1
|
Shepherd-Banigan M, Shapiro A, Stechuchak KM, Glynn S, Calhoun P, Ackland PE, Bokhour B, Edelman D, Falkovic M, Weidenbacher HJ, Eldridge MR, Lanford T, Swinkels C, Dedert E, Wells S, Ruffin R, Van Houtven CH. Feasibility of a family-involved intervention to increase engagement in evidenced-based psychotherapies for posttraumatic stress disorder: A pilot study. Psychol Trauma 2024:2024-44916-001. [PMID: 38236230 DOI: 10.1037/tra0001623] [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] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
OBJECTIVE To assess the feasibility of a family-involved intervention, family support in mental health recovery (FAMILIAR), for veterans with posttraumatic stress disorder (PTSD) seeking psychotherapy at a single Veterans Administration Health System. METHOD This mixed-methods study reports qualitative and quantitative findings from a single-group pilot of 24 veterans and their support partners (SPs) about experiences with the intervention and interviews with eight VA mental health clinicians and leaders and the study interventionist to explore intervention feasibility. Findings across data sources were merged within domains of Bowen and colleagues' pilot study feasibility framework. RESULTS Out of 24 dyads, 16 veterans and 15 associated SPs completed the intervention. Participants viewed the intervention to be valuable and feasible. Veterans and SPs reported that they enrolled in the study to develop a shared understanding of PTSD and treatment. While participants identified few logistical barriers, finding a time for conjoint sessions could be a challenge. Veterans, SPs, and providers discussed benefits of the intervention, including that it facilitated conversation between the veteran and SP about PTSD and mental health care and helped to prepare the dyad for treatment. Providers noted potential challenges integrating family-involved interventions into clinical workflow in VA and suggested the need for additional training and standardized procedures for family-centered care. CONCLUSIONS Our study identified potential implementation facilitators (e.g., standard operating procedures about session documentation, confidentiality, and family ethics) and challenges (e.g., clinical workflow integration) that require further study to bring FAMILIAR into routine clinical care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
Collapse
Affiliation(s)
| | - Abigail Shapiro
- Health Services Research and Development, Durham VA Health Care System
| | | | | | - Patrick Calhoun
- Health Services Research and Development, Durham VA Health Care System
| | - Princess E Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System
| | - Barbara Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System
| | - David Edelman
- Health Services Research and Development, Durham VA Health Care System
| | - Margaret Falkovic
- Health Services Research and Development, Durham VA Health Care System
| | | | | | - Tiera Lanford
- Health Services Research and Development, Durham VA Health Care System
| | - Cindy Swinkels
- Health Services Research and Development, Durham VA Health Care System
| | - Eric Dedert
- Health Services Research and Development, Durham VA Health Care System
| | - Stephanie Wells
- Health Services Research and Development, Durham VA Health Care System
| | - Rachel Ruffin
- Health Services Research and Development, Durham VA Health Care System
| | | |
Collapse
|
2
|
Hyland CJ, Mou D, Virji AZ, Sokas CM, Bokhour B, Pusic AL, Mjåset C. How to make PROMs work: qualitative insights from leaders at United States hospitals with successful PROMs programs. Qual Life Res 2023:10.1007/s11136-023-03388-z. [PMID: 36928649 PMCID: PMC10018634 DOI: 10.1007/s11136-023-03388-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2023] [Indexed: 03/18/2023]
Abstract
PURPOSE Elucidate facilitators, barriers, and key lessons learned regarding the implementation of system-wide clinical patient-reported outcome measure (PROM) programs among United States (US) healthcare leaders. METHODS We conducted semi-structured interviews with 35 US healthcare leaders, including chief-level executives, data directors, PROM directors, and department chairs involved in PROM implementation across seven diverse healthcare systems from February to June 2020. Transcripts were coded, evaluated for qualitative themes, and categorized according to the consolidated framework for implementation research (CFIR). RESULTS According to US hospital leaders with experience in existing clinical PROM programs, there are facilitators and barriers to implementation success in each CFIR domain. Allowing clinicians to select PROM measures and ensuring a user-friendly data platform (intervention); adapting data collection to patient home environments (outer setting); informing clinicians of the multi-faceted use of PROM data for research, clinical care, and business (inner setting); implementing PROM education earlier into clinician training (characteristics of individuals); and establishing specialty-agnostic PROM implementation teams (process) were among key facilitators to implementation success. CONCLUSION Leaders of geographically and clinically diverse PROM programs in the US identify common themes that facilitate successful implementation. Drivers of success depend on factors within and outside the clinical environment. These findings may serve to guide both establishing new PROM programs and refining existing PROM programs.
Collapse
Affiliation(s)
| | - Danny Mou
- Department of Surgery, Emory University, Atlanta, Georgia
| | | | - Claire M Sokas
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Barbara Bokhour
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | - Christer Mjåset
- Harvard T.H. Chan School of Public Health, Boston, MA, USA.,The Commonwealth Fund, 1 E 75th St, New York City, NY, USA
| |
Collapse
|
3
|
Mou D, Mjaset C, Sokas CM, Virji A, Bokhour B, Heng M, Sisodia RC, Pusic AL, Rosenthal MB. Impetus of US hospital leaders to invest in patient-reported outcome measures (PROMs): a qualitative study. BMJ Open 2022; 12:e061761. [PMID: 35793919 PMCID: PMC9260769 DOI: 10.1136/bmjopen-2022-061761] [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] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Though hospital leaders across the USA have invested significant resources in collection of patient-reported outcome measures (PROMs), there are very limited data on the impetus for hospital leadership to establish PROM programmes. In this qualitative study, we identify the drivers and motivators of PROM collection among hospital leaders in the USA. DESIGN Exploratory qualitative study. SETTING Thirty-seven hospital leaders representing seven different institutions with successful PROMs programs across twenty US states. METHODS Semistructured interviews conducted with hospital leaders. Transcripts were analysed using thematic analysis. RESULTS Leaders strongly believe that collecting PROMs is the 'right thing to do' and that the culture of the institution plays an important role in enabling PROMs. The study participants often believe that their institutions deliver superior care and that PROMs can be used to demonstrate the value of their services to payors and patients. Direct financial incentives are relatively weak motivators for collection of PROMs. Most hospital leaders have reservations about using PROMs in their current state as a meaningful performance metric. CONCLUSION These findings suggest that hospital leaders feel a strong moral imperative to collect PROMs, which is also supported by the culture of their institution. Although PROMs are used in negotiations with payors, direct financial return on investment is not a strong driver for the collection of PROMs. Understanding why leaders of major healthcare institutions invest in PROMs is critical to understanding the role that PROMs play in the US healthcare system.
Collapse
Affiliation(s)
- Danny Mou
- Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Physician Organization, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christer Mjaset
- Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Commonwealth Fund, New York, New York, USA
| | - Claire M Sokas
- Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Azan Virji
- Harvard Medical School, Boston, Massachusetts, USA
| | - Barbara Bokhour
- Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Marilyn Heng
- Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rachel C Sisodia
- Physician Organization, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrea L Pusic
- Division of Plastic and Reconstructive Surgery, Patient Reported Outcome Value and Experience (PROVE) Center, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
4
|
Kligler B, Hyde J, Gantt C, Bokhour B. The Whole Health Transformation at the Veterans Health Administration: Moving From "What's the Matter With You?" to "What Matters to You?". Med Care 2022; 60:387-391. [PMID: 35283434 DOI: 10.1097/mlr.0000000000001706] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The Veterans Health Administration is undergoing a system-wide transformation to a Whole Person/Whole Health approach to care. The Whole Health model of care is described including early outcome data on utilization and effectiveness. The paper describes the first 10 years of this transformation and provides lessons learned during that process regarding large-scale system change.
Collapse
Affiliation(s)
- Benjamin Kligler
- Office of Patient Centered Care & Cultural Transformation, Veterans Health Administration, Washington, DC
- Department of Family and Community Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Justeen Hyde
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System
- Department of General Internal Medicine, Boston University School of Medicine, Boston
| | - Cynthia Gantt
- Office of Patient Centered Care & Cultural Transformation, Veterans Health Administration, Washington, DC
| | - Barbara Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System
- Department of General Internal Medicine, Boston University School of Medicine, Boston
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA
| |
Collapse
|
5
|
Anderson E, Dvorin K, Etingen B, Barker AM, Rai Z, Herbst A, Mozer R, Kingston RP, Bokhour B. Lessons Learned From VHA's Rapid Implementation of Virtual Whole Health Peer-Led Groups During the COVID-19 Pandemic: Staff Perspectives. Glob Adv Health Med 2022; 11:21649561211064244. [PMID: 35106189 PMCID: PMC8795823 DOI: 10.1177/21649561211064244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Committed to implementing a person-centered, holistic (Whole Health) system of care, the Veterans Health Administration (VHA) developed a peer-led, group-based, multi-session "Taking Charge of My Life and Health" (TCMLH) program wherein Veterans reflect on values, set health and well-being-related goals, and provide mutual support. Prior work has demonstrated the positive impact of these groups. After face-to-face TCMLH groups were disrupted by the COVID-19 pandemic, VHA facilities rapidly implemented virtual (video-based) TCMLH groups. OBJECTIVE We sought to understand staff perspectives on the feasibility, challenges, and advantages of conducting TCMLH groups virtually. METHODS We completed semi-structured telephone interviews with 35 staff members involved in the implementation of virtual TCMLH groups across 12 VHA facilities and conducted rapid qualitative analysis of the interview transcripts. RESULTS Holding TCMLH groups virtually was viewed as feasible. Factors that promoted the implementation included use of standardized technology platforms amenable to delivery of group-based curriculum, availability of technical support, and adjustments in facilitator delivery style. The key drawbacks of the virtual format included difficulty maintaining engagement and barriers to relationship-building among participants. The perceived advantages of the virtual format included the positive influence of being in the home environment on Veterans' reflection, motivation, and self-disclosure, the greater convenience and accessibility of the virtual format, and the virtual group's role as an antidote to isolation during the COVID-19 pandemic. CONCLUSION Faced with the disruption caused by the COVID-19 pandemic, VHA pivoted by rapidly implementing virtual TCMLH groups. Staff members involved in implementation noted that delivering TCMLH virtually was feasible and highlighted both challenges and advantages of the virtual format. A virtual group-based program in which participants set and pursue personally meaningful goals related to health and well-being in a supportive environment of their peers is a promising innovation that can be replicated in other health systems.
