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Simione M, Frost HM, Farrar-Muir H, Luo M, Granadeño J, Torres C, Boudreau AA, Moreland J, Wallace J, Young J, Orav J, Sease K, Hambidge SJ, Taveras EM. Evaluating the Implementation of the Connect for Health Pediatric Weight Management Program. JAMA Netw Open 2024; 7:e2352648. [PMID: 38270953 PMCID: PMC10811559 DOI: 10.1001/jamanetworkopen.2023.52648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/29/2023] [Indexed: 01/26/2024] Open
Abstract
Importance Adoption of primary care interventions to reduce childhood obesity is limited. Progress in reducing obesity prevalence and eliminating disparities can be achieved by implementing effective childhood obesity management interventions in primary care settings. Objective To examine the extent to which implementation strategies supported the uptake of research evidence and implementation of the Connect for Health pediatric weight management program. Design, Setting, and Participants This quality improvement study took place at 3 geographically and demographically diverse health care organizations with substantially high numbers of children living in low-income communities in Denver, Colorado; Boston, Massachusetts; and Greenville, South Carolina, from November 2019 to April 2022. Participants included pediatric primary care clinicians and staff and families with children aged 2 to 12 years with a body mass index (BMI) in the 85th percentile or higher. Exposures Pediatric weight management program with clinician-facing tools (ie, clinical decision support tools) and family-facing tools (ie, educational handouts, text messaging program, community resource guide) along with implementation strategies (ie, training and feedback, technical assistance, virtual learning community, aligning with hospital performance metrics) to support the uptake. Main Outcomes and Measures Primary outcomes were constructs from the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) Framework examined through parent, clinician, and leadership surveys and electronic health record data to understand the number of children screened and identified, use of the clinical decision support tools, program acceptability, fidelity to the intervention and implementation strategies, and program sustainability. Results The program screened and identified 18 333 children across 3 organizations (Denver Health, 8480 children [46.3%]; mean [SD] age, 7.97 [3.31] years; 3863 [45.5%] female; Massachusetts General Hospital (MGH), 6190 children [33.8%]; mean [SD] age, 7.49 [3.19] years; 2920 [47.2%] female; Prisma Health, 3663 children [20.0%]; mean [SD] age, 7.33 [3.15] years; 1692 [46.2%] female) as having an elevated BMI. The actionable flagging system was used for 8718 children (48%). The reach was equitable, with 7843 children (92.4%) from Denver Health, 4071 children (65.8%) from MGH, and 1720 children (47%) from Prisma Health being from racially and ethnically minoritized groups. The sites had high fidelity to the program and 6 implementation strategies, with 4 strategies (67%) used consistently at Denver Health, 6 (100%) at MGH, and 5 (83%) at Prisma Health. A high program acceptability was found across the 3 health care organizations; for example, the mean (SD) Acceptability of Intervention Measure score was 3.72 (0.84) at Denver Health, 3.82 (0.86) at MGH, and 4.28 (0.68) at Prisma Health. The implementation strategies were associated with 7091 (39%) uses of the clinical decision support tool. The mean (SD) program sustainability scores were 4.46 (1.61) at Denver Health, 5.63 (1.28) at MGH, and 5.54 (0.92) at Prisma Health. Conclusions and Relevance These findings suggest that by understanding what strategies enable the adoption of scalable and implementation-ready programs by other health care organizations, it is feasible to improve the screening, identification, and management of children with overweight or obesity and mitigate existing disparities.
