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Farag A, Wakefield BJ, Jaske E, Paez M, Stewart G. Determinants of Patient Aligned Care Team (PACT) members' burnout and its relationship with patient-centered care. Appl Ergon 2024; 118:104272. [PMID: 38537519 DOI: 10.1016/j.apergo.2024.104272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/11/2024] [Accepted: 03/15/2024] [Indexed: 05/03/2024]
Abstract
Burnout is a prevalent issue among healthcare providers affecting up to 54% of physicians and 35% of nurses. Patient Aligned Care Teams (PACT) is a team-based primary care delivery model designed to assure the delivery of high-quality care while improving clinicians' well-being. Limited studies evaluated the relationship between work environment variables and PACT members' burnout and the relationship between PACT members' burnout and patient-centered care. This cross-sectional study is based on the 2018 Veterans Health Administration (VHA) national web-based PACT survey. Burnout was measured using a single-item question that was validated in previous studies. Descriptive statistics and logistic regression were used to analyze the data. Fifty-one percent of primary care providers and 40.12% of nurses reported high burnout. PACT members with a work environment characterized by high-quality team interaction, leadership support, and psychological safety experienced lower levels of burnout. PACT members' burnout explained 6% of the variance in PACT members' ability to deliver patient-centered care. Burnout among PACT members is attributed to multiple personal and occupational variables. This study identified modifiable work environment variables that can be used to inform burnout interventions.
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Affiliation(s)
- Amany Farag
- University of Iowa, College of Nursing, Iowa City, IA, USA.
| | | | - Erin Jaske
- VA Puget Sound Health Care System, Seattle, WA, USA
| | | | - Greg Stewart
- University of Iowa, Tippie College of Business, Iowa City, IA, USA
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2
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Carrico M, Frosch C, Craig K, Carter M, Falk J, Guerrero S, Huang L, Kossoudji A, Michelson TR, Miller P, Park C, Solt T, Wakefield BJ. Implementation of Video Blood Pressure Visits in the Veterans Health Administration. Telemed J E Health 2024; 30:1006-1012. [PMID: 37935031 DOI: 10.1089/tmj.2023.0269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
Introduction: Almost half of veterans (44.6%) seen in the U.S. Department of Veterans Affairs outpatient setting are diagnosed with hypertension (HTN). Because of the widespread nature of HTN, use of virtual visits has the potential to improve blood pressure (BP) management. This evaluation assessed the effectiveness of video blood pressure visits (VBPVs) in the management of HTN in veterans enrolled in Veterans Health Administration primary care. Methods: The program was implemented within the existing veteran-centered medical home. VBPVs are scheduled where the nurse observes veterans taking their BP and provides teaching or counseling. A national training curriculum was delivered to local nurse champions through Microsoft Teams. We analyzed improvement in BP over a 2-year period. We also captured actions taken by nurses during the VBPV by searching the electronic notes. Ratings of training and comments were summarized using feedback forms completed after training. Results: In total, 81,476 veterans participated in VBPVs over 2 years. Of those, 44,682 veterans had an existing ICD-10 code related to HTN. Of the 18,078 veterans who had a pre- and post-VBPV BP, the average change to systolic measurement was -10.6 mm Hg (range -82 to 78). Average change to diastolic measurement was -4.61 mm Hg (range -59 to 55). Most interventions addressed medication management (77%). Nurses' evaluations of the program were positive. Conclusions: Video visits provide reliable and convenient veteran-centered care. Such visits enable care when unanticipated interruptions occur such as the coronavirus disease 2019 pandemic. In addition to medication management, nurse-led interventions such as counseling on lifestyle changes can be effective in HTN management.
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Affiliation(s)
- Margaret Carrico
- Family Medicine, Tampa Veterans Administration Medical Center, Tampa, Florida, USA
| | - Cortney Frosch
- Implementation Strategies Support Team Lead, Iron Bow Technologies/Veterans Health Administration, Connected Health, Washington, District of Columbia, USA
| | - Kathleen Craig
- Nurse Lead, Video Blood Pressure Program, Boston Veterans Health Administration Medical Center, Boston, Massachusetts, USA
| | - Maia Carter
- Director of Virtual Care Integration, Office of Primary Care, Veterans Health Administration, Washington, District of Columbia, USA
| | - Jami Falk
- Chief Nurse Office of Primary Care Monitoring & Oversight, Office of Primary Care and Oversight, Veterans Health Administration, Washington, District of Columbia, USA
| | - Sandra Guerrero
- Nursing Service, Las Vegas Veterans Health Administration, Las Vegas, Nevada, USA
| | - Lisa Huang
- Librarian, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Andrea Kossoudji
- Nurse Educator, New Jersey War Related Illness and Injury Study Center, East Orange, New Jersey, USA
| | - Trevor R Michelson
- Computer Scientist, Veterans Health Administration, Washington, District of Columbia, USA
| | - Pamela Miller
- Management Analyst, Automated Data Processing Application Coordinator, North Texas Veterans Health Administration Health Care System, Dallas, Texas, USA
| | - Catherine Park
- Research Coordinator, Houston Veterans Health Administration Medical Center, Houston, Texas, USA
| | - Traci Solt
- Director for Clinical Services, Office of Primary Care, Veterans Health Administration, Washington, District of Columbia, USA
| | - Bonnie J Wakefield
- Sinclair School of Nursing, University of Missouri-Columbia, Columbia, Missouri, USA
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Wakefield BJ, Lampman MA, Paez MB, Farag A, Ferguson H, Stewart GL. Delegation of Work Within a Patient-Centered Medical Home. J Nurs Adm 2022; 52:679-684. [PMID: 36409262 DOI: 10.1097/nna.0000000000001231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The aim of this study was to analyze the perceptions of core team members implementing patient-centered medical home (PCMH) within the Veterans Health Administration regarding delegation of work. BACKGROUND Significant overlap exists in the performance of work tasks among PCMH team members (primary care providers, RNs, clinical associates, clerks), and scant literature exists on appropriate delegation within PCMH teams. METHODS This study conducted used a quantitative and qualitative analysis of 4254 respondents to a 2018 survey. RESULTS Primary care providers rely heavily on team members, and nurses report being relied upon at high levels. Lack of role clarity and a perceived need for a team leader were concerns voiced by participants. CONCLUSIONS Findings indicated a need for clear guidance on roles and responsibilities within the team. Patient-centered medical home team members need information about the scope of practice of each professional group to allow providers to function at the top of their scope of practice and ensure effective delegation.
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Affiliation(s)
- Bonnie J Wakefield
- Author Affiliations: Investigator (Drs Wakefield and Farag) and Analyst (Ms Ferguson), Veterans Integrated Service Network 23, Primary Care Analytic Team (Ms Paez), Iowa City VA Healthcare System, Iowa; Associate Professor (Dr Wakefield), Sinclair School of Nursing, University of Missouri, Columbia; Investigator (Dr Lampman), Ethnographic Methods and Implementation Core (EMIC) Program Manager (Ms Paez), and Director (Dr Stewart), Veterans Integrated Service Network 23, PCAT and VA Office of Patient Care Services, Iowa City VA Healthcare System, Iowa; Assistant Professor (Dr Lampman), Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota; EMIC Program Manager (Ms Paez), The Comprehensive Access and Delivery Research and Evaluation Center, Iowa City VA Healthcare System, Iowa; and Associate Professor (Dr Farag), University of Iowa College of Nursing; and Professor (Dr Stewart), Tippie College of Business, University of Iowa, Iowa City
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Drwal KR, Hurst D, Wakefield BJ. Effectiveness of a Home-Based Pulmonary Rehabilitation Program in Veterans. Telemed J E Health 2022. [PMID: 35584256 DOI: 10.1089/tmj.2022.0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: This study examined the effectiveness and safety of a home-based pulmonary rehabilitation (HBPR) program in Veterans. Methods: Patients were evaluated from five Veteran Affairs facilities that enrolled in the 12-week program. Pre- to postchanges were completed on clinical outcomes using paired t-tests and the Wilcoxon signed rank sum test. Descriptive statistics were used for patient demographics, emergency room visits, and hospitalizations. Results: Two hundred eighty-five patients with a mean age of 69.6 ± 8.3 years enrolled in the HBPR program from October 2018 to March 2020. There was a 62% (n = 176) completion rate of both pre- and post assessments. Significant improvements were detected after completion of the HBPR program in dyspnea (modified Medical Research Council: 3.1 ± 1.1 vs. 1.9 ± 1.1; p < 0.0001); exercise capacity (six-minute walk distance: 263.1 m ± 96.6 m vs. 311.0 m ± 103.6 m; p < 0.0001; Duke Activity Status Index: 13.8 ± 9.6 vs. 20.0 ± 12.7; p < 0.0001; self-reported steps per day: 1514.5 ± 1360.4 vs. 3033.8 ± 2716.2; p < 0.0001); depression (patient health questionnaire-9: 8.3 ± 5.7 vs. 6.4 ± 5.1); nutrition habits (rate your plate, heart: 45.3 ± 9.0 vs. 48.9 ± 9.2; p < 0.0001); multicomponent assessment tools (BODE Index: 5.1 ± 2.5 vs. 3.4 ± 2.4; p < 0.0001), GOLD ABCD Assessment: p < 0.0009); and quality of life (chronic obstructive pulmonary disease assessment test: 25.4 ± 7.7 vs. 18.7 ± 8.5; p < 0.0001). No adverse events were reported due to participation in HBPR. Conclusions: The HBPR program is a safe and effective model and provides an additional option to address the gap in pulmonary rehabilitation access and utilization in the Veterans Affairs.
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Affiliation(s)
- Kariann R Drwal
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City, Iowa City VA Healthcare System, Iowa City, Iowa, USA
- The Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, Iowa, USA
| | - Delanie Hurst
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City, Iowa City VA Healthcare System, Iowa City, Iowa, USA
- The Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, Iowa, USA
| | - Bonnie J Wakefield
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City, Iowa City VA Healthcare System, Iowa City, Iowa, USA
- The Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, Iowa, USA
- Sinclair School of Nursing, University of Missouri, Columbia, Missouri, USA
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Guzman-Clark J, Wakefield BJ, Farmer MM, Yefimova M, Viernes B, Lee ML, Hahn TJ. Adherence to the Use of Home Telehealth Technologies and Emergency Room Visits in Veterans with Heart Failure. Telemed J E Health 2021; 27:1003-1010. [PMID: 33275527 PMCID: PMC8172647 DOI: 10.1089/tmj.2020.0312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Prior studies have posited poor patient adherence to remote patient monitoring as the reason for observed lack of benefits. Introduction: The purpose of this study was to examine the relationship between average adherence to the daily use of home telehealth (HT) and emergency room (ER) visits in Veterans with heart failure. Materials and Methods: This was a retrospective study using administrative data of Veterans with heart failure enrolled in Veterans Affairs (VA) HT Program in the first half of 2014. Zero-inflated negative binomial regression was used to determine which predictors affect the probability of having an ER visit and the number of ER visits. Results: The final sample size was 3,449 with most being white and male. There were fewer ER visits after HT enrollment (mean ± standard deviation of 1.85 ± 2.8) compared with the year before (2.2 ± 3.4). Patient adherence was not significantly associated with ER visits. Age and being from a racial minority group (not white or black) and belonging to a large HT program were associated with having an ER visit. Being in poorer health was associated with higher expected count of ER visits. Discussion: Subgroups of patients (e.g., with depression, sicker, or from a racial minority group) may benefit from added interventions to decrease ER use. Conclusions: This study found that adherence was not associated with ER visits. Reasons other than adherence should be considered when looking at ER use in patients with heart failure enrolled in remote patient monitoring programs.