Collapse
Affiliation(s)
- Ekaterina Anderson
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Kelly Dvorin
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Bella Etingen
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines VA Hospital, Hines, IL, USA
| | - Anna M. Barker
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Zenith Rai
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Abigail Herbst
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Reagan Mozer
- Department of Mathematical Sciences, Bentley University, Waltham, MA, USA
| | - Rodger P. Kingston
- Veteran Engagement in Research Group, VA Bedford Healthcare System, Bedford, MA, USA
| | - Barbara Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| |
Collapse
|
6
|
Abadi M, Richard B, Shamblen S, Drake C, Schweinhart A, Bokhour B, Bauer R, Rychener D. Achieving Whole Health: A Preliminary Study of TCMLH, a Group-Based Program Promoting Self-Care and Empowerment Among Veterans. Health Educ Behav 2021; 49:347-357. [PMID: 34018443 DOI: 10.1177/10901981211011043] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE An emerging literature suggests patients with chronic illnesses can benefit from integrated, person-centric approaches to health care, including group-based programs. However, much of the research in this area is disease specific. The objective of this study was to collect preliminary evidence on the efficacy of Taking Charge of My Life and Health (TCMLH), a Whole Health group-based program that emphasizes self-care and empowerment on the overall health and well-being of veterans, a population burdened with high rates of multiple chronic conditions. METHOD Self-reported outcomes, including standardized survey measures, were collected at pretest, posttest, and 2-month follow-up from 77 participants across 15 groups at four VA sites. Random intercept mixed-model regressions were used to analyze data. RESULTS Results from this initial study showed high satisfaction with the program and facilitators, and high attendance. There were significant pre-post gains in self-care attitudes and behaviors, patient motivation, meaning and purpose, mental health, perceived stress, goal progress, and goal-specific hope. Outcomes were maintained at 2-month follow-up for patient motivation, perceived stress, goal-specific hope, and goal progress. Significant gains were observed in health care empowerment and physical health from pretest to follow-up. CONCLUSIONS Preliminary findings support the efficacy of TCMLH, a Whole Health group-based program that emphasizes patient empowerment, self-care practices, and peer support. Future research priorities include a rigorous evaluation with a larger sample size and control group to assess effectiveness.
Collapse
Affiliation(s)
- Melissa Abadi
- Pacific Institute for Research and Evaluation, Louisville, KY, USA
| | - Bonnie Richard
- Pacific Institute for Research and Evaluation, Louisville, KY, USA
| | - Steve Shamblen
- Pacific Institute for Research and Evaluation, Louisville, KY, USA
| | | | | | - Barbara Bokhour
- Center for Healthcare Organization and Implementation Research, Bedford, MA, USA.,Boston University School of Public Health, Boston, MA, USA
| | - Rachel Bauer
- Pacific Institute for Research and Evaluation, Louisville, KY, USA
| | - David Rychener
- Pacific Institute for Research and Evaluation, Louisville, KY, USA
| |
Collapse
|
7
|
Affiliation(s)
- G. Jasuja
- VA HSR&D Center for Healthcare Organization and Implementation Research (CHOIR) Bedford MA United States
| | - R. Engle
- Center for Healthcare Organization and Implementation Research VA Boston Healthcare System Boston MA United States
| | - A. Skolnik
- VA HSR&D Center for Healthcare Organization and Implementation Research (CHOIR) Bedford MA United States
| | - A. Rose
- Boston University School of Medicine Boston United States
| | - A. Male
- Center for Healthcare Organization and Implementation Research VA Boston Healthcare System Boston MA United States
| | - B. Bokhour
- VA HSR&D Center for Healthcare Organization and Implementation Research (CHOIR) Bedford MA United States
| |
Collapse
|
8
|
Bokhour B, Gelman H, Gaj L, Thomas E, Barker A, Whittington M, Douglas J, Defaccio R, Taylor S, Zeliadt S. Addressing Consumer and Patients’ Preferences and Needs Whole Health System of Care Improves Health and Well‐Being and Reduces Opioid Use for Veterans with Chronic Pain. Health Serv Res 2020. [DOI: 10.1111/1475-6773.13331] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- B. Bokhour
- ENRM VA Medical Center Bedford MA United States
- School of Public Health Boston University Boston MA United States
| | - H. Gelman
- VA Puget Sound Health Care System Seattle WA United States
| | - L. Gaj
- ENRM VA Medical Center Bedford MA United States
| | - E. Thomas
- VA Puget Sound Health Care System Seattle WA United States
| | - A. Barker
- ENRM VA Medical Center Bedford MA United States
| | - M. Whittington
- VA Eastern Colorado Health Care System Aurora CO United States
- University of Colorado Anschutz Medical Campus Aurora CO United States
| | - J. Douglas
- VA Puget Sound Health Care System Seattle WA United States
| | - R. Defaccio
- VA Puget Sound Health Care System Seattle WA United States
| | - S. Taylor
- VA Greater Los Angeles Healthcare System Los Angeles CA United States
- Fielding School of Public Health University of California Los Angeles Los Angeles CA United States
| | - S. Zeliadt
- VA Puget Sound Health Care System Seattle WA United States
- University of Washington Seattle WA United States
| |
Collapse
|
9
|
Gunn C, Bernstein J, Bokhour B, McCloskey L. Narratives of Gestational Diabetes Provide a Lens to Tailor Postpartum Prevention and Monitoring Counseling. J Midwifery Womens Health 2020; 65:681-687. [PMID: 32568461 DOI: 10.1111/jmwh.13122] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 03/02/2020] [Accepted: 03/10/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Women with gestational diabetes mellitus (GDM) have a marked increased risk of early onset type 2 diabetes, but less than half initiate postpartum glucose testing or connect with a primary care provider for continued follow-up after giving birth. This study analyzed women's narratives about their GDM-affected pregnancies to (1) identify different patterns (narrative archetypes) that capture the GDM experience; (2) explore how these patterns relate to awareness of ongoing risk after pregnancy and affect participation in self-care, monitoring, and preventive health care going forward; and (3) explore the use of identified patterns to tailor conversations with patients during prenatal and postpartum care to their actual perceptions and concerns about future risk. METHODS Open-ended interviews elicited women's experiences and perspectives about GDM and its management. A narrative analysis first identified segments of text related to risk and behaviors and then applied Frank's narrative archetypes (restitution, chaos, quest) as an interpretive lens. RESULTS Interviews were completed in English (n = 15), Spanish (n = 7), and Haitian Creole (n = 7). We found distinct patterns: stories of restitution (n = 13), quest (n = 4), chaos (n = 4), and mixed narratives (n = 7). Using these archetypes, we found differences in how women respond to challenges related to disease complexity, treatment, and future risks. These patterns led to marked differences in the steps women took to prevent early onset type 2 diabetes. DISCUSSION Frank's narrative types provided insight into women's responses to clinical protocols, health care advice, and subsequent prevention actions. A restitution pattern may result in premature closure and lack of awareness of risk. Similarly, a chaos pattern may contribute to a sense of helplessness to implement follow-up recommendations, despite risk awareness. Understanding these patterns can help clinicians tailor individualized support as women transition from GDM with its focus on a healthy fetus and newborn to preventive self-care to protect their health.
