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Horbal SR, Belancourt PX, Zhang P, Holcombe SA, Saini S, Wang SC, Sales AE, Su GL. Independent Associations of Aortic Calcification with Cirrhosis and Liver Related Mortality in Veterans with Chronic Liver Disease. Dig Dis Sci 2024:10.1007/s10620-024-08450-5. [PMID: 38653948 DOI: 10.1007/s10620-024-08450-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 04/12/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Abdominal aortic calcifications (AAC) are incidentally found on medical imaging and useful cardiovascular burden approximations. The Morphomic Aortic Calcification Score (MAC) leverages automated deep learning methods to quantify and score AACs. While associations of AAC and non-alcoholic fatty liver disease (NAFLD) have been described, relationships of AAC with other liver diseases and clinical outcome are sparse. This study's purpose was to evaluate AAC and liver-related death in a cohort of Veterans with chronic liver disease (CLD). METHODS We utilized the VISN 10 CLD cohort, a regional cohort of Veterans with the three forms of CLD: NAFLD, hepatitis C (HCV), alcohol-associated (ETOH), seen between 2008 and 2014, with abdominal CT scans (n = 3604). Associations between MAC and cirrhosis development, liver decompensation, liver-related death, and overall death were evaluated with Cox proportional hazard models. RESULTS The full cohort demonstrated strong associations of MAC and cirrhosis after adjustment: HR 2.13 (95% CI 1.63, 2.78), decompensation HR 2.19 (95% CI 1.60, 3.02), liver-related death HR 2.13 (95% CI 1.46, 3.11), and overall death HR 1.47 (95% CI 1.27, 1.71). These associations seemed to be driven by the non-NAFLD groups for decompensation and liver-related death [HR 2.80 (95% CI 1.52, 5.17; HR 2.34 (95% CI 1.14, 4.83), respectively]. DISCUSSION MAC was strongly and independently associated with cirrhosis, liver decompensation, liver-related death, and overall death. Surprisingly, stratification results demonstrated comparable or stronger associations among those with non-NAFLD etiology. These findings suggest abdominal aortic calcification may predict liver disease severity and clinical outcomes in patients with CLD.
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Affiliation(s)
- Steven R Horbal
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
- Morphomics Analysis Group, University of Michigan, Ann Arbor, MI, USA.
| | | | - Peng Zhang
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Morphomics Analysis Group, University of Michigan, Ann Arbor, MI, USA
| | - Sven A Holcombe
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Morphomics Analysis Group, University of Michigan, Ann Arbor, MI, USA
| | - Sameer Saini
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Stewart C Wang
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Anne E Sales
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Sinclair School of Nursing and Department of Family and Community Medicine, University of Missouri, Colombia, MO, USA
| | - Grace L Su
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
- Gastroenterology Section, Ann Arbor VA Healthcare System, Ann Arbor, MI, USA
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Skolarus TA, Hawley ST, Forman J, Sales AE, Sparks JB, Metreger T, Burns J, Caram MV, Radhakrishnan A, Dossett LA, Makarov DV, Leppert JT, Shelton JB, Stensland KD, Dunsmore J, Maclennan S, Saini S, Hollenbeck BK, Shahinian V, Wittmann DA, Deolankar V, Sriram S. Unpacking overuse of androgen deprivation therapy for prostate cancer to inform de-implementation strategies. Implement Sci Commun 2024; 5:37. [PMID: 38594740 PMCID: PMC11005280 DOI: 10.1186/s43058-024-00576-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 03/04/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Many men with prostate cancer will be exposed to androgen deprivation therapy (ADT). While evidence-based ADT use is common, ADT is also used in cases with no or limited evidence resulting in more harm than benefit, i.e., overuse. Since there are risks of ADT (e.g., diabetes, osteoporosis), it is important to understand the behaviors facilitating overuse to inform de-implementation strategies. For these reasons, we conducted a theory-informed survey study, including a discrete choice experiment (DCE), to better understand ADT overuse and provider preferences for mitigating overuse. METHODS Our survey used the Action, Actor, Context, Target, Time (AACTT) framework, the Theoretical Domains Framework (TDF), the Capability, Opportunity, Motivation-Behavior (COM-B) Model, and a DCE to elicit provider de-implementation strategy preferences. We surveyed the Society of Government Service Urologists listserv in December 2020. We stratified respondents based on the likelihood of stopping overuse as ADT monotherapy for localized prostate cancer ("yes"/"probably yes," "probably no"/"no"), and characterized corresponding Likert scale responses to seven COM-B statements. We used multivariable regression to identify associations between stopping ADT overuse and COM-B responses. RESULTS Our survey was completed by 84 respondents (13% response rate), with 27% indicating "probably no"/"no" to stopping ADT overuse. We found differences across respondents who said they would and would not stop ADT overuse in demographics and COM-B statements. Our model identified 2 COM-B domains (Opportunity-Social, Motivation-Reflective) significantly associated with a lower likelihood of stopping ADT overuse. Our DCE demonstrated in-person communication, multidisciplinary review, and medical record documentation may be effective in reducing ADT overuse. CONCLUSIONS Our study used a behavioral theory-informed survey, including a DCE, to identify behaviors and context underpinning ADT overuse. Specifying behaviors supporting and gathering provider preferences in addressing ADT overuse requires a stepwise, stakeholder-engaged approach to support evidence-based cancer care. From this work, we are pursuing targeted improvement strategies. TRIAL REGISTRATION ClinicalTrials.gov, NCT03579680.
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Affiliation(s)
- Ted A Skolarus
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA.
- Department of Surgery, Urology Section, University of Chicago, Chicago, USA.
| | - Sarah T Hawley
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jane Forman
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Anne E Sales
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Sinclair School of Nursing and Department of Family and Community Medicine, University of Missouri, Columbia, MO, USA
| | - Jordan B Sparks
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Tabitha Metreger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jennifer Burns
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Megan V Caram
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Archana Radhakrishnan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lesly A Dossett
- Department of Surgery, Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Danil V Makarov
- VA New York Harbor Healthcare System and NYU School of Medicine Departments of Urology and Population Health, New York, NY, USA
| | - John T Leppert
- Surgical Service, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Urology, Stanford University, Stanford, CA, USA
| | - Jeremy B Shelton
- VA Salt Lake City Healthcare System, Salt Lake City, UT, USA
- Department of Urology, University of California, Los Angeles, USA
| | - Kristian D Stensland
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jennifer Dunsmore
- Academic Urology Unit, University of Aberdeen, Aberdeen, Scotland, UK
| | - Steven Maclennan
- Academic Urology Unit, University of Aberdeen, Aberdeen, Scotland, UK
| | - Sameer Saini
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | | | - Vahakn Shahinian
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Daniela A Wittmann
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Varad Deolankar
- Ross School of Business, University of Michigan, Ann Arbor, MI, USA
| | - S Sriram
- Ross School of Business, University of Michigan, Ann Arbor, MI, USA
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Skolarus LE, Lin CC, Bi R, Bailey S, Corches CL, Sales AE, Springer MV, Burke JF. Reduction in Racial Differences in Stroke Thrombolytics in Flint, Michigan. Stroke 2024; 55:e24-e26. [PMID: 38152959 PMCID: PMC10872391 DOI: 10.1161/strokeaha.123.044663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Affiliation(s)
- Lesli E. Skolarus
- Northwestern University, Davee Department of Neurology, Chicago IL
- University of Michigan, Department of Neurology, Ann Arbor, MI
| | - Chun Chieh Lin
- Ohio State University, Department of Neurology, Columbus, OH
| | - Ran Bi
- Ohio State University, Department of Neurology, Columbus, OH
| | | | | | - Anne E. Sales
- Sinclair School of Nursing and Department of Family and Community Medicine, University of Missouri
- VA Ann Arbor Healthcare System, Ann Arbor, MI
| | | | - James F. Burke
- Ohio State University, Department of Neurology, Columbus, OH
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Polcari K, Hyman MJ, Skolarus TA, Sales AE, Meltzer DO, Modi PK. Industry Payments for Vibegron and Prescribing Patterns Among Urologic Clinicians. JAMA Health Forum 2023; 4:e234020. [PMID: 38127590 PMCID: PMC10739068 DOI: 10.1001/jamahealthforum.2023.4020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 09/18/2023] [Indexed: 12/23/2023] Open
Abstract
This cross-sectional study compares the prescribing practices among urologists and advanced practice clinicians who received vs did not receive payment from drug manufacturers.
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Affiliation(s)
- Kayla Polcari
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Max J. Hyman
- Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois
| | - Ted A. Skolarus
- Section of Urology, Department of Surgery, University of Chicago, Chicago, Illinois
| | - Anne E. Sales
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Family and Community Medicine, University of Missouri, Columbia
- Sinclair School of Nursing, University of Missouri School of Medicine, Columbia
| | - David O. Meltzer
- Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois
- Department of Medicine and Economics, Harris School of Public Policy Studies, University of Chicago, Chicago, Illinois
| | - Parth K. Modi
- Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois
- Section of Urology, Department of Surgery, University of Chicago, Chicago, Illinois
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Kononowech J, Scott W, Landis-Lewis Z, Sales AE. Randomized controlled trial of tailored audit with feedback in VHA long-term care settings. Implement Sci Commun 2023; 4:129. [PMID: 37885042 PMCID: PMC10601134 DOI: 10.1186/s43058-023-00510-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/09/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND The Long-Term Care QUERI program supported implementation of the Life-Sustaining Treatment Decisions Initiative in US Veterans Health Administration long-term care settings. The program worked with eleven Community Living Centers (CLCs) and twelve Home-Based Primary Care (HBPC) programs to increase rates of completed templates, using audit with feedback. We distributed monthly feedback reports to site champions showing the number of Veterans with appropriate documentation. Although feedback reports are a common implementation tool, little is known about the most effective ways to design, distribute, and support them. We sought to test tailoring reports with tips using site-specific data, as well as national comparator data. METHODS We conducted a cluster randomized controlled trial of monthly feedback reports utilizing site-tailored tips and national comparator data compared to our original feedback reports that included only graphical and numerical data. CLC and HBPC team members were invited to participate in brief surveys each quarter to determine if they had received and used the feedback reports. The outcome for CLC residents was the percent with a completed LST template any time prior to the 14th day of their stay. The outcome for HBPC residents was the percent of Veterans with a completed LST template by their second HBPC visit. RESULTS The response rate to the survey ranged between 6.8 and 19.3% of staff members across the CLC and HBPC sites with 12.8-25.5% of survey respondents reporting that they had seen the feedback reports. The linear regression models showed no significant association between receiving the enhanced feedback reports and having a higher documentation completion rate. CONCLUSIONS Receiving feedback reports tailored to sites by including tips based on baseline context assessments and qualitative findings, and reports showing national comparator data, did not have an impact on the number of Veterans with a completed LST template. Having a higher proportion of CLC or HBPC team members view the reports was not associated with an increase in LST template completion. These findings suggest that tailored audit with feedback may not have been effective at the program level, although the proportion of respondents who reported seeing the reports was small.
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Affiliation(s)
- Jennifer Kononowech
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd, Ann Arbor, MI 48109 USA
| | - Winifred Scott
- Geriatrics and Extended Care Data and Analysis Center, VA Palo Alto Health Care System, 3801 Miranda Ave, Palo Alto, CA 94304 USA
| | - Zach Landis-Lewis
- University of Michigan Medical School, 300 N. Ingalls Street, Ann Arbor, MI 48109 USA
| | - Anne E. Sales
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd, Ann Arbor, MI 48109 USA
- Sinclair School of Nursing and Department of Family and Community Medicine, University of Missouri, 915 Hitt Street, Columbia, MO 65211 USA
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Reed S, Singh A, Hyman MJ, Meltzer DO, Sales AE, Skolarus TA, Modi PK. Industry Payments to Urologists and Urologic Advanced Practice Providers in 2021. Urology 2023; 180:121-129. [PMID: 37517679 DOI: 10.1016/j.urology.2023.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/14/2023] [Accepted: 06/21/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE To compare industry payments from drug and medical device companies to urologists and urologic advanced practice providers (APPs) in 2021. METHODS We used the 2020 Medicare Data on Provider Practice and Specialty file to identify single-specialty urology practices, defined as those where the majority of physicians were urologists. We then used the Open Payments Program Year 2021 data to summarize the value and number of industry payments to urologists and APPs, including nurse practitioners and physician assistants, in these practices. We calculated the total value and number of payments and median total value and number of payments per provider for urologists and urologic APPs. RESULTS We identified 4418 urologists and 1099 APPs working in single-specialty urology practices in 2021 (Table 1). Of these, 3646 (87%) urologists received at least one industry payment, totaling $14,755,003 from 116,039 payments, and 954 urologic APPs (87%) received at least one industry payment, including 463 nurse practitioners (85%), totaling $401,283 from 13,035 payments, and 491 physician assistants (89%), totaling $543,429 from 14,626 payments. We observed significantly greater median total value and number of payments per provider for urologists ($620 and 24 payments) compared to urologic APPs ($473 and 21 payments; P < .001 and P = .017, respectively). CONCLUSION A similar percentage of urologists and urologic APPs received industry payments in 2021. While urologists received a higher total number and total value of payments in 2021, urologic APPs were a common target of industry marketing payments.
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Affiliation(s)
| | - Armaan Singh
- Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Max J Hyman
- Center for Health and the Social Sciences, University of Chicago, Chicago, IL
| | - David O Meltzer
- Center for Health and the Social Sciences, University of Chicago, Chicago, IL
| | - Anne E Sales
- Sinclair School of Nursing, University of Missouri, Columbia, MO
| | - Ted A Skolarus
- Section of Urology, Department of Surgery, University of Chicago, Chicago, IL
| | - Parth K Modi
- Section of Urology, Department of Surgery, University of Chicago, Chicago, IL.
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Skolarus LE, Bailey S, Corches CL, Sales AE, Lin CC, Bi R, Springer MV, Oliver A, Robles MC, Brooks T, Tupper M, Jaggi M, Al-Qasmi M, Trevithick BA, Barber K, Majjhoo A, Zimmerman MA, Meurer WJ, Brown DL, Morgenstern LB, Burke JF. Association of the Stroke Ready Community-Based Participatory Research Intervention With Incidence of Acute Stroke Thrombolysis in Flint, Michigan. JAMA Netw Open 2023; 6:e2321558. [PMID: 37399011 PMCID: PMC10318478 DOI: 10.1001/jamanetworkopen.2023.21558] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/17/2023] [Indexed: 07/04/2023] Open
Abstract
Importance Acute stroke treatment rates in the US lag behind those in other high-income nations. Objective To assess whether a hospital emergency department (ED) and community intervention was associated with an increased proportion of patients with stroke receiving thrombolysis. Design, Setting, and Participants This nonrandomized controlled trial of the Stroke Ready intervention took place in Flint, Michigan, from October 2017 to March 2020. Participants included adults living in the community. Data analysis was completed from July 2022 to May 2023. Intervention Stroke Ready combined implementation science and community-based participatory research approaches. Acute stroke care was optimized in a safety-net ED, and then a community-wide, theory-based health behavior intervention, including peer-led workshops, mailers, and social media, was conducted. Main Outcomes and Measures The prespecified primary outcome was the proportion of patients hospitalized with ischemic stroke or transient ischemic attack from Flint who received thrombolysis before and after the intervention. The association between thrombolysis and the Stroke Ready combined intervention, including the ED and community components, was estimated using logistic regression models, clustering at the hospital level and adjusting for time and stroke type. In prespecified secondary analyses, the ED and community intervention were explored separately, adjusting for hospital, time, and stroke type. Results In total, 5970 people received in-person stroke preparedness workshops, corresponding to 9.7% of the adult population in Flint. There were 3327 ischemic stroke and TIA visits (1848 women [55.6%]; 1747 Black individuals [52.5%]; mean [SD] age, 67.8 [14.5] years) among patients from Flint seen in the relevant EDs, including 2305 in the preintervention period from July 2010 to September 2017 and 1022 in the postintervention period from October 2017 to March 2020. The proportion of thrombolysis usage increased from 4% in 2010 to 14% in 2020. The combined Stroke Ready intervention was not associated with thrombolysis use (adjusted odds ratio [OR], 1.13; 95% CI, 0.74-1.70; P = .58). The ED component was associated with an increase in thrombolysis use (adjusted OR, 1.63; 95% CI, 1.04-2.56; P = .03), but the community component was not (adjusted OR, 0.99; 95% CI, 0.96-1.01; P = .30). Conclusions and Relevance This nonrandomized controlled trial found that a multilevel ED and community stroke preparedness intervention was not associated with increased thrombolysis treatments. The ED intervention was associated with increased thrombolysis usage, suggesting that implementation strategies in partnership with safety-net hospitals may increase thrombolysis usage. Trial Registration ClinicalTrials.gov Identifier: NCT036455900.