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Affiliation(s)
| | - Bonnie J Wakefield
- Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
- Sinclair School of Nursing, University of Missouri, Columbia Missouri, USA
| | - Melissa M Farmer
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Maria Yefimova
- VA/UCLA National Clinician Scholar, Los Angeles, California, USA
- Office of Research Patient Care Services Stanford Healthcare, Stanford, California, USA
| | - Benjamin Viernes
- VA Informatics and Computing Infrastructure (VINCI), VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Martin L Lee
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Biostatistics, University of California Los Angeles (UCLA) Fielding School of Public Health Los Angeles, California, USA
| | - Theodore J Hahn
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, UCLA School of Medicine, Los Angeles, California, USA
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Abstract
PURPOSE The conceptual utility of home-based cardiac rehabilitation (HBCR) is widely acknowledged. However, data substantiating its effectiveness and safety are limited. This study evaluated effectiveness and safety of the Veterans Affairs (VA) national HBCR program. METHODS Veterans completed a 12-wk HBCR program over 18 mo at 25 geographically dispersed VA hospitals. Pre- to post-changes were compared using paired t tests. Patient satisfaction and adverse events were also summarized descriptively. RESULTS Of the 923 Veterans with a mean age of 67.3 ± 10.6 yr enrolled in the HBCR program, 572 (62%) completed it. Findings included significant improvements in exercise capacity (6-min walk test distance: 355 vs 398 m; P < .05; Duke Activity Status Index: 27.1 vs 33.5; P < .05; self-reported steps/d: 3150 vs 4166; P < .05); depression measured by Patient Health Questionnaire (6.4 vs 4.9; P < .0001); cardiac self-efficacy (33.1 vs 39.2; P < .0001); body mass index (31.5 vs 31.1 kg/m2; P = .0001); and eating habits measured by Rate Your Plate, Heart (47.2 vs 51.1; P < .05). No safety issues were related to HBCR participation. Participants were highly satisfied. CONCLUSIONS The VA HBCR program demonstrates strong evidence of effectiveness and safety to a wide range of patients, including those with high clinical complexity and risk. HBCR provides an adjunct to site-based programs and access to cardiac rehabilitation. Additional research is needed to assess long-term effects, cost-effectiveness, and sustainability of the model.
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Affiliation(s)
- Kariann R Drwal
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City, Iowa City VA Healthcare System, Iowa City (Ms Drwal, Drs Wakefield and El Accaoui, and Mr Haraldsson); The Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City (Ms Drwal, Dr Wakefield, and Mr Haraldsson); Sinclair School of Nursing, University of Missouri, Columbia (Dr Wakefield); VA Pittsburgh Healthcare System, Pittsburgh, Department of Medicine, University of Pittsburgh, Pittsburgh, and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Forman); Center of Innovation in Long Term Services and Support, Providence VA Medical Center, Providence, Cardiovascular Rehab Center, Miriam Hospital, Providence, and Alpert Medical School and School of Public Health, Brown University, Providence, Rhode Island (Dr Wu); and Division of Cardiovascular Medicine, University of Iowa, Iowa City (Dr El Accaoui)
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7
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Popejoy LL, Vogelsmeier AA, Wang Y, Wakefield BJ, Galambos CM, Mehr DR. Testing Re-Engineered Discharge Program Implementation Strategies in SNFs. Clin Nurs Res 2020; 30:644-653. [PMID: 33349042 DOI: 10.1177/1054773820982612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Re-Engineered Discharge (RED) program, designed for hospitals, is being trialed in skilled nursing facilities (SNFs) with promising results. This paper reports on the quantitative results of a multimethod study testing two different RED program implementation strategies in SNFs. A pretest-posttest design was used to compare utilization outcomes of two different RED implementation strategies (Enhanced and Standard) and overall group differences in four Midwestern SNFs. In the Standard group there were higher odds of being readmitted in the pre-intervention versus post-intervention period. After adjusting coefficients using Poisson regression, in the pre-intervention period the adjusted number of rehospitalizations for the Standard group was 45% higher at 30 days, 50% higher at 60 days (p = .01), and 39% higher at 180 days (p = .001). SNF RED may be a useful program to reduce rehospitalizations after discharge. Benefit of SNF RED is dependent on degree of adoption of the intervention.
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Affiliation(s)
| | | | - Yan Wang
- University of Missouri, Columbia, USA
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8
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Omboni S, McManus RJ, Bosworth HB, Chappell LC, Green BB, Kario K, Logan AG, Magid DJ, Mckinstry B, Margolis KL, Parati G, Wakefield BJ. Evidence and Recommendations on the Use of Telemedicine for the Management of Arterial Hypertension: An International Expert Position Paper. Hypertension 2020; 76:1368-1383. [PMID: 32921195 DOI: 10.1161/hypertensionaha.120.15873] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [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: 02/07/2023]
Abstract
Telemedicine allows the remote exchange of medical data between patients and healthcare professionals. It is used to increase patients' access to care and provide effective healthcare services at a distance. During the recent coronavirus disease 2019 (COVID-19) pandemic, telemedicine has thrived and emerged worldwide as an indispensable resource to improve the management of isolated patients due to lockdown or shielding, including those with hypertension. The best proposed healthcare model for telemedicine in hypertension management should include remote monitoring and transmission of vital signs (notably blood pressure) and medication adherence plus education on lifestyle and risk factors, with video consultation as an option. The use of mixed automated feedback services with supervision of a multidisciplinary clinical team (physician, nurse, or pharmacist) is the ideal approach. The indications include screening for suspected hypertension, management of older adults, medically underserved people, high-risk hypertensive patients, patients with multiple diseases, and those isolated due to pandemics or national emergencies.
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Affiliation(s)
- Stefano Omboni
- From the Clinical Research Unit, Italian Institute of Telemedicine, Varese (S.O.).,Scientific Research Department of Cardiology, Science and Technology Park for Biomedicine, Sechenov First Moscow State Medical University, Russian Federation (S.O.)
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (R.J.M.)
| | - Hayden B Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, NC (H.B.B.).,Department of Psychiatry and Behavioral Sciences (H.B.B.), Duke University, Durham, NC.,Division of General Internal Medicine (H.B.B.), Duke University, Durham, NC.,Department of Population Health Sciences (H.B.B.), Duke University, Durham, NC
| | - Lucy C Chappell
- Women's Health Academic Centre, King's College London, United Kingdom (L.C.C.)
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Seattle (B.B.G.)
| | - Kazuomi Kario
- Department of Cardiology, Jichi Medical University School of Medicine, Tochigi, Japan (K.K.)
| | - Alexander G Logan
- Department of Medicine, Mount Sinai Hospital, University Health Network and University of Toronto, ON, Canada (A.G.L.)
| | - David J Magid
- Colorado Permanente Medical Group, Denver and School of Public Health, University of Colorado, Aurora (D.J.M.)
| | - Brian Mckinstry
- Emeritus Professor of Primary Care eHealth, Usher Institute, The University of Edinburgh, United Kingdom (B.M.)
| | | | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milano-Bicocca, Italy (G.P.).,Istituto Auxologico Italiano, IRCCS San Luca, Milano, Italy (G.P.)
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9
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Wakefield BJ, Howland C. Home Monitoring Technology: What is Next? West J Nurs Res 2020; 43:3-4. [PMID: 32744187 DOI: 10.1177/0193945920947695] [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: 11/15/2022]
Affiliation(s)
- Bonnie J Wakefield
- Associate Professor, Sinclair School of Nursing, University of Missouri, Columbia, MO, USA.,PhD student, Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
| | - Chelsea Howland
- Associate Professor, Sinclair School of Nursing, University of Missouri, Columbia, MO, USA.,PhD student, Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
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10
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Guzman-Clark J, Yefimova M, Farmer MM, Wakefield BJ, Viernes B, Lee ML, Hahn TJ. Home Telehealth Technologies for Heart Failure: An Examination of Adherence Among Veterans. J Gerontol Nurs 2020; 46:26-34. [PMID: 32597998 PMCID: PMC7375894 DOI: 10.3928/00989134-20200605-05] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The current retrospective cohort study uses Department of Veterans Affairs (VA) clinical and facility data of Veterans with heart failure enrolled in the VA Home Tele-health (HT) Program. General estimating equations with facility as a covariate were used to model percent average adherence at 1, 3, 6, and 12 months post-enrollment. Most HT patients were White, male, and of older age (mean = 71 years). Average adherence increased the longer patients remained in the HT program. Number of weekly reports of HT use, not having depression, and being of older age were all associated with higher adherence. Compared to White Veterans, Black and other non-White Veterans had lower adherence. These findings identify subgroups of patients (e.g., those with depression, of younger age, non-White) that may benefit from additional efforts to improve adherence to HT technologies. [Journal of Gerontological Nursing, 46(7), 26-34.].
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Powell KR, Wakefield BJ, Alexander GL. Leveraging Technology to Improve Care of Older Adults. J Gerontol Nurs 2020; 46:2. [PMID: 32597994 DOI: 10.3928/00989134-20200605-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Drwal KR, Forman DE, Wakefield BJ, El Accaoui RN. Cardiac Rehabilitation During COVID-19 Pandemic: Highlighting the Value of Home-Based Programs. Telemed J E Health 2020; 26:1322-1324. [PMID: 32552412 DOI: 10.1089/tmj.2020.0213] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Cardiac rehabilitation (CR) is a class I treatment for cardiovascular disease, however, underutilization of these services remains. Home-based CR (HBCR) models have been implemented as a potential solution to addressing access barriers to CR services. Home-based models have been shown to be effective, however, there continues to be large variation of protocols and minimal evidence of effectiveness in higher risk populations. In addition, lack of reimbursement models has discouraged the widespread adoption of HBCR. During the coronavirus 2019 (COVID-19) pandemic, an even greater gap in CR care has been present due to decreased availability of on-site services. The COVID-19 pandemic presents a time to highlight the value and experiences of home-based models as clinicians search for ways to continue to provide care. Continued review and standardization of HBCR models are essential to provide care for a wider range of patients and circumstances.