Collapse
Affiliation(s)
- Christine Gunn
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, Massachusetts.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Judith Bernstein
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts.,Department of Emergency Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Barbara Bokhour
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts.,Center for Health Quality, Outcomes and Economic Research at the Bedford Veterans Affairs, Boston, Massachusetts
| | - Lois McCloskey
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
| |
Collapse
|
10
|
Gunn CM, Bokhour B, Parker VA, Parker PA, Blakeslee S, Bandos H, Holmberg C. Exploring Explanatory Models of Risk in Breast Cancer Risk Counseling Discussions: NSABP/NRG Oncology Decision-Making Project 1. Cancer Nurs 2020; 42:3-11. [PMID: 28661894 PMCID: PMC5745305 DOI: 10.1097/ncc.0000000000000517] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Explanatory models represent patient understanding of etiology, pathophysiology, illness, symptoms, and treatments, but little attention has been paid to how they are used by patients "at risk" for future disease. OBJECTIVE The aims of this study were to elucidate what constitutes an explanatory model of risk and to describe explanatory models of risk related to developing breast cancer. METHODS Thirty qualitative interviews with women identified as at an increased risk for breast cancer were conducted. Interviews were coded to identify domains of explanatory models of risk using a priori codes derived from the explanatory model of illness framework. Within each domain, a grounded thematic analysis described participants' explanatory models related to breast cancer risk. RESULTS The domains of treatment and etiology remained similar in a risk context compared with illness, whereas course of illness, symptoms, and pathophysiology differed. We identified a new, integrative concept relative to other domains within explanatory models of risk: social comparisons, which was dominant in risk perhaps due to the lack of physical experiences associated with being "at risk." CONCLUSIONS Developing inclusive understandings of risk and its treatment is key to developing a framework for the care of high-risk patients that is both evidence based and sensitive to patient preferences. IMPLICATIONS FOR PRACTICE The concept of "social comparisons" can assist healthcare providers in understanding women's decision making under conditions of risk. Ensuring that healthcare providers understand patient perceptions of risk is important because it relates to patient decision making, particularly due to an increasing focus on risk assessment in cancer.
Collapse
Affiliation(s)
- Christine M Gunn
- Author Affiliations: Women's Health Unit, Section of General Internal Medicine, Boston University School of Medicine (Dr Gunn); Department of Health Law, Policy and Management, Boston University School of Public Health (Drs Gunn, Bokhour, and V.A. Parker), Massachusetts; Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York (Dr P.A. Parker); NRG Oncology, and The University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Bandos); and Institute of Public Health, Charité-Universitätsmedizin, Berlin, Germany (Dr Holmberg and Ms Blakeslee)
| | | | | | | | | | | | | |
Collapse
|
11
|
Wachterman MW, Leveille T, Keating NL, Simon SR, Waikar SS, Bokhour B. Nephrologists' emotional burden regarding decision-making about dialysis initiation in older adults: a qualitative study. BMC Nephrol 2019; 20:385. [PMID: 31651262 PMCID: PMC6814056 DOI: 10.1186/s12882-019-1565-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 12/14/2018] [Accepted: 09/26/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Conservative management, an approach to treating end-stage kidney disease without dialysis, while generally associated with shorter life expectancy than treatment with dialysis, is associated with fewer hospitalizations, better functional status and, potentially, better quality of life. Conservative management is a well-established treatment approach in a number of Western countries, including the United Kingdom (U.K.). In contrast, despite clinical practice guidelines in the United States (U.S.) recommending that nephrologists discuss all treatment options, including conservative management, with stage 4 and 5 chronic kidney disease patients, studies suggest that this rarely occurs. Therefore, we explored U.S. nephrologists' approaches to decision-making about dialysis and perspectives on conservative management among older adults. METHODS We conducted a qualitative research study. We interviewed 20 nephrologists - 15 from academic centers and 5 from community practices - utilizing a semi-structured interview guide containing open-ended questions. Interview transcripts were analyzed using grounded thematic analysis in which codes were generated inductively and iteratively modified, and themes were identified. Transcripts were coded independently by two investigators, and interviews were conducted until thematic saturation. RESULTS Twenty nephrologists (85% white, 75% male, mean age 50) participated in interviews. We found that decision-making about dialysis initiation in older adults can create emotional burden for nephrologists. We identified four themes that reflected factors that contribute to this emotional burden including nephrologists' perspectives that: 1) uncertainty exists about how a patient will do on dialysis, 2) the alternative to dialysis is death, 3) confronting death is difficult, and 4) patients do not regret initiating dialysis. Three themes revealed different decision-making strategies that nephrologists use to reduce this emotional burden: 1) convincing patients to "just do it" (i.e. dialysis), 2) shifting the decision-making responsibility to patients, and 3) utilizing time-limited trials of dialysis. CONCLUSIONS A decision not to start dialysis and instead pursue conservative management can be emotionally burdensome for nephrologists for a number of reasons including clinical uncertainty about prognosis on dialysis and discomfort with death. Nephrologists' attempts to reduce this burden may be reflected in different decision-making styles - paternalistic, informed, and shared decision-making. Shared decision-making may relieve some of the emotional burden while preserving patient-centered care.
Collapse
Affiliation(s)
- Melissa W. Wachterman
- Section of General Internal Medicine, Veterans Affairs Boston Healthcare System, 150 South Huntington Ave., Bldg. 9, Boston, MA 02130 USA
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA USA
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA USA
- Harvard Medical School, Boston, MA USA
| | | | - Nancy L. Keating
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA USA
- Harvard Medical School, Boston, MA USA
- Department of Health Care Policy, Harvard Medical School, Boston, MA USA
| | - Steven R. Simon
- Section of General Internal Medicine, Veterans Affairs Boston Healthcare System, 150 South Huntington Ave., Bldg. 9, Boston, MA 02130 USA
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA USA
- Harvard Medical School, Boston, MA USA
| | - Sushrut S. Waikar
- Harvard Medical School, Boston, MA USA
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA USA
| | - Barbara Bokhour
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA USA
- Center for Healthcare Organization and Implementation of Research, Edith Nourse Rogers Memorial VA Healthcare System, Bedford, MA USA
| |
Collapse
|
12
|
Gunn CM, Bokhour B, Battaglia TA, Silliman RA, Hanchate A. False-positive mammography and its association with health service use. Am J Manag Care 2018; 24:131-138. [PMID: 29553275] [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] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES A false-positive mammogram can result in anxiety, distress, and increased perceptions of breast cancer risk, potentially changing how women utilize healthcare. This study examined whether having an abnormal mammogram, considered a proxy for elevated risk perception, was associated with greater future health service use (outpatient visits and referrals). STUDY DESIGN A retrospective cohort study using electronic health record data, spanning 2008 to 2012, from Boston Medical Center, a safety-net hospital. METHODS We grouped 3920 women aged 40 to 75 years receiving primary care and who had a mammogram between 2010 and 2011 into 3 categories: false-positive mammogram at index date; previous false positive, but normal index mammogram; and no history of false-positive mammograms. We contrasted the longitudinal changes in outpatient visits and provider referrals, before versus after the index mammogram, between women with false-positive mammogram and those without using Poisson regression models with a difference-in-differences specification. Clinical, visit, and demographic data were obtained from the institutional clinical data warehouse. RESULTS Adjusting for baseline differences in sociodemographic characteristics across risk groups and for secular changes between pre- and postindex periods, a current false-positive mammogram was associated with an 18% increase in overall outpatient visits (incidence rate ratio [IRR], 1.18; 95% CI, 1.07-1.51), but no corresponding increase in provider referrals (IRR, 1.15; 95% CI, 0.99‑1.34), relative to never having a false positive. A previous false-positive mammogram had no associated change in outpatient utilization (IRR, 0.99; 95% CI, 0.91-1.07). CONCLUSIONS Providers should discuss the implications of mammography findings at the time of screening to help mitigate potential detrimental effects and promote appropriate engagement in health services.
Collapse
Affiliation(s)
- Christine M Gunn
- Women's Health Unit, Boston Medical Center, 801 Massachusetts Ave, 1st Fl, Boston, MA 02118.
