, Center for Pediatric Clinical Effectiveness and PolicyLab, Children's Hospital of Philadelphia (CHOP), USA; Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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10
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Merianos AL, Fiser K, Mahabee-Gittens EM, Lyons MS, Stone L, Gordon JS. Clinical decision support for tobacco screening and counseling parents of pediatric patients: A qualitative analysis of pediatric emergency department and urgent care professionals. DRUG AND ALCOHOL DEPENDENCE REPORTS 2021; 2:100019. [PMID: 36845898 PMCID: PMC9948809 DOI: 10.1016/j.dadr.2021.100019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 12/07/2021] [Accepted: 12/07/2021] [Indexed: 11/17/2022]
Abstract
Background Clinical Decision Support Systems (CDSS) embedded into electronic medical records is a best practices approach. However, information is needed on how to incorporate a CDSS to facilitate parental tobacco cessation counseling and reduce child tobacco smoke exposure (TSE) in Pediatric Emergency Department (PED) and Urgent Care (UC) settings. The objective was to explore the barriers and enablers of CDSS use to facilitate child TSE screening and parental tobacco cessation counseling by PED/UC nurses and physicians. Methods We conducted 29 semi-structured, focused interviews with nurses (n = 17) and physicians (n = 12) at a children's hospital PED/UC. The interview guide included a brief presentation about the design and components of a prior CDSS tobacco intervention. Participants were asked their opinions about CDSS components and recommendations for adapting and implementing the CDSS tobacco intervention in the PED/UC setting. A thematic framework analysis method was used to code and analyze qualitative data. Results Participant mean (± SD) age was 42 (± 10.1) years; the majority were female (82.8%), non-Hispanic white (93.1%), and never tobacco users (86.2%); all were never electronic cigarette users. Four themes emerged: (1) explore optimal timing to complete CDSS screening and counseling during visits; (2) CDSS additional information and feedback needs; (3) perceived enablers to CDSS use, such as the systematic approach; and (4) perceived barriers to CDSS use, such as lack of time and staff. Conclusions The CDSS intervention for child TSE screening and parental tobacco cessation during PED/UC visits received endorsements and suggestions for optimal implementation from nurses and physicians.
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Affiliation(s)
- Ashley L. Merianos
- University of Cincinnati, School of Human Services, PO Box 210068, Cincinnati, OH, 45221-0068, United States
- University of Cincinnati, College of Medicine, Center for Addiction Research, Cincinnati, OH, United States
- Corresponding author at: PO Box 210068, Cincinnati, OH, 45221-0068, United States
| | - Kayleigh Fiser
- University of Cincinnati, School of Human Services, PO Box 210068, Cincinnati, OH, 45221-0068, United States
| | - E. Melinda Mahabee-Gittens
- Cincinnati Children's Hospital Medical Center, Division of Emergency Medicine, University of Cincinnati, College of Medicine, 3333 Burnet Avenue, MLC 2008, Cincinnati, OH, 45229, United States
| | - Michael S. Lyons
- University of Cincinnati, College of Medicine, Center for Addiction Research, Cincinnati, OH, United States
- University of Cincinnati, College of Medicine, Department of Emergency Medicine, 231 Albert Sabin Way, ML 0769, Cincinnati, OH, 45267-0769, United States
| | - Lara Stone
- Cincinnati Children's Hospital Medical Center, Division of Emergency Medicine, 3333 Burnet Avenue, MLC 2008, Cincinnati, OH, 45229, United States
| | - Judith S. Gordon
- The University of Arizona, College of Nursing, 1305 N Martin Avenue, PO Box 210203, Tucson, AZ, 85721-0203, United States
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11
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Cecil E, Dewa LH, Ma R, Majeed A, Aylin P. General practitioner and nurse practitioner attitudes towards electronic reminders in primary care: a qualitative analysis. BMJ Open 2021; 11:e045050. [PMID: 34253661 PMCID: PMC8276294 DOI: 10.1136/bmjopen-2020-045050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Reminders in primary care administrative systems aim to help clinicians provide evidence-based care, prescribe safely and save money. However, increased use of reminders can lead to alert fatigue. Our study aimed to assess general practitioners' (GPs) and nurse practitioners' (NPs) views on electronic reminders in primary care. DESIGN A qualitative analysis using semistructured interviews. SETTING AND PARTICIPANTS Fifteen GPs and NP based in general practices located in North-West London and Yorkshire, England. METHODS We collected data on participants' views on: (1) perceptions of the value of information provided; (2) reminder-related behaviours and (3) how to improve reminders. We carried out a thematic analysis. RESULTS Participants were familiar with reminders in their clinical systems and felt many were important to support their clinical work. However, participants reported, on average, 70% of reminders were ignored. Four major themes emerged: (1) reaction to a reminder, which was mixed and varied by situation. (2) Factors influencing the decision to act on reminders, often related to experience, consultation styles and interests of participants. Time constraints, alert design, inappropriate presentation and litigation were also factors. (3) Negative consequences of using reminders were increased workload or costs and compromising GP and NPs behaviour. (4) Factors relating to improving users' engagement with reminders were prevention of unnecessary reminders through data linkage across healthcare administrative systems or the development of more intelligent algorithms. Participants felt training was vital to effectively manage reminders. CONCLUSIONS GPs and NPs believe reminders are useful in supporting the provision of good quality patient care. Improving GPs and NPs' engagement with reminders centres on further developing their relevance to their clinical practice, which is personalised, considers cognitive workflow and suppresses inappropriate presentation.