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Affiliation(s)
- Lesli E. Skolarus
- Davee Department of Neurology, Stroke and Vascular Neurology, Northwestern University, Chicago, Illinois
- Department of Neurology, University of Michigan, Ann Arbor
| | | | | | - Anne E. Sales
- Department of Family and Community Medicine, Sinclair School of Nursing, University of Missouri, Columbia
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Chun Chieh Lin
- Department of Neurology, University of Michigan, Ann Arbor
- Department of Neurology, Ohio State University, Columbus
| | - Ran Bi
- Department of Neurology, University of Michigan, Ann Arbor
| | | | | | | | - Tia Brooks
- Department of Neurology, University of Michigan, Ann Arbor
| | - Michael Tupper
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Emergency Medicine, Hurley Medical Center, Flint, Michigan
| | - Michael Jaggi
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Emergency Medicine, Hurley Medical Center, Flint, Michigan
| | - Mohammed Al-Qasmi
- Department of Emergency Medicine, Hurley Medical Center, Flint, Michigan
| | | | - Kimberly Barber
- Department of Clinical & Academic Research, Genesys Regional Medical Center, Grand Blanc, Michigan
| | - Aniel Majjhoo
- Department of Neurology, McLaren Flint Hospital, Flint, Michigan
| | | | | | - Devin L. Brown
- Department of Neurology, University of Michigan, Ann Arbor
| | - Lewis B. Morgenstern
- Department of Neurology, University of Michigan, Ann Arbor
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- School of Public Health, University of Michigan, Ann Arbor
| | - James F. Burke
- Department of Neurology, University of Michigan, Ann Arbor
- Department of Neurology, Ohio State University, Columbus
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Stensland KD, Sales AE, Vedapudi VK, Damschroder LJ, Skolarus TA. Exploring implementation outcomes in the clinical trial context: a qualitative study of physician trial stakeholders. Trials 2023; 24:297. [PMID: 37106368 PMCID: PMC10142148 DOI: 10.1186/s13063-023-07304-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
INTRODUCTION Cancer clinical trials can be considered evidence-based interventions with substantial benefits, but suffer from poor implementation leading to low enrollment and frequent failure. Applying implementation science approaches such as outcomes frameworks to the trial context could aid in contextualizing and evaluating trial improvement strategies. However, the acceptability and appropriateness of these adapted outcomes to trial stakeholders are unclear. For these reasons, we interviewed cancer clinical trial physician stakeholders to explore how they perceive and address clinical trial implementation outcomes. METHODS We purposively selected 15 cancer clinical trial physician stakeholders from our institution representing different specialties, trial roles, and trial sponsor types. We performed semi-structured interviews to explore a previous adaptation of Proctor's Implementation Outcomes Framework to the clinical trial context. Emergent themes from each outcome were developed. RESULTS The implementation outcomes were well understood and applicable (i.e., appropriate and acceptable) to clinical trial stakeholders. We describe cancer clinical trial physician stakeholder understanding of these outcomes and current application of these concepts. Trial feasibility and implementation cost were felt to be most critical to trial design and implementation. Trial penetration was most difficult to measure, primarily due to eligible patient identification. In general, we found that formal methods for trial improvement and trial implementation evaluation were poorly developed. Cancer clinical trial physician stakeholders referred to some design and implementation techniques used to improve trials, but these were infrequently formally evaluated or theory-based. CONCLUSION Implementation outcomes adapted to the trial context were acceptable and appropriate to cancer clinical trial physician stakeholders. Use of these outcomes could facilitate the evaluation and design of clinical trial improvement interventions. Additionally, these outcomes highlight potential areas for the development of new tools, for example informatics solutions, to improve the evaluation and implementation of clinical trials.
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Affiliation(s)
- Kristian D Stensland
- Department of Urology, Dow Division of Health Services Research, University of Michigan, NCRC, Building 16, 100S-12, Ann Arbor, MI, 48109, USA.
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA.
| | - Anne E Sales
- University of Missouri and Department of Family and Community Medicine, Sinclair School of Nursing, University of Missouri School of Medicine, Columbia, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | | | - Laura J Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Ted A Skolarus
- Department of Urology, Dow Division of Health Services Research, University of Michigan, NCRC, Building 16, 100S-12, Ann Arbor, MI, 48109, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Kononowech J, Hagedorn H, Hall C, Helfrich CD, Lambert-Kerzner AC, Miller SC, Sales AE, Damschroder L. Correction: Mapping the organizational readiness to change assessment to the Consolidated Framework for Implementation Research. Implement Sci Commun 2023; 4:32. [PMID: 36945073 PMCID: PMC10029170 DOI: 10.1186/s43058-023-00415-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Affiliation(s)
- Jennifer Kononowech
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd, Ann Arbor, MI, USA.
| | - Hildi Hagedorn
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, 1 Veterans Drive, Minneapolis, MN, USA
- Department of Psychiatry, University of Minnesota School of Medicine, 606 24Th Ave S, Minneapolis, MN, USA
| | - Carmen Hall
- Gusek Hall Consulting, 1362 Ryan Ave. W Ste 101, Roseville, MN, USA
| | - Christian D Helfrich
- Seattle-Denver Center of Innovation, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, USA
- School of Public Health, University of Washington, 1959 NE Pacific St, Seattle, WA, USA
| | - Anne C Lambert-Kerzner
- Department of Surgery, University of Colorado Anschutz Medical Campus, 12631 East 17Th Avenue, Aurora, CO, USA
| | - Susan C Miller
- Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 S. Main Street, Providence, RI, USA
| | - Anne E Sales
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd, Ann Arbor, MI, USA
- Department of Learning Health Sciences, University of Michigan Medical School, 300 N. Ingalls Street, Ann Arbor, MI, USA
| | - Laura Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd, Ann Arbor, MI, USA
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Paudel R, Ferrante S, Woodford J, Maitland C, Stockall E, Maatman T, Lane GI, Berry DL, Sales AE, Montie JE. Correction: Implementation of prostate cancer treatment decision aid in Michigan: a qualitative study. Implement Sci Commun 2023; 4:30. [PMID: 36941684 PMCID: PMC10026502 DOI: 10.1186/s43058-023-00410-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Affiliation(s)
- Roshan Paudel
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA.
| | - Stephanie Ferrante
- Michigan Urological Surgery Improvement Collaborative, University of Michigan, Ann Arbor, MI, USA
| | | | | | | | | | - Giulia I Lane
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Donna L Berry
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, USA
| | - Anne E Sales
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA
| | - James E Montie
- Michigan Urological Surgery Improvement Collaborative, University of Michigan, Ann Arbor, MI, USA
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Kononowech J, Landis-Lewis Z, Carpenter J, Ersek M, Hogikyan R, Levy C, Phibbs C, Scott W, Sales AE. Correction: Visual process maps to support implementation efforts: a case example. Implement Sci Commun 2023; 4:29. [PMID: 36941699 PMCID: PMC10026513 DOI: 10.1186/s43058-023-00414-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Affiliation(s)
- Jennifer Kononowech
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd, Ann Arbor, MI, 48109, USA.
| | - Zach Landis-Lewis
- University of Michigan Medical School, 300 N. Ingalls Street, Ann Arbor, MI, 48109, USA
| | - Joan Carpenter
- Corporal Michael J. Crescenz VAMC, 3900 Woodland Avenue, Philadelphia, PA, 19104, USA
- School of Nursing, University of Pennsylvania, 418 Curie Blvd, Philadelphia, PA, 19104, USA
| | - Mary Ersek
- Corporal Michael J. Crescenz VAMC, 3900 Woodland Avenue, Philadelphia, PA, 19104, USA
- School of Nursing, University of Pennsylvania, 418 Curie Blvd, Philadelphia, PA, 19104, USA
| | - Robert Hogikyan
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Cari Levy
- Eastern Colorado Health Care System, 1055 Clermont St, Denver, CO, 80220, USA
- School of Medicine, University of Colorado Anschutz Campus, 13001 E. 17th Pl, Aurora, CO, 80045, USA
| | - Ciaran Phibbs
- Geriatrics and Extended Care Data and Analysis Center, VA Palo Alto Health Care System, 3801 Miranda Ave, Palo Alto, CA, 94304, USA
- Department of Pediatrics, Stanford University School of Medicine, 725 Welch Road, Palo Alto, CA, 94304, USA
| | - Winifred Scott
- Geriatrics and Extended Care Data and Analysis Center, VA Palo Alto Health Care System, 3801 Miranda Ave, Palo Alto, CA, 94304, USA
| | - Anne E Sales
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd, Ann Arbor, MI, 48109, USA
- University of Michigan Medical School, 300 N. Ingalls Street, Ann Arbor, MI, 48109, USA
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12
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Skolarus TA, Forman J, Sparks JB, Metreger T, Hawley ST, Caram MV, Dossett L, Paniagua-Cruz A, Makarov DV, Leppert JT, Shelton JB, Stensland KD, Hollenbeck BK, Shahinian V, Sales AE, Wittmann DA. Correction: Learning from the "tail end" of de-implementation: the case of chemical castration for localized prostate cancer. Implement Sci Commun 2023; 4:31. [PMID: 36941664 PMCID: PMC10026413 DOI: 10.1186/s43058-023-00411-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Affiliation(s)
- Ted A Skolarus
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Jane Forman
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jordan B Sparks
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Tabitha Metreger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Megan V Caram
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lesly Dossett
- Rogel Cancer Center, Michigan Medicine, Ann Arbor, MI, USA
| | - Alan Paniagua-Cruz
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Danil V Makarov
- VA New York Harbor Healthcare System and NYU School of Medicine Departments of Urology and Population Health, New York, NY, USA
| | - John T Leppert
- Surgical Service, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Urology, Stanford University, Stanford, CA, USA
| | | | - Kristian D Stensland
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brent K Hollenbeck
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Vahakn Shahinian
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Anne E Sales
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Daniela A Wittmann
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
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13
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Stensland KD, Sales AE, Damschroder LJ, Skolarus TA. Correction: Applying implementation frameworks to the clinical trial context. Implement Sci Commun 2023; 4:27. [PMID: 36918958 PMCID: PMC10015771 DOI: 10.1186/s43058-023-00413-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Affiliation(s)
- Kristian D Stensland
- Department of Urology, Dow Division of Health Services Research, University of Michigan, NCRC Building 16, 100S-12, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA. .,Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA.
| | - Anne E Sales
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Sinclair School of Nursing, University of Missouri, Columbia, MO, USA.,Department of Family and Community Medicine, University of Missouri School of Medicine, Columbia, MO, USA
| | - Laura J Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Ted A Skolarus
- Department of Urology, Dow Division of Health Services Research, University of Michigan, NCRC Building 16, 100S-12, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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14
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Dorsch MP, Chen CS, Allen AL, Sales AE, Seagull FJ, Spoutz P, Sussman JB, Barnes GD. Nationwide Implementation of a Population Management Dashboard for Monitoring Direct Oral Anticoagulants: Insights From the Veterans Affairs Health System. Circ Cardiovasc Qual Outcomes 2023; 16:e009256. [PMID: 36484253 PMCID: PMC9974614 DOI: 10.1161/circoutcomes.122.009256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 11/21/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Direct oral anticoagulants are first-line therapy for common thrombotic conditions, including atrial fibrillation and venous thromboembolism. Despite their strong efficacy and safety profile, evidence-based prescribing can be challenging given differences in dosing based on indication, renal function, and drug-drug interactions. The Veterans Health Affairs developed and implemented a population management dashboard to support pharmacist review of anticoagulant prescribing. The dashboard includes information about direct oral anticoagulants and dose prescribed, renal function, age, and weight, potential interacting medications, and the need for direct oral anticoagulant medication refills. It is a stand-alone system. METHODS Using login data from the dashboard, nationwide implementation was evaluated using elements from the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. RESULTS Between August 2016 and June 2020, 150/164 sites within the Veterans Health Affairs system used the dashboard, averaging 1875 patients per site. The dashboard was made available to sites on a staggered basis. Moderate or high adoption, defined as at least one login on at least 2 separate days per month, began slowly with 3/5 sites in the pilot phase but rapidly grew to 142/150 (94.7%) sites by June 2020. The average number of unique users per site increased from 2.4 to 7.5 over the study period. Moderate to high adoption of the dashboard's use was maintained for > 6 months in 126/150 (84.0%) sites by the end of the study period. CONCLUSIONS There was rapid and sustained implementation and adoption of a population health dashboard for evidence-based anticoagulant prescribing across the national United States Veterans Health Administration health system. The impact of this tool on clinical outcomes and strategies to replicate this care model in other health systems will be important for broad dissemination and uptake.
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Affiliation(s)
- Michael P Dorsch
- College of Pharmacy (M.P.D.), University of Michigan, Ann Arbor
- Frankel Cardiovascular Center (M.P.D., G.D.B.), University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation (M.P.D., J.B.S., G.D.B.), University of Michigan, Ann Arbor
| | - Charity S Chen
- Ann Arbor Veterans Affairs Health System, MI (C.S.C., J.B.S.)
| | - Arthur L Allen
- Veterans Affairs Salt Lake City Health Care System, UT (A.L.A.)
| | - Anne E Sales
- School of Nursing, University of Missouri, Columbia (A.E.S.)
| | - F Jacob Seagull
- Michigan Medicine - Center for Bioethics and Social Science in Medicine (F.J.S.), University of Michigan, Ann Arbor
| | - Patrick Spoutz
- Pharmacy Benefits Management, Veterans Integrated Service Network 20, Vancouver, WA (P.S.)
| | - Jeremy B Sussman
- Institute for Healthcare Policy and Innovation (M.P.D., J.B.S., G.D.B.), University of Michigan, Ann Arbor
- Department of Internal Medicine, Medical School (J.B.S., G.D.B.), University of Michigan, Ann Arbor
- Ann Arbor Veterans Affairs Health System, MI (C.S.C., J.B.S.)