| | | | | | | | | |
Collapse
|
13
|
Chambers D, Simpson L, Neta G, Schwarz UVT, Percy-Laurry A, Aarons GA, Neta G, Brownson R, Vogel A, Stirman SW, Sherr K, Sturke R, Norton WE, Varley A, Chambers D, Vinson C, Klesges L, Heurtin-Roberts S, Massoud MR, Kimble L, Beck A, Neely C, Boggs J, Nichols C, Wan W, Staab E, Laiteerapong N, Moise N, Shah R, Essock S, Handley M, Jones A, Carruthers J, Davidson K, Peccoralo L, Sederer L, Molfenter T, Scudder A, Taber-Thomas S, Schaffner K, Herschell A, Woodward E, Pitcock J, Ritchie M, Kirchner J, Moore JE, Khan S, Rashid S, Park J, Courvoisier M, Straus S, Blonigen D, Rodriguez A, Manfredi L, Nevedal A, Rosenthal J, Smelson D, Timko C, Stadnick N, Regan J, Barnett M, Lau A, Brookman-Frazee L, Guerrero E, Fenwick K, Kong Y, Aarons G, Lengnick-Hall R, Fenwick K, Henwood B, Sayer N, Rosen C, Orazem R, Smith B, Rosen C, Zimmerman L, Lounsbury D, Rosen C, Kimerling R, Trafton JA, Lindley S, Bhargava R, Roberts H, Gibson L, Escobar GJ, Liu V, Turk B, Ragins A, Kipnis P, Gruszkowski AK, Kennedy MW, Drobek ER, Turgeman L, Milicevic AS, Hubert TL, Myaskovsky L, Tjader YC, Monte RJ, Sapnas KG, Ramly E, Lauver DR, Bartels CM, Elnahal S, Ippolito A, Peabody H, Clancy C, Cebul R, Love T, Einstadter D, Bolen S, Watts B, Yakovchenko V, Park A, Lukesh W, Miller DR, Thornton D, Drainoni ML, Gifford AL, Smith S, Kyle J, Bauer MS, Eisenberg D, Liebrecht C, Barbaresso M, Kilbourne A, Park E, Perez G, Ostroff J, Greene S, Parchman M, Austin B, Larson E, Ferreri S, Shea C, Smith M, Turner K, Bacci J, Bigham K, Curran G, Ferreri S, Frail C, Hamata C, Jankowski T, Lantaff W, McGivney MS, Snyder M, McCullough M, Gillespie C, Petrakis BA, Jones E, Park A, Lukas CV, Rose A, Shoemaker SJ, Curran G, Thomas J, Teeter B, Swan H, Teeter B, Thomas J, Curran G, Balamurugan A, Lane-Fall M, Beidas R, Di Taranti L, Buddai S, Hernandez ET, Watts J, Fleisher L, Barg F, Miake-Lye I, Olmos T, Chuang E, Rodriguez H, Kominski G, Yano B, Shortell S, Hook M, Fleisher L, Fiks A, Halkyard K, Gruver R, Sykes E, Vesco K, Beadle K, Bulkley J, Stoneburner A, Leo M, Clark A, Smith J, Smyser C, Wolf M, Trivedi S, Hackett B, Rao R, Cole FS, McGonigle R, Donze A, Proctor E, Mathur A, Sherr K, Gakidou E, Gloyd S, Audet C, Salato J, Vermund S, Amico R, Smith S, Nyirandagijimana B, Mukasakindi H, Rusangwa C, Franke M, Raviola G, Cummings M, Goldberg E, Mwaka S, Kabajaasi O, Cattamanchi A, Katamba A, Jacob S, Kenya-Mugisha N, Davis JL, Reed J, Ramaswamy R, Parry G, Sax S, Kaplan H, Huang KY, Cheng S, Yee S, Hoagwood K, McKay M, Shelley D, Ogedegbe G, Brotman LM, Kislov R, Humphreys J, Harvey G, Wilson P, Lieberthal R, Payton C, Sarfaty M, Valko G, Bolton R, Lukas CV, Hartmann C, Mueller N, Holmes SK, Bokhour B, Ono S, Crabtree B, Gordon L, Miller W, Balasubramanian B, Solberg L, Cohen D, McGraw K, Blatt A, Pittman D, McCullough M, Hartmann C, Kales H, Berlowitz D, Hudson T, Gillespie C, Helfrich C, Finley E, Garcia A, Rosen K, Tami C, McGeary D, Pugh MJ, Potter JS, Helfrich C, Stryczek K, Au D, Zeliadt S, Sayre G, Gillespie C, Leeman J, Myers A, Grant J, Wangen M, Queen T, Morshed A, Dodson E, Tabak R, Brownson RC, Sheldrick RC, Mackie T, Hyde J, Leslie L, Yanovitzky I, Weber M, Gesualdo N, Kristensen T, Stanick C, Halko H, Dorsey C, Powell B, Weiner B, Lewis C, Powell B, Weiner B, Stanick C, Halko H, Dorsey C, Lewis C, Weiner B, Dorsey C, Stanick C, Halko H, Powell B, Lewis C, Stirman SW, Carreno P, Mallard K, Masina T, Monson C, Swindle T, Curran G, Patterson Z, Whiteside-Mansell L, Hanson R, Saunders B, Schoenwald S, Moreland A, Birken S, Powell B, Presseau J, Miake-Lye I, Ganz D, Mittman B, Delevan D, Finley E, Hill JN, Locatelli S, Bokhour B, Fix G, Solomon J, Mueller N, Lavela SL, Scott V, Scaccia J, Alia K, Skiles B, Wandersman A, Wilson P, Sales A, Roberts M, Kennedy A, Chambers D, Khoury MJ, Sperber N, Orlando L, Carpenter J, Cavallari L, Denny J, Elsey A, Fitzhenry F, Guan Y, Horowitz C, Johnson J, Madden E, Pollin T, Pratt V, Rakhra-Burris T, Rosenman M, Voils C, Weitzel K, Wu R, Damschroder L, Lu C, Ceccarelli R, Mazor KM, Wu A, Rahm AK, Buchanan AH, Schwartz M, McCormick C, Manickam K, Williams MS, Murray MF, Escoffery NC, Lebow-Skelley E, Udelson H, Böing E, Fernandez ME, Wood RJ, Mullen PD, Parekh J, Caldas V, Stuart EA, Howard S, Thomas G, Jennings JM, Torres J, Markham C, Shegog R, Peskin M, Rushing SC, Gaston A, Gorman G, Jessen C, Williamson J, Ward D, Vaughn A, Morris E, Mazzucca S, Burney R, Ramanadhan S, Minsky S, Martinez-Dominguez V, Viswanath K, Barker M, Fahim M, Ebnahmady A, Dragonetti R, Selby P, Farrell M, Tompkins J, Norton W, Rapport K, Hargreaves M, Lee R, Ramanadhan S, Kruse G, Deutsch C, Lanier E, Gray A, Leppin A, Christiansen L, Schaepe K, Egginton J, Branda M, Gaw C, Dick S, Montori V, Shah N, Korn A, Hovmand P, Fullerton K, Zoellner N, Hennessy E, Tovar A, Hammond R, Economos C, Kay C, Gazmararian J, Vall E, Cheung P, Franks P, Barrett-Williams S, Weiss P, Kay C, Gazmararian J, Hamilton E, Cheung P, Kay C, Vall E, Gazmararian J, Marques L, Dixon L, Ahles E, Valentine S, Monson C, Shtasel D, Stirman SW, Parra-Cardona R, Northridge M, Kavathe R, Zanowiak J, Wyatt L, Singh H, Islam N, Monteban M, Freedman D, Bess K, Walsh C, Matlack K, Flocke S, Baily H, Harden S, Ramalingam N, Alia K, Scaccia J, Scott V, Ramaswamy R, Wandersman A, Gold R, Cottrell E, Hollombe C, Dambrun K, Bunce A, Middendorf M, Dearing M, Cowburn S, Mossman N, Melgar G, Hopfer S, Hecht M, Ray A, Miller-Day M, BeLue R, Zimet G, Nelson EL, Kuhlman S, Doolittle G, Krebill H, Spaulding A, Levin T, Sanchez M, Landau M, Escobar P, Minian N, Selby P, Noormohamed A, Zawertailo L, Baliunas D, Giesbrecht N, Le Foll B, Samokhvalov A, Meisel Z, Polsky D, Schackman B, Mitchell J, Sevarino K, Gimbel S, Mwanza M, Nisingizwe MP, Michel C, Hirschhorn L, Lane-Fall M, Beidas R, Di Taranti L, Choudhary M, Thonduparambil D, Fleisher L, Barg F, Meissner P, Pinnock H, Barwick M, Carpenter C, Eldridge S, Grandes-Odriozola G, Griffiths C, Rycroft-Malone J, Murray E, Patel A, Sheikh A, Taylor SJC, Mittman B, Guilliford M, Pearce G, Korngiebel D, West K, Burke W, Hannon P, Harris J, Hammerback K, Kohn M, Chan GKC, Mafune R, Parrish A, Helfrich C, Beresford S, Pike KJ, Shelton R, Jandorf L, Erwin D, Charles TA, Parchman M, Baldwin LM, Ike B, Fickel J, Lind J, Cowper D, Fleming M, Sadler A, Dye M, Katzburg J, Ong M, Tubbesing S, McCullough M, Simmons M, Yakovchenko V, Harnish A, Gabrielian S, McInnes K, Smith J, Smelson D, Ferrand J, Torres E, Green A, Aarons G, Bradbury AR, Patrick-Miller LJ, Egleston BL, Domchek SM, Olopade OI, Hall MJ, Daly MB, Fleisher L, Grana G, Ganschow P, Fetzer D, Brandt A, Chambers R, Clark DF, Forman A, Gaber RS, Gulden C, Horte J, Long J, Lucas T, Madaan S, Mattie K, McKenna D, Montgomery S, Nielsen S, Powers J, Rainey K, Rybak C, Seelaus C, Stoll J, Stopfer J, Yao XS, Savage M, Miech E, Damush T, Rattray N, Myers J, Homoya B, Winseck K, Klabunde C, Langer D, Aggarwal A, Neilson E, Gunderson L, Escobar GJ, Gardner M, O’Sulleabhain L, Kroenke C, Liu V, Kipnis P. Proceedings from the 9th annual conference on the science of dissemination and implementation. Implement Sci 2017. [PMCID: PMC5414666 DOI: 10.1186/s13012-017-0575-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
14
|
Appenheimer AB, Bokhour B, McInnes DK, Richardson KK, Thurman AL, Beck BF, Vaughan-Sarrazin M, Asch SM, Midboe AM, Taylor T, Dvorin K, Gifford AL, Ohl ME. Should Human Immunodeficiency Virus Specialty Clinics Treat Patients With Hypertension or Refer to Primary Care? An Analysis of Treatment Outcomes. Open Forum Infect Dis 2017; 4:ofx005. [PMID: 28480278 DOI: 10.1093/ofid/ofx005] [Citation(s) in RCA: 5] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 01/19/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Care for people with human immunodeficiency virus (HIV) increasingly focuses on comorbidities, including hypertension. Evidence indicates that antiretroviral therapy and opportunistic infections are best managed by providers experienced in HIV medicine, but it is unclear how to structure comorbidity care. Approaches include providing comorbidity care in HIV clinics ("consolidated care") or combining HIV care with comorbidity management in primary care clinics ("shared care"). We compared blood pressure (BP) control in HIV clinics practicing consolidated care versus shared care. METHODS We created a national cohort of Veterans with HIV and hypertension receiving care in HIV clinics in Veterans Administration facilities and merged these data with a survey asking HIV providers how they delivered hypertension care (5794 Veterans in 73 clinics). We defined BP control as BP ≤140/90 mmHg on the most recent measure. We compared patients' likelihood of experiencing BP control in clinics offering consolidated versus shared care, adjusting for patient and clinic characteristics. RESULTS Forty-two of 73 clinics (57.5%) practiced consolidated care for hypertension. These clinics were larger and more likely to use multidisciplinary teams. The unadjusted frequency of BP control was 65.6% in consolidated care clinics vs 59.4% in shared care clinics (P < .01). The likelihood of BP control remained higher for patients in consolidated care clinics after adjusting for patient and clinic characteristics (odds ratio, 1.32; 95% confidence interval, 1.04-1.68). CONCLUSIONS Patients were more likely to experience BP control in clinics reporting consolidated care compared with clinics reporting shared care. For shared-care clinics, improving care coordination between HIV and primary care clinics may improve outcomes.
