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Stover AM, Wang M, Shea CM, Richman E, Rees J, Cherrington AL, Cummings DM, Nicholson L, Peaden S, Craft M, Mackey M, Safford MM, Halladay JR. The Key Driver Implementation Scale (KDIS) for practice facilitators: Psychometric testing in the “Southeastern collaboration to improve blood pressure control” trial. PLoS One 2022; 17:e0272816. [PMID: 36001592 PMCID: PMC9401114 DOI: 10.1371/journal.pone.0272816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 07/17/2022] [Indexed: 11/19/2022] Open
Abstract
Background Practice facilitators (PFs) provide tailored support to primary care practices to improve the quality of care delivery. Often used by PFs, the “Key Driver Implementation Scale” (KDIS) measures the degree to which a practice implements quality improvement activities from the Chronic Care Model, but the scale’s psychometric properties have not been investigated. We examined construct validity, reliability, floor and ceiling effects, and a longitudinal trend test of the KDIS items in the Southeastern Collaboration to Improve Blood Pressure Control trial. Methods The KDIS items assess a practice’s progress toward implementing: a clinical information system (using their own data to drive change); standardized care processes; optimized team care; patient self-management support; and leadership support. We assessed construct validity and estimated reliability with a multilevel confirmatory factor analysis (CFA). A trend test examined whether the KDIS items increased over time and estimated the expected number of months needed to move a practice to the highest response options. Results PFs completed monthly KDIS ratings over 12 months for 32 primary care practices, yielding a total of 384 observations. Data was fitted to a unidimensional CFA model; however, parameter fit was modest and could be improved. Reliability was 0.70. Practices started scoring at the highest levels beginning in month 5, indicating low variability. The KDIS items did show an upward trend over 12 months (all p < .001), indicating that practices were increasingly implementing key activities. The expected time to move a practice to the highest response category was 9.1 months for standardized care processes, 10.2 for clinical information system, 12.6 for self-management support, 13.1 for leadership, and 14.3 months for optimized team care. Conclusions The KDIS items showed acceptable reliability, but work is needed in larger sample sizes to determine if two or more groups of implementation activities are being measured rather than one.
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Affiliation(s)
- Angela M. Stover
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
- Lineberger Comprehensive Cancer Center, Chapel Hill, NC, United States of America
- * E-mail:
| | - Mian Wang
- Lineberger Comprehensive Cancer Center, Chapel Hill, NC, United States of America
| | - Christopher M. Shea
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Erica Richman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Jennifer Rees
- NC Tracs Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Andrea L. Cherrington
- University of Alabama Birmingham, School of Medicine, Birmingham, AL, United States of America
| | | | - Liza Nicholson
- Department of Public Health, Samford University, Birmingham, AL, United States of America
| | - Shannon Peaden
- East Carolina University, Greenville, NC, United States of America
| | - Macie Craft
- University of Alabama Birmingham, School of Medicine, Birmingham, AL, United States of America
| | - Monique Mackey
- Area L Area Health Education Center (AHEC)—Part of the NC AHEC Program, Rocky Mount, NC, United States of America
| | | | - Jacqueline R. Halladay
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
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Feasibility of a pharmacist-led symptom monitoring and management intervention to improve breast cancer endocrine therapy adherence. J Am Pharm Assoc (2003) 2022; 62:1321-1328.e3. [PMID: 35393248 DOI: 10.1016/j.japh.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Adjuvant endocrine therapy (AET) for breast cancer reduces mortality, but one-third to one-half of patients discontinue it early or are nonadherent. OBJECTIVE We developed a pilot single-site study of patients with evidence of early nonadherence to AET to assess the feasibility of a novel, clinical pharmacist-led intervention targeting symptom and medication management. METHODS Patients with prescription fill records showing nonadherence were enrolled in a single-arm feasibility study. Automated reminders were sent by e-mail or text with a link to symptom monitoring assessments weekly for 1 month and monthly until 6 months. Clinical oncology pharmacists used guideline-based symptom management and other medication management tools to support adherence and ameliorate symptoms reported on the assessments. Patient-reported outcome assessments included physical, mental, and social health domains and self-efficacy to manage symptoms and medications. Feasibility outcomes included completion of symptom reports and pharmacist recommendations. RESULTS Of 19 participants who were nonadherent who enrolled and completed initial assessments, 18 completed all final study procedures, with 14 completing all assessments and no patient missing more than 3 assessments. All 18 participants reported at least one of 3 symptom types, and the majority reported attempting pharmacist recommendations. Patient-reported measures of physical, mental, and social health and self-efficacy improved, and 44% of the patients became adherent. CONCLUSION An intervention using pharmacists in an oncology practice to systematically monitor and manage symptoms shows promise to reduce symptoms, enhance support and self-efficacy, and improve adherence to AET.
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Calo WA, Francis E, Kong L, Hogentogler R, Heilbrunn E, Fisher A, Hood N, Kraschnewski J. Implementing Infection Control and Quality of Life Best Practices in Nursing Homes With Project ECHO: Protocol for a Patient-Centered Randomized Controlled Trial. JMIR Res Protoc 2022; 11:e34480. [PMID: 35476823 PMCID: PMC9109778 DOI: 10.2196/34480] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 04/18/2022] [Accepted: 04/26/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Nursing homes in the United States were devastated by COVID-19, with 710,000 cases and 138,000 deaths nationally through October 2021. Although facilities are required to have infection control staff, only 3% of designated infection preventionists have taken a basic infection control course prior to the COVID-19 pandemic. Most research has focused on infection control in the acute care setting. However, little is known about the implementation of infection control practices and effective interventions in nursing homes. This study utilizes Project ECHO (Extension for Community Health Outcomes), an evidence-based telementoring model, to connect Penn State University subject matter experts with nursing home staff and administrators to proactively support evidence-based infection control guideline implementation. OBJECTIVE Our study seeks to answer the research question of how evidence-based infection control guidelines can be implemented effectively in nursing homes, including comparing the effectiveness of two ECHO-delivered training interventions on key patient-centered outcomes such as reducing the number of residents with a COVID-19 diagnosis. METHODS A stratified cluster randomized design was utilized. Using a 1:1 ratio, we randomly assigned 136 nursing homes to ECHO or ECHO Plus arms. Randomization was stratified by geographic location, baseline COVID-19 infection rate, and facility capacity. The study had two phases. In phase one, completed in July 2021, nursing homes in both study arms received a 16-week infectious disease and quality improvement training intervention via real-time, interactive videoconferencing and the ECHO learning model. Phase one sessions were up to 90 minutes in duration. In phase two, completed in November 2021, the ECHO group was offered optional 60-minute office hours for 9 weeks and the ECHO Plus group received 9 weeks of 60-minute sessions on emerging topics and an additional 8-session refresher series on infection control. RESULTS A total of 290 nursing home facilities were assessed for eligibility, with 136 nursing homes recruited and randomly assigned to ECHO or ECHO Plus. Guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we will simultaneously evaluate the study's effectiveness and implementation outcomes at baseline (intervention start date), and at 4, 6, 12, and 18 months. The primary outcome is the COVID-19 infection rate in nursing homes. Secondary outcomes include COVID-19 hospitalizations and deaths, flu-like illness, and quality of life. Surveys and interviews with participants will also provide data as to the adoption, implementation, and maintenance of best practices taught throughout ECHO sessions. CONCLUSIONS A multipronged approach to improving infection control and emergency preparedness in nursing homes is important, given the toll that the COVID-19 pandemic has taken on residents and staff. The ECHO model has significant strengths when compared to traditional training, as it allows for remote learning delivered by a multidisciplinary team of experts, and utilizes case discussions that match the context and capacity of nursing homes. TRIAL REGISTRATION ClinicalTrials.gov NCT04499391; https://clinicaltrials.gov/ct2/show/NCT04499391.