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center (M.P.D., G.D.B.), University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation (M.P.D., J.B.S., G.D.B.), University of Michigan, Ann Arbor
- Department of Internal Medicine, Medical School (J.B.S., G.D.B.), University of Michigan, Ann Arbor
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Ervin JN, Dibble MR, Rentes VC, Sjoding MW, Gong MN, Hough CL, Iwashyna TJ, Sales AE. Prioritizing evidence-based practices for acute respiratory distress syndrome using digital data: an iterative multi-stakeholder process. Implement Sci 2022; 17:82. [PMID: 36527136 PMCID: PMC9756680 DOI: 10.1186/s13012-022-01255-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/23/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Evidence-based practices (EBPs) for patients receiving invasive mechanical ventilation vary in the quality of their underlying evidence and ease of implementation. RESEARCH QUESTION How do researchers and clinicians prioritize EBPs to help guide clinical decision-making and focus implementation efforts to improve patient care using existing, validated measures? STUDY DESIGN AND METHODS We developed a 4-step rapid method using existing criteria to prioritize EBPs associated with lower mortality and/or shorter duration of invasive mechanical ventilation for patients suffering from acute respiratory failure or acute respiratory distress syndrome. Using different types of data including surveys, we (1) identified relevant EBPs, (2) rated EBPs using the Guideline Implementability Appraisal (GLIA) tool, (3) surveyed practicing ICU clinicians from different hospital systems using a subset of GLIA criteria, and (4) developed metrics to assess EBP performance. In this paper, we describe steps 2 and 3. RESULTS In step 2, we prioritized 11 EBPs from an initial list of 30, using surveys and ratings among a small group of clinician researchers. In step 3, 42 clinicians from 8 different hospital systems provided assessments of these 11 EBPs which inform the final step of metric development. INTERPRETATION Our prioritization process allowed us to identify 11 EBPs out of a larger group that clinicians perceive is most likely to help optimize invasive mechanical ventilation and improve the outcomes of this vulnerable patient population. While this method was developed in critical care related to adults receiving invasive mechanical ventilation, it is adaptable to other health contexts.
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Affiliation(s)
- Jennifer N. Ervin
- grid.268154.c0000 0001 2156 6140Health Sciences, Office of Health Affairs, West Virginia University, Morgantown, WV USA ,grid.214458.e0000000086837370Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI USA
| | - Millie R. Dibble
- grid.214458.e0000000086837370Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI USA
| | - Victor C. Rentes
- grid.214458.e0000000086837370Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI USA
| | - Michael W. Sjoding
- grid.214458.e0000000086837370Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI USA ,grid.214458.e0000000086837370Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA
| | - Michelle N. Gong
- grid.251993.50000000121791997Divisions of Critical Care Medicine and Pulmonary Medicine, Department of Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, NY USA
| | - Catherine L. Hough
- grid.5288.70000 0000 9758 5690Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, OR USA
| | - Theodore J. Iwashyna
- grid.214458.e0000000086837370Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI USA ,grid.21107.350000 0001 2171 9311Division of Pulmonary and Critical Care, Department of Medicine and Department of Health Policy and Management, Johns Hopkins University, Baltimore, MD USA
| | - Anne E. Sales
- grid.214458.e0000000086837370Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI USA ,grid.214458.e0000000086837370Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI USA ,grid.134936.a0000 0001 2162 3504Sinclair School of Nursing and Department of Family and Community Medicine, University of Missouri, Columbia, MO USA ,grid.497654.d0000 0000 8603 8958VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI USA
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16
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Stensland KD, Sales AE, Damschroder LJ, Skolarus TA. Applying implementation frameworks to the clinical trial context. Implement Sci Commun 2022; 3:109. [PMID: 36217172 PMCID: PMC9552519 DOI: 10.1186/s43058-022-00355-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 09/24/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Clinical trials advance science, benefit society, and provide optimal care to individuals with some conditions, such as cancer. However, clinical trials often fail to reach their endpoints, and low participant enrollment remains a critical problem with trial conduct. In these ways, clinical trials can be considered beneficial evidence-based practices suffering from poor implementation. Prior approaches to improving trials have had difficulties with reproducibility and limited impact, perhaps due to the lack of an underlying trial improvement framework. For these reasons, we propose adapting implementation science frameworks to the clinical trial context to improve the implementation of clinical trials. MAIN TEXT We adapted an outcomes framework (Proctor's Implementation Outcomes Framework) and a determinants framework (the Consolidated Framework for Implementation Research) to the trial context. We linked these frameworks to ERIC-based improvement strategies and present an inferential process model for identifying and selecting trial improvement strategies based on the Implementation Research Logic Model. We describe example applications of the framework components to the trial context and present a worked example of our model applied to a trial with poor enrollment. We then consider the implications of this approach on improving existing trials, the design of future trials, and assessing trial improvement interventions. Additionally, we consider the use of implementation science in the clinical trial context, and how clinical trials can be "test cases" for implementation research. CONCLUSIONS Clinical trials can be considered beneficial evidence-based interventions suffering from poor implementation. Adapting implementation science approaches to the clinical trial context can provide frameworks for contextual assessment, outcome measurement, targeted interventions, and a shared vocabulary for clinical trial improvement. Additionally, exploring implementation frameworks in the trial context can advance the science of implementation through both "test cases" and providing fertile ground for implementation intervention design and testing.
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Affiliation(s)
- Kristian D Stensland
- Dow Division of Health Services Research, Department of Urology, University of Michigan, NCRC Building 16, 100S-12, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA. .,Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA.
| | - Anne E Sales
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Sinclair School of Nursing, University of Missouri, Columbia, MO, USA.,Department of Family and Community Medicine, University of Missouri School of Medicine, Columbia, MO, USA
| | - Laura J Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Ted A Skolarus
- Dow Division of Health Services Research, Department of Urology, University of Michigan, NCRC Building 16, 100S-12, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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17
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Stensland KD, Damschroder LJ, Sales AE, Schott AF, Skolarus TA. Envisioning clinical trials as complex interventions. Cancer 2022; 128:3145-3151. [PMID: 35766902 PMCID: PMC9378578 DOI: 10.1002/cncr.34357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 11/25/2022]
Abstract
Clinical trials are critical components of modern health care and infrastructure. Trials benefit society through scientific advancement and individual patients through trial participation. In fact, billions of dollars are spent annually in support of these benefits. Despite the massive investments, clinical trials often fail to accomplish their primary aims and trial enrollment rates remain low. Prior efforts to improve trial conduct and enrollment have had limited success, perhaps due to oversimplification of the complex, multilevel nature of trials. For these reasons, the authors propose applying implementation science to the clinical trials context. In this commentary, the authors posit clinical trials as complex, multilevel evidence-based interventions with significant societal and individual benefits yet with persistent gaps in implementation. An application of implementation science concepts to the clinical trials context as means to build common vocabulary and establish a platform for applying implementation science and practice to improve clinical trial conduct is introduced. Applying implementation science to the clinical trials context can augment improvement efforts and build capacity for better and more efficient evidence-based care for all patients and trial stakeholders throughout the clinical trials enterprise.
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Affiliation(s)
- Kristian D. Stensland
- Dow Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
- Department of Learning Health SciencesUniversity of MichiganAnn ArborMichiganUSA
| | - Laura J. Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Anne E. Sales
- Department of Learning Health SciencesUniversity of MichiganAnn ArborMichiganUSA
- Center for Clinical Management Research, VA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
- Sinclair School of Nursing, University of Missouri and Department of Family and Community MedicineUniversity of MissouriColumbiaMissouriUSA
| | - Anne F. Schott
- University of Michigan Rogel Cancer CenterAnn ArborMichiganUSA
| | - Ted A. Skolarus
- Dow Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
- Center for Clinical Management Research, VA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
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18
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Stensland KD, Richesson RL, Vince RA, Skolarus TA, Sales AE. Evolving a national clinical trials learning health system. Learn Health Syst 2022; 7:e10327. [PMID: 37066100 PMCID: PMC10091198 DOI: 10.1002/lrh2.10327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/26/2022] [Accepted: 06/28/2022] [Indexed: 11/07/2022] Open
Abstract
Clinical trials generate key evidence to inform decision making, and also benefit participants directly. However, clinical trials frequently fail, often struggle to enroll participants, and are expensive. Part of the problem with trial conduct may be the disconnected nature of clinical trials, preventing rapid data sharing, generation of insights and targeted improvement interventions, and identification of knowledge gaps. In other areas of healthcare, a learning health system (LHS) has been proposed as a model to facilitate continuous learning and improvement. We propose that an LHS approach could greatly benefit clinical trials, allowing for continuous improvements to trial conduct and efficiency. A robust trial data sharing system, continuous analysis of trial enrollment and other success metrics, and development of targeted trial improvement interventions are potentially key components of a Trials LHS reflecting the learning cycle and allowing for continuous trial improvement. Through the development and use of a Trials LHS, clinical trials could be treated as a system, producing benefits to patients, advancing care, and decreasing costs for stakeholders.
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Affiliation(s)
| | - Rachel L. Richesson
- Department of Learning Health SciencesUniversity of MichiganAnn ArborMichiganUSA
| | - Randy A. Vince
- Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
| | - Ted A. Skolarus
- Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
- Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Anne E. Sales
- Department of Learning Health SciencesUniversity of MichiganAnn ArborMichiganUSA
- Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
- Sinclair School of NursingUniversity of MissouriColumbiaMissouriUSA
- Department of Family and Community MedicineUniversity of Missouri School of MedicineColumbiaMissouriUSA
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Grigoryan L, Naik AD, Lichtenberger P, Graber CJ, Patel PK, Drekonja DM, Gauthier TP, Shukla B, Sales AE, Krein SL, Van JN, Dillon LM, Hysong SJ, Kramer JR, Walder A, Ramsey D, Trautner BW. Analysis of an Antibiotic Stewardship Program for Asymptomatic Bacteriuria in the Veterans Affairs Health Care System. JAMA Netw Open 2022; 5:e2222530. [PMID: 35877123 PMCID: PMC9315417 DOI: 10.1001/jamanetworkopen.2022.22530] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Antibiotic stewardship for asymptomatic bacteriuria (ASB) is an important quality improvement target. Understanding how to implement successful antibiotic stewardship interventions is limited. OBJECTIVE To evaluate the effectiveness of a quality improvement stewardship intervention on reducing unnecessary urine cultures and antibiotic use in patients with ASB. DESIGN, SETTING, AND PARTICIPANTS This interrupted time series quality improvement study was performed at the acute inpatient medical and long-term care units of 4 intervention sites and 4 comparison sites in the Veterans Affairs (VA) health care system from October 1, 2017, through April 30, 2020. Participants included the clinicians who order or collect urine cultures and who order, dispense, or administer antibiotics. Clinical outcomes were measured in all patients in a study unit during the study period. Data were analyzed from July 6, 2020, to May 24, 2021. INTERVENTION Case-based teaching on how to apply an evidence-based algorithm to distinguish urinary tract infection and ASB. The intervention was implemented through external facilitation by a centralized coordinating center, with a site champion at each intervention site serving as an internal facilitator. MAIN OUTCOMES AND MEASURES Urine culture orders and days of antibiotic therapy (DOT) and length of antibiotic therapy in days (LOT) associated with urine cultures, standardized by 1000 bed-days, were obtained from the VA's Corporate Data Warehouse. RESULTS Of 11 299 patients included, 10 703 (94.7%) were men, with a mean (SD) age of 72.6 (11.8) years. The decrease in urine cultures before and after the intervention was not significant in intervention sites per segmented regression analysis (-0.04 [95% CI, -0.17 to 0.09]; P = .56). However, difference-in-differences analysis comparing intervention with comparison sites found a significant reduction in the number of urine cultures ordered by 3.24 urine cultures per 1000 bed-days (P = .003). In the segmented regression analyses, the relative percentage decrease of DOT in the postintervention period at the intervention sites was 21.7% (P = .007), from 46.1 (95% CI, 28.8-63.4) to 37.0 (95% CI, 22.6-51.4) per 1000 bed-days. The relative percentage decrease of LOT in the postintervention period at the intervention sites was 21.0% (P = .001), from 36.7 (95% CI, 23.2-50.2) to 29.6 (95% CI, 18.2-41.0) per 1000 bed-days. CONCLUSIONS AND RELEVANCE The findings of this quality improvement study suggest that an individualized intervention for antibiotic stewardship for ASB was associated with a decrease in urine cultures and antibiotic use when implemented at multiple sites via external and internal facilitation. The electronic health record database-derived outcome measures and centralized facilitation approach are both suitable for dissemination.
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Affiliation(s)
- Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
| | - Aanand D. Naik
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center, Houston
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Paola Lichtenberger
- Department of Medicine, University of Miami Miller School of Medicine and the Miami VA Healthcare System, University of Miami, Miami, Florida
| | - Christopher J. Graber
- Infectious Diseases Section, VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA (University of California, Los Angeles)
| | - Payal K. Patel
- Division of Infectious Diseases, Department of Medicine, University of Michigan and VA Ann Arbor Healthcare System, Ann Arbor
| | - Dimitri M. Drekonja
- Division of Infectious Diseases and International Medicine, University of Minnesota Medical School and Minneapolis VA Health Care System, Minneapolis
| | | | - Bhavarth Shukla
- Department of Medicine, University of Miami Miller School of Medicine and the Miami VA Healthcare System, University of Miami, Miami, Florida
| | - Anne E. Sales
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor
| | - Sarah L. Krein
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - John N. Van
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
| | - Laura M. Dillon
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
| | - Sylvia J. Hysong
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Jennifer R. Kramer
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Annette Walder
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - David Ramsey
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Barbara W. Trautner
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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Sales AE, Barnaby DP, Rentes VC. Letter to the editor on "the implementation research logic model: a method for planning, executing, reporting, and synthesizing implementation projects" (Smith JD, Li DH, Rafferty MR. the implementation research logic model: a method for planning, executing, reporting, and synthesizing implementation projects. Implement Sci. 2020;15 (1):84. Doi:10.1186/s13012-020-01041-8). Implement Sci 2021; 16:97. [PMID: 34789294 PMCID: PMC8596800 DOI: 10.1186/s13012-021-01169-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 10/31/2021] [Indexed: 12/04/2022] Open
Affiliation(s)
- Anne E Sales
- Sinclair School of Nursing and Department of Family and Community Medicine, University of Missouri, Columbia, MO, USA. .,Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA. .,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
| | - Douglas P Barnaby
- Northwell Health Feinstein Institutes for Health Research, Manhasset, NY, USA
| | - Victor Cattani Rentes
- Sinclair School of Nursing and Department of Family and Community Medicine, University of Missouri, Columbia, MO, USA
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Skolarus TA, Forman J, Sparks JB, Metreger T, Hawley ST, Caram MV, Dossett L, Paniagua-Cruz A, Makarov DV, Leppert JT, Shelton JB, Stensland KD, Hollenbeck BK, Shahinian V, Sales AE, Wittmann DA. Learning from the "tail end" of de-implementation: the case of chemical castration for localized prostate cancer. Implement Sci Commun 2021; 2:124. [PMID: 34711274 PMCID: PMC8555144 DOI: 10.1186/s43058-021-00224-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 09/30/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Men with prostate cancer are often treated with the suppression of testosterone through long-acting injectable drugs termed chemical castration or androgen deprivation therapy (ADT). In most cases, ADT is not an appropriate treatment for localized prostate cancer, indicating low-value care. Guided by the Theoretical Domains Framework (TDF) and the Behavior Change Wheel's Capability, Opportunity, Motivation Model (COM-B), we conducted a qualitative study to identify behavioral determinants of low-value ADT use to manage localized prostate cancer, and theory-based opportunities for de-implementation strategy development. METHODS We used national cancer registry and administrative data from 2016 to 2017 to examine the variation in low-value ADT use across Veterans Health Administration facilities. Using purposive sampling, we selected high- and low-performing sites to conduct 20 urology provider interviews regarding low-value ADT. We coded transcripts into TDF domains and mapped content to the COM-B model to generate a conceptual framework for addressing low-value ADT practices. RESULTS Our interview findings reflected provider perspectives on prescribing ADT as low-value localized prostate cancer treatment, including barriers and facilitators to de-implementing low-value ADT. We characterized providers as belonging in 1 of 3 categories with respect to low-value ADT use: 1) never prescribe 2); willing, under some circumstances, to prescribe: and 3) prescribe as an acceptable treatment option. Provider capability to prescribe low-value ADT depended on their knowledge of localized prostate cancer treatment options (knowledge) coupled with interpersonal skills to engage patients in educational discussion (skills). Provider opportunity to prescribe low-value ADT centered on the environmental resources to inform ADT decisions (e.g., multi-disciplinary review), perceived guideline availability, and social roles and influences regarding ADT practices, such as prior training. Provider motivation involved goals of ADT use, including patient preferences, beliefs in capabilities/professional confidence, and beliefs about the consequences of prescribing or not prescribing ADT. CONCLUSIONS Use of the TDF domains and the COM-B model enabled us to conceptualize provider behavior with respect to low-value ADT use and clarify possible areas for intervention to effect de-implementation of low-value ADT prescribing in localized prostate cancer. TRIAL REGISTRATION ClinicalTrials.gov , NCT03579680.