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Affiliation(s)
- Kariann R Drwal
- VA Office of Rural Health, Veterans Rural Health Resource Center Iowa City VA Healthcare System, Iowa City, Iowa, USA.,The Comprehensive Access and Delivery Research and Evaluation Center Iowa City VA Healthcare System, Iowa City, Iowa, USA
| | - Daniel E Forman
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Bonnie J Wakefield
- VA Office of Rural Health, Veterans Rural Health Resource Center Iowa City VA Healthcare System, Iowa City, Iowa, USA.,The Comprehensive Access and Delivery Research and Evaluation Center Iowa City VA Healthcare System, Iowa City, Iowa, USA.,Sinclair School of Nursing, University of Missouri, Columbia, Missouri, USA
| | - Ramzi N El Accaoui
- VA Office of Rural Health, Veterans Rural Health Resource Center Iowa City VA Healthcare System, Iowa City, Iowa, USA.,Division of Cardiovascular Medicine, University of Iowa, Iowa City, Iowa, USA
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13
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Despins LA, Wakefield BJ. Making sense of blood glucose data and self-management in individuals with type 2 diabetes mellitus: A qualitative study. J Clin Nurs 2020; 29:2572-2588. [PMID: 32279366 DOI: 10.1111/jocn.15280] [Citation(s) in RCA: 4] [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] [Received: 07/19/2019] [Revised: 02/25/2020] [Accepted: 03/14/2020] [Indexed: 12/15/2022]
Abstract
AIMS AND OBJECTIVES To describe individuals' with type 2 diabetes mellitus sense-making of blood glucose data and other influences impacting self-management behaviour. BACKGROUND Type 2 diabetes mellitus prevalence is increasing globally. Adherence to effective diabetes self-management regimens is an ongoing healthcare challenge. Examining individuals' sense-making processes can advance staff knowledge of and improve diabetes self-management behaviour. DESIGN A qualitative exploratory design examining how individuals make sense of blood glucose data and symptoms, and the influence on self-management decisions. METHODS Sixteen one-on-one interviews with adults diagnosed with type 2 diabetes mellitus using a semi-structured interview guide were conducted from March-May 2018. An inductive-deductive thematic analysis of data using the Sensemaking Framework for Chronic Disease Self-Management was used. The consolidated criteria for reporting qualitative research (COREQ) checklist were used in completing this paper. RESULTS Three main themes described participants' type 2 diabetes mellitus sense-making and influences on self-management decisions: classifying blood glucose data, building mental models and making self-management decisions. Participants classified glucose levels based on prior personal experiences. Participants learned about diabetes from classes, personal experience, health information technology and their social network. Seven participants expressed a need for periodic refreshing of diabetes knowledge. CONCLUSION Individuals use self-monitored glucose values and/or HbA1C values to evaluate glucose control. When using glucose values, they analyse the context in which the value was obtained through the lens of personal parameters and expectations. Understanding how individuals make sense of glycaemic data and influences on diabetes self-management behaviour with periodic reassessment of this understanding can guide the healthcare team in optimising collaborative individualised care plans. RELEVANCE TO CLINICAL PRACTICE Nurses must assess sense-making processes in self-management decisions. Periodic "refresher" diabetes education may be needed for individuals with type 2 diabetes mellitus.
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Affiliation(s)
- Laurel A Despins
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
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Sheppard JP, Tucker KL, Davison WJ, Stevens R, Aekplakorn W, Bosworth HB, Bove A, Earle K, Godwin M, Green BB, Hebert P, Heneghan C, Hill N, Hobbs FDR, Kantola I, Kerry SM, Leiva A, Magid DJ, Mant J, Margolis KL, McKinstry B, McLaughlin MA, McNamara K, Omboni S, Ogedegbe O, Parati G, Varis J, Verberk WJ, Wakefield BJ, McManus RJ. Self-monitoring of Blood Pressure in Patients With Hypertension-Related Multi-morbidity: Systematic Review and Individual Patient Data Meta-analysis. Am J Hypertens 2020; 33:243-251. [PMID: 31730171 PMCID: PMC7162426 DOI: 10.1093/ajh/hpz182] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/11/2019] [Accepted: 11/13/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Studies have shown that self-monitoring of blood pressure (BP) is effective when combined with co-interventions, but its efficacy varies in the presence of some co-morbidities. This study examined whether self-monitoring can reduce clinic BP in patients with hypertension-related co-morbidity. METHODS A systematic review was conducted of articles published in Medline, Embase, and the Cochrane Library up to January 2018. Randomized controlled trials of self-monitoring of BP were selected and individual patient data (IPD) were requested. Contributing studies were prospectively categorized by whether they examined a low/high-intensity co-intervention. Change in BP and likelihood of uncontrolled BP at 12 months were examined according to number and type of hypertension-related co-morbidity in a one-stage IPD meta-analysis. RESULTS A total of 22 trials were eligible, 16 of which were able to provide IPD for the primary outcome, including 6,522 (89%) participants with follow-up data. Self-monitoring was associated with reduced clinic systolic BP compared to usual care at 12-month follow-up, regardless of the number of hypertension-related co-morbidities (−3.12 mm Hg, [95% confidence intervals −4.78, −1.46 mm Hg]; P value for interaction with number of morbidities = 0.260). Intense interventions were more effective than low-intensity interventions in patients with obesity (P < 0.001 for all outcomes), and possibly stroke (P < 0.004 for BP control outcome only), but this effect was not observed in patients with coronary heart disease, diabetes, or chronic kidney disease. CONCLUSIONS Self-monitoring lowers BP regardless of the number of hypertension-related co-morbidities, but may only be effective in conditions such obesity or stroke when combined with high-intensity co-interventions.
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Affiliation(s)
- J P Sheppard
- Nuffield Department of Primary Care, University of Oxford, Oxford, United Kingdom
| | - K L Tucker
- Nuffield Department of Primary Care, University of Oxford, Oxford, United Kingdom
| | - W J Davison
- Ageing and Stroke Medicine, Norwich Medical School, University of East Anglia, United Kingdom
| | - R Stevens
- Nuffield Department of Primary Care, University of Oxford, Oxford, United Kingdom
| | - W Aekplakorn
- Department of Community Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University Bangkok, Thailand
| | - H B Bosworth
- Center for Health Services Research in Primary Care, Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - A Bove
- Cardiology, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - K Earle
- Thomas Addison Diabetes Unit, St. George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - M Godwin
- Family Medicine, Memorial University of Newfoundland, St. John’s, Canada
| | - B B Green
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - P Hebert
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington, USA
| | - C Heneghan
- Nuffield Department of Primary Care, University of Oxford, Oxford, United Kingdom
| | - N Hill
- Nuffield Department of Primary Care, University of Oxford, Oxford, United Kingdom
| | - F D R Hobbs
- Nuffield Department of Primary Care, University of Oxford, Oxford, United Kingdom
| | - I Kantola
- Division of Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - S M Kerry
- Centre for Primary Care and Public Health, Queen Mary University of London, London, United Kingdom
| | - A Leiva
- Primary Care Research Unit of Mallorca, Baleares Health Services-IbSalut, Mallorca, Spain
| | - D J Magid
- Colorado School of Public Health, University of Colorado, Denver, Colorado, USA
| | - J Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - K L Margolis
- HealthPartners Institute, Minneapolis, Minnesota, USA
| | - B McKinstry
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - M A McLaughlin
- Icahn School of Medicine at Mount Sinai New York, New York, New York, USA
| | - K McNamara
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
- School of Medicine, Deakin University, Geelong, Australia
| | - S Omboni
- Clinical Research Unit, Italian Institute of Telemedicine, Varese, Italy
- Scientific Research Department of Cardiology, Science and Technology Park for Biomedicine, Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - O Ogedegbe
- Center for Healthful Behavior Change, Division of Health and Behavior, Department of Population Health, Langone School of Medicine, New York University, New York, USA
| | - G Parati
- Istituto Auxologico Italiano, IRCCS, Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - J Varis
- Division of Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - W J Verberk
- Cardiovascular Research Institute Maastricht and Departments of Internal Medicine, Maastricht University, Maastricht, The Netherlands
| | - B J Wakefield
- Department of Veterans (VA) Health Services Research and Development Centre for Comprehensive Access and Delivery Research and Evaluation (CADRE), VA Medical Centre, Iowa City, USA
| | - R J McManus
- Nuffield Department of Primary Care, University of Oxford, Oxford, United Kingdom
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Wakefield BJ, Turvey C, Hogan T, Shimada S, Nazi K, Cao L, Stroupe K, Martinez R, Smith B. Impact of Patient Portal Use on Duplicate Laboratory Tests in Diabetes Management. Telemed J E Health 2020; 26:1211-1220. [PMID: 32045320 DOI: 10.1089/tmj.2019.0237] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background: Patients seek care across multiple health care settings. One coordination issue is the unnecessary duplication of laboratory across different health care settings. This analysis examined the association between patient portal use and duplication of laboratory testing among Veterans who are dual users of Veterans Affairs (VA) and non-VA providers. Materials and Methods: A national sample of Veterans who were newly authenticated users of the portal during fiscal year (FY) 2013 who used Blue Button at least once were compared with a random sample of Veterans who were not registered to use the portal. From these two groups, Veterans who were also Medicare-eligible users in FY2014 were identified. Duplicate testing was defined as receipt of more than five HbA1c (hemoglobin A1c) in 1 year. Results: Use of the Blue Button decreased the odds of duplicate HbA1c testing in VA and Medicare-covered facilities across three comparisons: (1) overall between users and nonusers: portal users were less likely to have duplicate testing; (2) pre-post comparison: there was a trend toward lower duplicate testing in both groups across time; and (3) pre-post comparisons accounting for use of the portal: the trend toward lower duplicate testing was greater in Blue Button users. Conclusion: Duplicate HbA1c testing was significantly lower in dual users of VA and Medicare services who used the Blue Button feature of their VA patient portal. Non-VA providers encounter barriers to access of complete information about Veterans who also use VA health care. Provider endorsement of consumer-mediated health information exchange could help further this model of sharing information.
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Affiliation(s)
- Bonnie J Wakefield
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa, USA.,Sinclair School of Nursing, University of Missouri, Columbia, Missouri, USA
| | - Carolyn Turvey
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa, USA.,Rural Health Resource Center, Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa, USA.,Department of Psychiatry College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Timothy Hogan
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, USA.,Division of Health Informatics and Implementation Science, Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Stephanie Shimada
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, USA.,Division of Health Informatics and Implementation Science, Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Kim Nazi
- Independent Consultant, Albany, New York, USA
| | - Lishan Cao
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, Illinois, USA
| | - Kevin Stroupe
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, Illinois, USA.,Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, USA
| | - Rachael Martinez
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, Illinois, USA
| | - Bridget Smith
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, Illinois, USA.,Center for Healthcare Studies, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Wakefield BJ, Drwal K, Paez M, Grover S, Franciscus C, Reisinger HS, Kaboli PJ, El Accaoui R. Creating and disseminating a home-based cardiac rehabilitation program: experience from the Veterans Health Administration. BMC Cardiovasc Disord 2019; 19:242. [PMID: 31694570 PMCID: PMC6833278 DOI: 10.1186/s12872-019-1224-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 10/16/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiac rehabilitation (CR) programs provide significant benefit for people with cardiovascular disease. Despite these benefits, such services are not universally available. We designed and evaluated a national home-based CR (HBCR) program in the Veterans Health Administration (VHA). The primary aim of the study was to examine barriers and facilitators associated with site-level implementation of HBCR. METHODS This study used a convergent parallel mixed-methods design with qualitative data to analyze the process of implementation, quantitative data to determine low and high uptake of the HBCR program, and the integration of the two to determine which facilitators and barriers were associated with adoption. Data were drawn from 16 VHA facilities, and included semi-structured interviews with multiple stakeholders, document analysis, and quantitative analysis of CR program attendance codes. Qualitative data were analyzed using the Consolidated Framework for Implementation Research codes including three years of document analysis and 22 interviews. RESULTS Comparing high and low uptake programs, readiness for implementation (leadership engagement, available resources, and access to knowledge and information), planning, and engaging champions and opinion leaders were key to success. High uptake sites were more likely to seek information from the external facilitator, compared to low uptake sites. There were few adaptations to the design of the program at individual sites. CONCLUSION Consistent and supportive leadership, both clinical and administrative, are critical elements to getting HBCR programs up and running and sustaining programs over time. All sites in this study had external funding to develop their program, but high adopters both made better use of those resources and were able to leverage existing resources in the setting. These data will inform broader policy regarding use of HBCR services.