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Affiliation(s)
- William A Calo
- Department of Public Health Sciences, Penn State College of Medicine, Penn State University, Hershey, PA, United States
| | - Erica Francis
- Department of Medicine, College of Medicine, Penn State University, Hershey, PA, United States
| | - Lan Kong
- Department of Public Health Sciences, Penn State College of Medicine, Penn State University, Hershey, PA, United States
| | - Ruth Hogentogler
- Department of Medicine, College of Medicine, Penn State University, Hershey, PA, United States
| | - Emily Heilbrunn
- Department of Medicine, College of Medicine, Penn State University, Hershey, PA, United States
| | - Abbey Fisher
- Department of Medicine, College of Medicine, Penn State University, Hershey, PA, United States
| | - Nancy Hood
- Health Sciences Center, University of New Mexico, Albuquerque, NM, United States
| | - Jennifer Kraschnewski
- Department of Medicine, College of Medicine, Penn State University, Hershey, PA, United States
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Successful Trial of Practice Facilitation for Plan, Do, Study, Act Quality Improvement. J Am Board Fam Med 2021; 34:991-1002. [PMID: 34535524 PMCID: PMC8571730 DOI: 10.3122/jabfm.2021.05.210140] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/15/2021] [Accepted: 06/15/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Practice facilitation (PF) is a promising but relatively new intervention supporting data-driven practice change. There is a need to better detail research-based facilitation methods, which must balance intervention fidelity and time restrictions with the flexibility required for the intervention. As part of a multi-level 4-armed cluster randomized clinical trial (RCT), 32 rural primary care practices received PF for 1 year. We evaluated the feasibility of having facilitators guide practices to perform 4 key driver domain activities, implemented as Plan-Do-Study-Act (PDSA) cycles, to better understand facilitation "exposure." We describe the intervention and activity length such that our experiences may be useful to other PF research efforts. METHODS Thirty-two practices serving rural patients involved in the Southeastern Collaboration to Improvement Blood Pressure Control engaged with a facilitator to develop and implement PDSAs nested within key drivers of change domains. Numbers of months practices worked on activities deemed most likely to be sustained were captured along with practice satisfaction data. RESULTS All practices engaged in at least 4 domain-level activities, and 59% of the PDSAs were active for at least 3 months. There was variation by domain in the average length of the PDSA activities. Ninety-seven percent (31 of 32) of practices recommended similarly structured facilitation services to other primary care practices, and 84% (27 of 32) noted substantive changes in their care processes. CONCLUSION In this trial, it was feasible for PFs to engage practices in at least 4 Key Driver quality improvement activities within 1 year, which will inform PF methods and protocol development in future trials.
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Solberg LI, Peterson KA, Fu H, Eder M, Jacobsen R, Carlin CS. Strategies and Factors Associated With Top Performance in Primary Care for Diabetes: Insights From a Mixed Methods Study. Ann Fam Med 2021; 19:110-116. [PMID: 33685872 PMCID: PMC7939707 DOI: 10.1370/afm.2646] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 06/02/2020] [Accepted: 06/22/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The aim of this study was to determine what strategies and factors are most important for high performance in the primary care of patients with diabetes. METHODS We performed a mixed-methods, cross-sectional, observational analysis of interviews and characteristics of primary care clinics in Minnesota and bordering areas. We compared strategies, facilitators, and barriers identified by 31 leaders of 17 clinics in high-, middle-, and low-performance quartiles on a standardized composite measure of diabetes outcomes for 416 of 586 primary care clinics. Semistructured interview data were combined with quantitative data regarding clinic performance and a survey of the presence of care management processes. RESULTS The interview analysis identified 10 themes providing unique insights into the factors and strategies characterizing the 3 performance groups. The main difference was the degree to which top-performing clinics used patient data to guide proactive and outreach methods to intensify treatment and monitor effect. Top clinics also appeared to view visit-based care management processes as necessary but insufficient, whereas all respondents regarded being part of a large system as mostly helpful. CONCLUSIONS Top-performing clinic approaches to diabetes care differ from lower-performing clinics primarily by emphasizing data-driven proactive outreach to patients to intensify treatment. Although confirmatory studies are needed, clinical leaders should consider the value of this paradigm shift in approach to care.
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Affiliation(s)
| | | | - Helen Fu
- University of Minnesota, Minneapolis, Minnesota
| | - Milton Eder
- University of Minnesota, Minneapolis, Minnesota
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Halladay JR, Weiner BJ, In Kim J, DeWalt DA, Pierson S, Fine J, Lefebvre A, Mackey M, Bergmire D, Cené C, Henderson K, Cykert S. Practice level factors associated with enhanced engagement with practice facilitators; findings from the heart health now study. BMC Health Serv Res 2020; 20:695. [PMID: 32723386 PMCID: PMC7388469 DOI: 10.1186/s12913-020-05552-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 07/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Practice facilitation is a promising strategy to enhance care processes and outcomes in primary care settings. It requires that practices and their facilitators engage as teams to drive improvement. In this analysis, we explored the practice and facilitator factors associated with greater team engagement at the mid-point of a 12-month practice facilitation intervention focused on implementing cardiovascular prevention activities in practice. Understanding factors associated with greater engagement with facilitators in practice-based quality improvement can assist practice facilitation programs with planning and resource allocation. METHODS One hundred thirty-six ambulatory care small to medium sized primary care practices that participated in the EvidenceNow initiative's NC Cooperative, named Heart Health Now (HHN), fit the eligibility criteria for this analysis. We explored the practice and facilitator factors associated with greater team engagement at the mid-point of a 12-month intervention using a retrospective cohort design that included baseline survey data, monthly practice activity implementation data and information about facilitator's experience. Generalized linear mixed-effects models (GLMMs) identified variables associated with greater odds of team engagement using an ordinal scale for level of team engagement. RESULTS Among our practice cohort, over half were clinician-owned and 27% were Federally Qualified Health Centers. The mean number of clinicians was 4.9 (SD 4.2) and approximately 40% of practices were in Medically Underserved Areas (MUA). GLMMs identified a best fit model. The Model presented as odd ratios and 95% confidence intervals suggests greater odds ratios of higher team engagement with greater practice QI leadership 17.31 (5.24-57.19), [0.00], and practice location in a MUA 7.25 (1.8-29.20), [0.005]. No facilitator characteristics were independently associated with greater engagement. CONCLUSIONS Our analysis provides information for practice facilitation stakeholders to consider when considering which practices may be more amendable to embracing facilitation services.