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Affiliation(s)
- Meg Simione
- Department of Pediatrics, Mass General for Children, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Holly M. Frost
- Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, Denver, Colorado
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colorado
- Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Haley Farrar-Muir
- Department of Pediatrics, Mass General for Children, Boston, Massachusetts
| | - Man Luo
- Department of Pediatrics, Mass General for Children, Boston, Massachusetts
| | - Jazmin Granadeño
- Department of Pediatrics, Mass General for Children, Boston, Massachusetts
| | - Carlos Torres
- Department of Pediatrics, Mass General for Children, Boston, Massachusetts
| | | | | | - Jessica Wallace
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colorado
| | | | - John Orav
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Kerry Sease
- Prisma Health, Greenville, South Carolina
- Department of Pediatrics, University of South Carolina School of Medicine, Greenville
| | - Simon J. Hambidge
- Department of Pediatrics, University of Colorado School of Medicine, Aurora
- Ambulatory Care Services, Denver Health, Denver, Colorado
| | - Elsie M. Taveras
- Department of Pediatrics, Mass General for Children, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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O'Leary SC, Frost HM. Does HPV vaccination initiation at age 9, improve HPV initiation and vaccine series completion rates by age 13? Hum Vaccin Immunother 2023; 19:2180971. [PMID: 36892245 PMCID: PMC10026893 DOI: 10.1080/21645515.2023.2180971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023] Open
Abstract
Vaccination for Human Papillomavirus (HPV) is important to reduce rates of cervical and oropharyngeal cancer. We aimed to evaluate if a program to initiate HPV vaccination at 9 years improved initiation and completion rates by 13 years of age. Data on empaneled patients aged 9-13 years from January 1, 2021 to August 30, 2022 were abstracted from the electronic health record. Primary outcome measures included HPV vaccination initiation and series completion by 13 years of age. The secondary outcome measure was missed opportunities for HPV vaccination. In total, 25,888 patients were included (12,433 pre-intervention, and 13,455 post-intervention). The percentage of patients aged 9-13 with an in-person visit who received at least 1 dose of HPV vaccine increased from 30% pre-intervention to 43% post-intervention. The percentage of patients who received 2 doses of vaccine increased from 19.3% pre-intervention to 42.7% post-intervention. For the overall population seen in-person, initiation of HPV vaccination by age 13 years increased from 42% to 54%. HPV completion increased as well (13% to 18%). HPV vaccination initiation at 9 years of age may be an acceptable and effective approach to improving vaccination rates.
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Affiliation(s)
- Sonja C O'Leary
- Department of General Pediatrics, Denver Health Medical Center, Denver, CO, USA
- Department of General Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Holly M Frost
- Department of General Pediatrics, Denver Health Medical Center, Denver, CO, USA
- Department of General Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
- Center for Health Systems Research, Denver Health, Denver, CO, USA
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Simione M, Aschbrenner K, Farrar-Muir H, Luo M, Granadeno J, Caballero-Gonzalez A, Price SN, Torres C, Boudreau AA, Fiechtner L, Hambidge SJ, Sease K, Taveras EM. Adapting Connect for Health pediatric weight management program for telehealth in response to the COVID-19 pandemic. Implement Sci Commun 2023; 4:139. [PMID: 37974245 PMCID: PMC10652425 DOI: 10.1186/s43058-023-00523-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 10/28/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND To address the evolving needs and context changes due to the COVID-19 pandemic, we adapted Connect for Health, an evidence-based, primary care, pediatric weight management intervention. The objective of this study is to describe the planned adaptation process to ensure continued and equitable program uptake during the pandemic. METHODS Guided by adaptation frameworks, we identified the core functions and forms of Connect for Health and then adapted the intervention in response to a changing healthcare context. We engaged stakeholders and surveyed parents of children with a BMI ≥ 85th percentile and pediatric clinicians and examined their experiences using telehealth for pediatric weight management and needs and preferences. Using multivariable logistic regression, we examined the preferences of parents with limited English proficiency regarding key aspects of pediatric weight management. RESULTS We surveyed 200 parents and 43% had a primary language of Spanish. Parents wanted care to be a combination of in-person and virtual visits (80%). We found that parents with limited English proficiency had a higher odds ratio of affirming in-person visits are better than virtual visits for ensuring their child's health concern can be taken care of (OR: 2.91; 95% CI: 1.36, 6.21), feeling comfortable when discussing personal information (OR: 3.91; 95% CI: 1.82, 8.43), talking about healthy behaviors and setting goals (OR: 3.09; 95% CI: 1.39, 6.90), and talking about mental health and overall well-being (OR: 4.02; 95% CI: 1.83, 8.87) than parents without limited English proficiency. We surveyed 75 clinicians and 60% felt telehealth was a useful tool to provide care for pediatric weight management. Clinicians felt virtual visits did not pose barriers to all aspects of care. Informed by the surveys and stakeholder input, we made clinician- and family-level adaptations while retaining the program's function. CONCLUSIONS By engaging stakeholders and adapting the program for telehealth, we optimized the reach and fit of Connect for Health to ensure its continued uptake. We have provided a real-world example of how clinical innovations can evolve and how to systematically plan adaptations in response to changing healthcare contexts. TRIAL REGISTRATION Clinicaltrials.gov (NCT04042493), Registered on August 2, 2019.