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Affiliation(s)
- Bonnie J Wakefield
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Central Region, Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA, 52246-2208, USA. .,The Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA, 52246-2208, USA.
| | - Kariann Drwal
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Central Region, Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA, 52246-2208, USA
| | - Monica Paez
- The Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA, 52246-2208, USA
| | - Sara Grover
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Central Region, Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA, 52246-2208, USA
| | - Carrie Franciscus
- The Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA, 52246-2208, USA
| | - Heather Schacht Reisinger
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Central Region, Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA, 52246-2208, USA.,The Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA, 52246-2208, USA.,The Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, USA
| | - Peter J Kaboli
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Central Region, Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA, 52246-2208, USA.,The Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA, 52246-2208, USA.,The Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, USA
| | - Ramzi El Accaoui
- The Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, USA
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17
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Van Tiem JM, Stewart Steffensmeier KR, Wakefield BJ, Stewart GL, Zemblidge NA, Steffen MJA, Moeckli J. Taking note: A qualitative study of implementing a scribing practice in team-based primary care clinics. BMC Health Serv Res 2019; 19:574. [PMID: 31412861 PMCID: PMC6694617 DOI: 10.1186/s12913-019-4355-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 07/17/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Though much is known about the benefits attributed to medical scribes documenting patient visits (e.g., reducing documentation time for the provider, increasing patient-care time, expanding the roles of licensed and non-licensed personnel), little attention has been paid to how care workers enact scribing as a part of their existing practice. The purpose of this study was to perform an ethnographic process evaluation of an innovative medical scribing practice with primary care teams in Veterans Health Administration (VHA) clinics across the United States. The aim of our study was to understand barriers and facilitators to implementing a scribing practice in primary care. METHODS At three to six months after medical scribing was introduced, we used semi-structured interviews and direct observations during site visits to five sites to describe the intervention, understand if the intervention was implemented as planned, and to record the experience of the teams who implemented the intervention. This manuscript only reports on semi-structured interview data collected from providers and scribes. Initial matrix analysis based on categories outlined in the evaluation plan informed subsequent deductive coding using the social-shaping theory Normalization Process Theory. RESULTS Through illustrating the slow accumulation of interactions and knowledge that fostered cautious momentum of teams working to normalize scribing practice in VHA primary care clinics, we show how the practice had 1) an organizing effect, as it centered a shared goal (the creation of the note) between the provider, scribe, and patient, and 2) a generative effect, as it facilitated care workers developing relationships that were both interpersonally and inter-professionally valuable. Based on our findings, we suggest that a scribing practice emphasizes the complementarity of existing professional roles, which thus leverage the interactional possibilities already present in the primary care team. Scribing, as a skill, forged moments of interprofessional fit. Scribing, in practice, created opportunities for interpersonal connection. CONCLUSIONS Our research suggests that individuals will notice different benefits to scribing based on their professional expectations and organizational roles related to documenting patient visits.
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Affiliation(s)
- Jennifer M. Van Tiem
- VISN 23 Patient Aligned Care Team Demonstration Lab, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
- CADRE, the Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
| | - Kenda R. Stewart Steffensmeier
- VISN 23 Patient Aligned Care Team Demonstration Lab, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
- CADRE, the Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
| | - Bonnie J. Wakefield
- VISN 23 Patient Aligned Care Team Demonstration Lab, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
- CADRE, the Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
- Sinclair School of Nursing, University of Missouri, S313 School of Nursing, University of Missouri, Columbia, MO 65211 USA
| | - Greg L. Stewart
- VISN 23 Patient Aligned Care Team Demonstration Lab, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
- CADRE, the Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
- Tippie College of Business, University of Iowa, 21 E Market St, Iowa City, Iowa, 52242 USA
| | - Nancy A. Zemblidge
- VISN 23 Patient Aligned Care Team Demonstration Lab, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
- CADRE, the Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
| | - Melissa J. A. Steffen
- VISN 23 Patient Aligned Care Team Demonstration Lab, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
- CADRE, the Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
| | - Jane Moeckli
- CADRE, the Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
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18
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Orique SB, Despins L, Wakefield BJ, Erdelez S, Vogelsmeier A. Perception of clinical deterioration cues among medical-surgical nurses. J Adv Nurs 2019; 75:2627-2637. [PMID: 31012138 DOI: 10.1111/jan.14038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 02/12/2019] [Accepted: 04/02/2019] [Indexed: 11/28/2022]
Abstract
AIM To examine medical-surgical nurses' capacity and tendency to perceive cues indicating clinical deterioration and nursing characteristics influencing deterioration cue perception. DESIGN Cross-sectional, explorative study design. METHODS Data were collected over 10 weeks between September-November 2017. Medical-surgical nurses completed an online survey consisting of a demographic questionnaire, the Occupational Fatigue, Exhaustion Recovery scale and 50 detection trials. Descriptive statistics and statistical tests were used to describe and interpret data. FINDINGS A significant association was found between nurses' capacity and tendency to perceive deterioration cues. As nurses' capacity to perceive deterioration cues increased, nurses were more likely to classify patient cues as indicators of deterioration. Fatigue, education, and certification were not identified as characteristics associated with deterioration cue perception. However, experience was observed to significantly influence nurses' capacity to perceive deterioration cues based on levels of skills acquisition. CONCLUSION Study findings imply that future research should be directed at determining whether other individual factors and organizational system dynamics influence deterioration cue perception. IMPACT To better understand how nurses perceive deterioration cues, this study integrated concepts from the Situation Awareness model and Signal Detection Theory. Novice, advanced beginner and competent nurses were found to have a lower capacity to perceive deterioration cues compared with proficient and expert nurses. With simulation increasingly being used as a primary teaching modality in nursing, the development of a simulation-based signal detection training intervention may be beneficial in enhancing deterioration cue perception.
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Affiliation(s)
- Sabrina B Orique
- Advanced Nursing Practice Department, Kaweah Delta Health Care District, Visalia, California
| | - Laurel Despins
- Sinclair School of Nursing, University of Missouri, Columbia, Missouri
| | | | - Sanda Erdelez
- School of Library and Information Science, Simmons College, Boston, Massachusetts
| | - Amy Vogelsmeier
- Sinclair School of Nursing, University of Missouri, Columbia, Missouri
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19
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Folarinde B, Alexander GL, Galambos C, Wakefield BJ, Vogelsmeier A, Madsen RW. Exploring Perceptions of Health Care Providers' Use of Electronic Advance Directive Forms in Electronic Health Records. J Gerontol Nurs 2019; 45:17-21. [PMID: 30653233 DOI: 10.3928/00989134-20190102-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The current study explored the perceptions of health care providers' use of electronic advance directive (AD) forms in the electronic health record (EHR). The Technology Acceptance Model (TAM) was used to guide the study. Of 165 surveys distributed, 151 participants (92%) responded. A moderately strong positive correlation was noted between perceived usefulness and actual system usage (r = 0.70, p < 0.0001). Perceived ease of use and actual system usage also had a moderately strong positive correlation (r = 0.70, p < 0.0001). In contrast, the strength of the relationship between behavioral intention to use and actual system usage was more modest (r = 0.22, p < 0.004). There was a statistically significant difference in actual system usage of electronic ADs across six departments (χ2[5] = 79.325, p < 0.001). The relationships among primary TAM constructs found in this research are largely consistent with previous TAM studies, with the exception of behavioral intention to use, which is slightly lower. These data suggest that health care providers' perceptions have great influence on the use of electronic ADs. [Journal of Gerontological Nursing, 45(1), 17-21.].
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Abstract
This article describes our recommendation for adapting hospital-based RED (Reengineered Discharge) processes to skilled nursing facilities (SNFs). Using focus groups, the SNFs' discharge processes were assessed twice additionally, research staff then recorded field notes documenting discussions about facility discharge processes as they related to RED processes. Data were systematically analyzed using thematic analysis to identify recommendations for adapting RED to the SNF setting including (a) rapidly identifying, involving, and preparing family/caregivers to implement a patient focused SNF discharge plan; (b) reconnecting patients quickly to primary care providers; and (c) educating patients at discharge about their target health condition, medications, and impact of changes on other chronic health needs. Limited SNF staff capacity and corporate-level policies limited adoption of some key RED components. Transitional care processes such as RED, developed to avoid discharge problems, can be adapted for SNFs to improve their discharges.
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Abstract
Purpose The purpose of this study was to identify predictors of informal caregiver strain and satisfaction associated with caring for veterans with type 2 diabetes (T2DM). Methods This study is a secondary analysis of data from 2 prior studies of caregiving in the Veterans Health Administration. The original studies used a telephone survey to examine veteran and caregiver (CG) characteristics associated with caregivers’ responses to caregiving. The data reported here include 202 veterans with T2DM and 202 caregivers. Linear regression models were generated alternatively using forward and backward selection of veteran and caregiver characteristics. Results Higher caregiver strain was associated with the CG providing activities of daily living assistance, CG receiving less help from friends and relatives and use of unpaid help, CG use of coping strategies, and CG depression scores. Predictors of CG satisfaction included better relationship quality with the veteran and receipt of social support. Conclusions The important role of family and friends in supporting patients with T2DM is widely accepted. Clinicians may engage the caregiver when there is inadequate self-care by the patient. However, less attention has been focused on the effect of caregiving on the caregiver. Greater attention needs to be focused on in-depth exploration of family needs to design and test effective interventions to meet these needs.
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Affiliation(s)
- Bonnie J. Wakefield
- Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System, Iowa City, IA, USA
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
| | - Mary Vaughan-Sarrazin
- Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System, Iowa City, IA, USA
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
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22
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Despins LA, Wakefield BJ. Patient Identification of Health Risk. West J Nurs Res 2018. [DOI: 10.1177/0193945918763556] [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: 11/15/2022]
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23
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Wakefield BJ, Turvey CL, Nazi KM, Holman JE, Hogan TP, Shimada SL, Kennedy DR. Psychometric Properties of Patient-Facing eHealth Evaluation Measures: Systematic Review and Analysis. J Med Internet Res 2017; 19:e346. [PMID: 29021128 PMCID: PMC5656774 DOI: 10.2196/jmir.7638] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 06/14/2017] [Accepted: 08/25/2017] [Indexed: 11/13/2022] Open
Abstract
Background Significant resources are being invested into eHealth technology to improve health care. Few resources have focused on evaluating the impact of use on patient outcomes A standardized set of metrics used across health systems and research will enable aggregation of data to inform improved implementation, clinical practice, and ultimately health outcomes associated with use of patient-facing eHealth technologies. Objective The objective of this project was to conduct a systematic review to (1) identify existing instruments for eHealth research and implementation evaluation from the patient’s point of view, (2) characterize measurement components, and (3) assess psychometrics. Methods Concepts from existing models and published studies of technology use and adoption were identified and used to inform a search strategy. Search terms were broadly categorized as platforms (eg, email), measurement (eg, survey), function/information use (eg, self-management), health care occupations (eg, nurse), and eHealth/telemedicine (eg, mHealth). A computerized database search was conducted through June 2014. Included articles (1) described development of an instrument, or (2) used an instrument that could be traced back to its original publication, or (3) modified an instrument, and (4) with full text in English language, and (5) focused on the patient perspective on technology, including patient preferences and satisfaction, engagement with technology, usability, competency and fluency with technology, computer literacy, and trust in and acceptance of technology. The review was limited to instruments that reported at least one psychometric property. Excluded were investigator-developed measures, disease-specific assessments delivered via technology or telephone (eg, a cancer-coping measure delivered via computer survey), and measures focused primarily on clinician use (eg, the electronic health record). Results The search strategy yielded 47,320 articles. Following elimination of duplicates and non-English language publications (n=14,550) and books (n=27), another 31,647 articles were excluded through review of titles. Following a review of the abstracts of the remaining 1096 articles, 68 were retained for full-text review. Of these, 16 described an instrument and six used an instrument; one instrument was drawn from the GEM database, resulting in 23 articles for inclusion. None included a complete psychometric evaluation. The most frequently assessed property was internal consistency (21/23, 91%). Testing for aspects of validity ranged from 48% (11/23) to 78% (18/23). Approximately half (13/23, 57%) reported how to score the instrument. Only six (26%) assessed the readability of the instrument for end users, although all the measures rely on self-report. Conclusions Although most measures identified in this review were published after the year 2000, rapidly changing technology makes instrument development challenging. Platform-agnostic measures need to be developed that focus on concepts important for use of any type of eHealth innovation. At present, there are important gaps in the availability of psychometrically sound measures to evaluate eHealth technologies.