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Affiliation(s)
- Jacqueline R Halladay
- Department of Family Medicine, School of Medicine, The University of North Carolina at Chapel Hill, 590 Manning Drive, CB #7595, Chapel Hill, NC, 27599-7595, USA. .,Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd., CB #7590, Chapel Hill, NC, 27599-7590, USA.
| | - Bryan J Weiner
- Department of Global Health, University of Washington, Box 357965, Seattle, WA, 98195-7965, USA
| | - Jung In Kim
- Department of Statistics, Eberly College of Science, The Pennsylvania State University, University Park, State College, PA, USA.,Department of Nutritional Sciences, College of Health and Human Development, The Pennsylvania State University, University Park, State College, PA, USA
| | - Darren A DeWalt
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, The University of North Carolina at Chapel Hill, 5034 Old Clinic Bldg, CB #7110, Chapel Hill, NC, 27599-7110, USA
| | - Stephanie Pierson
- Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd., CB #7590, Chapel Hill, NC, 27599-7590, USA
| | - Jason Fine
- Department of Biostatistics, Gilling's School of Global Public Health, The University of North Carolina at Chapel Hill, 135 Dauer Drive, 3101 McGavran-Greenberg Hall, CB #7420, Chapel Hill, NC, 27599-7420, USA
| | - Ann Lefebvre
- Department of Family Medicine, South Carolina Area Health Education Center, Medical University of South Carolina, 5 Charleston Center, Suite 263, Charleston, SC, 29425, USA
| | - Monique Mackey
- Area L AHEC, 1631 S Wesleyan Blvd, Rocky Mount, NC, 27804, USA
| | - Dawn Bergmire
- Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd., CB #7590, Chapel Hill, NC, 27599-7590, USA
| | - Crystal Cené
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, The University of North Carolina at Chapel Hill, 5034 Old Clinic Bldg, CB #7110, Chapel Hill, NC, 27599-7110, USA
| | - Kamal Henderson
- Division of Cardiology, Department of Medicine, The University of North Carolina at Chapel Hill, 6th Floor, Burnett-Womack Bldg, 160 Dental Circle, CB #7075, Chapel Hill, NC, 27599-7075, USA
| | - Samuel Cykert
- Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd., CB #7590, Chapel Hill, NC, 27599-7590, USA.,Division of General Medicine and Clinical Epidemiology, Department of Medicine, The University of North Carolina at Chapel Hill, 5034 Old Clinic Bldg, CB #7110, Chapel Hill, NC, 27599-7110, USA
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Tuot DS, Rubinsky AD, Velasquez A, McCulloch CE, Schillinger D, Handley MA, Hsu CY, Powe NR. Interventions to Improve Blood Pressure Control Among Socioeconomically Disadvantaged Patients With CKD: Kidney Awareness Registry and Education Pilot Randomized Controlled Trial. Kidney Med 2019; 1:242-252. [PMID: 32734204 PMCID: PMC7380406 DOI: 10.1016/j.xkme.2019.07.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
RATIONALE & OBJECTIVE Sustainable interventions that enhance chronic kidney disease (CKD) management are not often studied in safety-net primary care, in which populations bear a disproportionate burden of disease and experience translational gaps between research and practice. We tested the feasibility of implementing and the impact of 2 technology-enhanced interventions designed to enhance CKD care delivery. STUDY DESIGN A 2×2 randomized controlled pilot trial. SETTING & PARTICIPANTS Primary care provider teams (n = 6) and 137 patients with CKD aged 18 to 75 years from 2 safety-net primary care clinics, 2013 to 2015. INTERVENTIONS Primary care provider teams were randomly assigned to access a CKD registry with point-of-care notifications and quarterly feedback or a usual-care registry for 12 months. Patients within provider teams were randomly assigned to participate in a CKD self-management support program or usual care for 12 months. OUTCOMES We examined recruitment, randomization, and participation in each intervention. We also examined the impact of each intervention and their combination on change in systolic blood pressure (SBP), albuminuria, and patient self-reported behavioral measures after 12 months. RESULTS Among potentially eligible patients identified using the electronic health record, 24% were eligible for study participation, of whom 35% (n = 137) were enrolled. Mean age was 55 years, 41% were non-English speaking, and 93% were of racial/ethnic minority. Mean baseline estimated glomerular filtration rate was 70.5 (SD = 30.3) mL/min/1.73 m2; mean baseline SBP was 131 (SD = 21.8) mm Hg. Nearly 90% of clinicians reported that the CKD registry influenced their CKD management. More than 95% of patients randomly assigned to CKD self-management support engaged regularly with the intervention. Estimated changes in SBP over 1 year were nonstatistically different in each of the 3 intervention groups compared with usual care: (usual care: 0.5 [95% CI, -5.2 to 6.3] mm Hg; CKD registry only: -5.4 [95% CI, -12.2 to 1.4] mm Hg; CKD self-management support only: -6.4 [95% CI, -13.7 to 1.0] mm Hg; and CKD registry plus CKD self-management support: -0.5 [-5.5 to 4.5] mm Hg), though differences were larger among those with baseline SBPs > 140/90 mm Hg. Decreases in albuminuria were similarly nonstatistically different in each of the intervention groups compared with usual care. No differences were observed in patient self-reported behaviors. LIMITATIONS Single health system. CONCLUSIONS Patient and provider interventions to improve CKD care are feasible to implement in low-income settings with promising results among those with uncontrolled blood pressure. FUNDING National Institute of Diabetes and Digestive and Kidney Diseases. TRIAL REGISTRATION ClinicalTrials.gov, number: NCT01530958.