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Affiliation(s)
- Ted A Skolarus
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Jane Forman
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jordan B Sparks
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Tabitha Metreger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Megan V Caram
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lesly Dossett
- Rogel Cancer Center, Michigan Medicine, Ann Arbor, MI, USA
| | - Alan Paniagua-Cruz
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Danil V Makarov
- VA New York Harbor Healthcare System and NYU School of Medicine Departments of Urology and Population Health, New York, NY, USA
| | - John T Leppert
- Surgical Service, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Urology, Stanford University, Stanford, CA, USA
| | | | - Kristian D Stensland
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brent K Hollenbeck
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Vahakn Shahinian
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Anne E Sales
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Daniela A Wittmann
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
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22
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Wallner LP, Abrahamse P, Gargaro JG, Radhakrishnan A, Mullins MA, An LC, Griggs JJ, Schott AF, Ayanian JZ, Sales AE, Katz S, Hawley ST. Improving the delivery of team-based survivorship care after primary breast cancer treatment through a multi-level intervention: a pilot randomized controlled trial. Breast Cancer Res Treat 2021; 189:81-92. [PMID: 34235608 PMCID: PMC8375358 DOI: 10.1007/s10549-021-06257-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/04/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE We developed and tested a multi-level intervention, ConnectedCancerCare (CCC), which includes a tailored website and appointment reminder system for women with early-stage breast cancer and a provider summary letter sent to their medical oncologist and primary care provider to improve the delivery of team-based survivorship care. METHODS We conducted a pilot randomized controlled trial to establish the feasibility and acceptability of CCC. Women diagnosed with stages 0-II breast cancer within one year of completing primary treatment were randomized to CCC (intervention) or a static online survivorship care plan (control). Participants completed baseline and 3-month follow-up surveys online. Post-trial interviews with 5 PCPs, 6 oncology providers, and 8 intervention patients were conducted. RESULTS Of the 160 eligible women invited to participate, 66 completed the baseline survey and were randomized (41%) and 54 completed a follow-up survey (83%). Participants in the intervention arm found the CCC content to be acceptable, with 82% reporting it was easy to use and 86% reporting they would recommend it to other patients. Women randomized to CCC (vs. control) more often reported scheduling a PCP follow-up visit (64% vs. 42%), communicating with their PCP about provider roles (67% vs. 18%), and higher mean team-based cancer care knowledge scores (3.7 vs. 3.4). CONCLUSION Deploying CCC in medical oncology practices was feasible, and the intervention content was acceptable. CCC shows promise for improving patient knowledge and patient-provider communication about provider roles in team-based cancer care and encouraging patients to engage with their PCP early in the survivorship period.
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Affiliation(s)
- Lauren P Wallner
- Division of General Medicine, Department of Internal Medicine, University of Michigan, North Campus Research Complex, 2800 Plymouth Road, Building 16, Room 409E, Ann Arbor, MI, 48109-2800, USA.
- Department of Epidemiology, University of Michigan, North Campus Research Complex, 2800 Plymouth Road, Building 16, Room 409E, Ann Arbor, MI, 48109-2800, USA.
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA.
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Paul Abrahamse
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Joan G Gargaro
- Ann Arbor VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Archana Radhakrishnan
- Division of General Medicine, Department of Internal Medicine, University of Michigan, North Campus Research Complex, 2800 Plymouth Road, Building 16, Room 409E, Ann Arbor, MI, 48109-2800, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Megan A Mullins
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Lawrence C An
- Division of General Medicine, Department of Internal Medicine, University of Michigan, North Campus Research Complex, 2800 Plymouth Road, Building 16, Room 409E, Ann Arbor, MI, 48109-2800, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer J Griggs
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Anne F Schott
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - John Z Ayanian
- Division of General Medicine, Department of Internal Medicine, University of Michigan, North Campus Research Complex, 2800 Plymouth Road, Building 16, Room 409E, Ann Arbor, MI, 48109-2800, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Anne E Sales
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Learning Health Sciences, Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Steven Katz
- Division of General Medicine, Department of Internal Medicine, University of Michigan, North Campus Research Complex, 2800 Plymouth Road, Building 16, Room 409E, Ann Arbor, MI, 48109-2800, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Sarah T Hawley
- Division of General Medicine, Department of Internal Medicine, University of Michigan, North Campus Research Complex, 2800 Plymouth Road, Building 16, Room 409E, Ann Arbor, MI, 48109-2800, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
- Ann Arbor VA Center for Clinical Management Research, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
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Springer MV, Sales AE, Islam N, McBride AC, Landis-Lewis Z, Tupper M, Corches CL, Robles MC, Skolarus LE. A step toward understanding the mechanism of action of audit and feedback: a qualitative study of implementation strategies. Implement Sci 2021; 16:35. [PMID: 33794952 PMCID: PMC8017642 DOI: 10.1186/s13012-021-01102-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 03/19/2021] [Indexed: 01/05/2023] Open
Abstract
Background Audit and feedback (A&F) is a widely used implementation strategy. Understanding mechanisms of action of A&F increases the likelihood that the strategy will lead to implementation of an evidence-based practice. We therefore sought to understand one hospital’s experience selecting and implementing an A&F intervention, to determine the implementation strategies that were used by staff and to specify the mechanism of action of those implementation strategies using causal pathway models, with the ultimate goal of improving acute stroke treatment practices. Methods We selected an A&F strategy in a hospital, initially based on implementation determinants and staff consideration of their performance on acute stroke treatment measures. After 7 months of A&F, we conducted semi-structured interviews of hospital providers and administrative staff to understand how it contributed to implementing guideline-concordant acute stroke treatment (medication named tissue plasminogen activator). We coded the interviews to identify the implementation strategies that staff used following A&F and to assess their mechanisms of action. Results We identified five implementation strategies that staff used following the feedback intervention. These included (1) creating folders containing the acute stroke treatment protocol for the emergency department, (2) educating providers about the protocol for acute stroke, (3) obtaining computed tomography imaging of stroke patients immediately upon emergency department arrival, (4) increasing access to acute stroke medical treatment in the emergency department, and (5) providing additional staff support for implementation of the protocol in the emergency department. We identified enablement, training, and environmental restructuring as mechanisms of action through which the implementation strategies acted to improve guideline-concordant and timely acute stroke treatment. Conclusions A&F of a hospital’s acute stroke treatment practices generated additional implementation strategies that acted through various mechanisms of action. Future studies should focus on how initial implementation strategies can be amplified through internal mechanisms. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-021-01102-6.
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Affiliation(s)
- Mellanie V Springer
- Stroke Program, University of Michigan Medical School, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Anne E Sales
- Department of Veteran Affairs Center for Clinical Management Research, Ann Arbor, MI, USA.,Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA
| | - Nishat Islam
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | - Zach Landis-Lewis
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA
| | - Michael Tupper
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Casey L Corches
- Stroke Program, University of Michigan Medical School, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Maria Cielito Robles
- Stroke Program, University of Michigan Medical School, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Lesli E Skolarus
- Stroke Program, University of Michigan Medical School, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
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Paudel R, Ferrante S, Woodford J, Maitland C, Stockall E, Maatman T, Lane GI, Berry DL, Sales AE, Montie JE. Implementation of prostate cancer treatment decision aid in Michigan: a qualitative study. Implement Sci Commun 2021; 2:27. [PMID: 33676583 PMCID: PMC7936475 DOI: 10.1186/s43058-021-00125-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 02/05/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The American Urological Association White Paper on Implementation of Shared Decision Making (SDM) into Urological Practice suggested SDM represents the state of the art in counseling for patients who are faced with difficult or uncertain medical decisions. The Michigan Urological Surgery Improvement Collaborative (MUSIC) implemented a decision aid, Personal Patient Profile-Prostate (P3P), in 2018 to help newly diagnosed prostate cancer patients make shared decisions with their clinicians. We conducted a qualitative study to assess statewide implementation of P3P throughout MUSIC. METHODS We recruited urologists and staff from 17 MUSIC practices (8 implementation and 9 comparator practices) to understand how practices engaged patients on treatment discussions and to assess facilitators and barriers to implementing P3P. Interview guides were developed based on the Tailored Interventions for Chronic Disease (TICD) Framework. Interviews were transcribed for analysis and coded independently by two investigators in NVivo, PRO 12. Additionally, quantitative program data were integrated into thematic analyses. RESULTS We interviewed 15 urologists and 11 staff from 16 practices. Thematic analysis of interview transcripts indicated three key themes including the following: (i) P3P is compatible as a SDM tool as over 80% of implementation urologists asked patients to complete the P3P questionnaire routinely and used P3P reports during treatment discussions; (ii) patient receptivity was demonstrated by 370 (50%) of newly diagnosed patients (n = 737) from 8 practices enrolled in P3P with 78% completion rate, which accounts for 39% of all newly diagnosed patients in these practices; and (iii) urologists' attitudes towards SDM varied. Over a third of urologists stated they did not rely on a decision aid. Comparator practices indicated habit, inertia, or concerns about clinic flow as reasons for not adopting P3P and some were unconvinced a decision aid is needed in their practice. CONCLUSION Urologists and staff affiliated with MUSIC implementation sites indicated that P3P focuses the treatment discussion on items that are important to patients. Experiences of implementation practices indicate that once initiated, there were no negative effects on clinic flow and urologists indicated P3P saves time during patient counseling, as patients were better prepared for focused discussions. Lack of awareness, personal habits, and inertia are reasons for not implementing P3P among the comparator practices.
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Affiliation(s)
- Roshan Paudel
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI USA
| | - Stephanie Ferrante
- Michigan Urological Surgery Improvement Collaborative, University of Michigan, Ann Arbor, MI USA
| | | | | | | | | | - Giulia I. Lane
- Department of Urology, University of Michigan, Ann Arbor, MI USA
| | - Donna L. Berry
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA USA
| | - Anne E. Sales
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI USA
| | - James E. Montie
- Michigan Urological Surgery Improvement Collaborative, University of Michigan, Ann Arbor, MI USA
| | - for the Michigan Urological Surgery Improvement Collaborative (MUSIC), Ann Arbor, Michigan, USA
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI USA
- Michigan Urological Surgery Improvement Collaborative, University of Michigan, Ann Arbor, MI USA
- University of Michigan, Ann Arbor, MI USA
- Sherwood Medical Center, Detroit, MI USA
- Capital Urological Associates, Okemos, MI USA
- Michigan Urological Clinic, Grand Rapids, MI USA
- Department of Urology, University of Michigan, Ann Arbor, MI USA
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA USA
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Kononowech J, Hagedorn H, Hall C, Helfrich CD, Lambert-Kerzner AC, Miller SC, Sales AE, Damschroder L. Mapping the organizational readiness to change assessment to the Consolidated Framework for Implementation Research. Implement Sci Commun 2021; 2:19. [PMID: 33581728 PMCID: PMC7881456 DOI: 10.1186/s43058-021-00121-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 02/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Implementation researchers recognize the influential role of organizational factors and, thus, seek to assess these factors using quantitative measurement instruments. However, researchers are hindered by instruments that measure similar constructs but rely on different nomenclature and/or definitions. The Consolidated Framework for Implementation Research (CFIR) provides a taxonomy of constructs derived from prior frameworks and empirical studies of implementation-related constructs. The CFIR includes constructs based on the original Promoting Action on Research Implementation in Health Services (PARiHS) framework which highlights the key roles of strength of evidence for a specific evidence-based intervention (EBI), favorability of organizational context for change, and capacities to facilitate implementation of the EBI. Although the CFIR is among the most frequently used implementation frameworks, it does not include quantitative measures. The Organizational Resource and Context Assessment (ORCA) is a quantitative measurement instrument that was developed based on PARiHS, assessing its three domains. Factors within these three domains are conceptually similar to constructs in the CFIR but do not match directly. The aim of this work was to map ORCA survey items to CFIR constructs to enable direct comparisons and syntheses of findings across studies using the CFIR and/or ORCA. METHODS Two distinct, independent research teams, each used rigorous constant comparative techniques with deliberation and consensus to map individual items from the ORCA to the five domains and 39 constructs of CFIR. RESULTS ORCA items were mapped primarily to three of five CFIR domains: Inner Setting, Process, and Intervention Characteristics. The two research teams agreed on 88% of mappings at the higher domain level; at the lower construct level, their mappings aligned for 62.2% of the ORCA items. CONCLUSIONS Mapping results reveal that the ORCA focuses measurement prominently on Inner Setting, Process, and Intervention Characteristics. This mapping guide can help improve consistency in measurement and reporting, enabling more efficient comparison and synthesis of findings that use either the ORCA instrument or the CFIR framework. The guide helps advance implementation science utilizing mixed methods by providing CFIR users with quantitative measures for selected constructs and enables ORCA users to map their findings to CFIR constructs.
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Affiliation(s)
- Jennifer Kononowech
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd, Ann Arbor, MI, USA.
| | - Hildi Hagedorn
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, 1 Veterans Drive, Minneapolis, MN, USA
- Department of Psychiatry, University of Minnesota School of Medicine, 606 24th Ave S, Minneapolis, MN, USA
| | - Carmen Hall
- Gusek Hall Consulting, 1362 Ryan Ave. W Ste 101, Roseville, MN, USA
| | - Christian D Helfrich
- Seattle-Denver Center of Innovation, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, USA
- School of Public Health, University of Washington, 1959 NE Pacific St, Seattle, WA, USA
| | - Anne C Lambert-Kerzner
- Department of Surgery, University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue, Aurora, CO, USA
| | - Susan C Miller
- Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 S. Main Street, Providence, RI, USA
| | - Anne E Sales
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd, Ann Arbor, MI, USA
- Department of Learning Health Sciences, University of Michigan Medical School, 300 N. Ingalls Street, Ann Arbor, MI, USA
| | - Laura Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd, Ann Arbor, MI, USA
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Kononowech J, Landis-Lewis Z, Carpenter J, Ersek M, Hogikyan R, Levy C, Phibbs C, Scott W, Sales AE. Visual process maps to support implementation efforts: a case example. Implement Sci Commun 2020; 1:105. [PMID: 33292818 PMCID: PMC7687814 DOI: 10.1186/s43058-020-00094-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/07/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Process mapping is often used in quality improvement work to examine current processes and workflow and to identify areas to intervene to improve quality. Our objective in this paper is to describe process maps as a visual means of understanding modifiable behaviors and activities, in this case example to ensure that goals of care conversations are part of admitting a veteran in long-term care settings. METHODS We completed site visits to 6 VA nursing homes and reviewed their current admission processes. We conducted interviews to document behaviors and activities that occur when a veteran is referred to a long-term care setting, during admission, and during mandatory VA reassessments. We created visualizations of the data using process mapping approaches. Process maps for each site were created to document the admission activities for each VA nursing home and were reviewed by the research team to identify consistencies across sites and to identify potential opportunities for implementing goals of care conversations. RESULTS We identified five consistent behaviors that take place when a veteran is referred and admitted in long-term care. These behaviors are assessing, discussing, decision-making, documenting, and re-assessing. CONCLUSIONS Based on the process maps, it seems feasible that the LST note and order template could be completed along with other routine assessment processes. However, this will require more robust multi-disciplinary collaboration among both prescribing and non-prescribing health care providers. Completing the LST template during the current admission process would increase the likelihood that the template is completed in a timely manner, potentially alleviate the perceived time burden, and help with the provision of veteran-centered care.