Collapse
Affiliation(s)
- A Ben Appenheimer
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Barbara Bokhour
- Boston University School of Public Health, Department of Health Law, Policy, and Management, Massachusetts.,Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Healthcare System, Bedford, Massachusetts
| | - D Keith McInnes
- Boston University School of Public Health, Department of Health Law, Policy, and Management, Massachusetts.,Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Healthcare System, Bedford, Massachusetts
| | - Kelly K Richardson
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa
| | - Andrew L Thurman
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa
| | - Brice F Beck
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa
| | - Mary Vaughan-Sarrazin
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Steven M Asch
- Division of General Medical Science, Department of Medicine, Stanford University School of Medicine, Palo Alto, California.,Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Amanda M Midboe
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Thom Taylor
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Kelly Dvorin
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Healthcare System, Bedford, Massachusetts
| | - Allen L Gifford
- Boston University School of Public Health, Department of Health Law, Policy, and Management, Massachusetts.,Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Healthcare System, Bedford, Massachusetts
| | - Michael E Ohl
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| |
Collapse
|
15
|
Wagner TH, Taylor T, Cowgill E, Asch SM, Su P, Bokhour B, Durfee J, Martinello RA, Maguire E, Elwy AR. Intended and unintended effects of large-scale adverse event disclosure: a controlled before-after analysis of five large-scale notifications. BMJ Qual Saf 2016; 24:295-302. [PMID: 25882785 PMCID: PMC4413746 DOI: 10.1136/bmjqs-2014-003800] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND OBJECTIVE How patients respond to being notified of a large-scale adverse event (LSAE), such as improper sterilisation of medical equipment that exposes them to bloodborne pathogens, is not well known. The objective of this study was to determine, using administrative data, the intended and unintended consequences of patient notification following a LSAE. METHODS We examined five LSAEs where patients may have been inadvertently exposed to hepatitis C virus (HCV), HIV, and hepatitis B virus (HBV). A total of 9638 cases were identified at five Department of Veteran Affairs (VA) medical facilities between 2009 and 2012. We identified controls at the same facility prior to the exposure period and at neighbouring facilities (n=45,274). Difference-in-differences models were used with Veterans Health Administration (VHA) and Medicare data to examine infectious disease testing rates and subsequent utilisation patterns. RESULTS Receipt of a LSAE notification was associated with a 73.2, 76.8 and 77.1 adjusted percentage point increase for HCV, HIV and HBV testing, respectively (all p<0.001). Compared with white patients, African-American patients were significantly less likely to return to VHA for follow-up testing. Patients exposed to a dental LSAE reduced their use of preventive and restorative dental care over the subsequent year, but they eventually came back to VHA for dental services 18-months post exposure. CONCLUSIONS The majority of patients notified of a LSAE responded by getting tested for HCV, HIV and HBV, although there remains room for improvement. Potential exposure to a LSAE was associated with increased odds of subsequently using non-VA facilities, but the size and timing of the shift depended on the type of care.
Collapse
Affiliation(s)
- Todd H Wagner
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA Department of Health Research and Policy, Stanford University, Stanford, California, USA
| | - Thomas Taylor
- Department of Health Research and Policy, Stanford University, Stanford, California, USA
| | - Elizabeth Cowgill
- Department of Health Research and Policy, Stanford University, Stanford, California, USA
| | - Steven M Asch
- Department of Health Research and Policy, Stanford University, Stanford, California, USA Division of General Internal Medicine, Stanford University, Stanford California, USA
| | - Pon Su
- Department of Health Research and Policy, Stanford University, Stanford, California, USA
| | - Barbara Bokhour
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, USA Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Janet Durfee
- Veterans Health Administration, Office of Public Health, Washington DC, USA
| | - Richard A Martinello
- Veterans Health Administration, Office of Public Health, Washington DC, USA Yale School of Medicine, Departments of Internal Medicine and Pediatrics, New Haven, Conneticut, USA
| | - Elizabeth Maguire
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, USA
| | - A Rani Elwy
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, USA Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
16
|
Appenheimer AB, Bokhour B, Mcinnes D, Richardson K, Midboe A, Gifford A, Asch S, Dvorin K, Thurman A, Vaughan-Sarrazin M, Ohl M. HIV Specialty Clinics as Primary Care Providers: Relationship to Hypertension Outcomes. Open Forum Infect Dis 2016. [DOI: 10.1093/ofid/ofw172.1227] [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: 11/13/2022] Open
Affiliation(s)
- A Ben Appenheimer
- University of Iowa Carver College of Medicine, Iowa City, IA
- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Medical Center, Iowa City, IA
| | - Barbara Bokhour
- Center for Healthcare Organization & Implementation Research (CHOIR), Edith Nourse Rogers Memorial VA Healthcare System, Bedford, MA
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA
| | - Donald Mcinnes
- Center for Healthcare Organization & Implementation Research (CHOIR), Edith Nourse Rogers Memorial VA Healthcare System, Bedford, MA
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA
| | - Kelly Richardson
- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Medical Center, Iowa City, IA
| | - Amanda Midboe
- Center for Innovation to Implementation, VA Palo Alto Medical Care System, Menlo Park, CA
| | - Allen Gifford
- Center for Healthcare Organization & Implementation Research (CHOIR), Edith Nourse Rogers Memorial VA Healthcare System, Bedford, MA
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA
| | - Steven Asch
- Center for Innovation to Implementation, VA Palo Alto Medical Care System, Menlo Park, CA
| | - Kelly Dvorin
- Center for Healthcare Organization & Implementation Research (CHOIR), Edith Nourse Rogers Memorial VA Healthcare System, Bedford, MA
| | - Andrew Thurman
- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Medical Center, Iowa City, IA
| | - Mary Vaughan-Sarrazin
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Michael Ohl
- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Medical Center, Iowa City, IA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| |
Collapse
|
17
|
Richardson KK, Bokhour B, McInnes DK, Yakovchenko V, Okwara L, Midboe AM, Skolnik A, Vaughan-Sarrazin M, Asch SM, Gifford AL, Ohl ME. Racial Disparities in HIV Care Extend to Common Comorbidities: Implications for Implementation of Interventions to Reduce Disparities in HIV Care. J Natl Med Assoc 2016; 108:201-210.e3. [PMID: 27979005 DOI: 10.1016/j.jnma.2016.08.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 07/13/2016] [Accepted: 08/08/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Prior studies have described racial disparities in the quality of care for persons with HIV infection, but it is unknown if these disparities extend to common comorbid conditions. To inform implementation of interventions to reduce disparities in HIV care, we examined racial variation in a set of quality measures for common comorbid conditions among Veterans in care for HIV in the United States. METHOD The cohort included 23,974 Veterans in care for HIV in 2013 (53.4% black; 46.6% white). Measures extracted from electronic health record and administrative data were receipt of combination antiretroviral therapy (cART), HIV viral control (serum RNA < 200 copies/ml among those on cART), hypertension control (blood pressure < 140/90 mm Hg among those with hypertension), diabetes control (hemoglobin A1C < 9% among those with diabetes), lipid monitoring, guideline-concordant antidepressant prescribing, and initiation and engagement in substance use disorder (SUD) treatment. Black persons were less likely than their white counterparts to receive cART (90.2% vs. 93.2%, p<.001), and experience viral control (84.6% vs. 91.3%, p<.001), hypertension control (61.9% vs. 68.3%, p<.001), diabetes control (85.5% vs. 89.5%, p<.001), and lipid monitoring (81.5% vs. 85.2%, p<.001). Initiation and engagement in SUD treatment were similar among blacks and whites. Differences remained after adjusting for age, comorbidity, retention in HIV care, and a measure of neighborhood social disadvantage created from census data. SIGNIFICANCE Implementation of interventions to reduce racial disparities in HIV care should comprehensively address and monitor processes and outcomes of care for key comorbidities.