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Affiliation(s)
- Delphine S. Tuot
- Division of Nephrology, University of California, San Francisco, CA
- Center for Vulnerable Populations at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA
- Kidney Health Research Collaborative, University of California, San Francisco, CA
| | - Anna D. Rubinsky
- Kidney Health Research Collaborative, University of California, San Francisco, CA
- San Francisco Veterans Affairs Health Care System, University of California, San Francisco, San Francisco, CA
| | | | - Charles E. McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Dean Schillinger
- Center for Vulnerable Populations at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA
- Division of General Internal Medicine at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA
| | - Margaret A. Handley
- Center for Vulnerable Populations at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
- Division of General Internal Medicine at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA
| | - Chi-yuan Hsu
- Division of Nephrology, University of California, San Francisco, CA
- Kidney Health Research Collaborative, University of California, San Francisco, CA
| | - Neil R. Powe
- Center for Vulnerable Populations at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA
- Division of General Internal Medicine at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA
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Nassif A, Katoue MG, Wake DJ, George J. Management of Low Density Lipoprotein Cholesterol at a primary care diabetes clinic in Kuwait. Prim Care Diabetes 2019; 13:259-265. [PMID: 30578166 DOI: 10.1016/j.pcd.2018.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/07/2018] [Accepted: 11/15/2018] [Indexed: 11/17/2022]
Abstract
AIMS To evaluate the impact of clinical audit and focused interventions on reducing cardiovascular diseases risk by treating Low Density Lipoprotein Cholesterol (LDL-C) in patients with type 2 diabetes attending a primary care clinic in Kuwait. METHODS Using LDL as a surrogate for cardiovascular risk, the audit team performed a clinical audit with focus on the care process indicator of statin prescription. The basic audit reviewed 100 patients' medical records retrospectively to assess patients' lipid profiles and statin prescription. A lipid management protocol and algorithm based on national clinical practice guidelines distributed to all healthcare professionals and was implemented for 3 months followed by re-audit of another 100 records. Descriptive and comparative statistics (pre and post) were performed using SPSS, version 22. RESULTS Statin prescription increased significantly from (26%) in the basic audit to (85%) in the post-intervention audit (p<0.001). The mean LDL-C value decreased significantly from 3.37±0.67mmol/L to 2.71±0.79mmol/L, p<0.001. Mean total cholesterol was significantly reduced from 5.15±0.73mmol/L to 4.68±0.88mmol/L, p<0.001. Ten years CHD risk decreased from 18.46±11.1% to 16.8±12.23%, p=0.152. CONCLUSIONS Implementing a clinical audit coupled with focused intervention was successful in improving management of LDL-C among patients with type 2 diabetes mellitus attending the primary healthcare sector in Kuwait.
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Affiliation(s)
- Alfred Nassif
- Al-Naeem Diabetes Clinic, Primary Health Care, Jahra, Kuwait.
| | - Maram Gamal Katoue
- Department of Pharmacology and Therapeutics, Faculty of Pharmacy, Kuwait University, Kuwait
| | - Deborah Jane Wake
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, UK
| | - Jacob George
- University of Dundee Ninewells Hospital, Dundee, Scotland, UK
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Price DW, Biernacki H, Nora LM. Can Maintenance of Certification Work? Associations of MOC and Improvements in Physicians' Knowledge and Practice. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:1872-1881. [PMID: 29952770 DOI: 10.1097/acm.0000000000002338] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE To summarize the findings of studies, conducted by individuals both internal and external to the American Board of Medical Specialties (ABMS) Member Boards, of the associations of Maintenance of Certification (MOC) and improvements in physicians' knowledge and patient care processes or outcomes. METHOD The authors conducted a narrative review of studies identified by searching PubMed and Web of Science for English-language articles from the United States published between 2000 and May 2017. To be included, articles had to examine the relationship of MOC to physician knowledge, clinical practice processes, or patient care outcomes. The initial search yielded 811 articles. After two rounds of review and excluding those articles that did not fit the study criteria, 39 articles were included for analysis. RESULTS The 39 included studies were conducted by or included diplomates of 12 ABMS Member Boards. Twenty-two studies examined MOC processes that were developed by an ABMS Board; 17 examined interventions that were developed by nonboard entities but accepted for MOC credit by an ABMS Board. Thirty-eight studies examined a single component of MOC; 24 studied the improvement in medical practice component. Thirty-seven studies reported at least one positive outcome. CONCLUSIONS Most of the studies included in this review highlighted circumstances in which MOC was associated with positive impacts on physician knowledge and patient care processes or outcomes. Future collaborative research is needed to improve the relevance, helpfulness, and generalizability of continuing certification to different physicians across specialties and practice settings.
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Affiliation(s)
- David W Price
- D.W. Price is senior vice president, Research and Education Foundation, and executive director, Multispecialty Portfolio Program, American Board of Medical Specialties, Chicago, Illinois, and professor, Department of Family Medicine, University of Colorado School of Medicine, Denver, Colorado; ORCID: https://orcid.org/0000-0002-7645-0126. H. Biernacki is manager, Research Operations, American Board of Medical Specialties, Chicago, Illinois. L.M. Nora is immediate past president and chief executive officer, American Board of Medical Specialties, Chicago, Illinois
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Tuot DS, McCulloch CE, Velasquez A, Schillinger D, Hsu CY, Handley M, Powe NR. Impact of a Primary Care CKD Registry in a US Public Safety-Net Health Care Delivery System: A Pragmatic Randomized Trial. Am J Kidney Dis 2018; 72:168-177. [PMID: 29699885 DOI: 10.1053/j.ajkd.2018.01.058] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 01/22/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Many individuals with chronic kidney disease (CKD) do not receive guideline-concordant care. We examined the impact of a team-based primary care CKD registry on clinical measures and processes of care among patients with CKD cared for in a public safety-net health care delivery system. STUDY DESIGN Pragmatic trial of a CKD registry versus a usual-care registry for 1 year. SETTING & PARTICIPANTS Primary care providers (PCPs) and their patients with CKD in a safety-net primary care setting in San Francisco. INTERVENTION The CKD registry identified at point of care all patients with CKD, those with blood pressure (BP)>140/90mmHg, those without angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB) prescription, and those without albuminuria quantification in the past year. It also provided quarterly feedback pertinent to these metrics to promote "outreach" to patients with CKD. The usual-care registry provided point-of-care cancer screening and immunization data. OUTCOMES Changes in systolic BP at 12 months (primary outcome), proportion of patients with BP control, prescription of ACE inhibitors/ARBs, quantification of albuminuria, severity of albuminuria, and estimated glomerular filtration rate. RESULTS The patient population (n=746) had a mean age of 56.7±12.1 (standard deviation) years, was 53% women, and was diverse (8% non-Hispanic white, 35.7% black, 24.5% Hispanic, and 24.4% Asian). Randomization to the CKD registry (30 PCPs, 285 patients) versus the usual-care registry (49 PCPs, 461 patients) was associated with 2-fold greater odds of ACE inhibitor/ARB prescription (adjusted OR, 2.25; 95% CI, 1.45-3.49) and albuminuria quantification (adjusted OR, 2.44; 95% CI, 1.38-4.29) during the 1-year study period. Randomization to the CKD registry was not associated with changes in systolic BP, proportion of patients with uncontrolled BP, or degree of albuminuria or estimated glomerular filtration rate. LIMITATIONS Potential misclassification of CKD; missing baseline medication data; limited to study of a public safety-net health care system. CONCLUSIONS A team-based safety-net primary care CKD registry did not improve BP parameters, but led to greater albuminuria quantification and more ACE inhibitor/ARB prescriptions after 1 year. Adoption of team-based CKD registries may represent an important step in translating evidence into practice for CKD management.