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Affiliation(s)
- Elizabeth Cecil
- Department of Primary Care and Public Health, Imperial College London, London, UK
- School of Life Course Sciences, King's College London, London, UK
| | - Lindsay Helen Dewa
- Patient Safety Translational Research Centre, Imperial College London, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Richard Ma
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Paul Aylin
- Department of Primary Care and Public Health, Imperial College London, London, UK
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12
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Klein JD, Chamberlin ME, Kress EA, Geraci MW, Rosenblatt S, Boykan R, Jenssen B, Rosenblatt SM, Milberger S, Adams WG, Goldstein AO, Rigotti NA, Hovell MF, Holm AL, Vandivier RW, Croxton TL, Young PL, Blissard L, Jewell K, Richardson L, Ostrow J, Resnick EA. Asking the Right Questions About Secondhand Smoke. Nicotine Tob Res 2021; 23:57-62. [PMID: 31407779 DOI: 10.1093/ntr/ntz125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/25/2019] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Despite knowledge about major health effects of secondhand tobacco smoke (SHS) exposure, systematic incorporation of SHS screening and counseling in clinical settings has not occurred. METHODS A three-round modified Delphi Panel of tobacco control experts was convened to build consensus on the screening questions that should be asked and identify opportunities and barriers to SHS exposure screening and counseling. The panel considered four questions: (1) what questions should be asked about SHS exposure; (2) what are the top priorities to advance the goal of ensuring that these questions are asked; (3) what are the barriers to achieving these goals; and (4) how might these barriers be overcome. Each panel member submitted answers to the questions. Responses were summarized and successive rounds were reviewed by panel members for consolidation and prioritization. RESULTS Panelists agreed that both adults and children should be screened during clinical encounters by asking if they are exposed or have ever been exposed to smoke from any tobacco products in their usual environment. The panel found that consistent clinician training, quality measurement or other accountability, and policy and electronic health records interventions were needed to successfully implement consistent screening. CONCLUSIONS The panel successfully generated screening questions and identified priorities to improve SHS exposure screening. Policy interventions and stakeholder engagement are needed to overcome barriers to implementing effective SHS screening. IMPLICATIONS In a modified Delphi panel, tobacco control and clinical prevention experts agreed that all adults and children should be screened during clinical encounters by asking if they are exposed or have ever been exposed to smoke from tobacco products. Consistent training, accountability, and policy and electronic health records interventions are needed to implement consistent screening. Increasing SHS screening will have a significant impact on public health and costs.
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Affiliation(s)
- Jonathan D Klein
- Department of Pediatrics, University of Illinois at Chicago, Chicago, IL, USA.,Julius B. Richmond Center of Excellence, American Academy of Pediatrics, Itasca, IL, USA
| | | | | | - Mark W Geraci
- Department of Medicine, Indiana University, Indianapolis, IN, USA
| | - Susan Rosenblatt
- Flight Attendant Medical Research Institute, Coral Gables, FL, USA
| | - Rachel Boykan
- Department of Pediatrics, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Brian Jenssen
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Sharon Milberger
- Michigan Developmental Disabilities Institute, Wayne State University, Detroit, MI, USA
| | - William G Adams
- Department of Pediatrics, Boston University School of Medicine, Boston, MA, USA
| | - Adam O Goldstein
- Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Nancy A Rigotti
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston, MA, USA
| | - Melbourne F Hovell
- Division of Health Promotion and Behavioral Science, San Diego State University School of Public Health, San Diego, CA, USA
| | - Amanda L Holm
- Center of Health Promotion and Disease Prevention, Henry Ford Health System, Detroit, MI, USA
| | - Richard W Vandivier
- Department of Medicine, Pulmonary Sciences & Critical Care, University of Colorado School of Medicine, Aurora, CO, USA
| | - Thomas L Croxton
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Patricia L Young
- Flight Attendant Medical Research Institute, Coral Gables, FL, USA
| | - Lani Blissard
- Flight Attendant Medical Research Institute, Coral Gables, FL, USA
| | - Kate Jewell
- Flight Attendant Medical Research Institute, Coral Gables, FL, USA
| | - Leisa Richardson
- Flight Attendant Medical Research Institute, Coral Gables, FL, USA
| | - John Ostrow
- Flight Attendant Medical Research Institute, Coral Gables, FL, USA
| | - Elissa A Resnick
- Department of Pediatrics, University of Illinois at Chicago, Chicago, IL, USA
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13
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Stonesifer C, Crusco S, Rajupet S. Improving smoking cessation referrals among elective surgery clinics through electronic clinical decision support. Tob Prev Cessat 2021; 7:14. [PMID: 33644496 PMCID: PMC7896627 DOI: 10.18332/tpc/131823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/28/2020] [Accepted: 12/19/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Preoperative visits are an exceptional opportunity to encourage smoking cessation, as studies demonstrate the experience of scheduling elective surgery produces an actionable incentive to quit. However, studies suggest surgeons do not regularly assess smoking behavior or offer cessation therapies. Clinical decision support (CDS) is a system in which providers are presented with clinically integrated tools to enhance decision-making. METHODS A CDS tool was designed to facilitate treatment referrals for smoking cessation services among patients seeking elective surgery. Two clinics were selected: the plastic and vascular surgeries. The study objectives were to assess the utilization rate and effectiveness of this system. RESULTS No smoking cessation referrals had been submitted by the plastic surgery or vascular surgery clinics in the year before CDS tool implementation. Providers at the plastic surgery clinic utilized the CDS tool in 95.0% (191 of 201) eligible patient encounters. Of these patients, 16.3% were identified as active smokers, and 16.1% of these smokers accepted treatment referrals. Providers at the vascular surgery clinic utilized the CDS tool in 50.3% (98 of 195) eligible patient encounters. Of these patients, 10.2% were identified as active smokers, and 30.0% of these smokers accepted treatment referrals. CONCLUSIONS The CDS tool improved the incidence of smoking cessation referrals in two surgical clinics from pretest baselines and achieved satisfactory utilization rates. This report demonstrates the feasibility of CDS tools to actualize the preoperative visit as an opportunity to promote smoking cessation.