Collapse
Affiliation(s)
- Kelly K Richardson
- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Medical Center, 601 Hwy 6 West, Iowa City, IA 52246, USA.
| | - Barbara Bokhour
- Center for Healthcare Organization & Implementation Research (CHOIR), Edith Nourse Rogers Memorial VA Healthcare System, 200 Springs Road, Bedford, MA 01730, USA; Boston University School of Public Health, Department of Health Law, Policy, and Management, 715 Albany St, Boston, MA 02118, USA
| | - D Keith McInnes
- Center for Healthcare Organization & Implementation Research (CHOIR), Edith Nourse Rogers Memorial VA Healthcare System, 200 Springs Road, Bedford, MA 01730, USA; Boston University School of Public Health, Department of Health Law, Policy, and Management, 715 Albany St, Boston, MA 02118, USA
| | - Vera Yakovchenko
- Center for Healthcare Organization & Implementation Research (CHOIR), Edith Nourse Rogers Memorial VA Healthcare System, 200 Springs Road, Bedford, MA 01730, USA; Boston University School of Public Health, Department of Health Law, Policy, and Management, 715 Albany St, Boston, MA 02118, USA
| | - Leonore Okwara
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 3801 Miranda Ave, Palo Alto, CA 94304, USA
| | - Amanda M Midboe
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 3801 Miranda Ave, Palo Alto, CA 94304, USA
| | - Avy Skolnik
- Center for Healthcare Organization & Implementation Research (CHOIR), Edith Nourse Rogers Memorial VA Healthcare System, 200 Springs Road, Bedford, MA 01730, USA
| | - Mary Vaughan-Sarrazin
- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Medical Center, 601 Hwy 6 West, Iowa City, IA 52246, USA; Department of Internal Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Steven M Asch
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 3801 Miranda Ave, Palo Alto, CA 94304, USA; Division of General Medical Science, Department of Medicine, Stanford University School of Medicine, 875 Blake Wilbur Dr, Palo Alto, CA 94304, USA
| | - Allen L Gifford
- Center for Healthcare Organization & Implementation Research (CHOIR), Edith Nourse Rogers Memorial VA Healthcare System, 200 Springs Road, Bedford, MA 01730, USA; Boston University School of Public Health, Department of Health Law, Policy, and Management, 715 Albany St, Boston, MA 02118, USA
| | - Michael E Ohl
- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Medical Center, 601 Hwy 6 West, Iowa City, IA 52246, USA; Department of Internal Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA
| |
Collapse
|
18
|
Richardson K, Swan H, Mcinnes D, Yakochenko V, Okwara L, Midboe A, Bokhour B, Ohl M. Racial Disparities Extend to Common Comorbidities Among Persons in Care for HIV Infection. Open Forum Infect Dis 2015. [DOI: 10.1093/ofid/ofv131.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
19
|
Ohl M, Richardson K, Parker V, Swan H, Mcinnes D, Yakovchenko V, Midboe A, Bokhour B. HIV Viral Control and Comorbidity Control Are Not Highly Correlated at the Level of the HIV Clinic. Open Forum Infect Dis 2015. [DOI: 10.1093/ofid/ofv131.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
20
|
Gunn CM, Bokhour B, Battaglia TA, Blakeslee S, Holmberg C. Abstract B68: Explanatory models of risk: The role of social context in breast cancer risk perception and decision making. Cancer Epidemiol Biomarkers Prev 2015. [DOI: 10.1158/1538-7755.disp14-b68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Background: The current practice of counseling high-risk breast cancer patients using probabilistic risk estimates has not proven to be effective in engaging women, with less than 1% of eligible women participating in medical interventions to reduce breast cancer risk. Further, studies show that racial and ethnic minority women are under-represented in breast cancer prevention clinical trials (Cyrus-David, 2006), and they are less likely than whites to be aware of, discuss, or take chemoprevention agents (Kaplan et al., 2006). This study seeks to describe how a diverse group of women use explanatory models of risk to describe perceptions of breast cancer risk and make decisions about risk-reducing behaviors.
Methods: 30 in-depth, qualitative interviews were collected at two US academic hospitals as part of a National Surgical Adjuvant Breast and Bowel Project mixed-methods study to oversample for racial and ethnic minorities. Women identified to have an elevated risk of developing breast cancer were interviewed following risk counseling with a medical provider. A thematic analysis informed by grounded theory methods was conducted. The explanatory model framework (Kleinman, 1978) guided formation of codes around explanatory model topic areas (etiology, symptoms, pathophysiology, course of illness, and treatment). These explanatory model codes were supplemented with inductive codes developed through open coding related to beliefs about cancer, risk, health, and social context.
Results: Two key themes were identified as closely linked to women's explanatory models of risk: ‘risk perception’ and ‘control over risk’. These perceptions of risk and control were used to identify patterns in how women chose to manage their risk for breast cancer. Whether women had high or low perceptions of risk and control affected the ways in which they used explanatory models to describe their decisions. For example, women with perceptions of high risk and high control all discussed their social network as influential in modeling how they could reduce their own risk. These women adopted a variety of behaviors to gain control over risk, ranging from diet and exercise changes to the use of chemoprevention agents. Conversely, women with perceptions of high risk and low control based decisions much more closely on their general explanatory models of health, falling back on established philosophies in their decision-making. Women who opted for chemoprevention agents in this group discussed their philosophy of decision making as dependent on physician recommendations.
How women interpreted ‘symptoms’ of risk was also essential to women's descriptions of their participation in risk-reduction behaviors. Those women who perceived their risk to be high interpreted symptoms such as ADH, ALH, or LCIS as a disease that required medical intervention. On the other hand, women with perceptions of low risk interpreted these symptoms as in the normal course of bodily changes, contrasting with information provided by physicians suggesting an increased risk for breast cancer.
Discussion: There are important differences in how women use explanatory models of risk that contribute to the adoption of medical interventions. Risk counseling must address patient explanatory models, which influence both perceptions of risk and control over risk. These perceptions subsequently influence the ways in which women describe their decisions about participating in risk-reducing behaviors. New approaches are needed to address patient beliefs and perceptions about risk and prevention for breast cancer. Failing to acknowledge the experiences of patients threatens to marginalize minority groups from preventive care.
Citation Format: Christine M. Gunn, Barbara Bokhour, Tracy A. Battaglia, Sarah Blakeslee, Christine Holmberg. Explanatory models of risk: The role of social context in breast cancer risk perception and decision making. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr B68.
Collapse
|
21
|
Linsky A, Simon SR, Marcello TB, Bokhour B. Clinical provider perceptions of proactive medication discontinuation. Am J Manag Care 2015; 21:277-283. [PMID: 26014466] [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] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES Polypharmacy and adverse drug events lead to considerable healthcare costs and morbidity, yet there is little to guide clinical providers in the area of discontinuing medications that may not be necessary. We sought to understand providers' beliefs and attitudes about polypharmacy and medication discontinuation. STUDY DESIGN Qualitative study using semi-structured interviews of 20 providers with prescribing privileges at 2 US Veterans Affairs Medical Centers, from April 2012 to October 2012. METHODS Transcribed interviews were analyzed using grounded thematic analysis, a systematic approach to deriving qualitative themes from textual data. RESULTS We identified 10 themes within 4 domains of medication discontinuation. Within the first domain (medication factors), we identified 2 themes: 1) medication characteristics, and 2) uncertainties of why a patient was taking a particular drug. Within the second domain (patient factors), we identified 3 themes: 3) clinical picture of the patient, 4) clinicians' understanding of the patients' knowledge and beliefs, and 5) patients' adherence. Within the third domain (clinical provider factors), we identified 2 themes: 6) professional identity, and 7) providers' decisions related to their own beliefs about medications. Within the fourth domain (system factors), we identified 3 themes: 8) multiple providers, 9) workload, and 10) external directives and policies such as structural components of a healthcare system. CONCLUSIONS Provider decisions to discontinue medications are affected by factors at all levels of the clinical encounter. Our findings have implications for development and implementation of interventions to improve appropriate medication discontinuation via enhanced medication reviews, enriched patient-provider communication, and better system-level structures. This, in turn, may reduce the continued prescribing of potentially inappropriate medications that can lead to adverse outcomes or increased healthcare costs.