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Affiliation(s)
- Bonnie J Wakefield
- The Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Healthcare System, Iowa City, IA, United States
| | - Carolyn L Turvey
- The Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Healthcare System, Iowa City, IA, United States
| | - Kim M Nazi
- Veterans and Consumers Health Informatics Office, Veterans Health Administration, Washington, DC, United States
| | - John E Holman
- The Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Healthcare System, Iowa City, IA, United States
| | - Timothy P Hogan
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Affairs Medical Center, Boston, MA, United States
| | - Stephanie L Shimada
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Affairs Medical Center, Boston, MA, United States
| | - Diana R Kennedy
- Department of Health Management and Informatics, University of Missouri, Columbia, MO, United States
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Abstract
BACKGROUND Remote health monitoring applications are being adopted to improve the health of chronically ill individuals. Little work has focused on the effects of these technologies on informal caregivers (CG) of patients with chronic illnesses. OBJECTIVES To examine differences in caregiving appraisal between CG of enrolled and nonenrolled Veterans in the home telehealth (HT) program. METHODS Cross-sectional survey methodology in 244 dyads (Veteran and CG) from 6 rural Midwestern Veterans Affairs Medical Centers. Survey variables were derived from the 2004 National Alliance for Caregiving survey, along with measures of caregiving strain, burden, and satisfaction. RESULTS We found no differences when comparing HT and non-HT CG. In multivariate analyses combining the two groups, CG characteristics associated with CG strain included younger age, providing help with activities of daily living and instrumental activities of daily living, use of coping skills, depressive symptoms, and less use of unpaid help (all p ≤ 0.001). Burden was associated with CG use of coping skills, caregiving confidence, and relationship quality with the Veteran (all p < 0.0001). CG satisfaction was associated with presence of social support (p < 0.0001). High CG strain was associated with Veteran hospitalization in the combined group (p = 0.03). Burden (p = 0.0002) was significantly associated with CG satisfaction. DISCUSSION Existing HT infrastructure provides an opportunity to incorporate training and support programs for CG of chronically ill patients. Such programs could improve CG confidence and use of positive coping skills, lower strain and burden, and potentially improve the health of both the care recipient and CG.
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Affiliation(s)
- Bonnie J Wakefield
- 1 Center for Comprehensive Access & Delivery Research and Evaluation , Iowa City Veteran's Affairs Healthcare System, Iowa City, Iowa.,2 Rural Health Resource Center-Central Region , Iowa City Veteran's Affairs Healthcare System, Iowa City, Iowa.,3 Sinclair School of Nursing, University of Missouri , Columbia, Missouri
| | - Mary Vaughan-Sarrazin
- 1 Center for Comprehensive Access & Delivery Research and Evaluation , Iowa City Veteran's Affairs Healthcare System, Iowa City, Iowa.,2 Rural Health Resource Center-Central Region , Iowa City Veteran's Affairs Healthcare System, Iowa City, Iowa.,4 Department of Internal Medicine, University of Iowa Roy and Lucille Carver College of Medicine , Iowa City, Iowa
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Abstract
For older adults, acute-care hospital stays can result in functional decline that leads to increased risk of hospitalization, nursing home admission, or mortality. This study describes functional trajectories in hospitalized older adults and identifies risk factors associated with those trajectories. Respondents ( N = 45) exhibited five of six possible functional trajectory patterns. The largest change in functional status was a decline in activities of daily living (ADL) from baseline at 2 weeks before admission to the time of admission; ADL did not return to baseline during the first 4 days in the hospital. Depression scores were significantly higher in respondents who reported experiencing ADL decline before admission. Respondents whose ADL scores declined during hospitalization (regardless of baseline status) were more likely than others to die within 3 months of discharge. Functional trajectory in hospitalized elderly patients is an important and underappreciated prognostic concept requiring further attention.
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Affiliation(s)
- Bonnie J Wakefield
- Harry S. Truman Memorial Veterans Hospital, Health Services Research and Development, Columbia, USA
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26
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Abstract
Recent reports in the lay and professional press document the failings of our patient care systems and have led to a multitude of suggestions for patient care quality and safety improvement initiatives. Given the complexity and range of services being offered, hospitals are launching numerous improvement initiatives in nearly all clinical care and support areas. This article describes a quality improvement framework, the "10 Rights," designed to help leaders better understand, organize, and prioritize patient care quality and safety issues and approaches. In addition to describing the framework, each Right is linked to 3 current national efforts at enhancing patient care quality and safety: the Joint Commission on Accreditation of Healthcare Organizations' National Patient Safety Goals, the National Quality Forum 30 Safe Practices, and the Centers for Medicare and Medicaid Services Hospital Quality Measures.
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Affiliation(s)
- Douglas S Wakefield
- University of Missouri Center for Health Care Quality, Department of Health Management and Informatics, Missouri, USA
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27
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Abstract
We examined nurse-patient communication on two videoconferencing systems: a video-phone (PSTN video) and a PC-based system (IP video). The former used data transmission via a modem at 33.6 kbit/s and the latter via a local-area network at up to 512 kbit/s. Twenty-six nurses and 18 volunteers (simulated patients) participated. On each video system nurse-patient dyads completed scripted interactions; they then completed questionnaires to assess communication. Of the participants, 84% ( n=37) preferred IP video and 14% ( n=6) preferred PSTN video (one expressed no preference). IP video was rated significantly higher in all communication quality areas except self-consciousness/embarrassment. Although participants' overall ratings were higher for the IP video system, two important advantages of the PSTN video system were identified by both nurses and patients: first, it provided superior visualization of the medication bottle, insulin syringe and the patient's skin; and second, it was easier to use. Video quality and audio quality are important determinants of patient and provider perceptions, but ease of use, clinical appropriateness, and the need for training and support must not be forgotten.
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28
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Dixon B, Smith R, Santamaria JD, Orford NR, Wakefield BJ, Ives K, McKenzie R, Zhang B, Yap CH. A trial of nebulised heparin to limit lung injury following cardiac surgery. Anaesth Intensive Care 2016; 44:28-33. [PMID: 26673586 DOI: 10.1177/0310057x1604400106] [Citation(s) in RCA: 8] [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: 10/27/2022]
Abstract
Cardiac surgery with cardiopulmonary bypass triggers an acute inflammatory response in the lungs. This response gives rise to fibrin deposition in the microvasculature and alveoli of the lungs. Fibrin deposition in the microvasculature increases alveolar dead space, while fibrin deposition in alveoli causes shunting. We investigated whether prophylactic nebulised heparin could limit this form of lung injury. We undertook a single-centre double-blind randomised trial. Forty patients undergoing elective cardiac surgery with cardiopulmonary bypass were randomised to prophylactic nebulised heparin (50,000 U) or placebo. The primary endpoint was the change in arterial oxygen levels over the operative period. Secondary endpoints included end-tidal CO₂, the alveolar dead space fraction and bleeding complications. We found nebulised heparin did not improve arterial oxygen levels. Nebulised heparin was, however, associated with a lower alveolar dead space fraction (P <0.05) and lower tidal volumes at the end of surgery (P <0.01). Nebulised heparin was not associated with bleeding complications. In conclusion, prophylactic nebulised heparin did not improve oxygenation, but was associated with evidence of better alveolar perfusion and CO₂elimination at the end of surgery.
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Affiliation(s)
- B Dixon
- Department of Critical Care, St.Vincent's Hospital, Melbourne, Victoria
| | - R Smith
- Department of Critical Care, St.Vincent's Hospital, Melbourne, Victoria
| | - J D Santamaria
- Department of Critical Care, St.Vincent's Hospital, Melbourne, Victoria
| | - N R Orford
- Department of Critical Care, Barwon Health University Hospital, Geelong, Victoria
| | - B J Wakefield
- Department of Critical Care, Barwon Health University Hospital, Geelong, Victoria
| | - K Ives
- Department of Critical Care, Barwon Health University Hospital, Geelong, Victoria
| | - R McKenzie
- Department of Critical Care, Barwon Health University Hospital, Geelong, Victoria
| | - B Zhang
- Department of Cardiothoracic Surgery, Barwon Health University Hospital, Geelong, Victoria
| | - C H Yap
- Department of Epidemiology and Preventive Medicine, Monash University and School of Medicine, Deakin University, Melbourne, Victoria
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29
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Tucker KL, Sheppard JP, Stevens R, Bosworth HB, Bove A, Bray EP, Godwin M, Green B, Hebert P, Hobbs FDR, Kantola I, Kerry S, Magid DJ, Mant J, Margolis KL, McKinstry B, Omboni S, Ogedegbe O, Parati G, Qamar N, Varis J, Verberk W, Wakefield BJ, McManus RJ. Individual patient data meta-analysis of self-monitoring of blood pressure (BP-SMART): a protocol. BMJ Open 2015; 5:e008532. [PMID: 26373404 PMCID: PMC4577873 DOI: 10.1136/bmjopen-2015-008532] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Self-monitoring of blood pressure is effective in reducing blood pressure in hypertension. However previous meta-analyses have shown a considerable amount of heterogeneity between studies, only part of which can be accounted for by meta-regression. This may be due to differences in design, recruited populations, intervention components or results among patient subgroups. To further investigate these differences, an individual patient data (IPD) meta-analysis of self-monitoring of blood pressure will be performed. METHODS AND ANALYSIS We will identify randomised trials that have compared patients with hypertension who are self-monitoring blood pressure with those who are not and invite trialists to provide IPD including clinic and/or ambulatory systolic and diastolic blood pressure at baseline and all follow-up points where both intervention and control groups were measured. Other data requested will include measurement methodology, length of follow-up, cointerventions, baseline demographic (age, gender) and psychosocial factors (deprivation, quality of life), setting, intensity of self-monitoring, self-monitored blood pressure, comorbidities, lifestyle factors (weight, smoking) and presence or not of antihypertensive treatment. Data on all available patients will be included in order to take an intention-to-treat approach. A two-stage procedure for IPD meta-analysis, stratified by trial and taking into account age, sex, diabetes and baseline systolic BP will be used. Exploratory subgroup analyses will further investigate non-linear relationships between the prespecified variables. Sensitivity analyses will assess the impact of trials which have and have not provided IPD. ETHICS AND DISSEMINATION This study does not include identifiable data. Results will be disseminated in a peer-reviewed publication and by international conference presentations. CONCLUSIONS IPD analysis should help the understanding of which self-monitoring interventions for which patient groups are most effective in the control of blood pressure.