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Affiliation(s)
- Connor Stonesifer
- Vagelos College of Physicians and Surgeons, Columbia University, New York, United States
| | - Salvatore Crusco
- Icahn School of Medicine at Mount Sinai, New York, United States.,James J. Peters VA Medical Center, Bronx, United States
| | - Sritha Rajupet
- Vagelos College of Physicians and Surgeons, Columbia University, New York, United States.,Icahn School of Medicine at Mount Sinai, New York, United States.,James J. Peters VA Medical Center, Bronx, United States
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14
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Aronson PL, Politi MC, Schaeffer P, Fleischer E, Shapiro ED, Niccolai LM, Alpern ER, Bernstein SL, Fraenkel L. Development of an App to Facilitate Communication and Shared Decision-making With Parents of Febrile Infants ≤ 60 Days Old. Acad Emerg Med 2021; 28:46-59. [PMID: 32648270 DOI: 10.1111/acem.14082] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 06/21/2020] [Accepted: 07/07/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVES We aimed to develop and test a tool to engage parents of febrile infants ≤ 60 days of age evaluated in the emergency department (ED). The tool was designed to improve communication for all parents and to support shared decision-making (SDM) about whether to perform a lumbar puncture (LP) for infants 29 to 60 days of age. METHODS We conducted a multiphase development and testing process: 1) individual, semistructured interviews with parents and clinicians (pediatric and general emergency medicine [EM] physicians and pediatric EM nurses) to learn their preferences for a communication and SDM tool; 2) design of a "storyboard" of the tool with design impression testing; 3) development of a software application (i.e., app) prototype, called e-Care; and 4) usability testing of e-Care, using qualitative assessment and the system usability scale (SUS). RESULTS We interviewed 27 parents and 23 clinicians. Interviews revealed several themes, including that a communication tool should augment but not replace verbal communication; a Web-based format was preferred; and information about infections and testing, including the rationales for specific tests, would be valuable. We then developed separate versions of e-Care for infants ≤ 28 days and 29 to 60 days of age, in both English and Spanish. The e-Care app includes four sections: 1) homepage; 2) why testing is done; 3) what tests are done; and 4) what happens after testing, including a table for parents of infants 29 to 60 days of age to compare the risks/benefits of LP in preparation for an SDM conversation. Parents and clinicians reported that e-Care was understandable and helpful. The mean SUS score was 90.3 (95% confidence interval = 84 to 96.6), representing "excellent" usability. CONCLUSIONS The e-Care app is a useable and understandable tool to support communication and SDM with parents of febrile infants ≤ 60 days of age in the ED.
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Affiliation(s)
- Paul L. Aronson
- From the Department of PediatricsYale School of Medicine New HavenCTUSA
- the Department of Emergency Medicine Yale School of Medicine New Haven CTUSA
| | - Mary C. Politi
- the Department of Surgery Division of Public Health Sciences School of Medicine Washington University St. Louis MOUSA
| | - Paula Schaeffer
- From the Department of PediatricsYale School of Medicine New HavenCTUSA
| | - Eduardo Fleischer
- From the Department of PediatricsYale School of Medicine New HavenCTUSA
| | - Eugene D. Shapiro
- From the Department of PediatricsYale School of Medicine New HavenCTUSA
- the Department of Epidemiology of Microbial Diseases Yale School of Public Health Yale School of Public Health New Haven CTUSA
| | - Linda M. Niccolai
- the Department of Epidemiology of Microbial Diseases Yale School of Public Health Yale School of Public Health New Haven CTUSA
| | - Elizabeth R. Alpern
- the Department of Pediatrics, Division of Emergency Medicine Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine Chicago ILUSA
| | - Steven L. Bernstein
- the Department of Emergency Medicine Yale School of Medicine New Haven CTUSA
- and the Yale Center for Implementation Science Yale School of Medicine New Haven CTUSA
| | - Liana Fraenkel
- and the Department of Internal Medicine Yale School of Medicine New Haven CTUSA
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15
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Jassal MS, Lewis-Land C, Thompson RE, Butz A. Linkage of Maternal Caregiver Smoking Behaviors on Environmental and Clinical Outcomes of Children with Asthma: A Post-Hoc Analysis of a Financial Incentive Trial Targeting Reduction in Pediatric Tobacco Smoke Exposures. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E8502. [PMID: 33212796 PMCID: PMC7696714 DOI: 10.3390/ijerph17228502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/09/2020] [Accepted: 11/12/2020] [Indexed: 11/17/2022]
Abstract
(1) Background: Monthly variability in smoking behaviors in caregivers of pediatric asthmatics yields questions of how much and when does smoking reduction result in improved environmental and clinical outcomes. (2) Methods: Post hoc analysis of data from a 6 month pilot randomized-control trial occurring from May 2017 to May 2018 in Baltimore City (MD, USA). The initial trial's primary intervention explored the utility of financial incentives in modifying caregiver smoking behaviors. Post hoc analyses examined all dyads independent of the initial trial's randomization status. All caregivers received pediatric tobacco smoke harm reduction education, in addition to monthly encouragement to access the state tobacco quitline for individual phone-based counseling and nicotine replacement therapy. Maternal caregivers who were active cigarette smokers and their linked asthmatic child (aged 2-12 years) were grouped into two classifications ("high" versus "low") based on the child and caregiver's cotinine levels. A "low" cotinine level was designated by at least a 25% reduction in cotinine levels during 3 months of the trial period; achieving ≤2 months of low cotinine levels defaulted to the "high" category. Twenty-seven dyads (caregivers and children) (total n = 54) were assigned to the "high" category, and eighteen dyads (caregivers and children) (total n = 36) were allocated to the "low" category. The primary outcome measure was the correlation of caregiver cotinine levels with pediatric cotinine values. Secondary outcomes included asthma control, in addition to caregiver anxiety and depression. (3) Results: Caregivers with 3 months of ≥25% decrease in cotinine levels had a significantly greater mean change in child cotinine levels (p = 0.018). "Low" caregiver cotinine levels did not significantly improve pediatric asthma control (OR 2.12 (95% CI: 0.62-7.25)). Caregiver anxiety and depression outcomes, measured by Patient Health Questionnaire (PHQ)-4 scores, was not significantly different based on cotinine categorization (p = 0.079); (4) Conclusion: Reduced pediatric cotinine levels were seen in caregivers who reduced their smoking for at least 3 months, but clinical outcome measures remained unchanged.
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Affiliation(s)
- Mandeep S. Jassal
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA; (C.L.-L.); (A.B.)
| | - Cassia Lewis-Land
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA; (C.L.-L.); (A.B.)
| | - Richard E. Thompson
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21287, USA;
| | - Arlene Butz
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA; (C.L.-L.); (A.B.)