Collapse
Affiliation(s)
- Amy Linsky
- VA Boston Healthcare System, 150 S Huntington Ave, Bldg 9, Rm 425 (152G), Boston, MA 02130. E-mail:
| | | | | | | |
Collapse
|
22
|
Linsky A, Simon SR, Bokhour B. Patient perceptions of proactive medication discontinuation. Patient Educ Couns 2015; 98:220-225. [PMID: 25435516 DOI: 10.1016/j.pec.2014.11.010] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 10/09/2014] [Accepted: 11/08/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVE While many patients prefer fewer medications, decisions about medication discontinuation involve collaboration between patients and providers. We sought to identify patient perspectives on intentional medication discontinuation in order to optimize medication use. METHODS We conducted 20 interviews and two focus groups with a convenience sample of patients (22 men, 5 women; mean age 66 years) at two US Veterans Affairs Medical Centers. We queried patients' experiences with and attitudes toward taking multiple medications, preferences about taking fewer medications, and communication with their providers about stopping a medicine. Transcripts were analyzed qualitatively. RESULTS Three main themes emerged to create a conceptual model of medication discontinuation from the patient perspective: (1) conflicting views of medication, encompassing the sub-themes of desire for fewer medications, adherence, and specific versus general; (2) importance of patient-provider relationships, encompassing the sub-themes of trust, relying on expertise, shared decision making, and balancing multiple providers; and (3) limited experience with medication discontinuation. CONCLUSION Many patients who have a preference to take fewer medicines do not share their beliefs with providers and recall few instances of provider-initiated medication discontinuation. PRACTICE IMPLICATIONS Strengthening patient-provider relationships and eliciting patient attitudes about taking fewer medications may enable appropriate discontinuation of unnecessary medications.
Collapse
Affiliation(s)
- Amy Linsky
- Section of General Internal Medicine, VA Boston Healthcare System, Boston, USA; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System and ENRM Veterans Affairs Medical Center, Boston and Bedford , MA, USA; Section of General Internal Medicine, Boston Medical Center, Boston, USA; Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, USA.
| | - Steven R Simon
- Section of General Internal Medicine, VA Boston Healthcare System, Boston, USA; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System and ENRM Veterans Affairs Medical Center, Boston and Bedford , MA, USA; Section of General Internal Medicine, Boston Medical Center, Boston, USA; Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, USA.
| | - Barbara Bokhour
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System and ENRM Veterans Affairs Medical Center, Boston and Bedford , MA, USA; Department of Health Policy & Management, Boston University School of Public Health, Boston, USA.
| |
Collapse
|
23
|
McDoom MM, Bokhour B, Sullivan M, Drainoni ML. How older black women perceive the effects of stigma and social support on engagement in HIV care. AIDS Patient Care STDS 2015; 29:95-101. [PMID: 25494607 DOI: 10.1089/apc.2014.0184] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
As black women over age 50 represent a growing share of women living with HIV, understanding what helps them persist and engage in ongoing HIV care will become increasingly important. Delineating the specific roles of social support and stigma on HIV care experiences among this population remains unclear. We qualitatively examined how experiences with stigma and social support either facilitated or inhibited engagement in HIV care, from the perspective of older black women. Semi-structured interviews were conducted with 20 older black women currently receiving HIV care at primary care clinics in the Metropolitan Boston area. Women expressed that experiences with stigma and seeking support played an important role in evaluating the risks and benefits of engaging in care. Social support facilitated their ability to engage in care, while stigma interfered with their ability to engage in care throughout the course of their illness. Providers in particular, can facilitate engagement by understanding the changes in these women's lives as they struggle with stigma and disclosure while engaging in HIV care. The patient's experiences with social support and stigma and their perceptions about engagement are important considerations for medical teams to tailor efforts to engage older black women in regular HIV care.
Collapse
Affiliation(s)
- M. Maya McDoom
- Social Science Research Center, Mississippi State University, Starkville, Mississippi
- Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts
| | - Barbara Bokhour
- Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts
- Center for Healthcare Organization and Implementation Research, ENRM VA Hospital, Boston, Massachusetts
| | - Meg Sullivan
- Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts
| | - Mari-Lynn Drainoni
- Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts
- Center for Healthcare Organization and Implementation Research, ENRM VA Hospital, Boston, Massachusetts
- Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts
| |
Collapse
|
24
|
Rodrigues S, Bokhour B, Mueller N, Dell N, Osei-Bonsu PE, Zhao S, Glickman M, Eisen SV, Elwy AR. Impact of Stigma on Veteran Treatment Seeking for Depression. American Journal of Psychiatric Rehabilitation 2014. [DOI: 10.1080/15487768.2014.903875] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
25
|
Wilkinson J, Dreyfus D, Bowen D, Bokhour B. Patient and provider views on the use of medical services by women with intellectual disabilities. J Intellect Disabil Res 2013; 57:1058-1067. [PMID: 22974084 DOI: 10.1111/j.1365-2788.2012.01606.x] [Citation(s) in RCA: 5] [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] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND People with intellectual disabilities (ID) receive primary care in community-based practices and are encouraged to participate in the physician-patient relationship. However, the nature of this participation is not known. METHODS Qualitative data were analysed to obtain perspectives from patients and providers regarding clinic visits. Patient participants were recruited from community organisations, while physician participants were recruited from emails and phone calls to local and regional practices and a national and regional list serve. Analysis methods derived from grounded theory were used. RESULTS Twenty-seven women with ID and 22 family physicians were interviewed. Themes important to both groups included time, how the support worker should be used in the encounter and the nature of the physician-patient relationship. Patients expressed frustration at how little time they spent with their physician, and wished that physicians would speak directly to them instead of to their support worker. Physicians felt that patients with ID took too much time, and said that they preferred communicating with the support worker. The interviews also revealed unconscious biases about people with ID. CONCLUSIONS Patient participation is encouraged for people with ID, but is limited because of both physician and patient factors. Greater awareness of these factors may improve care for patients with ID.
Collapse
Affiliation(s)
- J Wilkinson
- Family Medicine, Boston University School of Medicine, Boston, MA, USA Community Health Sciences, Boston University School of Public Health, Boston, MA, USA Health Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | | | | | | |
Collapse
|
26
|
Anaya HD, Bokhour B, Feld J, Golden JF, Asch SM, Knapp H. Implementation of Routine Rapid HIV Testing Within the U.S. Department of Veterans Affairs Healthcare System. J Healthc Qual 2012; 34:7-14. [DOI: 10.1111/j.1945-1474.2011.00151.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
27
|
Dossa A, Bokhour B, Hoenig H. Care transitions from the hospital to home for patients with mobility impairments: patient and family caregiver experiences. Rehabil Nurs 2012; 37:277-85. [PMID: 23212952 DOI: 10.1002/rnj.047] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE Our study described patient and caregiver experiences with care transitions following hospital discharge to home for patients with mobility impairments receiving physical and occupational therapy. METHODS The study was a qualitative longitudinal interview study. Interviews were conducted at 2 weeks, 1 month, and 2 months post discharge. Participants were men, Caucasian, between 70 and 88 years old, and had either a medical or surgical diagnosis. RESULTS Breakdowns in communication in four domains impacted continuity of care and patient recovery: (a) Poor communication between patients and providers regarding ongoing care at home, (b) Whom to contact post discharge, (c) Provider response to phone calls following discharge, and (d) Provider-provider communication. DISCUSSION AND CONCLUSIONS Improved systems are needed to address patient concerns after discharge from the hospital, specifically for patients with mobility impairments. Better communication between patients, hospital providers, and home care providers is needed to improve care coordination, facilitate recovery at home, and prevent potential adverse outcomes.
Collapse
Affiliation(s)
- Almas Dossa
- Center for Health Quality, Outcomes and Economic Research, Bedford, VA, USA.
| | | | | |
Collapse
|
28
|
Wilkinson J, Dreyfus D, Cerreto M, Bokhour B. "Sometimes I feel overwhelmed": educational needs of family physicians caring for people with intellectual disability. Intellect Dev Disabil 2012; 50:243-50. [PMID: 22731973 PMCID: PMC3708475 DOI: 10.1352/1934-9556-50.3.243] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Primary care physicians who care for adults with intellectual disability often lack experience with the population, and patients with intellectual disability express dissatisfaction with their care. Establishing a secure primary care relationship is particularly important for adults with intellectual disability, who experience health disparities and may rely on their physician to direct/coordinate their care. The authors conducted semistructured interviews with 22 family physicians with the goal of identifying educational needs of family physicians who care for people with intellectual disability. Interviews were transcribed and coded using tools from grounded theory. Several themes related to educational needs were identified. Physician participants identified themes of "operating without a map," discomfort with patients with intellectual disability, and a need for more exposure to/experience with people with intellectual disability as important content areas. The authors also identified physician frustration and lack of confidence, compounded by anxiety related to difficult behaviors and a lack of context or frame of reference for patients with intellectual disability. Primary care physicians request some modification of their educational experience to better equip them to care for patients with intellectual disability. Their request for experiential, not theoretical, learning fits well under the umbrella of cultural competence (a required competency in U.S. medical education).
Collapse
Affiliation(s)
- Joanne Wilkinson
- Boston University, Family Medicine, 1 BMC Place, Dowling 5, Boston, MA 02118, USA.
| | | | | | | |
Collapse
|
29
|
D'Amore M, McCloskey L, Bokhour B, Paasche-Orlow M, Jack B, Parker V. How do young, Black women view birth control and talk to their health care providers about family planning? Contraception 2012. [DOI: 10.1016/j.contraception.2011.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
30
|
Young G, Meterko M, White B, Sautter K, Bokhour B, Baker E, Silver J. Pay-for-performance in safety net settings: issues, opportunities, and challenges for the future. J Healthc Manag 2010; 55:132-142. [PMID: 20402368] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
A major trend among Medicaid programs is the adoption of pay-for-performance (P4P) programs, but little evidence exists about the impact of these programs on quality improvement. Our in-depth case investigation of P4P in two safety net settings suggests that such programs may have minimal short-term effect on quality improvement. Two potentially important barriers for P4P in safety net settings are limited motivational effects from financial incentives and complex patient care requirements. We did not uncover any opposition against P4P among providers, nor did we find any evidence that P4P programs may compromise quality of care through unintended consequences. Overall, study results point to opportunities to improve the design and implementation of P4P programs in safety net settings.