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Affiliation(s)
- Jennifer Kononowech
- grid.413800.e0000 0004 0419 7525Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd, Ann Arbor, MI 48109 USA
| | - Zach Landis-Lewis
- grid.214458.e0000000086837370University of Michigan Medical School, 300 N. Ingalls Street, Ann Arbor, MI 48109 USA
| | - Joan Carpenter
- Corporal Michael J. Crescenz VAMC, 3900 Woodland Avenue, Philadelphia, PA 19104 USA
- grid.25879.310000 0004 1936 8972School of Nursing, University of Pennsylvania, 418 Curie Blvd, Philadelphia, PA 19104 USA
| | - Mary Ersek
- Corporal Michael J. Crescenz VAMC, 3900 Woodland Avenue, Philadelphia, PA 19104 USA
- grid.25879.310000 0004 1936 8972School of Nursing, University of Pennsylvania, 418 Curie Blvd, Philadelphia, PA 19104 USA
| | - Robert Hogikyan
- grid.413800.e0000 0004 0419 7525VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105 USA
| | - Cari Levy
- grid.280930.0Eastern Colorado Health Care System, 1055 Clermont St, Denver, CO 80220 USA
- grid.430503.10000 0001 0703 675XSchool of Medicine, University of Colorado Anschutz Campus, 13001 E. 17th Pl, Aurora, CO 80045 USA
| | - Ciaran Phibbs
- grid.280747.e0000 0004 0419 2556Geriatrics and Extended Care Data and Analysis Center, VA Palo Alto Health Care System, 3801 Miranda Ave, Palo Alto, CA 94304 USA
- grid.168010.e0000000419368956Department of Pediatrics, Stanford University School of Medicine, 725 Welch Road, Palo Alto, CA 94304 USA
| | - Winifred Scott
- grid.280747.e0000 0004 0419 2556Geriatrics and Extended Care Data and Analysis Center, VA Palo Alto Health Care System, 3801 Miranda Ave, Palo Alto, CA 94304 USA
| | - Anne E. Sales
- grid.413800.e0000 0004 0419 7525Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd, Ann Arbor, MI 48109 USA
- grid.214458.e0000000086837370University of Michigan Medical School, 300 N. Ingalls Street, Ann Arbor, MI 48109 USA
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Vachon B, Curran JA, Karunananthan S, Brehaut J, Graham ID, Moher D, Sales AE, Straus SE, Fiander M, Paprica PA, Grimshaw JM. Changing research culture toward more use of replication research: a narrative review of barriers and strategies. J Clin Epidemiol 2020; 129:21-30. [PMID: 33007459 DOI: 10.1016/j.jclinepi.2020.09.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/18/2020] [Accepted: 09/02/2020] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The aim of this paper is to review the literature on barriers to conducting replication research and strategies to increase its use and promotion by researchers, editors, and funders. STUDY DESIGN AND SETTING This review was part of a larger meta-narrative review aimed at conducting a concept analysis of replication and developing a replication research framework. A combination of systematic and snowball search strategies was used to identify relevant literature in multiple research fields. Data were coded and analyzed using the Theoretical Domains Framework for barriers to replication and the behavior change wheel for solutions. RESULTS In total, 153 papers were included in this narrative review. Multiple barriers limit the use of replication research by researchers, editors, and funders. Many of the barriers were related to knowledge and skills of all these actors. Social influences and the research environmental context were also described as not supportive. Multiple strategies were proposed to create positive outcomes expectations, reinforcement, and structural changes in the physical and social context of research. CONCLUSION A social change involving advisory groups, research organizations, and institutions is required to establish new norms that will value, promote, support, and reward replication research.
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Affiliation(s)
- Brigitte Vachon
- Occupational Therapy Program, School of Rehabilitation, Université de Montréal, 7077 Avenue du Parc, Montreal, Quebec H3C 3J7, Canada.
| | - Janet A Curran
- School of Nursing, Faculty of Health, Dalhousie University, 5869 University Avenue, Halifax, Nova Scotia B3H 4R2, Canada
| | - Sathya Karunananthan
- Centre for Practice-Changing Research, Ottawa Hospital Research Institute, 501 Smyth Road, Box 711, Ottawa, Ontario K1H 8L6, Canada
| | - Jamie Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, 501 Smyth Road, Box 711, Ottawa, Ontario K1H 8L6, Canada
| | - Ian D Graham
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, 501 Smyth Road, Box 711, Ottawa, Ontario K1H 8L6, Canada
| | - David Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, 501 Smyth Road, Box 711, Ottawa, Ontario K1H 8L6, Canada
| | - Anne E Sales
- Medical School, University of Michigan, 209 Victor Vaughan Building, 1111 E. Catherine Street, Ann Arbor, MI 48109-2054, USA
| | - Sharon E Straus
- Department of Geriatric Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada
| | - Michele Fiander
- Centre for Practice-Changing Research, Ottawa Hospital Research Institute, 501 Smyth Road, Box 711, Ottawa, Ontario K1H 8L6, Canada
| | - P Alison Paprica
- Institute of Health Policy, Management and Evaluation University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, Ontario M5T 3M6, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, 501 Smyth Road, Box 711, Ottawa, Ontario K1H 8L6, Canada
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Barnes GD, Sippola E, Dorsch M, Errickson J, Lanham M, Allen A, Spoutz P, Sales AE, Sussman J. Applying population health approaches to improve safe anticoagulant use in the outpatient setting: the DOAC Dashboard multi-cohort implementation evaluation study protocol. Implement Sci 2020; 15:83. [PMID: 32958020 PMCID: PMC7504868 DOI: 10.1186/s13012-020-01044-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 09/10/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Use of direct oral anticoagulants (DOAC) is rapidly growing for treatment of atrial fibrillation and venous thromboembolism. However, incorrect dosing of these medications is common and puts patients at risk of adverse drug events. One way to improve safe prescribing is the use of population health tools, including interactive dashboards built into the electronic health record (EHR). As such tools become more common, exploring ways to understand which aspects are effective in specific settings and how to effectively adapt and implement in existing anticoagulation clinics across different health systems is vital. METHODS This three-phase project will evaluate a current nation-wide implementation effort of the DOAC Dashboard in the Veterans Health Administration (VHA) using both quantitative and qualitative methods. Informed by this evaluation, the DOAC Dashboard will be implemented in four new health systems using an implementation strategy derived from the VHA experience and interviews with providers in those new health systems. Quantitative evaluation of the VHA and non-VHA implementation will follow the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Qualitative interviews with stakeholders will be analyzed using the Consolidated Framework for Implementation Research and Technology Acceptance Models to identify key determinants of implementation success. DISCUSSION This study will (1) evaluate the implementation of an EHR-based population health tool for medication management within a large, nation-wide, highly integrated health system; (2) guide the adoption in a set of four different health systems; and (3) evaluation that multi-center implementation effort. These findings will help to inform future EHR-based implementation efforts in a wide variety of health care settings.
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Affiliation(s)
- Geoffrey D Barnes
- University of Michigan Frankel Cardiovascular Center and Institute for Healthcare Policy and Innovation, 2800 Plymouth Rd, B14 G214, Ann Arbor, MI, 48109-2800, USA.
| | - Emily Sippola
- University of Michigan Center for Bioethics and Social Science in Medicine, Ann Arbor, USA
| | - Michael Dorsch
- University of Michigan School of Pharmacy and Institute for Healthcare Policy and Innovation, Ann Arbor, USA
| | - Joshua Errickson
- University of Michigan Center for Statistical Consultation and Research, Ann Arbor, USA
| | - Michael Lanham
- University of Michigan Department of Learning Health Sciences, Ann Arbor, USA
| | - Arthur Allen
- VA Salt Lake City Health Care System, Salt Lake City, USA
| | - Patrick Spoutz
- Veterans Health Affairs VISN 20 Pharmacy Benefits Management, Vancouver, USA
| | - Anne E Sales
- University of Michigan Department of Learning Health Sciences, Institute for Healthcare Policy and Innovation, and Ann Arbor Veterans Health Affairs Center for Clinical Management and Research, Ann Arbor, USA
| | - Jeremy Sussman
- University of Michigan Department of Internal Medicine, Institute for Healthcare Policy and Innovation, and Ann Arbor Veterans Health Affairs Center for Clinical Management and Research, Ann Arbor, USA
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Moldestad M, Greene PA, Sayre GG, Neely EL, Sulc CA, Sales AE, Reddy A, Wong ES, Liu CF. Comparable, but distinct: Perceptions of primary care provided by physicians and nurse practitioners in full and restricted practice authority states. J Adv Nurs 2020; 76:3092-3103. [PMID: 32875584 DOI: 10.1111/jan.14501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 06/04/2020] [Accepted: 06/12/2020] [Indexed: 11/28/2022]
Abstract
AIMS To understand patients' and providers' perceptions of primary care delivered by nurse practitioners (NPs) in the Veterans Affairs Healthcare System. DESIGN Qualitative exploratory study (in convergent mixed-methods design). METHODS Semi-structured interviews in 2016 with primary care providers and patients from facilities in states with full and restricted practice authority for NPs. Patient sample based on reassignment to: (a) a NP; or (b) a different physician following an established physician relationship. Data were analysed using content analysis. RESULTS We interviewed 28 patients, 17 physicians and 14 NPs. We found: (a) NPs provided more holistic care than physicians; (b) patients were satisfied with NPs; and (c) providers' professional experience outweighed provider type. CONCLUSIONS Patients' preferences for NPs (compared with prior physicians) contributed to perceptions of patient centredness. Similarities in providers' perceptions suggest NPs and physicians are both viable providers for primary care. IMPACT Nurse Practitioners (NPs): practice authority Veterans Affairs Health care: nurse practitioners will continue to be a viable resource for primary care delivery United States Health care: challenges notions patients may not be satisfied with care provided by NPs and supports expanding their use to provide much-needed access to primary care services; expanding Full Practice Authority would allow states to provide acceptable primary care without diminishing patient or provider experiences.
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Affiliation(s)
- Megan Moldestad
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA
| | - Preston A Greene
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA
| | - George G Sayre
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
| | - Emily L Neely
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA
| | - Christine A Sulc
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA
| | - Anne E Sales
- VHA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA.,Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ashok Reddy
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA.,Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Edwin S Wong
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
| | - Chuan-Fen Liu
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
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Hutchinson AM, Brotto V, Chapman A, Sales AE, Mohebbi M, Bucknall TK. Use of an audit with feedback implementation strategy to promote medication error reporting by nurses. J Clin Nurs 2020; 29:4180-4193. [PMID: 32757427 DOI: 10.1111/jocn.15447] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 06/18/2020] [Accepted: 07/16/2020] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To outline the development and effect of an audit with feedback implementation strategy that intended to increase the rate of voluntary medication error reporting by nurses. BACKGROUND Medication errors are a serious global health issue. Audit with feedback is a widely used implementation strategy that has potential to modify nurses' reporting behaviour and improve medication error reporting rates. DESIGN Quasi-experimental implementation study (fulfilling the TIDieR checklist) with two pairs of matched wards at a private hospital in Australia was conducted from March 2015-September 2016. One ward from each pair was randomised to either the intervention or control group. METHOD Nurses within intervention wards received audit with feedback on a quarterly basis over a 12-month implementation period. Control wards underwent quarterly audits only (without feedback). Feedback consisted of a one-page infographic poster, with content based on medication error data obtained from audits and the hospitals' risk management system (RiskMan). The primary outcome-rate of medication errors reported per month-was determined in both groups at pre-implementation, implementation and postimplementation phases. Differences between groups were compared using generalised linear mixed models with Poisson distribution and log link. RESULTS A nonsignificant intervention effect was found for rate of medication errors reported per month. Interestingly, when combining data from both groups, a significant increasing time trend was observed for medication errors reported per month across pre-implementation and implementation phases (80% increase). CONCLUSIONS The audit with feedback strategy developed in the present study did not effectively influence the voluntary reporting of medication errors by nurses. RELEVANCE TO CLINICAL PRACTICE Despite the lack of intervention effects, the use of a published checklist to optimise the reporting quality of this study will contribute to the field by furthering the understanding of how to enhance audit with feedback implementation strategies for nurses.
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Affiliation(s)
- Alison M Hutchinson
- School of Nursing & Midwifery, Centre for Quality & Patient Safety Research, Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, VIC, Australia.,Monash Health, Clayton, VIC, Australia
| | - Vanessa Brotto
- School of Nursing & Midwifery, Centre for Quality & Patient Safety Research, Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, VIC, Australia
| | - Anna Chapman
- School of Nursing & Midwifery, Centre for Quality & Patient Safety Research, Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, VIC, Australia.,Monash Health, Clayton, VIC, Australia
| | - Anne E Sales
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Mohammadreza Mohebbi
- Biostatistics Unit, Faculty of Health, Deakin University, Geelong, VIC, Australia
| | - Tracey K Bucknall
- School of Nursing & Midwifery, Centre for Quality & Patient Safety Research, Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, VIC, Australia.,Alfred Health, Melbourne, VIC, Australia
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Ooi CY, Ng CJ, Sales AE, Lim HM. Implementation Strategies for Web-Based Apps for Screening: Scoping Review. J Med Internet Res 2020; 22:e15591. [PMID: 32706655 PMCID: PMC7400029 DOI: 10.2196/15591] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 12/11/2019] [Accepted: 05/14/2020] [Indexed: 11/13/2022] Open
Abstract
Background Screening is an effective primary prevention strategy in health care, as it enables the early detection of diseases. However, the uptake of such screening remains low. Different delivery methods for screening have been developed and found to be effective in increasing the uptake of screening, including the use of web-based apps. Studies have shown that web-based apps for screening are effective in increasing the uptake of health screening among the general population. However, not much is known about the effective implementation of such web-based apps in the real-world setting. Implementation strategies are theory-based methods or techniques used to enhance the adoption, implementation, and sustainability of evidence-based interventions. Implementation strategies are important, as they allow us to understand how to implement an evidence-based intervention. Therefore, a scoping review to identify the various implementation strategies for web-based apps for screening is warranted. Objective This scoping review aims to identify (1) strategies used to implement web-based apps for health screening, (2) frameworks used for implementing web-based apps for health screening, (3) outcome measures of implementation strategies, and (4) effective implementation strategies. Methods This scoping review was conducted based on Arksey and O’Malley’s framework. After identifying the review question, two researchers independently screened and selected relevant literature from PubMed, Embase, Cochrane, Cumulative Index of Nursing and Allied Health Literature, PsycINFO, International Standard Randomised Controlled Trial Number Registry, OpenGrey, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and Web of Science. This was followed by charting the data using a standardized form. Finally, we collated, summarized, and reported the results quantitatively and qualitatively based on the review objectives. Results A total of 16,476 studies were retrieved, of which 5669 were duplicates. From a total of 10,807 studies, 10,784 studies were excluded based on their titles and abstracts. There were 23 full-text articles reviewed, and 4 articles were included in the final analysis. Many studies were excluded because they focused on the effectiveness and not on the implementation of web-based apps. Facilitation was the most cited implementation strategy used, followed by reminders, clinical champions, and educational meetings and materials. Only 2 studies used implementation frameworks to guide the evaluation of their studies. Common outcome measures for implementation strategies were feasibility, fidelity, and penetration. Implementation strategies reported to be effective were quality improvement meetings, facilitation, educational meetings, and clinical champions. Conclusions There is a dearth of literature on the implementation of web-based apps for health screening. Implementation strategies were developed without any reported use of implementation theories or frameworks in most studies. More research on the development and evaluation of web-based screening app implementations is needed.