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16
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LeLaurin JH, Theis RP, Thompson LA, Tan ASL, Young-Wolff KC, Carter-Harris L, Shenkman EA, Salloum RG. Tobacco-Related Counseling and Documentation in Adolescent Primary Care Practice: Challenges and Opportunities. Nicotine Tob Res 2020; 22:1023-1029. [PMID: 31074792 DOI: 10.1093/ntr/ntz076] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 05/09/2019] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Primary care visits present an opportunity to reduce tobacco use and tobacco smoke exposure (TSE) among adolescents. To date, few studies have examined tobacco-related electronic health record (EHR) documentation in adolescent visits. The purpose of this study was to (1) describe tobacco-related EHR documentation practices in adolescent care clinics, including whether alternative tobacco products, parental use, and TSE were addressed; and (2) identify aspects of adolescent tobacco use that may inform EHR updates and counseling and documentation practices. METHODS Following a convergent mixed-methods design, we conducted an EHR review of 508 adolescent well-child visits, performed focus groups with pediatric providers and staff, and conducted in-depth interviews with adolescent patients. Record review data and interview transcripts were analyzed and interpreted concurrently. RESULTS In the EHR review, cigarette screening was documented in 92.3% of visits, smokeless tobacco screening in 51.4%, parental tobacco use in 23.2%, and home TSE in 33.1% of visits. Smoking status options were not mutually exclusive and did not include noncigarette products. No records documented assessment of e-cigarette use, despite nearly half of adolescent interview respondents citing these as the most popular products among adolescents. In interviews, adolescents discussed their experiences with alternative tobacco/nicotine products more than cigarettes. CONCLUSIONS Tobacco use status prompts should be revised for clarity and include noncigarette tobacco products and TSE. Provider education on noncigarette products and TSE assessment is needed. Improvements in EHR systems, resources, and tools can lead to better tobacco screening, prevention, and treatment practices among primary care providers. IMPLICATIONS Clinical guidelines call for pediatricians to assess and treat adolescent and parental tobacco use during primary care visits. The use of electronic health records (EHRs) can improve screening and counseling practices; however, few studies have examined tobacco-related EHR documentation practices in adolescent care settings. This mixed-methods study found low rates of EHR documentation related to noncigarette nicotine/tobacco products, parental tobacco use, and tobacco smoke exposure. These results demonstrate the need for increased provider training and EHR modifications to facilitate comprehensive tobacco control efforts in the adolescent population.
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Affiliation(s)
- Jennifer H LeLaurin
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL.,Institute for Child Health Policy, College of Medicine, University of Florida, Gainesville, FL
| | - Ryan P Theis
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL.,Institute for Child Health Policy, College of Medicine, University of Florida, Gainesville, FL
| | - Lindsay A Thompson
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL.,Institute for Child Health Policy, College of Medicine, University of Florida, Gainesville, FL.,Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL
| | - Andy S L Tan
- Department of Social and Behavioral Health, Harvard TH Chan School of Public Health, Boston, MA
| | - Kelly C Young-Wolff
- Dana-Farber Cancer Institute, Boston, MA.,Kaiser Permanente Division of Research, Oakland, CA
| | - Lisa Carter-Harris
- Department of Psychology and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Elizabeth A Shenkman
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL.,Institute for Child Health Policy, College of Medicine, University of Florida, Gainesville, FL
| | - Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL.,Institute for Child Health Policy, College of Medicine, University of Florida, Gainesville, FL
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17
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Clinical Decision Support for Recognizing and Managing Hypertensive Blood Pressure in Youth: No Significant Impact on Medical Costs. Acad Pediatr 2020; 20:848-856. [PMID: 32004709 PMCID: PMC7872738 DOI: 10.1016/j.acap.2020.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 01/17/2020] [Accepted: 01/23/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate economic costs from the health system perspective of an electronic health record-based clinical decision support (CDS) tool, TeenBP, designed to assist in the recognition and management of hypertension in youth. METHODS Twenty primary care clinics within an integrated health system were randomized to the TeenBP CDS or usual care (UC), with patient enrollment from 4/15/14 to 4/14/16. The 12-month change in standardized medical care costs for insured patients aged 10 to 17 years without prior hypertension were calculated for each study arm. The primary analysis compared patients with ≥1 visit with blood pressure (BP) ≥95th percentile (isolated hypertensive BP), and secondary analyses compared patients with ≥3 visits within one year with BP ≥95th percentile (incident hypertension). Generalized estimating equation models estimated the difference-in-differences in costs between groups over time. RESULTS Among 925 insured patients with an isolated hypertensive BP, the pre-to-post change in overall costs averaged $22 more for TeenBP CDS versus UC patients over 12 months, but this difference was not statistically significant (P = .723). Among 159 insured patients with incident hypertension, the pre-to-post change in overall costs over 12 months was higher by $227 per person on average for TeenBP CDS versus UC patients, but this difference also was not statistically significant (P = .313). CONCLUSIONS The TeenBP CDS intervention was previously found to significantly improve identification and management of hypertensive BP in youth, and in this study, we find that this tool did not significantly increase care costs in its first 12 months of clinical use.
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18
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Jenssen BP, Kelly MK, Faerber J, Hannan C, Asch DA, Shults J, Schnoll RA, Fiks AG. Parent Preferences for Pediatric Clinician Messaging to Promote Smoking Cessation Treatment. Pediatrics 2020; 146:peds.2019-3901. [PMID: 32571991 PMCID: PMC7329258 DOI: 10.1542/peds.2019-3901] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Insights from behavioral economics suggests that the effectiveness of health messages depends on how a message is framed. Parent preferences for smoking cessation messaging has not been studied in pediatrics, warranting further exploration to maximize benefit. We sought to assess parents' perceptions regarding the relative importance of distinct message framings to promote their smoking cessation. METHODS We conducted a cross-sectional discrete choice experiment in which parent smokers rated the relative importance of 26 messages designed to encourage them to begin cessation treatment. Messages varied on who was featured (child, parent, or family), whether the message was gain or loss framed, and what outcome was included (general health, cancer, respiratory illnesses, child becoming a smoker, or financial impact). The participants were 180 parent smokers attending primary care visits with their children at 4 diverse pediatric sites. The main outcome was the importance of smoking cessation messages based on who was featured, gain or loss framing, and the outcome emphasized. RESULTS Parent smokers highly prioritized cessation messages emphasizing the impact of quitting smoking on their child versus parent or family. Messages focusing on respiratory illness, cancer, or general health outcomes consistently ranked highest, whereas messages focused on the financial benefits of quitting ranked lowest. Gain versus loss framing did not meaningfully influence rankings. CONCLUSIONS Parent smokers identified smoking cessation messages that emphasized the impact on their child, with outcomes focused on respiratory health, cancer, or general health, as most important. The clinical impact of these messages should be tested in future research.