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Affiliation(s)
- Delphine S Tuot
- Division of Nephrology, University of California, San Francisco, CA; Center for Vulnerable Populations at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA; Kidney Health Research Institute, University of California, San Francisco, San Francisco, CA.
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
| | | | - Dean Schillinger
- Division of General Internal Medicine at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, CA; Center for Vulnerable Populations at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA
| | - Chi-Yuan Hsu
- Division of Nephrology, University of California, San Francisco, CA; Kidney Health Research Institute, University of California, San Francisco, San Francisco, CA
| | - Margaret Handley
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA; Division of General Internal Medicine at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, CA; Center for Vulnerable Populations at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA
| | - Neil R Powe
- Division of General Internal Medicine at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, CA; Center for Vulnerable Populations at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA
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Henderson KH, DeWalt DA, Halladay J, Weiner BJ, Kim JI, Fine J, Cykert S. Organizational Leadership and Adaptive Reserve in Blood Pressure Control: The Heart Health NOW Study. Ann Fam Med 2018; 16:S29-S34. [PMID: 29632223 PMCID: PMC5891311 DOI: 10.1370/afm.2210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 01/21/2018] [Accepted: 01/24/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Our purpose was to assess whether a practice's adaptive reserve and high leadership capability in quality improvement are associated with population blood pressure control. METHODS We divided practices into quartiles of blood pressure control performance and considered the top quartile as the benchmark for comparison. Using abstracted clinical data from electronic health records, we performed a cross-sectional study to assess the association of top quartile hypertension control and (1) the baseline practice adaptive reserve (PAR) scores and (2) baseline practice leadership scores, using modified Poisson regression models adjusting for practice-level characteristics. RESULTS Among 181 practices, 46 were in the top quartile, which averaged 68% or better blood pressure control. Practices with higher PAR scores compared with lower PAR scores were not more likely to reside in the top quartile of performance (prevalence ratio [PR] = 1.92 for highest quartile; 95% CI, 0.9-4.1). Similarly, high quality improvement leadership capability compared with lower capability did not predict better blood pressure control performance (PR = 0.94; 95% CI, 0.57-1.56). Practices with higher proportions of commercially insured patients were more likely than practices with lower proportions of commercially insured patients to have top quartile performance (37% vs 26%, P =.002), whereas lower proportions of the uninsured (8% vs 14%, P =.055) were associated with better performance. CONCLUSIONS Our findings show that adaptive reserve and leadership capability in quality improvement implementation are not statistically associated with achieving top quartile practice-level hypertension control at baseline in the Heart Health NOW project. Our findings, however, may be limited by a lack of patient-related factors and small sample size to preclude strong conclusions.
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Affiliation(s)
- Kamal H Henderson
- Division of Cardiology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina .,Division of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Darren A DeWalt
- Division of General Medicine and Clinical Epidemiology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Jacquie Halladay
- Division of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Bryan J Weiner
- Departments of Global Health and Biostatistics, University of Washington, Seattle, Washington
| | - Jung I Kim
- UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Jason Fine
- UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Samuel Cykert
- Division of General Medicine and Clinical Epidemiology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
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12
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Strait A, Velasquez A, Handley MA, Leong K, Najmabadi A, Powe NR, Tuot DS. Acceptability of a multilevel intervention to improve blood pressure control among patients with chronic kidney disease in a public health care delivery system. Clin Kidney J 2017; 11:540-548. [PMID: 30094019 PMCID: PMC6070069 DOI: 10.1093/ckj/sfx141] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 11/09/2017] [Indexed: 12/19/2022] Open
Abstract
Background The Kidney Awareness Registry and Education (KARE) trial examined the impact of a multilevel intervention on blood pressure control among patients with chronic kidney disease (CKD) in a public health care delivery system. KARE consisted of a clinic-based intervention (a primary care CKD registry with point-of-care provider notifications and quarterly feedback related to CKD management) and a patient-directed intervention [a CKD self-management support (CKD-SMS) program that included low literacy educational materials, automated telephone-administered self-management modules and telephone health coaching]. We explored the acceptability of these interventions among end users. Methods At trial conclusion, we surveyed 39 primary care providers (PCPs) to identify preferences about components of the clinic intervention, conducted two focus groups among non-PCP staff to elicit in-depth attitudes and experiences with operationalizing the team-based CKD registry, and conducted eight focus groups with English- and Spanish-speaking patients to hear about their experiences with the CKD-SMS program. Focus group transcripts were analyzed using thematic analysis. Self-reported participation and data from the automated telephone program were used to evaluate patient engagement. Results Most PCPs (94%) believed that the point-of-care notifications benefited clinic workflow and agreed that quarterly feedback enhanced their ability to identify (89.5%) and manage (73.7%) CKD. Staff confirmed usefulness of point-of-care notifications. Patients suggested the automated telephone system was impersonal, though easy to use; that frequent automated calls were helpful to reinforce self-management behaviors; and that telephone health coaching was convenient. Nearly 40% of patients completed >80% of automated phone calls, 95% participated in calls with their health coach and 77% created at least one action plan. Conclusions A CKD registry is acceptable to primary care health care teams and has potential to enhance identification and management of CKD in primary care. Low-income patients appreciated and engaged with a telephone-based CKD-SMS program, demonstrating its potential for increasing awareness and health engagement among populations with CKD within a public health care delivery system.
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Affiliation(s)
- Adrienne Strait
- Division of Nephrology, University of California, San Francisco, CA, USA
| | | | - Margaret A Handley
- Department of Medicine, University of California, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Karen Leong
- Division of Nephrology, University of California, San Francisco, CA, USA
| | - Adriana Najmabadi
- Division of Nephrology, University of California, San Francisco, CA, USA
| | - Neil R Powe
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Delphine S Tuot
- Division of Nephrology, University of California, San Francisco, CA, USA
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13
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da Silva Marinho MG, Fontbonne A, Vasconcelos Barbosa JM, de Melo Rodrigues H, Freese de Carvalho E, Vieira de Souza W, Pessoa Cesse EA. The impact of an intervention to improve diabetes management in primary healthcare professionals' practices in Brazil. Prim Care Diabetes 2017; 11:538-545. [PMID: 28663022 DOI: 10.1016/j.pcd.2017.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 05/30/2017] [Accepted: 06/03/2017] [Indexed: 12/01/2022]
Abstract
AIMS To evaluate the results of a structured intervention in primary healthcare to improve type 2 diabetes management. METHODS The intervention was implemented in 2011-2012 in two cities in the State of Pernambuco, Brazil, and evaluated in 2013 by interviewing healthcare professionals about their practices in all primary care facilities of these two cities (intervention group), and of two paired control cities (control group). Comparisons between the intervention and control groups were made using standard parametric tests. RESULTS The percentage of professionals who measured adherence to treatment, developed educational actions to control high-risk situations or prevent complications, or declared that they "explained" the disease to the patients, was higher in the control group (p<0.05). Multidisciplinary involvement, requests for electrocardiograms and referrals to specialists were also more frequent in the control group (p<0.01). The only differences favoring the intervention group were the higher proportion of nurses (p<0.05) and community health workers (p<0.01) trained for diabetes management and a greater frequency of discussing the cases of diabetic patients at team meetings (p<0.01). CONCLUSIONS These negative results raise questions about the effectiveness of actions aiming to improve diabetes management in primary care, and reinforce the need for careful evaluation of their impact.