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Affiliation(s)
- Chor Yau Ooi
- University of Malaya eHealth Initiative, Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Kota Samarahan, Malaysia
| | - Chirk Jenn Ng
- University of Malaya eHealth Initiative, Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Anne E Sales
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, United States.,University of Michigan Medical School, Ann Arbor, MI, United States
| | - Hooi Min Lim
- University of Malaya eHealth Initiative, Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Ervin JN, Rentes VC, Dibble ER, Sjoding MW, Iwashyna TJ, Hough CL, Ng Gong M, Sales AE. Evidence-Based Practices for Acute Respiratory Failure and Acute Respiratory Distress Syndrome: A Systematic Review of Reviews. Chest 2020; 158:2381-2393. [PMID: 32682771 PMCID: PMC7768938 DOI: 10.1016/j.chest.2020.06.080] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 06/03/2020] [Accepted: 06/25/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The recent pandemic highlights the essential nature of optimizing the use of invasive mechanical ventilation (IMV) in complex critical care settings. This review of reviews maps evidence-based practices (EBPs) that are associated with better outcomes among adult patients with acute respiratory failure or ARDS on the continuum of care, from intubation to liberation. RESEARCH QUESTION What EPBs are recommended to reduce the duration of IMV and mortality rate among patients with acute respiratory failure/ARDS? STUDY DESIGN AND METHODS We identified an initial set of reports that links EBPs to mortality rates and/or duration of IMV. We conducted a review of reviews, focusing on preappraised guidelines, meta-analyses, and systematic reviews. We searched Scopus, CINAHL, and PubMed from January 2016 to January 2019 for additional evidence that has not yet been incorporated into current guidelines. RESULTS Our initial search produced 61 publications that contained 42 EBPs. We excluded 42 manuscripts during the data extraction process, primarily because they were not associated with improved patient outcomes. The remaining 19 preappraised guidelines, meta-analyses, and systematic reviews met our full inclusion criteria and spanned the continuum of IMV care from intubation to liberation. These contained 20 EBPs, a majority of which were supported with moderate levels of evidence. Of these, six EBPs focused on intubation and escalation of care, such as ventilator management and synchrony; ten EBPs reduced complications associated with IMV, which included spontaneous awakening and breathing trials and early mobility protocols; and four EBPs promoted timely extubation and postextubation recovery. INTERPRETATION This review describes EBPs that are associated with fewer ventilator days and/or lower mortality rates among patients who received IMV for acute respiratory failure/ARDS. Many of these EBPs are connected across the care continuum, which indicates the need to promote and assess effective implementation jointly, rather than individually.
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Affiliation(s)
- Jennifer N Ervin
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI.
| | - Victor C Rentes
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI
| | - Emily R Dibble
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI; College of Human Ecology, Cornell University, Ithaca, NY
| | - Michael W Sjoding
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; University of Michigan, Ann Arbor, MI
| | - Theodore J Iwashyna
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; University of Michigan, Ann Arbor, MI; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, OR
| | - Michelle Ng Gong
- Department of Medicine, Divisions of Critical Care Medicine and Pulmonary Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, NY
| | - Anne E Sales
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
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Barnes GD, Spranger E, Sippola E, Renner E, Ruff A, Sales AE, Kurlander JE. Assessment of a Best Practice Alert and Referral Process for Preprocedure Antithrombotic Medication Management for Patients Undergoing Gastrointestinal Endoscopic Procedures. JAMA Netw Open 2020; 3:e1920548. [PMID: 32022882 PMCID: PMC7416616 DOI: 10.1001/jamanetworkopen.2019.20548] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Management of antithrombotic medications presents a challenge for many clinicians and patients before procedures. Anticoagulation clinic involvement may improve preprocedure coordination, satisfaction on the part of patients and clinicians, last-minute procedure cancellations, and patient safety. OBJECTIVE To assess the implementation of an electronic medical record (EMR) best practice alert (BPA) and anticoagulation clinic referral process to assist with management of antithrombotic medication before gastrointestinal endoscopic procedures. DESIGN, SETTING, AND PARTICIPANTS This multimodal evaluation of a quality improvement intervention using EMRs and survey data included patients using oral antithrombotic medications who were scheduled for elective gastrointestinal endoscopic procedures at an academic medical center along with the clinicians who ordered these procedures. Data were collected from November 1, 2017, through December 19, 2018. Data were analyzed in September 2019. EXPOSURES Following a multidisciplinary intervention, a BPA and referral process for periprocedural antithrombotic medication management was implemented in November 2017. MAIN OUTCOMES AND MEASURES The following implementation outcomes were assessed through EMR review and surveys through December 2018: use of BPAs, patient and clinician satisfaction with preprocedure anticoagulation management, procedure cancelation rates, reach, and spread by patient and clinician characteristics. Multilevel logistic regression was used to estimate variance in BPA use at the clinician level. RESULTS A total of 2082 patients (mean [SD] age, 64.1 [11.9] years) and 144 clinicians were included in the analysis. The BPA was used broadly across the health system, resulting in anticoagulation clinic referral for 1389 patients (66.7%). Referral was more common for patients using anticoagulant vs antiplatelet medications (1041 of 1524 [68.3%] vs 346 of 556 [62.2%]; adjusted odds ratio [aOR], 1.51; 95% CI, 1.15-1.98) and for procedures ordered by gastroenterologists vs primary care clinicians (933 of 1241 [75.2%] vs 365 of 618 [59.1%]; aOR, 2.15; 95% CI, 1.46-3.17). Individual clinician behavior patterns explained 26.5% (95% CI, 18.7%-36.1%) of variation in anticoagulation clinic referrals. Implementation of the intervention was associated with high patient satisfaction and improvements in multidimensional measures of clinician satisfaction (clinician response rate, 44.2% [144 of 326]). In multivariable analysis, the odds of altered or canceled procedures because of medication mismanagement declined after implementation (8 of 50 [16.0%] vs 1 of 52 [1.9%]; aOR, 0.11; 95% CI, 0.01-0.96; P = .02). CONCLUSIONS AND RELEVANCE A newly implemented BPA and anticoagulation clinic referral process was broadly adopted and used, had high satisfaction by patients and clinicians, and was associated with fewer disruptions to planned procedures caused by medication mismanagement.
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Affiliation(s)
- Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Center for Bioethics and Social Science in Medicine, University of Michigan, Ann Arbor
| | - Elizabeth Spranger
- Quality and Continuous Improvement, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Emily Sippola
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor
- Center for Bioethics and Social Science in Medicine, University of Michigan, Ann Arbor
| | - Elizabeth Renner
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Allison Ruff
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Anne E Sales
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Learning Health Sciences, University of Michigan, Ann Arbor
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan
| | - Jacob E Kurlander
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Division of Gastroenterology, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor
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Liu CF, Hebert PL, Douglas JH, Neely EL, Sulc CA, Reddy A, Sales AE, Wong ES. Outcomes of primary care delivery by nurse practitioners: Utilization, cost, and quality of care. Health Serv Res 2020; 55:178-189. [PMID: 31943190 DOI: 10.1111/1475-6773.13246] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To examine whether nurse practitioner (NP)-assigned patients exhibited differences in utilization, costs, and clinical outcomes compared to medical doctor (MD)-assigned patients. DATA SOURCES Veterans Affairs (VA) administrative data capturing characteristics, outcomes, and provider assignments of 806 434 VA patients assigned to an MD primary care provider (PCP) who left VA practice between 2010 and 2012. STUDY DESIGN We applied a difference-in-difference approach comparing outcomes between patients reassigned to MD and NP PCPs, respectively. We examined measures of outpatient (primary care, specialty care, and mental health) and inpatient (total and ambulatory care sensitive hospitalizations) utilization, costs (outpatient, inpatient and total), and clinical outcomes (control of hemoglobin A1c, LDL, and blood pressure) in the year following reassignment. PRINCIPAL FINDINGS Compared to MD-assigned patients, NP-assigned patients were less likely to use primary care and specialty care services and incurred fewer total and ambulatory care sensitive hospitalizations. Differences in costs, clinical outcomes, and receipt of diagnostic tests between groups were not statistically significant. CONCLUSIONS Patients reassigned to NPs experienced similar outcomes and incurred less utilization at comparable cost relative to MD patients. NPs may offer a cost-effective approach to addressing anticipated shortages of primary care physicians.
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Affiliation(s)
- Chuan-Fen Liu
- Department of Health Services, Magnuson Health Sciences Center, University of Washington School of Public Health, Seattle, Washington
| | - Paul L Hebert
- Department of Health Services, Magnuson Health Sciences Center, University of Washington School of Public Health, Seattle, Washington.,Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Jamie H Douglas
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Emily L Neely
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Christine A Sulc
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Ashok Reddy
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington.,Division of General Internal Medicine, Department of Medicine, Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington
| | - Anne E Sales
- Center of Innovation for Clinical Management Research, Ann Arbor, Michigan.,Division of Learning and Knowledge Systems, University of Michigan Medical School, Ann Arbor, Michigan
| | - Edwin S Wong
- Department of Health Services, Magnuson Health Sciences Center, University of Washington School of Public Health, Seattle, Washington.,Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
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Carpenter J, Miller SC, Kolanowski AM, Karel MJ, Periyakoil VS, Lowery J, Levy C, Sales AE, Ersek M. Partnership to Enhance Resident Outcomes for Community Living Center Residents With Dementia: Description of the Protocol and Preliminary Findings. J Gerontol Nurs 2019; 45:21-30. [PMID: 30789986 DOI: 10.3928/00989134-20190211-03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 01/09/2019] [Indexed: 11/20/2022]
Abstract
The goal of this quality improvement project is to improve care planning around preferences for life-sustaining treatments (LST) and daily care to promote quality of life, autonomy, and safety for U.S. Department of Veterans Affairs (VA) Community Living Center (CLC) (i.e., nursing home) residents with dementia. The care planning process occurs through partnerships between staff and family surrogate decision makers. This process is separate from but supports implementation of the LST Decision Initiative-developed by the VA National Center for Ethics in Health Care-which seeks to increase the number, quality, and documentation of goals of care conversations (GOCC) with Veterans who have life-limiting illnesses. The current authors will engage four to six VA CLCs in the Mid-Atlantic states, provide teams with audit and feedback reports, and establish learning collaboratives to address implementation concerns and support action planning. The expected outcomes are an increase in CLC residents with dementia who have documented GOCC and LST plans. [Journal of Gerontological Nursing, 45(3), 21-30.].
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Chapman CH, Caram MEV, Radhakrishnan A, Tsodikov A, Deville C, Burns J, Zaslavsky A, Chang M, Leppert JT, Hofer T, Sales AE, Hawley ST, Hollenbeck BK, Skolarus TA. Association between PSA values and surveillance quality after prostate cancer surgery. Cancer Med 2019; 8:7903-7912. [PMID: 31691526 PMCID: PMC6912050 DOI: 10.1002/cam4.2663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Although prostate-specific antigen (PSA) testing is used for prostate cancer detection and posttreatment surveillance, thresholds in these settings differ. The screening cutoff of 4.0 ng/mL may be inappropriately used during postsurgery surveillance, where 0.2 ng/mL is typically used, creating missed opportunities for effective salvage radiation treatment. We performed a study to determine whether guideline concordance with annual postoperative PSA surveillance increases when PSA values exceed 4 ng/mL, which represents a screening threshold that is not relevant after surgery. METHODS We used US Veterans Health Administration data to perform a retrospective longitudinal cohort study of men diagnosed with nonmetastatic prostate cancer from 2005 to 2008 who underwent radical prostatectomy. We used logistic regression to examine the association between postoperative PSA levels and receipt of an annual PSA test. RESULTS Among 10 400 men and 38 901 person-years of follow-up, annual guideline concordance decreased from 95% in year 1 to 79% in year 7. After adjustment, guideline concordance was lower for the youngest and oldest men, Black, and unmarried men. Guideline concordance significantly increased as PSA exceeded 4 ng/mL (adjusted odds ratio 2.20 PSA > 4-6 ng/mL vs PSA > 1-4 ng/mL, 95% confidence interval 1.20-4.03; P = .01). CONCLUSIONS Guideline concordance with prostate cancer surveillance increased when PSA values exceeded 4 ng/mL, suggesting a screening threshold not relevant after prostate cancer surgery, where 0.2 ng/mL is considered treatment failure, is impacting cancer surveillance quality. Clarification of PSA thresholds for early detection vs cancer surveillance, as well as emphasizing adherence for younger and Black men, appears warranted.
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Affiliation(s)
- Christina Hunter Chapman
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Megan E V Caram
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Alexander Tsodikov
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Curtiland Deville
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Jennifer Burns
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | | | - Michael Chang
- Hunter Holmes McGuire Veterans Affairs Healthcare System, Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | - John T Leppert
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System and the Department of Urology, Stanford University, Stanford, CA, USA
| | - Timothy Hofer
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Anne E Sales
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA
| | - Sarah T Hawley
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Ted A Skolarus
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Urology, University of Michigan, Ann Arbor, MI, USA
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Sales AE, Wilson PM, Wensing M, Aarons GA, Armstrong R, Flottorp S, Hutchinson AM, Presseau J, Rogers A, Sevdalis N, Squires J, Straus S, Weiner BJ. Implementation Science and Implementation Science Communications: our aims, scope, and reporting expectations. Implement Sci 2019; 14:77. [PMID: 31387596 PMCID: PMC6685161 DOI: 10.1186/s13012-019-0922-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 07/01/2019] [Indexed: 11/24/2022] Open
Abstract
In the 13 years since the inception of Implementation Science, we have witnessed a continued rise in the number of submissions, reflecting the growing global interest in methods to enhance the uptake of research findings into healthcare practice and policy. We now receive over 800 submissions annually, and there is a large gap between what is submitted and what gets published. To better serve the needs of the research community, we announce our plans to introduce a new journal, Implementation Science Communications, which we believe will support publication of types of research reports currently not often published in Implementation Science. In this editorial, we state both journals' scope and current boundaries and set out our expectations for the scientific reporting, quality, and transparency of the manuscripts we receive.
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Affiliation(s)
- Anne E. Sales
- Department of Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, 300 N. Ingalls Street, Suite 1161, Ann Arbor, MI 48109-5430 USA
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, USA
| | - Paul M. Wilson
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | | | | | | | - Signe Flottorp
- Norwegian Knowledge Centre for the Health Services, Oslo, Norway
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Radhakrishnan A, Henry J, Zhu K, Hawley ST, Hollenbeck BK, Hofer T, Wittmann DA, Sales AE, Skolarus TA. Determinants of quality prostate cancer survivorship care across the primary and specialty care interface: Lessons from the Veterans Health Administration. Cancer Med 2019; 8:2686-2702. [PMID: 30950216 PMCID: PMC6536973 DOI: 10.1002/cam4.2106] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/05/2019] [Accepted: 03/05/2019] [Indexed: 11/20/2022] Open
Abstract
Background With over 3 million US prostate cancer survivors, ensuring high‐quality, coordinated cancer survivorship care is important. However, implementation of recommended team‐based cancer care has lagged, and determinants of quality care across primary and specialty care remain unclear. Guided by the theoretical domains framework (TDF), we explored multidisciplinary determinants of quality survivorship care in an integrated delivery system. Methods We conducted semistructured interviews with primary (4) and specialty (7) care providers across 6 Veterans Health Administration clinic sites. Using template analysis, we coded interview transcripts into the TDF, mapping statements to specific constructs within each domain. We assessed whether each construct was perceived a barrier or facilitator, examining results for both primary care providers (PCPs) and prostate cancer specialists. Results Cancer specialists and PCPs identified 2 primary TDF domains impacting their prostate cancer survivorship care: Knowledge and Environmental context and resources. Both groups noted knowledge (about survivorship care) and procedural knowledge (about how to deliver survivorship care) as positive determinants or facilitators, whereas resources/material resources (to deliver survivorship care) was noted as a negative determinant or barrier to care. Additional domains more commonly referenced by cancer specialists included Social/professional role and identity and Goals, while PCPs reported the domain Beliefs about capabilities as relevant. Conclusions We used the TDF to identify several behavioral domains acting as determinants of high‐quality, team‐based prostate cancer survivorship care. These results can inform prostate cancer survivorship care plan content, and may guide tailored, multidisciplinary implementation strategies to improve survivorship care across the primary and specialty care interface.