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Affiliation(s)
- Brian P. Jenssen
- Departments of Pediatrics,,PolicyLab and the Center for Pediatric Clinical
Effectiveness, Children’s Hospital of Philadelphia, Philadelphia,
Pennsylvania
| | - Mary Kate Kelly
- PolicyLab and the Center for Pediatric Clinical
Effectiveness, Children’s Hospital of Philadelphia, Philadelphia,
Pennsylvania
| | | | - Chloe Hannan
- PolicyLab and the Center for Pediatric Clinical
Effectiveness, Children’s Hospital of Philadelphia, Philadelphia,
Pennsylvania
| | | | | | - Robert A. Schnoll
- Psychiatry, Perelman School of Medicine, University
of Pennsylvania, Philadelphia, Pennsylvania,Abramson Cancer Center, Penn Medicine, Philadelphia,
Pennsylvania
| | - Alexander G. Fiks
- Departments of Pediatrics,,PolicyLab and the Center for Pediatric Clinical
Effectiveness, Children’s Hospital of Philadelphia, Philadelphia,
Pennsylvania
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19
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Nabi-Burza E, Drehmer JE, Hipple Walters B, Rigotti NA, Ossip DJ, Levy DE, Klein JD, Regan S, Gorzkowski JA, Winickoff JP. Treating Parents for Tobacco Use in the Pediatric Setting: The Clinical Effort Against Secondhand Smoke Exposure Cluster Randomized Clinical Trial. JAMA Pediatr 2019; 173:931-939. [PMID: 31403675 PMCID: PMC6692696 DOI: 10.1001/jamapediatrics.2019.2639] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Despite the availability of free and effective treatment, few pediatric practices identify and treat parental tobacco use. OBJECTIVE To determine if the Clinical Effort Against Secondhand Smoke Exposure (CEASE) intervention can be implemented and sustained in pediatric practices and test whether implementing CEASE led to changes in practice-level prevalence of smoking among parents over 2 years. DESIGN, SETTING, AND PARTICIPANTS This cluster randomized clinical trial was conducted from April 2015 to October 2017. Ten pediatric practices in 5 states were randomized to either implement the CEASE protocol or maintain usual care (as a control group). All parents who screened positive for tobacco use by exit survey after their child's clinical visit 2 weeks (from April to October 2015) and 2 years after intervention implementation (April to October 2017) were eligible to participate. Data analysis occurred from January 2018 to March 2019. INTERVENTIONS The CEASE intervention is a practice-change intervention designed to facilitate both routine screening in pediatric settings of families for tobacco use and delivery of tobacco cessation treatment to individuals in screened households who use tobacco. MAIN OUTCOMES AND MEASURES The primary outcome was delivery of meaningful tobacco treatment, defined as the prescription of nicotine replacement therapy or quit line enrollment. Furthermore, changes in practice-level smoking prevalence and cotinine-confirmed quit rates over the 2 years of intervention implementation were assessed. RESULTS Of the 8184 parents screened after their child's visit 2 weeks after intervention implementation, 961 (27.1%) were identified as currently smoking in intervention practices; 1103 parents (23.9%) were currently smoking in control practices. Among the 822 and 701 eligible parents who completed the survey in intervention and control practices, respectively 364 in the intervention practices (44.3%) vs 1 in a control practice (0.1%) received meaningful treatment at that visit (risk difference, 44.0% [95% CI, 9.8%-84.8%]). Two years later, of the 9794 parents screened, 1261 (24.4%) in intervention practices and 1149 (25.0%) in control practices were identified as currently smoking. Among the 804 and 727 eligible parents completing the survey in intervention and control practices, respectively, 113 in the intervention practices (14.1%) vs 2 in the control practices (0.3%) received meaningful treatment at that visit (risk difference, 12.8% [95% CI, 3.3%-37.8%]). Change in smoking prevalence over the 2 years of intervention implementation favored the intervention (-2.7% vs 1.1%; difference -3.7% [95% CI, -6.3% to -1.2%]), as did the cotinine-confirmed quit rate (2.4% vs -3.2%; difference, 5.5% [95% CI, 1.4%-9.6%]). CONCLUSIONS AND RELEVANCE In this trial, integrating screening and treatment for parental tobacco use in pediatric practices showed both immediate and long-term increases in treatment delivery, a decline in practice-level parental smoking prevalence, and an increase in cotinine-confirmed cessation, compared with usual care. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01882348.
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Affiliation(s)
- Emara Nabi-Burza
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston,Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston
| | - Jeremy E. Drehmer
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston,Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston
| | - Bethany Hipple Walters
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston,Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston
| | - Nancy A. Rigotti
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston,Harvard Medical School, Boston, Massachusetts,Mongan Institute Health Policy Center, Massachusetts General Hospital, Boston
| | - Deborah J. Ossip
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
| | - Douglas E. Levy
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston,Harvard Medical School, Boston, Massachusetts,Mongan Institute Health Policy Center, Massachusetts General Hospital, Boston
| | - Jonathan D. Klein
- American Academy of Pediatrics, Julius B. Richmond Center of Excellence, Itasca, Illinois,Department of Pediatrics, University of Illinois at Chicago
| | - Susan Regan
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston
| | - Julie A. Gorzkowski
- American Academy of Pediatrics, Julius B. Richmond Center of Excellence, Itasca, Illinois
| | - Jonathan P. Winickoff
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston,Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston,Harvard Medical School, Boston, Massachusetts,American Academy of Pediatrics, Julius B. Richmond Center of Excellence, Itasca, Illinois
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20
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Hood-Medland EA, Stewart SL, Nguyen H, Avdalovic M, MacDonald S, Zhu SH, Mayoral A, Tong EK. Health System Implementation of a Tobacco Quitline eReferral. Appl Clin Inform 2019; 10:735-742. [PMID: 31578046 PMCID: PMC6774758 DOI: 10.1055/s-0039-1697593] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 08/02/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Proactive referrals through electronic orders (eReferrals) can increase patient connection with tobacco quitlines. More information is needed on "real-world" implementation of electronic health record tools to promote tobacco cessation while minimizing provider burden. OBJECTIVES This paper examines the health system implementation of an eReferral to a tobacco quitline without best practice alerts in primary care, specialty, and hospital settings in an academic health system. METHODS This is a prospective implementation study of a health system tobacco eReferral to a state quitline that was completed with an approach to minimize provider cognitive burden. Data are drawn from electronic health record data at University of California, Davis Health Systems (March 2013-February 2016). RESULTS Over 3 years, 16,083 encounters with smokers resulted in 1,137 eReferral orders (7.1%). Treatment reach was 1.6% for quitline services and 2.3% for outpatient group classes. While the group classes were offered to outpatient smokers, the eReferral order was included in an outpatient order set and eventually an automated inpatient discharge order set; no provider alerts were implemented. Referrals were sustained and doubled after inpatient order set implementation. Among all first time eReferral patients, 12.2% had a 6 to 12 month follow-up visit at which they were documented as nonsmoking. CONCLUSION This study demonstrates a quitline eReferral order can be successfully implemented and sustained with minimal promotion, without provider alerts and in conjunction with group classes. Reach and effectiveness were similar to previously described literature.