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Affiliation(s)
| | - James P Sheppard
- Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | - Richard Stevens
- Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | - Hayden B Bosworth
- Center for Health Services Research in Primary Care, Durham VAMC, Durham, North Carolina, USA
| | - Alfred Bove
- Nuffield Department of Primary Care, University of Oxford, Oxford, UK Center for Health Services Research in Primary Care, Durham VAMC, Durham, North Carolina, USA Department of Cardiology, Temple University School of Medicine, Philadelphia, USA School of Psychology, University of Central Lancashire, Preston, UK Family Medicine, Memorial University of Newfoundland, St. John's, Newfoundland, Canada Group Health Research Institute, Seattle, Washington, USA Department of Health Services, University of Washington School of Public Health, Washington, DC, USA Department of Medicine, Turku University Hospital, Turku, Finland Centre for Primary Care and Public Health, Queen Mary University of London, London, UK Colorado School of Public Health, University of Colorado, Denver, Colorado, USA Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK Health Partners Institute for Education and Research, Minneapolis, Minnesota, USA Centre for Population Health Sciences, University of Edinburgh, Edinburgh, Midlothian, UK Clinical Research Unit, Italian Institute of Telemedicine, Solbiate Arno, Varese, Italy Division of Health and Behavior, Department of Population Health, Center for Healthful Behavior Change, New York University, Langone School of Medicine, New York, USA Departments of Cardiology, and Clinical Medicine and Prevention, University of Milano Bicocca, Milan, Italy Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK Departments of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Maastricht, The Netherlands Department of Veterans (VA) Health Services Research, Development Centre for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Medical Centre, University of Iowa, Iowa City, Iowa, USA
| | - Emma P Bray
- Department of Cardiology, Temple University School of Medicine, Philadelphia, USA School of Psychology, University of Central Lancashire, Preston, UK
| | - Marshal Godwin
- Family Medicine, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| | - Beverly Green
- Group Health Research Institute, Seattle, Washington, USA
| | - Paul Hebert
- Department of Health Services, University of Washington School of Public Health, Washington, DC, USA
| | - F D Richard Hobbs
- Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | - Ilkka Kantola
- Department of Medicine, Turku University Hospital, Turku, Finland
| | - Sally Kerry
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - David J Magid
- Colorado School of Public Health, University of Colorado, Denver, Colorado, USA
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Karen L Margolis
- Health Partners Institute for Education and Research, Minneapolis, Minnesota, USA
| | - Brian McKinstry
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, Midlothian, UK
| | - Stefano Omboni
- Clinical Research Unit, Italian Institute of Telemedicine, Solbiate Arno, Varese, Italy
| | - Olugbenga Ogedegbe
- Division of Health and Behavior, Department of Population Health, Center for Healthful Behavior Change, New York University, Langone School of Medicine, New York, USA
| | - Gianfranco Parati
- Departments of Cardiology, and Clinical Medicine and Prevention, University of Milano Bicocca, Milan, Italy
| | - Nashat Qamar
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Juha Varis
- Department of Medicine, Turku University Hospital, Turku, Finland
| | - Willem Verberk
- Departments of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Maastricht, The Netherlands
| | - Bonnie J Wakefield
- Department of Veterans (VA) Health Services Research, Development Centre for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Medical Centre, University of Iowa, Iowa City, Iowa, USA
| | - Richard J McManus
- Nuffield Department of Primary Care, University of Oxford, Oxford, UK
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Hooper L, Abdelhamid A, Attreed NJ, Campbell WW, Channell AM, Chassagne P, Culp KR, Fletcher SJ, Fortes MB, Fuller N, Gaspar PM, Gilbert DJ, Heathcote AC, Kafri MW, Kajii F, Lindner G, Mack GW, Mentes JC, Merlani P, Needham RA, Olde Rikkert MGM, Perren A, Powers J, Ranson SC, Ritz P, Rowat AM, Sjöstrand F, Smith AC, Stookey JJD, Stotts NA, Thomas DR, Vivanti A, Wakefield BJ, Waldréus N, Walsh NP, Ward S, Potter JF, Hunter P. Clinical symptoms, signs and tests for identification of impending and current water-loss dehydration in older people. Cochrane Database Syst Rev 2015; 2015:CD009647. [PMID: 25924806 PMCID: PMC7097739 DOI: 10.1002/14651858.cd009647.pub2] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is evidence that water-loss dehydration is common in older people and associated with many causes of morbidity and mortality. However, it is unclear what clinical symptoms, signs and tests may be used to identify early dehydration in older people, so that support can be mobilised to improve hydration before health and well-being are compromised. OBJECTIVES To determine the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs and tests to be used as screening tests for detecting water-loss dehydration in older people by systematically reviewing studies that have measured a reference standard and at least one index test in people aged 65 years and over. Water-loss dehydration was defined primarily as including everyone with either impending or current water-loss dehydration (including all those with serum osmolality ≥ 295 mOsm/kg as being dehydrated). SEARCH METHODS Structured search strategies were developed for MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL, LILACS, DARE and HTA databases (The Cochrane Library), and the International Clinical Trials Registry Platform (ICTRP). Reference lists of included studies and identified relevant reviews were checked. Authors of included studies were contacted for details of further studies. SELECTION CRITERIA Titles and abstracts were scanned and all potentially relevant studies obtained in full text. Inclusion of full text studies was assessed independently in duplicate, and disagreements resolved by a third author. We wrote to authors of all studies that appeared to have collected data on at least one reference standard and at least one index test, and in at least 10 people aged ≥ 65 years, even where no comparative analysis has been published, requesting original dataset so we could create 2 x 2 tables. DATA COLLECTION AND ANALYSIS Diagnostic accuracy of each test was assessed against the best available reference standard for water-loss dehydration (serum or plasma osmolality cut-off ≥ 295 mOsm/kg, serum osmolarity or weight change) within each study. For each index test study data were presented in forest plots of sensitivity and specificity. The primary target condition was water-loss dehydration (including either impending or current water-loss dehydration). Secondary target conditions were intended as current (> 300 mOsm/kg) and impending (295 to 300 mOsm/kg) water-loss dehydration, but restricted to current dehydration in the final review.We conducted bivariate random-effects meta-analyses (Stata/IC, StataCorp) for index tests where there were at least four studies and study datasets could be pooled to construct sensitivity and specificity summary estimates. We assigned the same approach for index tests with continuous outcome data for each of three pre-specified cut-off points investigated.Pre-set minimum sensitivity of a useful test was 60%, minimum specificity 75%. As pre-specifying three cut-offs for each continuous test may have led to missing a cut-off with useful sensitivity and specificity, we conducted post-hoc exploratory analyses to create receiver operating characteristic (ROC) curves where there appeared some possibility of a useful cut-off missed by the original three. These analyses enabled assessment of which tests may be worth assessing in further research. A further exploratory analysis assessed the value of combining the best two index tests where each had some individual predictive ability. MAIN RESULTS There were few published studies of the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs or tests to be used as screening tests for detecting water-loss dehydration in older people. Therefore, to complete this review we sought, analysed and included raw datasets that included a reference standard and an index test in people aged ≥ 65 years.We included three studies with published diagnostic accuracy data and a further 21 studies provided datasets that we analysed. We assessed 67 tests (at three cut-offs for each continuous outcome) for diagnostic accuracy of water-loss dehydration (primary target condition) and of current dehydration (secondary target condition).Only three tests showed any ability to diagnose water-loss dehydration (including both impending and current water-loss dehydration) as stand-alone tests: expressing fatigue (sensitivity 0.71 (95% CI 0.29 to 0.96), specificity 0.75 (95% CI 0.63 to 0.85), in one study with 71 participants, but two additional studies had lower sensitivity); missing drinks between meals (sensitivity 1.00 (95% CI 0.59 to 1.00), specificity 0.77 (95% CI 0.64 to 0.86), in one study with 71 participants) and BIA resistance at 50 kHz (sensitivities 1.00 (95% CI 0.48 to 1.00) and 0.71 (95% CI 0.44 to 0.90) and specificities of 1.00 (95% CI 0.69 to 1.00) and 0.80 (95% CI 0.28 to 0.99) in 15 and 22 people respectively for two studies, but with sensitivities of 0.54 (95% CI 0.25 to 0.81) and 0.69 (95% CI 0.56 to 0.79) and specificities of 0.50 (95% CI 0.16 to 0.84) and 0.19 (95% CI 0.17 to 0.21) in 21 and 1947 people respectively in two other studies). In post-hoc ROC plots drinks intake, urine osmolality and axillial moisture also showed limited diagnostic accuracy. No test was consistently useful in more than one study.Combining two tests so that an individual both missed some drinks between meals and expressed fatigue was sensitive at 0.71 (95% CI 0.29 to 0.96) and specific at 0.92 (95% CI 0.83 to 0.97).There was sufficient evidence to suggest that several stand-alone tests often used to assess dehydration in older people (including fluid intake, urine specific gravity, urine colour, urine volume, heart rate, dry mouth, feeling thirsty and BIA assessment of intracellular water or extracellular water) are not useful, and should not be relied on individually as ways of assessing presence or absence of dehydration in older people.No tests were found consistently useful in diagnosing current water-loss dehydration. AUTHORS' CONCLUSIONS There is limited evidence of the diagnostic utility of any individual clinical symptom, sign or test or combination of tests to indicate water-loss dehydration in older people. Individual tests should not be used in this population to indicate dehydration; they miss a high proportion of people with dehydration, and wrongly label those who are adequately hydrated.Promising tests identified by this review need to be further assessed, as do new methods in development. Combining several tests may improve diagnostic accuracy.
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Helfrich CD, Dolan ED, Fihn SD, Rodriguez HP, Meredith LS, Rosland AM, Lempa M, Wakefield BJ, Joos S, Lawler LH, Harvey HB, Stark R, Schectman G, Nelson KM. Association of medical home team-based care functions and perceived improvements in patient-centered care at VHA primary care clinics. Healthc (Amst) 2014; 2:238-44. [PMID: 26250630 DOI: 10.1016/j.hjdsi.2014.09.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 08/22/2014] [Accepted: 09/19/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Team-based care is central to the patient-centered medical home (PCMH), but most PCMH evaluations measure team structure exclusively. We assessed team-based care in terms of team structure, process and effectiveness, and the association with improvements in teams׳ abilities to deliver patient-centered care. MATERIAL AND METHODS We fielded a cross-sectional survey among 913 VA primary care clinics implementing a PCMH model in 2012. The dependent variable was clinic-level respondent-reported improvements in delivery of patient-centered care. Independent variables included three sets of measures: (1) team structure, (2) team process, and (3) team effectiveness. We adjusted for clinic workload and patient comorbidity. RESULTS 4819 surveys were returned (25% estimated response rate). The highest ratings were for team structure (median of 89% of respondents being assigned to a teamlet, i.e., a PCP working with the same clinical associate, nurse care manager and clerk) and lowest for team process (median of 10% of respondents reporting the lowest level of stress/chaos). In multivariable regression, perceived improvements in patient-centered care were most strongly associated with participatory decision making (β=32, P<0.0001) and history of change in the clinic (β=18, P=0008) (both team processes). A stressful/chaotic clinic environment was associated with higher barriers to patient centered care (β=0.16-0.34, P=<0.0001), and lower improvements in patient-centered care (β=-0.19, P=0.001). CONCLUSIONS Team process and effectiveness measures, often omitted from PCMH evaluations, had stronger associations with perceived improvements in patient-centered care than team structure measures. IMPLICATIONS Team process and effectiveness measures may facilitate synthesis of evaluation findings and help identify positive outlier clinics.