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Affiliation(s)
| | - Jennifer Henry
- VA Health Service Research & Development Center for Clinical Management Research, Ann Arbor, Michigan
| | - Kevin Zhu
- VA Health Service Research & Development Center for Clinical Management Research, Ann Arbor, Michigan
| | - Sarah T Hawley
- Division of General Medicine, University of Michigan, Ann Arbor, Michigan.,VA Health Service Research & Development Center for Clinical Management Research, Ann Arbor, Michigan.,Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
| | - Brent K Hollenbeck
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Timothy Hofer
- Division of General Medicine, University of Michigan, Ann Arbor, Michigan.,VA Health Service Research & Development Center for Clinical Management Research, Ann Arbor, Michigan
| | - Daniela A Wittmann
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan.,School of Social Work, University of Michigan, Ann Arbor, Michigan
| | - Anne E Sales
- VA Health Service Research & Development Center for Clinical Management Research, Ann Arbor, Michigan.,Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan
| | - Ted A Skolarus
- VA Health Service Research & Development Center for Clinical Management Research, Ann Arbor, Michigan.,Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
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Acosta J, Graves C, Spranger E, Kurlander J, Sales AE, Barnes GD. Periprocedural Antithrombotic Management from a Patient Perspective: A Qualitative Analysis. Am J Med 2019; 132:525-529. [PMID: 30521795 PMCID: PMC6445720 DOI: 10.1016/j.amjmed.2018.11.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 11/13/2018] [Accepted: 11/14/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Periprocedural antithrombotic medication management is a complex, often confusing process for patients and their providers. Communication difficulties often lead to suboptimal medication management, resulting in delayed or canceled procedures. METHODS We conducted telephone surveys with patients taking chronic antithrombotic medications who had recently undergone an endoscopy procedure. In the survey, we sought to better understand the periprocedural process for patients taking antithrombotic medications. We conducted a content analysis of patients' unstructured responses from the periprocedural patient phone calls. We used a multistep group coding process to analyze responses. Relationships between different themes and categories were analyzed using original quotes and retrieving thematic segments from the transcripts. RESULTS The survey was administered to 81 patients; 74/81 respondents (91%) said they understood the plan to manage their antithrombotics, but 21/81 respondents (26%) were not completely satisfied with the coordination, communication, and management of their medications. Five primary themes emerged from the content analysis as patient-centered design features affecting periprocedural care: (1) patients require accurate and timely information; (2) a patient's prior experience with antithrombotic therapy affects their understanding of the process; (3) patients prefer receiving their information from a single source, and (4) also prefer different methods of instruction; (5) finally, patients expect their clinician(s) to be available through the periprocedural management process. CONCLUSION To optimize the periprocedural medication management communication process, patients desire timeliness, accuracy, and adaptiveness to prior patient experience while offering a single, consistently available point of contact.
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Affiliation(s)
| | | | | | - Jacob Kurlander
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor; Veterans Affairs Ann Arbor Health Care System, Mich
| | - Anne E Sales
- Center for Clinical Management Research, VA Ann Arbor Healthcare System; Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor
| | - Geoffrey D Barnes
- Center for Bioethics and Social Science in Medicine; Frankel Cardiovascular Center.
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Skolarus LE, Neshewat GM, Evans L, Green M, Rehman N, Landis-Lewis Z, Schrader JW, Sales AE. Understanding determinants of acute stroke thrombolysis using the tailored implementation for chronic diseases framework: a qualitative study. BMC Health Serv Res 2019; 19:182. [PMID: 30894152 PMCID: PMC6425596 DOI: 10.1186/s12913-019-4012-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 03/14/2019] [Indexed: 11/10/2022] Open
Abstract
Background The Tailored Implementation in Chronic Disease (TICD) framework is a comprehensive framework describing the determinants of implementation success that has been used extensively in primary care settings. We explored the utility of the TICD to identify determinants of practice in an acute setting, namely guideline concordant acute stroke thrombolysis in a low-resourced, predominately minority serving, large, Emergency Department (ED). Methods Through workshops and expert review, we developed an interview guide informed by the TICD framework. We then conducted semi-structured interviews with data collected through written transcripts, audio transcripts or interviewer notes based on participant availability. Three independent coders then performed a content analysis using template analysis, but open to new determinants that arose from the data, into the TICD framework. Results We performed a total of 15 semi-structured interviews with ED acute stroke providers including medical technicians, nurses, and physicians. We found that guideline factors, individual health professional factors, and patient factors domains were barriers to guideline concordant acute stroke thrombolysis. The domain professional interactions was a facilitator to treatment. We identified three determinants, healthcare professional burnout, health care professional turnover and surrogate decision making, that are not part of the TICD framework. Conclusions Most determinants of acute stroke thrombolysis are included within the TICD framework. Inclusion of healthcare professional burnout, healthcare professional turnover and surrogate decision making may assist in expanding the TICD to time-sensitive ED conditions. Further work is needed to confirm this finding and to establish whether the TICD is applicable for use in non-time sensitive ED conditions. Interventions that address guideline, individual health professional and patient factors may improve guideline concordant acute stroke thrombolysis. Electronic supplementary material The online version of this article (10.1186/s12913-019-4012-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lesli E Skolarus
- Stroke Program, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, SPC 5856, Ann Arbor, MI, 48109-5856, USA. .,School of Public Health, University of Michigan, Ann Arbor, MI, USA.
| | - Gina M Neshewat
- Stroke Program, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, SPC 5856, Ann Arbor, MI, 48109-5856, USA
| | - Lacey Evans
- Stroke Program, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, SPC 5856, Ann Arbor, MI, 48109-5856, USA
| | - Molly Green
- Stroke Program, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, SPC 5856, Ann Arbor, MI, 48109-5856, USA.,School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Narmeen Rehman
- Stroke Program, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, SPC 5856, Ann Arbor, MI, 48109-5856, USA
| | - Zach Landis-Lewis
- Department of Learning Health Science, University of Michigan, Ann Arbor, USA
| | | | - Anne E Sales
- Department of Learning Health Science, University of Michigan, Ann Arbor, USA.,Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Skolarus LE, Sales AE, Zimmerman MA, Corches CL, Landis-Lewis Z, Robles MC, McBride AC, Rehman N, Oliver A, Islam N, Springer MV, O'Brien A, Bailey S, Morgenstern LB, Meurer WJ, Burke JF. Stroke Ready: a multi-level program that combines implementation science and community-based participatory research approaches to increase acute stroke treatment: protocol for a stepped wedge trial. Implement Sci 2019; 14:24. [PMID: 30845958 PMCID: PMC6407173 DOI: 10.1186/s13012-019-0869-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 02/07/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Post-stroke disability is common, costly, and projected to increase. Acute stroke treatments can substantially reduce post-stroke disability, but few patients take advantage of these cost-effective treatments. Practical, cost-efficient, and sustainable interventions to address underutilized acute stroke treatments are currently lacking. In this context, we present the Stroke Ready project, a stepped wedge design, multi-level intervention that combines implementation science and community-based participatory research approaches to increase acute stroke treatments in the predominately African American community of Flint, Michigan, USA. METHODS Guided by the Tailored Implementation of Chronic Disease (TICD) framework, we begin with optimization of acute stroke care in emergency departments, with particular attention given to our safety-net hospital partners. Then, we move to a community-wide, multi-faceted, stroke preparedness intervention, with workshops led by peer educators, over 2 years. Measures of engagement of the safety-net hospital and the feasibility and sustainability of the implementation strategy as well as community intervention reach, dose delivered, and satisfaction will be collected. The primary outcome is acute stroke treatment rates, which includes both intravenous tissue plasminogen activator, and endovascular treatment. The co-secondary outcomes are intravenous tissue plasminogen activator treatment rates and the proportion of stroke patients who arrive by ambulance. DISCUSSION If successful, Stroke Ready will increase acute stroke treatment rates through emergency department and community level interventions. The stepped wedge design and process evaluation will provide insight into how Stroke Ready works and where it might work best. By exploring the relative effectiveness of the emergency department optimization and the community intervention, we will inform hospitals and communities as they determine how best to use their resources to optimize acute stroke care. TRIAL REGISTRATION ClinicalTrials.gov Trial Identifier NCT03645590 .
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Affiliation(s)
- Lesli E Skolarus
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA. .,School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA.
| | - Anne E Sales
- Department of Learning Health Sciences, University of Michigan, 1111 E. Catherine St, Ann Arbor, MI, 48109, USA.,VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Ann Arbor, MI, 48105, USA
| | - Marc A Zimmerman
- School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Casey L Corches
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Zach Landis-Lewis
- Department of Learning Health Sciences, University of Michigan, 1111 E. Catherine St, Ann Arbor, MI, 48109, USA
| | - Maria Cielito Robles
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - A Camille McBride
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.,School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Narmeen Rehman
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.,School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Alina Oliver
- Bethlehem Temple Church, 3401 M L King Ave, Flint, MI, 48505, USA
| | - Nishat Islam
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.,School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Mellanie V Springer
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Alison O'Brien
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.,School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | | | - Lewis B Morgenstern
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.,School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - William J Meurer
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.,Emergency Department, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - James F Burke
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.,Department of Neurology, VA Ann Arbor Healthcare System, Ann Arbor, MI, 48105, USA
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Su GL, Glass L, Tapper EB, Van T, Waljee AK, Sales AE. Virtual Consultations Through the Veterans Administration SCAN-ECHO Project Improves Survival for Veterans With Liver Disease. Hepatology 2018; 68:2317-2324. [PMID: 29729194 DOI: 10.1002/hep.30074] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 04/30/2018] [Indexed: 12/22/2022]
Abstract
Access to specialty care has been associated with improved survival in patients with liver disease but universal access is not always feasible. Methods of care delivery using virtual modalities including the SCAN-ECHO (Specialty Access Network-Extension of Community Healthcare Outcome) program were implemented by the Veterans Health Administration (VHA) to address this need but limited data are available on patient outcomes. We sought to evaluate the efficacy of a SCAN-ECHO visit within the context of a regional cohort of patients with liver disease in the VHA (n = 62,237) following implementation in the Ann Arbor SCAN-ECHO Liver Clinic from June 1, 2011, to March 31, 2015. The effect of a SCAN-ECHO visit on all-cause mortality was compared with patients with no liver clinic visit. To adjust for the differences among patients who had a SCAN-ECHO visit versus those with no visit, propensity score matching was performed on condition factors that affect the likelihood of a SCAN-ECHO visit: demographics, geographic location, liver disease diagnosis, severity, and comorbidities. During the study period, 513 patients who had a liver SCAN-ECHO visit were found within the cohort. Patients who had completed a virtual SCAN-ECHO visit were more likely younger, rural, with more significant liver disease, and evidence for cirrhosis. Propensity-adjusted mortality rates using the Cox Proportional Hazard Model showed that a SCAN-ECHO visit was associated with a hazard ratio of 0.54 (95% confidence interval 0.36-0.81, P = 0.003) compared with no visit. Conclusion: Improved survival in patients using SCAN-ECHO suggests that this approach may be an effective method to improve access for selected patients with liver disease, particularly in rural and underserved populations where access to specialty care is limited.
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Affiliation(s)
- Grace L Su
- Medicine Service, VA Ann Arbor Healthcare System, Ann Harbor, Michigan.,University of Michigan Medical School, Ann Arbor, Michigan
| | - Lisa Glass
- Medicine Service, VA Ann Arbor Healthcare System, Ann Harbor, Michigan.,University of Michigan Medical School, Ann Arbor, Michigan
| | - Elliot B Tapper
- Medicine Service, VA Ann Arbor Healthcare System, Ann Harbor, Michigan.,University of Michigan Medical School, Ann Arbor, Michigan
| | - Tony Van
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Akbar K Waljee
- Medicine Service, VA Ann Arbor Healthcare System, Ann Harbor, Michigan.,University of Michigan Medical School, Ann Arbor, Michigan.,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, Michigan
| | - Anne E Sales
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.,Department of Learning Health Science, University of Michigan, Ann Arbor, Michigan
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Skolarus TA, Hawley ST, Wittmann DA, Forman J, Metreger T, Sparks JB, Zhu K, Caram MEV, Hollenbeck BK, Makarov DV, Leppert JT, Shelton JB, Shahinian V, Srinivasaraghavan S, Sales AE. De-implementation of low value castration for men with prostate cancer: protocol for a theory-based, mixed methods approach to minimizing low value androgen deprivation therapy (DeADT). Implement Sci 2018; 13:144. [PMID: 30486836 PMCID: PMC6262964 DOI: 10.1186/s13012-018-0833-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 10/30/2018] [Indexed: 01/27/2023] Open
Abstract
Background Men with prostate cancer are often castrated with long-acting injectable drugs termed androgen deprivation therapy (ADT). Although many benefit, ADT is also used in patients with little or nothing to gain. The best ways to stop this practice are unknown, and range from blunt pharmacy restrictions to informed decision-making. This study will refine and pilot two different de-implementation strategies for reducing ADT use among those unlikely to benefit in preparation for a comparative effectiveness trial. Methods/design This innovative mixed methods research program has three aims. Aim 1: To assess preferences and barriers for de-implementation of chemical castration in prostate cancer. Guided by the theoretical domains framework (TDF), urologists and patients from facilities with the highest and lowest castration rates across the VA will be interviewed to identify key preferences and de-implementation barriers for reducing castration as prostate cancer treatment. This qualitative work will inform Aim 2 while gathering rich information for two proposed pilot intervention strategies. Aim 2: To use a discrete choice experiment (DCE), a novel barrier prioritization approach, for de-implementation strategy tailoring. The investigators will conduct national surveys of urologists to prioritize key barriers identified in Aim 1 for stopping incident castration as localized prostate cancer treatment using a DCE experiment design. These quantitative results will identify the most important barriers to be addressed through tailoring of two pilot de-implementation strategies in preparation for Aim 3 piloting. Aim 3: To pilot two tailored de-implementation strategies to reduce castration as localized prostate cancer treatment. Building on findings from Aims 1 and 2, two de-implementation strategies will be piloted. One strategy will focus on formulary restriction at the organizational level and the other on physician/patient informed decision-making at different facilities. Outcomes will include acceptability, feasibility, and scalability in preparation for an effectiveness trial comparing these two widely varying de-implementation strategies. Discussion Our innovative approach to de-implementation strategy development is directly aligned with state-of-the-art complex implementation intervention development and implementation science. This work will broadly advance de-implementation science for low value cancer care, and foster participation in our de-implementation evaluation trial by addressing barriers, facilitators, and concerns through pilot tailoring. Trial registration ClinicalTrials.gov Identifier: NCT03579680, First Posted July 6, 2018.