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Affiliation(s)
- Eve Angeline Hood-Medland
- Department of Internal Medicine, University of California, Davis in Sacramento, California, United States
| | - Susan L. Stewart
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis in Sacramento, California, United States
| | - Hien Nguyen
- Department of Internal Medicine, University of California, Davis in Sacramento, California, United States
| | - Mark Avdalovic
- Department of Internal Medicine, University of California, Davis in Sacramento, California, United States
| | - Scott MacDonald
- Department of Clinical Informatics, University of California, Davis in Sacramento, California, United States
| | - Shu-Hong Zhu
- Department of Family Medicine, Moores Cancer Center, University of California, San Diego in San Diego, California, United States
| | - Antonio Mayoral
- Department of Family Medicine, Moores Cancer Center, University of California, San Diego in San Diego, California, United States
| | - Elisa K. Tong
- Department of Internal Medicine, University of California, Davis in Sacramento, California, United States
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21
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Jenssen BP, Muthu N, Kelly MK, Baca H, Shults J, Grundmeier RW, Fiks AG. Parent eReferral to Tobacco Quitline: A Pragmatic Randomized Trial in Pediatric Primary Care. Am J Prev Med 2019; 57:32-40. [PMID: 31122792 PMCID: PMC6644070 DOI: 10.1016/j.amepre.2019.03.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 03/14/2019] [Accepted: 03/15/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Quitlines are effective in helping smokers quit, but pediatrician quitline referral rates are low, and few parents who smoke use the service. This study compared enrollment of parents who smoke in the quitline using electronic referral with that using manual referral. STUDY DESIGN The study was designed as a pragmatic RCT. SETTING/PARTICIPANTS Participants were recruited from one large, urban pediatric primary care site in Philadelphia, Pennsylvania with a high percentage of low-income families. Participants included adult parents who smoked and were present at their child's healthcare visit. INTERVENTION Pediatricians screened for tobacco use; smokers were given brief advice to quit and, if interested in quitting, were referred to the quitline. The eReferral ("warm handoff") involved electronically sending parent information to the quitline (parent received a call within 24-48 hours). Control group procedures were identical to eReferral, except the quitline number was provided to the parent. Data were collected between March 2017 and February 2018 and analyzed in 2018. MAIN OUTCOME MEASURES The primary outcome was the proportion of parents enrolled in quitline treatment. Secondary outcomes included parent factors (e.g., demographics, nicotine dependence, and quitting motivation) associated with successful enrollment. Number of quitline contacts was also explored. RESULTS During the study period, in the eReferral group, 10.3% (24 of 233) of parents who smoked and were interested in quitting enrolled in the quitline, whereas only 2.0% (5 of 251) of them in the control group enrolled in the quitline-a difference of 8.3% (95% CI=4.0, 12.6). Parents aged ≥50 years enrolled in the quitline more frequently. Although more parents in the eReferral group connected to the quitline, among parents who had at least one quitline contact, there was no significant difference in the mean number of quitline contacts between eReferral and control groups (mean, 2.04 vs 2.40 calls; difference, 0.36 [95% CI=0.35, 1.06]). CONCLUSIONS Smoking parent eReferral from pediatric primary care may increase quitline enrollment and could be adopted by practices interested in increasing rates of parent treatment. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT02997735.
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Affiliation(s)
- Brian P Jenssen
- Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania; PolicyLab and the Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Naveen Muthu
- Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania; PolicyLab and the Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mary Kate Kelly
- PolicyLab and the Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Justine Shults
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert W Grundmeier
- Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania; PolicyLab and the Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alexander G Fiks
- Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania; PolicyLab and the Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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22
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Grau LE, Weiss J, O’Leary TK, Camenga D, Bernstein SL. Electronic decision support for treatment of hospitalized smokers: A qualitative analysis of physicians' knowledge, attitudes, and practices. Drug Alcohol Depend 2019; 194:296-301. [PMID: 30469101 PMCID: PMC7720717 DOI: 10.1016/j.drugalcdep.2018.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 09/20/2018] [Accepted: 10/01/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND We recently demonstrated the ability of a suite of tools embedded in an electronic medical record (EMR) to improve tobacco cessation treatment for adult smokers admitted to the hospital. A randomized controlled trial conducted by our group demonstrated the ability of an EMR-embedded tobacco use disorder treatment tool, the Electronic Support Tool and Orders for the Prevention of Smoking (E-STOPS), to increase the identification and treatment of smokers, but its uptake varied among 126 physicians randomized to the intervention arm. The purpose of this study was to identify facilitators and barriers to using E-STOPS. METHODS Semi-structured individual interviews from a purposive sample of 12 hospitalist attending physicians and nine internal medicine residents who were randomized to the E-STOPS intervention were analyzed thematically. RESULTS Three themes shaped E-STOPS use: the inpatient environment, prescriber attitudes and beliefs, and information needs. Overall, participants were pleased with E-STOPS, but had specific suggestions for improvements regarding the timing of the intervention, suppression logic, and additional decision support and training. A few had concerns about the clinical appropriateness of beginning treatment for tobacco dependence during a hospitalization and the proper role of the inpatient team in that treatment. CONCLUSIONS Tobacco dependence treatment for hospitalized smokers and facilitated by the EMR is generally acceptable to hospitalists and resident physicians. Improvements in provider training and feedback as well as the timing and content of the electronic tools may increase their utilization by inpatient physicians.