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Affiliation(s)
- Christian D Helfrich
- VA Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, WA, USA; Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA.
| | - Emily D Dolan
- VA Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, WA, USA
| | - Stephan D Fihn
- Office of Analytics and Business Intelligence, US Department of Veterans Affairs, Seattle, WA, USA
| | - Hector P Rodriguez
- Division of Health Policy and Management, School of Public Health, University of California, Berkeley, CA, USA
| | - Lisa S Meredith
- RAND Corporation, Santa Monica, CA, USA; Veterans Health Administration Health Services Research & Development Center of Excellence, VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
| | - Ann-Marie Rosland
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA; University of Michigan Medical School, Department of Internal Medicine, USA
| | - Michele Lempa
- Philadelphia VA Medical Center, US Department of Veterans Affairs, Philadelphia, PA, USA
| | - Bonnie J Wakefield
- VA Iowa City Health Services Research & Development Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City, IA, USA
| | - Sandra Joos
- Portland VA Medical Center, VISN 20 PACT Demonstration Laboratory, US Department of Veterans Affairs, Portland, OR, USA
| | - Lauren H Lawler
- Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA
| | - Henry B Harvey
- Office of Analytics and Business Intelligence, US Department of Veterans Affairs, Seattle, WA, USA
| | - Richard Stark
- VA Office of Clinical Operations, Washington, DC, USA
| | | | - Karin M Nelson
- VA Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, WA, USA
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Abstract
The prevalence of multiple chronic conditions (MCC) is increasing, creating challenges for patients, families, and the health care system. A systematic literature search was conducted to locate studies describing patient's perceptions of facilitators and barriers to management of MCC. Thirteen articles met study inclusion criteria. Patients reported nine categories of barriers including financial constraints, logistical challenges, physical limitations, lifestyle changes, emotional impact, inadequate family and social support, and the complexity of managing multiple conditions, medications, and communicating with health care providers. Four facilitators were found, including health system support, individualized care education and knowledge, informal support from family and social systems, and having personal mental and emotional strength. Existing research on management of MCC from the patient's perspective is limited. Interventions are needed to improve management practices with particular attention to the knowledge and skills required by this unique population.
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Affiliation(s)
- Gina Koch
- University of Missouri Sinclair School of Nursing, Columbia, MO, USA
| | - Bonnie J Wakefield
- University of Missouri Sinclair School of Nursing, Columbia, MO, USA Iowa City Veterans Affairs Healthcare System Center for Comprehensive Access and Delivery Research & Evaluation (CADRE), Iowa City, IA, USA
| | - Douglas S Wakefield
- University of Missouri Center for Health Care Quality, Columbia, MO, USA University of Missouri Department of Health Management & Informatics, Columbia, MO, USA
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33
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Helfrich CD, Dolan ED, Simonetti J, Reid RJ, Joos S, Wakefield BJ, Schectman G, Stark R, Fihn SD, Harvey HB, Nelson K. Elements of team-based care in a patient-centered medical home are associated with lower burnout among VA primary care employees. J Gen Intern Med 2014; 29 Suppl 2:S659-66. [PMID: 24715396 PMCID: PMC4070238 DOI: 10.1007/s11606-013-2702-z] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND A high proportion of the US primary care workforce reports burnout, which is associated with negative consequences for clinicians and patients. Many protective factors from burnout are characteristics of patient-centered medical home (PCMH) models, though even positive organizational transformation is often stressful. The existing literature on the effects of PCMH on burnout is limited, with most findings based on small-scale demonstration projects with data collected only among physicians, and the results are mixed. OBJECTIVE To determine if components of PCMH related to team-based care were associated with lower burnout among primary care team members participating in a national medical home transformation, the VA Patient Aligned Care Team (PACT). DESIGN Web-based, cross-sectional survey and administrative data from May 2012. PARTICIPANTS A total of 4,539 VA primary care personnel from 588 VA primary care clinics. MAIN MEASURES The dependent variable was burnout, and the independent variables were measures of team-based care: team functioning, time spent in huddles, team staffing, delegation of clinical responsibilities, working to top of competency, and collective self-efficacy. We also included administrative measures of workload and patient comorbidity. KEY RESULTS Overall, 39 % of respondents reported burnout. Participatory decision making (OR 0.65, 95 % CI 0.57, 0.74) and having a fully staffed PACT (OR 0.79, 95 % CI 0.68, 0.93) were associated with lower burnout, while being assigned to a PACT (OR 1.46, 95 % CI 1.11, 1.93), spending time on work someone with less training could do (OR 1.29, 95 % CI 1.07, 1.57) and a stressful, fast-moving work environment (OR 4.33, 95 % CI 3.78, 4.96) were associated with higher burnout. Longer tenure and occupation were also correlated with burnout. CONCLUSIONS Lower burnout may be achieved by medical home models that are appropriately staffed, emphasize participatory decision making, and increase the proportion of time team members spend working to the top of their competency level.
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Affiliation(s)
- Christian D Helfrich
- VA Puget Sound Health Services Research & Development Center of Excellence, US Department of Veterans Affairs, Seattle, WA, USA,
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Alexander GL, Wakefield BJ, Anbari AB, Lyons V, Prentice D, Shepherd M, Strecker EB, Weston MJ. A usability evaluation exploring the design of American Nurses Association state web sites. Comput Inform Nurs 2014; 32:378-87; quiz 388-9. [PMID: 24818790 DOI: 10.1097/cin.0000000000000068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
National leaders are calling for opportunities to facilitate the Future of Nursing. Opportunities can be encouraged through state nurses association Web sites, which are part of the American Nurses Association, that are well designed, with appropriate content, and in a language professional nurses understand. The American Nurses Association and constituent state nurses associations provide information about nursing practice, ethics, credentialing, and health on Web sites. We conducted usability evaluations to determine compliance with heuristic and ethical principles for Web site design. We purposefully sampled 27 nursing association Web sites and used 68 heuristic and ethical criteria to perform systematic usability assessments of nurse association Web sites. Web site analysis included seven double experts who were all RNs trained in usability analysis. The extent to which heuristic and ethical criteria were met ranged widely from one state that met 0% of the criteria for "help and documentation" to states that met greater than 92% of criteria for "visibility of system status" and "aesthetic and minimalist design." Suggested improvements are simple yet make an impact on a first-time visitor's impression of the Web site. For example, adding internal navigation and tracking features and providing more details about the application process through help and frequently asked question documentation would facilitate better use. Improved usability will improve effectiveness, efficiency, and consumer satisfaction with these Web sites.
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Affiliation(s)
- Gregory L Alexander
- Author Affiliations: Sinclair School of Nursing, University of Missouri, Columbia (Drs Alexander and Wakefield and Ms Anbari); The Center for Comprehensive Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Healthcare System, IA (Dr Wakefield); Murray-Calloway County Hospital, Murray, KY (Ms Lyons); Barnes-Jewish Hospital, St Louis, MO (Ms Prentice); Blessing Rieman College of Nursing, Quincy, IL (Ms Shepherd); Cerner Corporation, Kansas City, MO (Mr Strecker); and American Nurses Association, Silver Spring, MD (Dr Weston)
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Wakefield BJ, Koopman RJ, Keplinger LE, Bomar M, Bernt B, Johanning JL, Kruse RL, Davis JW, Wakefield DS, Mehr DR. Effect of home telemonitoring on glycemic and blood pressure control in primary care clinic patients with diabetes. Telemed J E Health 2014; 20:199-205. [PMID: 24404819 DOI: 10.1089/tmj.2013.0151] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Patient self-management support may be augmented by using home-based technologies that generate data points that providers can potentially use to make more timely changes in the patients' care. The purpose of this study was to evaluate the effectiveness of short-term targeted use of remote data transmission on treatment outcomes in patients with diabetes who had either out-of-range hemoglobin A1c (A1c) and/or blood pressure (BP) measurements. MATERIALS AND METHODS A single-center randomized controlled clinical trial design compared in-home monitoring (n=55) and usual care (n=53) in patients with type 2 diabetes and hypertension being treated in primary care clinics. Primary outcomes were A1c and systolic BP after a 12-week intervention. RESULTS There were no significant differences between the intervention and control groups on either A1c or systolic BP following the intervention. CONCLUSIONS The addition of technology alone is unlikely to lead to improvements in outcomes. Practices need to be selective in their use of telemonitoring with patients, limiting it to patients who have motivation or a significant change in care, such as starting insulin. Attention to the need for effective and responsive clinic processes to optimize the use of the additional data is also important when implementing these types of technology.
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Koopman RJ, Wakefield BJ, Johanning JL, Keplinger LE, Kruse RL, Bomar M, Bernt B, Wakefield DS, Mehr DR. Implementing home blood glucose and blood pressure telemonitoring in primary care practices for patients with diabetes: lessons learned. Telemed J E Health 2013; 20:253-60. [PMID: 24350806 DOI: 10.1089/tmj.2013.0188] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [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
BACKGROUND Prior telemonitoring trials of blood pressure and blood glucose have shown improvements in blood pressure and glycemic targets. However, implementation of telemonitoring in primary care practices may not yield the same results as research trials with extra resources and rigid protocols. In this study we examined the process of implementing home telemonitoring of blood glucose and blood pressure for patients with diabetes in six primary care practices. MATERIALS AND METHODS Grounded theory qualitative analysis was conducted in parallel with a randomized controlled effectiveness trial of home telemonitoring. Data included semistructured interviews with 6 nurse care coordinators and 12 physicians in six participating practices and field notes from exit interviews with 93 of 108 randomized patients. RESULTS The three stakeholder groups (patients, nurse care coordinators, and physicians) exhibited some shared themes and some unique to the particular stakeholder group. Major themes were that practices should (1) understand the capabilities and limitations of the technology and the willingness of patient and physician stakeholders to use it, (2) understand the workflow, flow of information, and human factors needed to optimize use of the technology, (3) engage and prepare the physicians, and (4) involve the patient in the process. Although there was enthusiasm for a patient-centered medical home model that included between-visit telemonitoring, there was concern about the support and resources needed to provide this service to patients. CONCLUSIONS As with many technology interventions, careful consideration of workflow and information flow will help enable effective implementations.