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Affiliation(s)
- Ted A Skolarus
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA. .,Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.
| | - Sarah T Hawley
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Daniela A Wittmann
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Jane Forman
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Tabitha Metreger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Jordan B Sparks
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Kevin Zhu
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Megan E V Caram
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brent K Hollenbeck
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Danil V Makarov
- Departments of Urology and Population Health, NYU Langone Medical Center, New York City, NY, USA.,VA New York Harbor Healthcare System, 423 E. 23rd St, New York City, NY, 10010, USA
| | - John T Leppert
- Department of Urology, Stanford University School of Medicine, Grant Building, S-287, 300 Pasteur Drive, Stanford, CA, 94305, USA.,VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Jeremy B Shelton
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA
| | - Vahakn Shahinian
- Division of Nephrology, University of Michigan Medical School, Medical School, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA
| | | | - Anne E Sales
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
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Kim HM, Gerlach LB, Yosef M, Stano C, Conroy DA, Valenstein M, Pfeiffer PN, Sales AE, Zivin K. Responsiveness of Veterans Affairs Health Care System to Zolpidem Safety Warnings. J Clin Sleep Med 2018; 14:1135-1141. [PMID: 29991420 PMCID: PMC6040786 DOI: 10.5664/jcsm.7210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 02/08/2018] [Accepted: 03/14/2018] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Sedative hypnotic medications are routinely prescribed for insomnia treatment, but have been associated with significant risks of morning-after impairment. We evaluated responsiveness in the Veterans Health Administration (VHA) facilities to two drug safety warnings recommending against high-dose zolpidem use-a 2007 Veterans Administration Pharmacy Benefits Management Service warning and a 2013 Food and Drug Administration (FDA) warning. METHODS We used interrupted time-series design to assess how the two warnings influenced prescribing within the VHA in outpatients from 2005 to 2014. We assessed two outcomes: monthly outpatient use of (1) higher-than-recommended dose of zolpidem among zolpidem users and (2) any-dose zolpidem among all VHA users. In sensitivity analyses, we compared zolpidem prescribing to prescribing other sleep medications not subject to safety warnings. RESULTS After the 2007 VHA warning, high-dose zolpidem use decreased significantly among both sexes from approximately 10% to 2%. Following the 2013 FDA warning, high-dose zolpidem use declined again; however, approximately half of women Veterans remained on high doses. Overall zolpidem use nearly quadrupled between the 2007 VHA and 2013 FDA warnings, but the overall use declined after the 2013 FDA warning. Increase in sedating antidepressant use was seen after the FDA warning, suggesting potential substitution. CONCLUSIONS Higher than recommended dose use within the VHA decreased after each zolpidem high dose warning. Although overall use also decreased after the FDA warning, almost 50% of high-dose use among women Veterans is concerning. Different strategies to communicate the warnings should be examined. COMMENTARY A commentary on this article appears in this issue on page 1093.
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Affiliation(s)
- Hyungjin Myra Kim
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, Michigan
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Lauren B. Gerlach
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
| | - Matheos Yosef
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Claire Stano
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Deirdre A. Conroy
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
| | - Marcia Valenstein
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
| | - Paul N. Pfeiffer
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
| | - Anne E. Sales
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan
| | - Kara Zivin
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
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Sales AE, Ersek M, Intrator OK, Levy C, Carpenter JG, Hogikyan R, Kales HC, Landis-Lewis Z, Olsan T, Miller SC, Montagnini M, Periyakoil VS, Reder S. Correction to: Implementing goals of care conversations with veterans in VA long-term care setting: a mixed methods protocol. Implement Sci 2018; 13:29. [PMID: 29426346 PMCID: PMC5809112 DOI: 10.1186/s13012-018-0724-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 02/01/2018] [Indexed: 11/10/2022] Open
Affiliation(s)
- Anne E Sales
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA. .,University of Michigan Medical School, 300 N. Ingalls Street, Room 1161-I, Ann Arbor, MI, 48109-5423, USA.
| | - Mary Ersek
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Orna K Intrator
- Canandaigua VAMC, Canandaigua, NY, USA.,University of Rochester Medical Center, Rochester, NY, USA
| | - Cari Levy
- Eastern Colorado Health Care System, Denver, CO, USA.,School of Medicine, University of Colorado Anschutz Campus, Denver, CO, USA
| | | | - Robert Hogikyan
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,University of Michigan Medical School, 300 N. Ingalls Street, Room 1161-I, Ann Arbor, MI, 48109-5423, USA
| | - Helen C Kales
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,University of Michigan Medical School, 300 N. Ingalls Street, Room 1161-I, Ann Arbor, MI, 48109-5423, USA
| | - Zach Landis-Lewis
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Tobie Olsan
- Canandaigua VAMC, Canandaigua, NY, USA.,University of Rochester Medical Center, Rochester, NY, USA
| | - Susan C Miller
- Brown University School of Public Health, Providence, RI, USA
| | - Marcos Montagnini
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,University of Michigan Medical School, 300 N. Ingalls Street, Room 1161-I, Ann Arbor, MI, 48109-5423, USA
| | - Vyjeyanthi S Periyakoil
- VA Palo Alto Health Care System, Palo Alto, CA, USA.,Stanford University School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Sheri Reder
- Puget Sound Health Care System, Seattle, WA, USA
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Skolarus TA, Lehmann T, Tabak RG, Harris J, Lecy J, Sales AE. Assessing citation networks for dissemination and implementation research frameworks. Implement Sci 2017; 12:97. [PMID: 28754140 PMCID: PMC5534119 DOI: 10.1186/s13012-017-0628-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 07/13/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A recent review of frameworks used in dissemination and implementation (D&I) science described 61 judged to be related either to dissemination, implementation, or both. The current use of these frameworks and their contributions to D&I science more broadly has yet to be reviewed. For these reasons, our objective was to determine the role of these frameworks in the development of D&I science. METHODS We used the Web of Science™ Core Collection and Google Scholar™ to conduct a citation network analysis for the key frameworks described in a recent systematic review of D&I frameworks (Am J Prev Med 43(3):337-350, 2012). From January to August 2016, we collected framework data including title, reference, publication year, and citations per year and conducted descriptive and main path network analyses to identify those most important in holding the current citation network for D&I frameworks together. RESULTS The source article contained 119 cited references, with 50 published articles and 11 documents identified as a primary framework reference. The average citations per year for the 61 frameworks reviewed ranged from 0.7 to 103.3 among articles published from 1985 to 2012. Citation rates from all frameworks are reported with citation network analyses for the framework review article and ten highly cited framework seed articles. The main path for the D&I framework citation network is presented. CONCLUSIONS We examined citation rates and the main paths through the citation network to delineate the current landscape of D&I framework research, and opportunities for advancing framework development and use. Dissemination and implementation researchers and practitioners may consider frequency of framework citation and our network findings when planning implementation efforts to build upon this foundation and promote systematic advances in D&I science.
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Affiliation(s)
- Ted A. Skolarus
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105 USA
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI 48109 USA
- Urology Section, VA Ann Arbor Healthcare System, Department of Urology, University of Michigan, Ann Arbor, MI 48109 USA
| | - Todd Lehmann
- Department of Political Science, College of Literature, Science and the Arts, University of Michigan, Ann Arbor, MI 48109 USA
| | - Rachel G. Tabak
- Department of Political Science, College of Literature, Science and the Arts, University of Michigan, Ann Arbor, MI 48109 USA
| | - Jenine Harris
- Prevention Research Center in St. Louis/George Warren Brown School of Social Work at Washington University in St. Louis, St. Louis, MO 63130 USA
| | - Jesse Lecy
- Maxwell School of Citizenship and Public Affairs, Syracuse University, Syracuse, NY 13244 USA
| | - Anne E. Sales
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105 USA
- Department of Learning Health Sciences, University of Michigan Medical School, University of Michigan, Ann Arbor, MI 48109 USA
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Fraser KD, Sales AE, Baylon MAB, Schalm C, Miklavcic JJ. Data for Improvement and Clinical Excellence: a report of an interrupted time series trial of feedback in home care. Implement Sci 2017; 12:66. [PMID: 28521750 PMCID: PMC5437696 DOI: 10.1186/s13012-017-0600-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 05/09/2017] [Indexed: 11/10/2022] Open
Abstract
Background There is substantial evidence about the effectiveness of audit with feedback, but none that we know have been conducted in home care settings. The primary purpose of the Data for Improvement and Clinical Excellence – Home Care (DICE-HC) project was to evaluate the effects of an audit and feedback delivered to care providers on home care client outcomes. The objective of this paper is to report the effects of feedback on four specific quality indicators: pain, falls, delirium, and hospital visits. Methods A 10-month audit with feedback intervention study was conducted with care providers in seven home care offices in Alberta, Canada, which involved delivery of four quarterly feedback reports consisting of data derived from the Resident Assessment Instrument – Home Care (RAI-HC). The primary evaluation employed an interrupted time series design using segmented regression analysis to assess the effects of feedback reporting on the four quality indicators: pain, falls, delirium, and hospitalization. Changes in level and trend of the quality indicators were measured before, during, and after the implementation of feedback reports. Pressure ulcer reporting was analyzed as a comparator condition not included in the feedback report. Care providers were surveyed on responses to feedback reporting which informed a process evaluation. Results At initiation of feedback report implementation, the percentage of clients reporting pain and falls significantly increased. Though the percentage of clients reporting pain and falls tended to increase and reporting of delirium and hospital visits tended to decrease relative to the pre-intervention period, there was no significant effect of feedback reporting on quality indicators during the 10-month intervention. The percentage of clients reporting falls, delirium, and hospital visits significantly increased in the 6-month period following feedback reporting relative to the intervention period. About 50% of the care providers that read and understand the feedback reports found the reports useful to make changes to the way clients are cared for. Conclusions Routinely collected data used over time for feedback is feasible in home care settings. A high proportion of care providers find feedback reports useful for informing how they care for clients. Since reporting on the frequency of quality indicators increased in the post-intervention period, this study suggests that ongoing use of audit with feedback to enhance health outcomes in home care may promote improved reporting on standardized instruments. Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0600-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kimberly D Fraser
- Faculty of Nursing, Level 3 Edmonton Clinic Health Academy, University of Alberta, 11405 - 87 Ave NW, Edmonton, AB, T6G 1C9, Canada.
| | - Anne E Sales
- Centre for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, PO Box 130170, Ann Arbor, MI, 48113, USA
| | - Melba Andrea B Baylon
- Faculty of Nursing, Level 3 Edmonton Clinic Health Academy, University of Alberta, 11405 - 87 Ave NW, Edmonton, AB, T6G 1C9, Canada
| | - Corinne Schalm
- Alberta Health and Wellness, 10025 Jasper Ave NW, Edmonton, AB, T5J 1S6, Canada
| | - John J Miklavcic
- Faculty of Nursing, Level 3 Edmonton Clinic Health Academy, University of Alberta, 11405 - 87 Ave NW, Edmonton, AB, T6G 1C9, Canada
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Costa DK, White MR, Ginier E, Manojlovich M, Govindan S, Iwashyna TJ, Sales AE. Identifying Barriers to Delivering the Awakening and Breathing Coordination, Delirium, and Early Exercise/Mobility Bundle to Minimize Adverse Outcomes for Mechanically Ventilated Patients: A Systematic Review. Chest 2017; 152:304-311. [PMID: 28438605 DOI: 10.1016/j.chest.2017.03.054] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 03/22/2017] [Accepted: 03/23/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Improved outcomes are associated with the Awakening and Breathing Coordination, Delirium, and Early exercise/mobility bundle (ABCDE); however, implementation issues are common. As yet, no study has integrated the barriers to ABCDE to provide an overview of reasons for less successful efforts. The purpose of this review was to identify and catalog the barriers to ABCDE delivery based on a widely used implementation framework, and to provide a resource to guide clinicians in overcoming barriers to implementation. METHODS We searched MEDLINE via PubMed, CINAHL, and Scopus for original research articles from January 1, 2007, to August 31, 2016, that identified barriers to ABCDE implementation for adult patients in the ICU. Two reviewers independently reviewed studies, extracted barriers, and conducted thematic content analysis of the barriers, guided by the Consolidated Framework for Implementation Research. Discrepancies were discussed, and consensus was achieved. RESULTS Our electronic search yielded 1,908 articles. After applying our inclusion/exclusion criteria, we included 49 studies. We conducted thematic content analysis of the 107 barriers and identified four classes of ABCDE barriers: (1) patient-related (ie, patient instability and safety concerns); (2) clinician-related (ie, lack of knowledge, staff safety concerns); (3) protocol-related (ie, unclear protocol criteria, cumbersome protocols to use); and, not previously identified in past reviews, (4) ICU contextual barriers (ie, interprofessional team care coordination). CONCLUSIONS We provide the first, to our knowledge, systematic differential diagnosis of barriers to ABCDE delivery, moving beyond the conventional focus on patient-level factors. Our analysis offers a differential diagnosis checklist for clinicians planning ABCDE implementation to improve patient care and outcomes.
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Affiliation(s)
| | | | - Emily Ginier
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, MI
| | | | - Sushant Govindan
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Theodore J Iwashyna
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical School, Ann Arbor, MI; VA Center for Clinical Management Research, Ann Arbor, MI
| | - Anne E Sales
- VA Center for Clinical Management Research, Ann Arbor, MI; Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI
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Duffy SA, Anderson J, Barks L, Cowan L, Daggett V, Hendrix C, Oka R, Sales AE, Alt-White AC. How to get your research published. Int J Nurs Stud 2017; 66:A1-A5. [DOI: 10.1016/j.ijnurstu.2016.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sales AE, Ersek M, Intrator OK, Levy C, Carpenter JG, Hogikyan R, Kales HC, Landis-Lewis Z, Olsan T, Miller SC, Montagnini M, Periyakoil VS, Reder S. Implementing goals of care conversations with veterans in VA long-term care setting: a mixed methods protocol. Implement Sci 2016; 11:132. [PMID: 27682236 PMCID: PMC5041212 DOI: 10.1186/s13012-016-0497-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 09/20/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The program "Implementing Goals of Care Conversations with Veterans in VA LTC Settings" is proposed in partnership with the US Veterans Health Administration (VA) National Center for Ethics in Health Care and the Geriatrics and Extended Care Program Offices, together with the VA Office of Nursing Services. The three projects in this program are designed to support a new system-wide mandate requiring providers to conduct and systematically record conversations with veterans about their preferences for care, particularly life-sustaining treatments. These treatments include cardiac resuscitation, mechanical ventilation, and other forms of life support. However, veteran preferences for care go beyond whether or not they receive life-sustaining treatments to include issues such as whether or not they want to be hospitalized if they are acutely ill, and what kinds of comfort care they would like to receive. METHODS Three projects, all focused on improving the provision of veteran-centered care, are proposed. The projects will be conducted in Community Living Centers (VA-owned nursing homes) and VA Home-Based Primary Care programs in five regional networks in the Veterans Health Administration. In all the projects, we will use data from context and barrier and facilitator assessments to design feedback reports for staff to help them understand how well they are meeting the requirement to have conversations with veterans about their preferences and to document them appropriately. We will also use learning collaboratives-meetings in which staff teams come together and problem-solve issues they encounter in how to get veterans' preferences expressed and documented, and acted on-to support action planning to improve performance. DISCUSSION We will use data over time to track implementation success, measured as the proportions of veterans in Community Living Centers (CLCs) and Home-Based Primary Care (HBPC) who have a documented goals of care conversation soon after admission. We will work with our operational partners to spread approaches that work throughout the Veterans Health Administration.
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Affiliation(s)
- Anne E Sales
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA. .,University of Michigan Medical School, 300 N. Ingalls Street, Room 1161-I, Ann Arbor, MI, 48109-5423, USA.
| | - Mary Ersek
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Orna K Intrator
- Canandaigua VAMC, Canandaigua, NY, USA.,University of Rochester Medical Center, Rochester, NY, USA
| | - Cari Levy
- Eastern Colorado Health Care System, Denver, CO, USA.,School of Medicine, University of Colorado Anschutz Campus, Denver, CO, USA
| | | | - Robert Hogikyan
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,University of Michigan Medical School, 300 N. Ingalls Street, Room 1161-I, Ann Arbor, MI, 48109-5423, USA
| | - Helen C Kales
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,University of Michigan Medical School, 300 N. Ingalls Street, Room 1161-I, Ann Arbor, MI, 48109-5423, USA
| | - Zach Landis-Lewis
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Tobie Olsan
- Canandaigua VAMC, Canandaigua, NY, USA.,University of Rochester Medical Center, Rochester, NY, USA
| | - Susan C Miller
- Brown University School of Public Health, Providence, RI, USA
| | - Marcos Montagnini
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,University of Michigan Medical School, 300 N. Ingalls Street, Room 1161-I, Ann Arbor, MI, 48109-5423, USA
| | - Vyjeyanthi S Periyakoil
- VA Palo Alto Health Care System, Palo Alto, CA, USA.,Stanford University School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Sheri Reder
- Puget Sound Health Care System, Seattle, WA, USA
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