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Affiliation(s)
- Lauretta E. Grau
- Yale University School of Public Health, Department of Epidemiology of Microbial Diseases, New Haven, CT, 06520, USA,Yale School of Public Health, Yale University, 60 College St, New Haven, CT 06520, USA,Corresponding author at: Yale School of Public Health, PO Box 208034, 60 College Street, New Haven, CT 06520-8034, USA. (L.E. Grau)
| | - June Weiss
- Yale School of Medicine, Department of Emergency Medicine, New Haven, CT, 06519, USA
| | - Teresa K. O’Leary
- Yale School of Medicine, Department of Emergency Medicine, New Haven, CT, 06519, USA
| | - Deepa Camenga
- Yale School of Medicine, Department of Emergency Medicine, New Haven, CT, 06519, USA
| | - Steven L. Bernstein
- Yale School of Medicine, Department of Emergency Medicine, New Haven, CT, 06519, USA,Yale University School of Public Health, Department of Health Policy and Management, New Haven, CT, 06520, USA
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23
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Price SN, Studts JL, Hamann HA. Tobacco Use Assessment and Treatment in Cancer Patients: A Scoping Review of Oncology Care Clinician Adherence to Clinical Practice Guidelines in the U.S. Oncologist 2018; 24:229-238. [PMID: 30446582 DOI: 10.1634/theoncologist.2018-0246] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 10/16/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Smoking after a cancer diagnosis negatively impacts health outcomes; smoking cessation improves symptoms, side effects, and overall prognosis. The Public Health Service and major oncology organizations have established guidelines for tobacco use treatment among cancer patients, including clinician assessment of tobacco use at each visit. Oncology care clinicians (OCCs) play important roles in this process (noted as the 5As: Asking about tobacco use, Advising users to quit, Assessing willingness to quit, Assisting in quit attempts, and Arranging follow-up contact). However, OCCs may not be using the "teachable moments" related to cancer diagnosis, treatment, and survivorship to provide cessation interventions. MATERIALS AND METHODS In this scoping literature review of articles from 2006 to 2017, we discuss (1) frequency and quality of OCCs' tobacco use assessments with cancer patients and survivors; (2) barriers to providing tobacco treatment for cancer patients; and (3) the efficacy and future of provider-level interventions to facilitate adherence to tobacco treatment guidelines. RESULTS OCCs are not adequately addressing smoking cessation with their patients. The reviewed studies indicate that although >75% assess tobacco use during an intake visit and >60% typically advise patients to quit, a substantially lower percentage recommend or arrange smoking cessation treatment or follow-up after a quit attempt. Less than 30% of OCCs report adequate training in cessation interventions. CONCLUSION Intervention trials focused on provider- and system-level change are needed to promote integration of evidence-based tobacco treatment into the oncology setting. Attention should be given to the barriers faced by OCCs when targeting interventions for the oncologic context. IMPLICATIONS FOR PRACTICE This article reviews the existing literature on the gap between best and current practices for tobacco use assessment and treatment in the oncologic context. It also identifies clinician- and system-level barriers that should be addressed in order to lessen this gap and provides suggestions that could be applied across different oncology practice settings to connect patients with tobacco use treatments that may improve overall survival and quality of life.
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Affiliation(s)
- Sarah N Price
- Department of Psychology, University of Arizona, Tucson, Arizona, USA
| | - Jamie L Studts
- Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Heidi A Hamann
- Department of Psychology, University of Arizona, Tucson, Arizona, USA
- Department of Family and Community Medicine, University of Arizona, Tucson, Arizona, USA
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24
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Thomas KEH, Kisely S, Urrego F. Electronic Heath Record Prompts May Increase Screening for Secondhand Smoke Exposure. Clin Pediatr (Phila) 2018; 57:27-30. [PMID: 28135880 DOI: 10.1177/0009922816688261] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The American Academy of Pediatrics recommends that pediatricians promote smoking cessation among caregivers at every visit. Currently, there are inconsistencies between recommendations and clinical practice. This study aims to compare results generated from 3 intervention methods on the rate at which pediatricians screen for secondhand smoke exposure (SHSe). METHODS Pediatricians were randomly assigned to 1 of 3 intervention groups: no lecture, changes in electronic health record (EHR) (G1); lecture, no changes in the EHR (G2); or a lecture and EHR changes (G3). Data between groups were compared using a 1-way analysis of variance. RESULTS Documentation of SHSe was statistically significantly greater in G3, when compared with G1 and G2 ( P < .01). Documentation of SHSe was statistically significantly greater in G1, when compared with G2 ( P < .05). CONCLUSION A brief lecture with EHR prompts may be a simple way to increase screening for SHSe in the pediatric primary care setting.
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Affiliation(s)
| | - Steve Kisely
- 2 University of Queensland, Brisbane, Queensland, Australia
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25
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An Electronic Health Record-Based Strategy to Address Child Tobacco Smoke Exposure. Am J Prev Med 2018; 54:64-71. [PMID: 29102458 PMCID: PMC5736447 DOI: 10.1016/j.amepre.2017.08.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 07/07/2017] [Accepted: 08/08/2017] [Indexed: 12/18/2022]
Abstract
INTRODUCTION A high proportion of children presenting to pediatric urgent cares are exposed to tobacco smoke. An electronic health record-based clinical decision support system for nurses to facilitate guideline-based tobacco smoke exposure screening and counseling for caregivers who smoke was designed and evaluated. DESIGN A mixed-methods, 3-month, prospective study that began in November 2015, data were analyzed in June 2016. SETTING/PARTICIPANTS Five urgent cares that were part of a large children's hospital in Cincinnati, OH. Participants were urgent care nurses. INTERVENTION The clinical decision support system prompted nurses to Ask, Advise, Assess, and Assist caregivers to quit smoking. Monthly feedback reports were also provided. MAIN OUTCOME MEASURE Clinical decision support system use rates, nurses' attitudes towards tobacco smoke exposure intervention, and percentage of children screened and caregivers counseled. RESULTS All nurses used the clinical decision support system. Compared with Month 1, nurses were twice as likely to advise and assess during Months 2 and 3. There was significant improvement in nurses feeling prepared to assist caregivers in quitting. Nurses reported that feedback reports motivated them to use the clinical decision support system, and that it was easy to use. Almost 65% of children were screened for tobacco smoke exposure; 19.5% screened positive. Of caregivers identified as smokers, 26% were advised to quit and 29% were assessed for readiness to quit. Of those assessed, 67% were interested in quitting, and of those, 100% were assisted. CONCLUSIONS A clinical decision support system increased rates of tobacco smoke exposure screening and intervention in pediatric urgent cares. Rates might further improve by incorporating all components of the clinical decision support system into the electronic health record. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT02489708.