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MESH Headings
- Adolescent
- Adult
- Aged
- Brazil/epidemiology
- Cross-Sectional Studies
- Delivery of Health Care, Integrated/standards
- Diabetes Mellitus, Type 2/blood
- Diabetes Mellitus, Type 2/diagnosis
- Diabetes Mellitus, Type 2/epidemiology
- Diabetes Mellitus, Type 2/therapy
- Female
- Health Care Surveys
- Health Knowledge, Attitudes, Practice
- Health Services Research
- Humans
- Male
- Middle Aged
- Patient Care Team/standards
- Patient Education as Topic/standards
- Practice Patterns, Physicians'/standards
- Primary Health Care/standards
- Process Assessment, Health Care/standards
- Professional Practice/standards
- Program Evaluation
- Quality Improvement/standards
- Quality Indicators, Health Care/standards
- Self Care/standards
- Time Factors
- Treatment Outcome
- Urban Health Services/standards
- Young Adult
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Affiliation(s)
| | - Annick Fontbonne
- UMR 204 Nutripass, Institute of Research for Development (IRD), Montpellier University, Montpellier, France.
| | | | | | - Eduardo Freese de Carvalho
- Department of Community Health, Aggeu Magalhães Research Centre, Oswaldo Cruz Foundation (Fiocruz), Recife, Brazil
| | - Wayner Vieira de Souza
- Department of Community Health, Aggeu Magalhães Research Centre, Oswaldo Cruz Foundation (Fiocruz), Recife, Brazil
| | - Eduarda Angela Pessoa Cesse
- Department of Community Health, Aggeu Magalhães Research Centre, Oswaldo Cruz Foundation (Fiocruz), Recife, Brazil
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14
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Katzenellenbogen JM, Ralph AP, Wyber R, Carapetis JR. Rheumatic heart disease: infectious disease origin, chronic care approach. BMC Health Serv Res 2017; 17:793. [PMID: 29187184 PMCID: PMC5708129 DOI: 10.1186/s12913-017-2747-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 11/20/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Rheumatic heart disease (RHD) is a chronic cardiac condition with an infectious aetiology, causing high disease burden in low-income settings. Affected individuals are young and associated morbidity is high. However, RHD is relatively neglected due to the populations involved and its lower incidence relative to other heart diseases. METHODS AND RESULTS In this narrative review, we describe how RHD care can be informed by and integrated with models of care developed for priority non-communicable diseases (coronary heart disease), and high-burden communicable diseases (tuberculosis). Examining the four-level prevention model (primordial through tertiary prevention) suggests primordial and primary prevention of RHD can leverage off existing tuberculosis control efforts, given shared risk factors. Successes in coronary heart disease control provide inspiration for similarly bold initiatives for RHD. Further, we illustrate how the Chronic Care Model (CCM), developed for use in non-communicable diseases, offers a relevant framework to approach RHD care. Systems strengthening through greater integration of services can improve RHD programs. CONCLUSION Strengthening of systems through integration/linkages with other well-performing and resourced services in conjunction with policies to adopt the CCM framework for the secondary and tertiary prevention of RHD in settings with limited resources, has the potential to significantly reduce the burden of RHD globally. More research is required to provide evidence-based recommendations for policy and service design.
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Affiliation(s)
- Judith M Katzenellenbogen
- Telethon Kids Institute, The University of Western Australia, Perth, Western, Australia.
- School of Population and Global Health, The University of Western Australia, Perth, Western, Australia.
| | - Anna P Ralph
- Global and Tropical Health, Menzies School of Health Research, Darwin, Northern Territory, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia
| | - Rosemary Wyber
- Telethon Kids Institute, The University of Western Australia, Perth, Western, Australia
| | - Jonathan R Carapetis
- Telethon Kids Institute, The University of Western Australia, Perth, Western, Australia
- Princess Margaret Hospital for Children, Perth, Western, Australia
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15
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Saucier AN, Ansa B, Coffin J, Akhtar M, Miller A, Mahoney H, Hodo DM, Duffie C, Fontenot B, Andrews HE, Smith SA. Patient perspectives of an individualized diabetes care management plan. ACTA ACUST UNITED AC 2017; 5:213-219. [PMID: 28835847 DOI: 10.5750/ejpch.v5i2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE This cross sectional study examines patients' knowledge, attitudes and beliefs about a diabetic care management plan (DCMP) that was developed to provide patient education on diabetes guidelines and display individual diabetic core measures. Secondary objectives included a comparison of diabetic core measures [hemoglobin A1C (HbA1C), systolic and diastolic blood pressure (SBP, DBP), low-density lipoprotein (LDL) and urine microalbumin (Um)] before and after DCMP implementation. We hypothesize this tool will contribute to patients' awareness of current disease status, diabetes knowledge and diabetic core value improvement over time. METHODS A consecutive sample of 102 adult patients with diabetes mellitus type 2 in a primary care setting participated. Patients' perspectives on the care plan and knowledge about diabetes was collected via survey after care plan implementation. A comparison of selected diabetic core measures was conducted at baseline and post-DCMP. Descriptive statistics summarized survey response and diabetic core measures. A repeated measures ANOVA was used to assess change in diabetic core measures over time. RESULTS Participants understood the DCMP (96%), found it important because it explained their laboratory results and medications (89%) and believed it would help them to have better diabetic control (99%). There was a significant interaction between time and being at goal pre-DCMP for HbA1c, SBP and LDL. Patients not at goal pre-DCMP for the above measures decreased significantly over time (P = <0.01 for HbA1c, SBP and LDL). Participants at goal for all diabetic core measures increased pre- to post-DCMP from 13% to 20% (P = 0.28). CONCLUSION Patients perceived the diabetic care management plan favorably and their diabetic core measurements improved over time. This simple and reproducible self-management intervention can enhance self-management in a patient population with diabetes mellitus type 2.