Collapse
Affiliation(s)
- Gary Young
- Department of Health Policy and Management, Boston University School of Public Health, USA.
| | | | | | | | | | | | | |
Collapse
|
31
|
Galbraith AA, Smith LA, Bokhour B, Miroshnik IL, Sawicki GS, Glauber JH, Hohman KH, Gay C, Lieu TA. Asthma care quality for children with minority-serving providers. ACTA ACUST UNITED AC 2010; 164:38-45. [PMID: 20048240 DOI: 10.1001/archpediatrics.2009.243] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To compare asthma care quality for children with and without minority-serving providers. DESIGN Cross-sectional telephone survey of parents, linked with a mailed survey of their children's providers. SETTING A Medicaid-predominant health plan and multispecialty provider group in Massachusetts. PARTICIPANTS A total of 563 children with persistent asthma, identified by claims and encounter data. Main Exposure Whether the child's provider was minority serving (>25% of patients black or Latino). Outcomes Parent report of whether the child had (1) ever received inhaled steroids, (2) received influenza vaccination during the past season, and (3) received an asthma action plan in the past year. RESULTS In unadjusted analyses, Latino children and those with minority-serving providers were more likely to have never received inhaled steroids. In adjusted models, the odds of never receiving inhaled steroids were not statistically significantly different for children with minority-serving providers (odds ratio [OR], 1.29; 95% confidence interval [CI], 0.63-2.64), or for Latino vs white children (OR, 1.76; 95% CI, 0.74-4.18); odds were increased for children receiving care in community health centers (OR, 4.88; 95% CI, 1.70-14.02) or hospital clinics (OR, 4.53; 95% CI, 1.09-18.92) vs multispecialty practices. Such differences were not seen for influenza vaccinations or action plans. CONCLUSIONS Children with persistent asthma are less likely to receive inhaled steroids if they receive care in community health centers or hospital clinics. Practice setting mediated initially observed disparities in inhaled steroid use by Latino children and those with minority-serving providers. No differences by race/ethnicity or minority-serving provider were observed for influenza vaccinations or asthma action plans.
Collapse
Affiliation(s)
- Alison A Galbraith
- Center for Child Health Care Studies, Department of Population Medicine, Harvard Pilgrim Health Care and Harvard Medical School, 133 Brookline Ave, 6th Floor, Boston, MA 02215, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Cohn ES, Cortés DE, Hook JM, Yinusa-Nyahkoon LS, Solomon JL, Bokhour B. A narrative of resistance: presentation of self when parenting children with asthma. Commun Med 2009; 6:27-37. [PMID: 19798833 DOI: 10.1558/cam.v6i1.27] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Using a social constructivist perspective and narrative analysis, the purpose of this paper is to illustrate how an understanding of self-presentation in interactions may inform health care interventions. We examine how a single African American mother, living in poverty, presents her sense of self in the context of obtaining and providing asthma care for her children. By analyzing four separate encounters--two interviews with the children's mother, the clinical encounter between the mother and her children's doctor, and an interview with the doctor, we gain an understanding of the mother's self-presentation and identity and the doctor's view of the mother. The analyses reveal the mother's consistent desire to protect her children in an unpredictable social world. By examining self-presentation, behavior that is typically construed as non-adherence is reframed as resilience, one mother's attempt to assert control. We argue that an understanding of identity production may enable practitioners and patients to create collaborative interventions. The analysis presented in this paper points to the need for a co-constructed intervention that allows for choice and control and honors the mother's sense of self.
Collapse
Affiliation(s)
- Ellen S Cohn
- Boston University, College of Health and Rehabilitation Services, Boston, MA 02215, USA.
| | | | | | | | | | | |
Collapse
|
33
|
Smith LA, Bokhour B, Hohman KH, Miroshnik I, Kleinman KP, Cohn E, Cortés DE, Galbraith A, Rand C, Lieu TA. Modifiable risk factors for suboptimal control and controller medication underuse among children with asthma. Pediatrics 2008; 122:760-9. [PMID: 18829799 DOI: 10.1542/peds.2007-2750] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [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] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Our aims were (1) to describe rates of suboptimal control and controller medication underuse in a diverse population of children with asthma and (2) to identify potentially modifiable parental behaviors and beliefs associated with these outcomes. METHODS We conducted telephone interviews with parents of 2- to 12-year-old children with persistent asthma, in a Medicaid plan and a large provider group. Suboptimal control was defined as >or=4 symptom days, >or=1 symptom night, or >or=4 albuterol use days in the previous 2 weeks. Controller medication underuse was defined as suboptimal control and parent report of <6 days/week of inhaled steroid use. Multivariate analyses identified factors that were independently associated with suboptimal control and controller medication underuse. RESULTS Of the 754 study children, 280 (37%) had suboptimal asthma control; this problem was more common in Hispanic children (51%) than in black (37%) or white (32%) children. Controller medication underuse was present for 133 children (48% of those with suboptimal asthma control and 18% overall). Controller medication underuse was more common among Hispanic (44%) and black (34%) children than white (22%) children. In multivariate analyses, suboptimal control was associated with potentially modifiable factors including low parental expectations for symptom control and high levels of worry about competing household priorities. Controller medication underuse was associated with potentially modifiable factors including parental estimation of asthma control that was discordant with national guidelines and no set time to administer asthma medications. CONCLUSIONS Deficiencies in asthma control and controller medication use are associated with potentially modifiable parental beliefs, which seem to mediate racial/ethnic and socioeconomic disparities in suboptimal control and controller medication underuse.
Collapse
Affiliation(s)
- Lauren A Smith
- Department of Pediatrics, School of Medicine, Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, Massachusetts, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Sawicki GS, Smith L, Bokhour B, Gay C, Hohman KH, Galbraith AA, Lieu TA. Periodic use of inhaled steroids in children with mild persistent asthma: what are pediatricians recommending? Clin Pediatr (Phila) 2008; 47:446-51. [PMID: 18192640 DOI: 10.1177/0009922807312184] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [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] [Indexed: 11/17/2022]
Abstract
Although asthma treatment guidelines recommend daily inhaled corticosteroid (ICS) use for all persistent asthma, pediatricians may recommend alternative treatment plans for children with mild persistent disease. The authors administered a survey of pediatricians to describe prescribing patterns for mild persistent asthma. More than 99% of providers agreed that periodic ICS could be effective for some asthma patients. Overall, 129/251 providers (51%) reported prescribing daily ICS to most patients with mild persistent asthma, whereas 78 (31%) reported recommending periodic ICS for most such patients. Providers with patient populations > or = 25% black were significantly less likely to report prescribing daily ICS (odds ratio, 0.3; 95% confidence interval, 0.2-0.6) for mild persistent asthma. Further research is needed on the effectiveness of periodic ICS use for children with mild persistent asthma and on underlying reasons for differing provider practice patterns.
Collapse
Affiliation(s)
- Gregory S Sawicki
- Harvard Pediatric Health Services Research Fellowship Program, Children's Hospital Boston, Boston, MA 02115, USA.
| | | | | | | | | | | | | |
Collapse
|
35
|
Pugh MJV, Berlowitz DR, Montouris G, Bokhour B, Cramer JA, Bohm V, Bollinger M, Helmers S, Ettinger A, Meador KJ, Fountain N, Boggs J, Tatum WO, Knoefel J, Harden C, Mattson RH, Kazis L. What constitutes high quality of care for adults with epilepsy? Neurology 2007; 69:2020-7. [PMID: 17928576 DOI: 10.1212/01.wnl.0000291947.29643.9f] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Providers are increasingly being held accountable for the quality of care provided. While quality indicators have been used to benchmark the quality of care for a number of other disease states, no such measures are available for evaluating the quality of care provided to adults with epilepsy. In order to assess and improve quality of care, it is critical to develop valid quality indicators. Our objective is to describe the development of quality indicators for evaluating care of adults with epilepsy. As most care is provided in primary and general neurology care, we focused our assessment of quality on care within primary care and general neurology clinics. METHODS We reviewed existing national clinical guidelines and systematic reviews of the literature to develop an initial list of quality indicators; supplemented the list with indicators derived from patient focus groups; and convened a 10-member expert panel to rate the appropriateness, reliability, and necessity of each quality indicator. RESULTS From the original 37 evidence-based and 10 patient-based quality indicators, the panel identified 24 evidence-based and 5 patient-based indicators as appropriate indicators of quality. Of these, the panel identified 9 that were not necessary for high quality care. CONCLUSION There is, at best, a poor understanding of the quality of care provided for adults with epilepsy. These indicators, developed based on published evidence, expert opinion, and patient perceptions, provide a basis to assess and improve the quality of care for this population.
Collapse
Affiliation(s)
- M J V Pugh
- Department of Veterans Affairs, South Texas Veterans Health Care System (VERDICT), San Antonio, TX 78229-4404, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|