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26
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Merianos AL, Jandarov RA, Mahabee-Gittens EM. Secondhand Smoke Exposure and Pediatric Healthcare Visits and Hospitalizations. Am J Prev Med 2017; 53:441-448. [PMID: 28532658 PMCID: PMC5610064 DOI: 10.1016/j.amepre.2017.03.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 03/10/2017] [Accepted: 03/27/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION This study assessed the relationship between secondhand smoke exposure (SHSe) as measured by serum cotinine and healthcare utilization among children. METHODS In 2016, the 2009-2012 National Health and Nutrition Examination Survey data were analyzed including 4,985 children aged 3-19 years. Associations between SHSe and having a routine place for healthcare, type of place, and hospital utilization were examined using logistic regression models. Poisson regression analyses assessed the relationship between SHSe and number of hospital admissions. Relationships between SHSe and acute care visits and hospital utilization were examined among asthmatic children. RESULTS SHSe level did not differ by having a routine place for healthcare, although children with high SHSe indicative of active smoking (cotinine ≥3 ng/mL) were 3.49 times (95% CI=1.77, 6.89) more likely to use an emergency department. Children with high SHSe were 2.85 times (95% CI=1.87, 4.34) more likely to have had an overnight hospital stay. Children with high SHSe had 2.05 times (95% CI=1.46, 2.87) the risk of having a higher number of hospital admissions for overnight stays versus children with no SHSe (cotinine <0.05 ng/mL). Among asthmatic children, those with high SHSe and low SHSe (cotinine 0.05-2.99 ng/mL) were more likely to have an acute care visit, overnight hospital stay, and higher number of hospital admissions than asthmatic children with no SHSe. CONCLUSIONS High SHSe is associated with increased healthcare utilization. The emergency department and inpatient settings are important venues in which to routinely offer cessation and SHSe reduction interventions.
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Affiliation(s)
- Ashley L Merianos
- School of Human Services, University of Cincinnati, Cincinnati, Ohio.
| | - Roman A Jandarov
- Division of Biostatistics and Bioinformatics, Department of Environmental Health, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - E Melinda Mahabee-Gittens
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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27
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Thomas KEH, Kisely S, Urrego F. Increasing Pediatricians' Smoking Cessation Promotion and Knowledge of the Smoking Cessation Trust. Clin Pediatr (Phila) 2017; 56:461-466. [PMID: 27462047 DOI: 10.1177/0009922816660542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The link between second hand smoke exposure (SHSe) and health issues in children has been well established. The objective of this study was to determine if a short intervention implemented among pediatricians promotes improvement in the promotion of smoking cessation to caregivers and increase pediatricians' awareness of the Smoking Cessation Trust (SCT). Pediatricians from 6 clinics were randomly assigned to the control or intervention group. All pediatricians received a survey to assess baseline knowledge, confidence and behaviors in smoking cessation promotion and utilization of the SCT. Pediatricians in intervention group received an educational lecture delivered by a physician. Two months post intervention, pediatricians in the control and intervention group received a survey to assess changes from baseline. Out of 36 general pediatricians, 27 completed the surveys for use in the analysis of this study (75%). Intervention group made more referrals to the SCT, compared to controls (p=0.048) and to baseline (p=0.0065). Pediatricians in the intervention group were more confident in recommending the use of NRT (0.040) and schedule a follow up to discuss smoking cessation (p=0.029) after the intervention. The intervention group was more likely to refer caregivers to smoking cessation programs (p=0.027), discuss a child's health risk from SHSe (0.031) and recommending the use of NRT to help quit (p=0.047) post intervention. The results from this study indicate that a short intervention can increase confidence and behavior in various parameters of smoking cessation promotion and significantly improve the rate in which pediatricians refer smoking caregivers to the SCT.
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Affiliation(s)
| | - Steve Kisely
- 2 University of Queensland, Brisbane, Queensland, Australia
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28
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Jenssen BP, Wilson KM. Tobacco Control and Treatment for the Pediatric Clinician: Practice, Policy, and Research Updates. Acad Pediatr 2017; 17:233-242. [PMID: 28069410 DOI: 10.1016/j.acap.2016.12.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 11/30/2016] [Accepted: 12/17/2016] [Indexed: 12/15/2022]
Abstract
Tobacco use is the leading cause of preventable death in the United States, and exposure to tobacco smoke harms children from conception forward. There is no safe level of tobacco exposure. Although overall smoking rates have declined, the advent of new products, such as electronic cigarettes, threatens to perpetuate nicotine addiction without clear health benefits. In addition to reviewing traditional and new tobacco products, we discuss the unique role that pediatricians should play in tobacco treatment and control efforts. New policies and technologies can empower pediatric clinicians and pediatric health care systems to help parent smokers quit, and new policies outside of the health care setting might help prevent smoking initiation as well as improve cessation treatments. Future research is needed to continue to study the consequences of tobacco use exposure as well as the best ways to help patients and parents stop tobacco use.
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Affiliation(s)
- Brian P Jenssen
- Department of Pediatrics, University of Pennsylvania School of Medicine and PolicyLab, The Children's Hospital of Philadelphia.
| | - Karen M Wilson
- Division of General Pediatrics, Kravis Children's Hospital at Mount Sinai, New York, NY
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29
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Kazdin AE, Fitzsimmons-Craft EE, Wilfley DE. Addressing critical gaps in the treatment of eating disorders. Int J Eat Disord 2017; 50:170-189. [PMID: 28102908 PMCID: PMC6169314 DOI: 10.1002/eat.22670] [Citation(s) in RCA: 186] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 12/21/2016] [Accepted: 12/22/2016] [Indexed: 12/11/2022]
Abstract
Remarkable progress has been made in developing psychosocial interventions for eating disorders and other mental disorders. Two priorities in providing treatment consist of addressing the research-practice gap and the treatment gap. The research-practice gap pertains to the dissemination of evidence-based treatments from controlled settings to routine clinical care. Closing the gap between what is known about effective treatment and what is actually provided to patients who receive care is crucial in improving mental health care, particularly for conditions such as eating disorders. The treatment gap pertains to extending treatments in ways that will reach the large number of people in need of clinical care who currently receive nothing. Currently, in the United States (and worldwide), the vast majority of individuals in need of mental health services for eating disorders and other mental health problems do not receive treatment. This article discusses the approaches required to better ensure: (1) that more people who are receiving treatment obtain high-quality, evidence-based care, using such strategies as train-the-trainer, web-centered training, best-buy interventions, electronic support tools, higher-level support and policy; and (2) that a higher proportion of those who are currently underserved receive treatment, using such strategies as task shifting and disruptive innovations, including treatment delivery via telemedicine, the Internet, and mobile apps.
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Affiliation(s)
- Alan E. Kazdin
- Department of Psychology, Yale University, New Haven, CT, USA
| | | | - Denise E. Wilfley
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
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