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Affiliation(s)
- Ashley N Saucier
- Associate Professor & Associate Director of Medical Student Education, Department of Family Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Benjamin Ansa
- Senior Research Associate, Institute of Public & Preventative Health, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Janis Coffin
- Professor & Family Medicine Clinic Director, Department of Family Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Mariam Akhtar
- Assistant Professor, Department of Family Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Andre Miller
- Chief Resident, Department of Family Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Holly Mahoney
- Chief Resident, Department of Family Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Denise M Hodo
- Research Associate, Department of Family Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Carla Duffie
- Clinic Coordinator, Department of Family Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Brittney Fontenot
- Research Associate, Institute of Public & Preventative Health, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Holly E Andrews
- Research Associate, Department of Family Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Selina A Smith
- Director of Research, Professor & Curtis G. Hames, MD, Distinguished Chair, Department of Family Medicine Medical College of Georgia at Augusta University; President, Georgia Public Health Association & Editor, Journal of the Georgia Public Health Association, Augusta, Georgia, USA
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16
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Practice Level Costs of Office-Based Hypertension Performance Improvement. J Healthc Manag 2017; 62:136-150. [DOI: 10.1097/jhm-d-17-00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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McHugh M, Harvey J, Hamil J, Verevkina NI, Alexander J, Scanlon DP. The Impact of the Affordable Care Act on Health Care Alliances' Quality Improvement Efforts in Targeted Communities: Perceptions of Health Care Alliance Leaders. Jt Comm J Qual Patient Saf 2016; 42:137-45. [PMID: 26892703 DOI: 10.1016/s1553-7250(16)42017-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Megan McHugh
- Center for Healthcare Studies and Department of Emergency Medicine, Northwestern University, Feinberg School of Medicine, Chicago, USA
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Abstract
BACKGROUND The National Committee for Quality Assurance patient-centered medical home recognition program provides practices an opportunity to implement medical home activities. Understanding the costs to apply for recognition may enable practices to plan their work. METHODS Practice coaches identified 5 exemplar practices (3 pediatric and 2 family medicine practices) that received level 3 recognition. This analysis focuses on 4 that received recognition in 2011. Clinical, informatics, and administrative staff participated in 2- to 3-hour interviews. We determined the time required to develop, implement, and maintain required activities. We categorized costs as (1) nonpersonnel, (2) developmental, (3) those used to implement activities, (4) those used to maintain activities, (5) those to document the work, and (6) consultant costs. Only incremental costs were included and are presented as costs per full-time equivalent (pFTE) provider. RESULTS Practice size ranged from 2.5 to 10.5 pFTE providers, and payer mixes ranged from 7% to 43% Medicaid. There was variation in the distribution of costs by activity by practice, but the costs to apply were remarkably similar ($11,453-15,977 pFTE provider). CONCLUSION The costs to apply for 2011 recognition were noteworthy. Work to enhance care coordination and close loops were highly valued. Financial incentives were key motivators. Future efforts to minimize the burden of low-value activities could benefit practices.
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Advancing heart health in North Carolina primary care: the Heart Health NOW study protocol. Implement Sci 2015; 10:160. [PMID: 26577091 PMCID: PMC4650518 DOI: 10.1186/s13012-015-0348-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 11/09/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The objective of Heart Health NOW (HHN) is to determine if primary care practice support-a comprehensive evidence-based quality improvement strategy involving practice facilitation, academic detailing, technology support, and regional learning collaboratives-accelerates widespread dissemination and implementation of evidence-based guidelines for cardiovascular disease (CVD) prevention in small- to medium-sized primary care practices and, additionally, increases practices' capacity to incorporate other evidence-based clinical guidelines in the future. METHODS/DESIGN HHN is a stepped wedge, stratified, cluster randomized trial to evaluate the effect of primary care practice support on evidence-based CVD prevention, organizational change process measures, and patient outcomes. Each practice will start the trial as a control, receive the intervention at a randomized time point, and then enter a maintenance period 12 months after the start of the intervention. The intervention will be randomized to practices in one of four strata defined by region of the state (east or west) and degree of practice readiness for change. Seventy-five practices in each region with a high degree of readiness will be randomized 1:1:1 in blocks of 3 sometime prior to month 8 to receive the intervention at month 9, 11, or 12. An additional 75 practices within each region that have a low degree of readiness or are recruited later will be randomized 1:1 in blocks of 2 prior to month 13 to receive the intervention at month 14 or 16. The sites will be ordered within each strata based on time of enrollment with the blocking based on this ordering. Evaluation will examine the effect of primary care practice support on (1) practice-level delivery of evidence-based CVD prevention, (2) patient-level health outcomes, (3) practice-level implementation of clinical and organizational changes that support delivery of evidence-based CVD prevention, and (4) practice-level capacity to implement future evidence-based clinical guidelines. DISCUSSION Results will indicate whether primary care practice support is an effective strategy for widespread dissemination and implementation of evidence-based clinical guidelines in primary care practices. Discernible reductions in cardiovascular risk in 300 practices covering over an estimated 900,000 adult patients would likely lead to prevention of thousands of cardiovascular events within 10 years. TRIAL REGISTRATION ClinicalTrials.gov NCT02585557.
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Deavers F, DePesa N, Mitchell J, Mazza A, Cassisi J. Integration of Behavioral Health and Medical Services: Using Patient Experience as a Guide. J Patient Exp 2015; 2:6-13. [PMID: 28725817 PMCID: PMC5513630 DOI: 10.1177/2374373515615976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives: This study aimed to assess patient satisfaction with behavioral health consultation in a primary and specialty care setting and to gauge patient interest in other behavioral health services. Methods: We surveyed patients with type 2 diabetes mellitus (N = 65), following a brief behavioral health consultation about their satisfaction with the experience and their interest in various behavioral health services. Doctoral students with master’s degrees in clinical psychology provided the consultations. Results: Patients were highly satisfied with behavioral health consultations and expressed moderate to high interest in various potential behavioral health services. Patients with more diabetes-related concerns were less satisfied with brief behavioral health consultations but reported greater interest in other behavioral health services. Conclusions: Results were used to build stakeholder support and guide expansion of integrated behavioral health services. Examining patient experience can help identify patients who need more extensive services and ensure that services are patient centered.
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Tuot DS, Velasquez A, McCulloch CE, Banerjee T, Zhu Y, Hsu CY, Handley M, Schillinger D, Powe NR. The Kidney Awareness Registry and Education (KARE) study: protocol of a randomized controlled trial to enhance provider and patient engagement with chronic kidney disease. BMC Nephrol 2015; 16:166. [PMID: 26494562 PMCID: PMC4618520 DOI: 10.1186/s12882-015-0168-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/14/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is common and is associated with excess mortality and morbidity. Better management could slow progression of disease, prevent metabolic complications, and reduce cardiovascular outcomes. Low patient awareness of CKD and ineffective patient-provider communication can impede such efforts. We developed provider and patient-directed interventions that harness health information technology to enhance provider recognition of CKD and delivery of guideline concordant care and augment patient understanding and engagement in CKD care. METHODS/DESIGN We report the design and protocol of the Kidney Awareness Registry and Education (KARE) Study, a 2x2 factorial randomized controlled trial that examines the impact of a multi-level intervention on health outcomes among low-income English, Spanish and Cantonese-speaking patients with CKD in a safety net system. The intervention includes: (1) implementation of a primary care electronic CKD registry that notifies practice teams of patients' CKD status and employs a patient profile and quarterly feedback to encourage provision of guideline-concordant care at point-of-care and via outreach; and (2) a language-concordant, culturally-sensitive self-management support program that consists of automated telephone modules, provision of low-literacy written patient-educational materials and telephone health coaching. The primary outcomes of the trial are changes in systolic blood pressure (BP) and the proportion of patients with BP control (≤ 140/90 mmHg) after one year. Secondary outcomes include patient understanding of CKD, participation in healthy behaviors, and practice team delivery of guideline-concordant CKD care. DISCUSSION Results from the KARE study will provide data on the feasibility, effectiveness, and acceptability of technology-based interventions that support primary care efforts at improving health outcomes among vulnerable patients with CKD. TRIAL REGISTRATION ClinicalTrials.gov, number: NCT01530958.