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Affiliation(s)
- Meg Simione
- Division of General Academic Pediatrics, Department of Pediatrics, Mass General for Children, 125 Nashua St, Suite 860, Boston, MA, 02114, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Kelly Aschbrenner
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Haley Farrar-Muir
- Division of General Academic Pediatrics, Department of Pediatrics, Mass General for Children, 125 Nashua St, Suite 860, Boston, MA, 02114, USA
| | - Man Luo
- Division of General Academic Pediatrics, Department of Pediatrics, Mass General for Children, 125 Nashua St, Suite 860, Boston, MA, 02114, USA
| | - Jazmin Granadeno
- Division of General Academic Pediatrics, Department of Pediatrics, Mass General for Children, 125 Nashua St, Suite 860, Boston, MA, 02114, USA
| | - Ariadne Caballero-Gonzalez
- Division of General Academic Pediatrics, Department of Pediatrics, Mass General for Children, 125 Nashua St, Suite 860, Boston, MA, 02114, USA
| | - Sarah N Price
- Division of General Academic Pediatrics, Department of Pediatrics, Mass General for Children, 125 Nashua St, Suite 860, Boston, MA, 02114, USA
| | - Carlos Torres
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- MGH Chelsea HealthCare Center, Chelsea, MA, USA
| | - Alexy Arauz Boudreau
- Division of General Academic Pediatrics, Department of Pediatrics, Mass General for Children, 125 Nashua St, Suite 860, Boston, MA, 02114, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Lauren Fiechtner
- Division of General Academic Pediatrics, Department of Pediatrics, Mass General for Children, 125 Nashua St, Suite 860, Boston, MA, 02114, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Simon J Hambidge
- Ambulatory Care Services, Denver Health, Denver, CO, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kerry Sease
- Department of Pediatrics, University of South Carolina School of Medicine, Greenville, SC, USA
- Prisma Health, Greenville, SC, USA
| | - Elsie M Taveras
- Division of General Academic Pediatrics, Department of Pediatrics, Mass General for Children, 125 Nashua St, Suite 860, Boston, MA, 02114, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Smith NR, Simione M, Farrar-Muir H, Granadeno J, Moreland JW, Wallace J, Frost HM, Young J, Craddock C, Sease K, Hambidge SJ, Taveras EM, Levy DE. Costs to Implement a Pediatric Weight Management Program Across 3 Distinct Contexts. Med Care 2023; 61:715-725. [PMID: 37943527 PMCID: PMC10478682 DOI: 10.1097/mlr.0000000000001891] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
BACKGROUND The Connect for Health program is an evidence-based program that aligns with national recommendations for pediatric weight management and includes clinical decision support, educational handouts, and community resources. As implementation costs are a major driver of program adoption and maintenance decisions, we assessed the costs to implement the Connect for Health program across 3 health systems that primarily serve low-income communities with a high prevalence of childhood obesity. METHODS We used time-driven activity-based costing methods. Each health system (site) developed a process map and a detailed report of all implementation actions taken, aligned with major implementation requirements (eg, electronic health record integration) or strategies (eg, providing clinician training). For each action, sites identified the personnel involved and estimated the time they spent, allowing us to estimate the total costs of implementation and breakdown costs by major implementation activities. RESULTS Process maps indicated that the program integrated easily into well-child visits. Overall implementation costs ranged from $77,103 (Prisma Health) to $84,954 (Denver Health) to $142,721 (Massachusetts General Hospital). Across implementation activities, setting up the technological aspects of the program was a major driver of costs. Other cost drivers included training, engaging stakeholders, and audit and feedback activities, though there was variability across systems based on organizational context and implementation choices. CONCLUSIONS Our work highlights the major cost drivers of implementing the Connect for Health program. Accounting for context-specific considerations when assessing the costs of implementation is crucial, especially to facilitate accurate projections of implementation costs in future settings.
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Affiliation(s)
- Natalie Riva Smith
- Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital
| | - Meg Simione
- Division of General Academic Pediatrics, Department of Pediatrics, Mass General for Children
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Haley Farrar-Muir
- Division of General Academic Pediatrics, Department of Pediatrics, Mass General for Children
| | - Jazmin Granadeno
- Division of General Academic Pediatrics, Department of Pediatrics, Mass General for Children
| | | | | | - Holly M. Frost
- Department of Pediatrics, Denver Health
- Center for Health Systems Research, Denver Health, Denver
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | | | - Cassie Craddock
- Department of Ambulatory Quality and Reliability, Prisma Health
| | - Kerry Sease
- Department of Pediatrics, University of South Carolina School of Medicine
- Prisma Health Children’s Hospital, Greenville, SC
| | - Simon J. Hambidge
- Ambulatory Care Services, Denver Health, Denver
- Harvard Medical School, Boston, MA
| | - Elsie M. Taveras
- Division of General Academic Pediatrics, Department of Pediatrics, Mass General for Children
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Douglas E. Levy
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital
- Harvard Medical School, Boston, MA
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