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Affiliation(s)
- Delphine S Tuot
- Division of Nephrology, University of California, San Francisco, San Francisco, CA, 94143, USA.
- Center for Vulnerable Populations at San Francisco General Hospital, San Francisco, CA, USA.
- Renal Center at San Francisco General Hospital, 1001 Potrero Avenue Bldg 100, Room 342, San Francisco, CA, 94110, USA.
| | - Alexandra Velasquez
- Division of Nephrology, University of California, San Francisco, San Francisco, CA, 94143, USA.
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, 94143, USA.
| | - Tanushree Banerjee
- Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94143, USA.
- Center for Vulnerable Populations at San Francisco General Hospital, San Francisco, CA, USA.
| | - Yunnuo Zhu
- Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94143, USA.
| | - Chi-yuan Hsu
- Division of Nephrology, University of California, San Francisco, San Francisco, CA, 94143, USA.
| | - Margaret Handley
- Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94143, USA.
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, 94143, USA.
| | - Dean Schillinger
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, 94143, USA.
- Center for Vulnerable Populations at San Francisco General Hospital, San Francisco, CA, USA.
| | - Neil R Powe
- Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94143, USA.
- Center for Vulnerable Populations at San Francisco General Hospital, San Francisco, CA, USA.
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McHugh M, Harvey JB, Kang R, Shi Y, Scanlon DP. Measuring the Dose of Quality Improvement Initiatives. Med Care Res Rev 2015; 73:227-46. [PMID: 26330005 DOI: 10.1177/1077558715603567] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 08/07/2015] [Indexed: 11/15/2022]
Abstract
Although intervention dose-defined as the quality and quantity of an intervention and participation-might be key to understanding why some multisite quality improvement (QI) initiatives work and others do not, evaluations rarely consider dose, and there is no widely accepted method for measuring it. In this exploratory study, the authors examined the literature on QI dose, identified four methods for measuring QI dose, applied them to 14 communities participating in a QI initiative, examined whether the dose scores aligned with perceptions of QI dose among individuals knowledgeable of the initiative, and report on lessons learned. They conclude it is feasible to measure QI dose and found a high level of concordance between scores on a comprehensive dose measure and knowledgeable informants' perceptions. However, measuring QI dose presents many challenges, including subjective decisions about the elements of dose to include in a measure and the need for extensive data collection.
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Affiliation(s)
| | | | | | - Yunfeng Shi
- The Pennsylvania State University, University Park, PA, USA
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23
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Van Casteren VFA, Bossuyt NHE, Moreels SJS, Goderis G, Vanthomme K, Wens J, De Clercq EW. Does the Belgian diabetes type 2 care trajectory improve quality of care for diabetes patients? Arch Public Health 2015; 73:31. [PMID: 26171143 PMCID: PMC4499949 DOI: 10.1186/s13690-015-0080-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 05/05/2015] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The Belgian care trajectory (CT) for diabetes mellitus type 2 (T2DM), implemented in September 2009, aims at providing integrated, evidence-based, multidisciplinary patient- centred care, based on the chronic care model. The research project ACHIL (Ambulatory Care Health Information Laboratory) studied the adherence of CT patients, in the early phases of CT programme implementation, with CT obligations, their uptake of incentives for self-management, whether the CT programme was targeting the appropriate group of patients, how care processes for these patients evolved over time and whether CT start led to better quality in the processes and outcomes of care. METHODS This observational study took place in the period 2006-2011 and covered T2DM patients who started a CT between 01/09/2009 and 31/12/2011. Four data sources were used: outcome data, from electronic patient records (EPRs) on all CT patients, provided by general practitioners (GPs); reimbursement process data on all CT patients and clinically comparable patients; and data from a sample of CT patients and clinically comparable patients from an EPR-based regional GP network and a paper-based national GP network, respectively. Through multilevel analysis of cross-sectional and longitudinal data, the effect of CT inclusion on processes and outcome was estimated, controlling for potential confounders. RESULTS By the end of 2011, data on 18,250 CT patients had been collected. Approximately 50 % of these CT patients had received reimbursement for a glucometer and nearly 60 % had had at least one encounter with a diabetes educator. The CT programme recruited T2DM patients who had been difficult to control in the past. In the years prior to CT start, there had been a gradual improvement in the follow up of these patients. Moreover, compared to non-CT patients, the proportion of CT patients adhering to the recommended frequency for monitoring of parameters, such as HbA1c, increased significantly around CT start. Some data sources, albeit not all, suggested there had been an improvement in certain outcomes, such as HbA1c, after CT inclusion. CONCLUSIONS According to this study, CT enrolment is associated with better quality of care processes compared to non-CT patients. This improvement was found in several of the data sources used in this study. However, results on outcome parameters remain inconclusive.
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Affiliation(s)
- Viviane F. A. Van Casteren
- />Scientific Institute of Public Health, Operational Direction Public Health and Surveillance, J. Wytsmanstreet 14, 1050 Brussels, Belgium
| | - Nathalie H. E. Bossuyt
- />Scientific Institute of Public Health, Operational Direction Public Health and Surveillance, J. Wytsmanstreet 14, 1050 Brussels, Belgium
| | - Sarah J. S. Moreels
- />Scientific Institute of Public Health, Operational Direction Public Health and Surveillance, J. Wytsmanstreet 14, 1050 Brussels, Belgium
| | - Geert Goderis
- />Katholieke Universiteit Leuven - Academisch Centrum voor Huisartsgeneeskunde, Kapucijnevoer 33 Blok J Bus 7001, 3000 Leuven, Belgium
- />UZ Leuven - MIR (Management Informatie Rapportering, Herestraat 49, 3000 Leuven, Belgium
| | - Katrien Vanthomme
- />Vrije Universiteit Brussel, Demografie, Pleinlaan 2, 1050 Brussel, Belgium
| | - Johan Wens
- />Universiteit Antwerpen, Academisch Centrum voor Huisartsgeneeskunde, Campus 3 Eiken, Universiteitsplein 1, 2610 Wilrijk, Belgium
| | - Etienne W De Clercq
- />Université Catholique de Louvain, Institut de Recherche Santé et Société, Clos Chapelle aux Champs 30, 1200 Brussels, Belgium
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