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Affiliation(s)
- Richelle J Koopman
- 1 Curtis W. and Ann H. Long Department of Family and Community Medicine, University of Missouri School of Medicine , Columbia, Missouri
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Keplinger LE, Koopman RJ, Mehr DR, Kruse RL, Wakefield DS, Wakefield BJ, Canfield SM. Patient portal implementation: resident and attending physician attitudes. Fam Med 2013; 45:335-340. [PMID: 23681685 PMCID: PMC6980343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Electronic patient portals are increasingly common, but there is little information regarding attitudes of faculty and residents at academic medical centers toward them. METHODS The primary objective was to investigate attitudes toward electronic patient portals among primary care residents and faculty and changes in faculty attitudes after implementation. The study design included a pre-implementation survey of 39 general internal medicine and family medicine residents and 43 generalist faculty addressing attitudes and expectations of a planned patient portal and also a pre- and post-implementation survey of general internal medicine and family medicine faculty physicians. The survey also addressed email communication with patients. RESULTS Prior to portal implementation, residents reported receiving much less e-mail from patients than faculty physicians; 68% and 9% of residents and faculty, respectively, reported no email exchange in a typical month. Residents were less likely to agree with allowing patients to view selected parts of their medical record on-line than faculty physicians (57% and 81%, respectively). Physicians who participated in the portal's pilot implementation had expected workload to increase (64% agreed), but after implementation, 87% of those responding were neutral or disagreed that workload had increased. After implementation, only 33% believed quality of care had improved compared to 55% who had expected it to improve prior to implementation. CONCLUSIONS Residents and faculty physicians need to be prepared for a changing environment of electronic communication with patients. Some positive and negative expectations of physicians toward enhanced electronic access by patients were not borne out by experience.
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Affiliation(s)
- Lynn E. Keplinger
- Department of Internal Medicine, Division of General Internal Medicine, University of Missouri School of Medicine
| | - Richelle J. Koopman
- Curtis W. and Ann H. Long Department of Family & Community Medicine, University of Missouri School of Medicine
| | - David R. Mehr
- Curtis W. and Ann H. Long Department of Family & Community Medicine, University of Missouri School of Medicine
| | - Robin L. Kruse
- Curtis W. and Ann H. Long Department of Family & Community Medicine, University of Missouri School of Medicine
| | - Douglas S. Wakefield
- Center for Healthcare Quality, Department of Health Management & Informatics, University of Missouri School of Medicine
| | | | - Shannon M. Canfield
- Curtis W. and Ann H. Long Department of Family & Community Medicine, University of Missouri School of Medicine
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Abstract
BACKGROUND The use of telemonitoring of patients with chronic illness in their homes is growing. Current literature does not describe what types of patient problems are addressed by nurses in these programs and what actions are taken in response to identified problems. This study defined and analyzed patient problems and nursing actions delivered in a telemonitoring program focused on chronic disease management. SUBJECTS AND METHODS Data were drawn from a clinical trial that evaluated telemonitoring in patients with comorbid diabetes and hypertension. Using study patient records, patient problems and nursing actions were coded using an inductive approach. RESULTS In total, 2,336 actions were coded for 68 and 65 participants in two intervention groups. The most frequent reasons for contact were reporting information to the primary care provider and lifestyle information related to diabetes and hypertension (e.g., diet, smoking cessation, foot care, and social contacts). The most frequent mode of contact was the study sending a letter to a participant. CONCLUSIONS Detailed descriptions of interventions delivered facilitate analysis of the unique contributions of nurses in the expanding market of telemonitoring, enable identification of the appropriate number and combination of interventions needed to improve outcomes, and make possible more systematic translation of findings to practice. Furthermore, this information can inform calculation of appropriate panel sizes for care managers and the competencies needed to provide this care.
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Affiliation(s)
- Bonnie J Wakefield
- VA Health Services Research and Development Center for Comprehensive Access & Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa City, Iowa 52246, USA.
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Abstract
The purpose of this qualitative study was to describe the process by which hospital staff nurses keep patients safe within their hospital safety culture. Findings from this study culminated in a grounded theory of Managing Risk, the process by which nurses keep their patients safe from harm. Participants perceived that their patients were always at risk ( it’s always something), thus keeping patients safe was a continual, repetitive process of managing risk to prevent harm to patients. Stages of this process included risk assessment, risk recognition, prioritization, and protective interventions. Practicing nurses can use this theory to understand and articulate their critical role in keeping patients safe in hospitals. Further examination of this process is necessary for targeted assessment of a safety culture’s impact on bedside nursing practice, thus providing a basis for specific interventions to improve patient safety.
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Wakefield DS, Clements K, Wakefield BJ, Burns J, Hahn-Cover K. A Framework for Analyzing Data from the Electronic Health Record: Verbal Orders as a Case in Point. Jt Comm J Qual Patient Saf 2012; 38:444-51. [DOI: 10.1016/s1553-7250(12)38059-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Wakefield BJ, Holman JE, Ray A, Scherubel M, Adams MR, Hills SL, Rosenthal GE. Outcomes of a home telehealth intervention for patients with diabetes and hypertension. Telemed J E Health 2012; 18:575-9. [PMID: 22873700 DOI: 10.1089/tmj.2011.0237] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Home telehealth programs often focus on a single disease, yet many patients who need monitoring have multiple conditions. This study evaluated secondary outcomes from a clinical trial evaluating the efficacy of home telehealth to improve outcomes of patients with co-morbid diabetes and hypertension. SUBJECTS AND METHODS A single-center randomized controlled clinical trial compared two remote monitoring intensity levels (low and high) and usual care in patients with type 2 diabetes and hypertension being treated in primary care. Secondary outcomes assessed were knowledge (diabetes, hypertension, medications), self-efficacy, adherence (diabetes, medications), and patient perceptions of the intervention mode. RESULTS Knowledge scores improved in the high-intensity intervention group participants, but upon further analysis, we found the intervention effect was not mediated by gain in knowledge. No significant differences were found across the groups in self-efficacy, adherence, or patient perceptions of the intervention mode. CONCLUSIONS Home telehealth can enhance detection of key clinical symptoms that occur between regular physician visits. While our intervention improved glycemic and blood pressure control, the mechanism of the effect for this improvement was not clear.
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Affiliation(s)
- Bonnie J Wakefield
- Center for Comprehensive Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa, USA
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Kruse RL, Koopman RJ, Wakefield BJ, Wakefield DS, Keplinger LE, Canfield SM, Mehr DR. Internet use by primary care patients: where is the digital divide? Fam Med 2012; 44:342-347. [PMID: 23027117] [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: 06/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Internet-based technologies such as personal health records and patient portals are increasingly viewed as essential for enhancing patient-provider communication and patient-centered care. We examined how primary care patients use the Internet, particularly patient characteristics associated with Internet use. METHODS We surveyed patients in five primary care clinic waiting rooms. Patients who had used email or the Internet in the past month (Internet users) were asked how often they used a computer for a variety of tasks. Participants who reported not using the Internet were asked about several potential barriers to Internet use. RESULTS We approached 713 patients, and 638 (89.6%) completed questionnaires; 499 (78%) were Internet users and 139 (22%) were non-users. Lack of computer access and not knowing how to use email or the Internet were the most common barriers to Internet use. Younger age, higher education and income, better health, and absence of a chronic illness were associated with Internet use. After controlling for age and other variables, chronic illness was no longer associated with Internet use. CONCLUSIONS Internet use was high among our primary care patients. The major factor associated with Internet use among patients with chronic conditions was their age. If older adults with chronic illness are to reap the benefits of health information technology, their Internet access will need to be improved. Institutions that are planning to offer consumer health information technology should be aware of groups with lower Internet access.
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Affiliation(s)
- Robin L Kruse
- Department of Family and Community Medicine, University of Missouri, Columbia 65212, USA.
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Wakefield DS, Kruse RL, Wakefield BJ, Koopman RJ, Keplinger LE, Canfield SM, Mehr DR. Consistency of patient preferences about a secure Internet-based patient communications portal: contemplating, enrolling, and using. Am J Med Qual 2012; 27:494-502. [PMID: 22517909 DOI: 10.1177/1062860611436246] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [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]
Abstract
Internet-based secure communication portals (portal) have the potential to enhance patient care via improved patient-provider communications. This study examines differences among primary care patients' perceptions when contemplating using, enrolling to use, and using a portal for health care purposes. A total of 3 groups of patients from 1 Midwestern academic medical center were surveyed at different points in time: (1) Waiting Room survey asking about hypothetical interest in using a portal to communicate with their physicians; (2) patient portal Enrollment survey; and (3) Follow-up postenrollment experience survey. Those who enroll and use a patient portal have different demographic characteristics and interest levels in selected portal functions (eg, e-mailing providers, viewing medical records online, making appointments) and initially perceive only limited improvements in care because of the portal. These differences have potential market implications and provide insight into selecting and maintaining portal functions of greater interest to patients who use the portal.
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Wakefield DS, Wakefield BJ, Despins L, Brandt J, Davis W, Clements K, Steinmann W. A review of verbal order policies in acute care hospitals. Jt Comm J Qual Patient Saf 2012; 38:24-33. [PMID: 22324188 DOI: 10.1016/s1553-7250(12)38004-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although verbal and telephone orders (VOs) are commonly used in the patient care process, there has been little examination of the strategies and tactics used to ensure their appropriate use or how to ensure that they are accurately communicated, correctly understood, initially documented, and subsequently transcribed into the medical record and ultimately carried out as intended. A systematic review was conducted of hospital verbal and telephone order policies in acute care settings. METHODS A stratified random sample of hospital verbal and telephone order policy documents were abstracted from critical access, rural, rural referral, and urban hospitals located in Iowa and Missouri and from academic medical centers from across the United States. FINDINGS Substantial differences were found across 40 acute care settings in terms of who is authorized to give (including nonlicensed personnel) and take VOs and in terms of time allowed for the prescriber to cosign the VO. When a nonphysician or other licensed prescriber was allowed to communicate VOs, there was no discussion of the process to review the VO before it was communicated in turn to the hospital personnel receiving the order. Policies within several of the same hospitals were inconsistent in terms of the periods specified for prescriber cosignature. Few hospitals required authentication of the identity of the person making telephone VOs, nor the use of practices to improve communication reliability. CONCLUSION Careful review and updating of hospital VO policies is necessary to ensure that they are internally consistent and optimize patient safety. The implementation of computerized medical records and ordering systems can reduce but not eliminate the need for VOs.
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Hooper L, Attreed NJ, Campbell WW, Channell AM, Chassagne P, Culp KR, Fletcher SJ, Fuller N, Gaspar PM, Gilbert DJ, Heathcote AC, Lindner G, Mack GW, Mentes JC, Needham RA, Olde Rikkert MGM, Ranson SC, Ritz P, Rowat AM, Smith AC, Stookey JJD, Thomas DR, Wakefield BJ, Ward S, Potter JF, Hunter PR. Clinical and physical signs for identification of impending and current water-loss dehydration in older people. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd009647] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Turvey CL, Zulman DM, Nazi KM, Wakefield BJ, Woods SS, Hogan TP, Weaver FM, McInnes K. Transfer of information from personal health records: a survey of veterans using My HealtheVet. Telemed J E Health 2012; 18:109-14. [PMID: 22304439 DOI: 10.1089/tmj.2011.0109] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [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
OBJECTIVE Personal health records provide patients with ownership of their health information and allow them to share information with multiple healthcare providers. However, the usefulness of these records relies on patients understanding and using their records appropriately. My HealtheVet is a Web-based patient portal containing a personal health record administered by the Veterans Health Administration. The goal of this study was to explore veterans' interest and use of My HealtheVet to transfer and share information as well as to identify opportunities to increase veteran use of the My HealtheVet functions. MATERIALS AND METHODS Two waves of data were collected in 2010 through an American Customer Satisfaction Index Web-based survey. A random sample of veterans using My HealtheVet was invited to participate in the survey conducted on the My HealtheVet portal through a Web-based pop-up browser window. RESULTS Wave One results (n=25,898) found that 41% of veterans reported printing information, 21% reported saving information electronically, and only 4% ever sent information from My HealtheVet to another person. In Wave Two (n=18,471), 30% reported self-entering medication information, with 18% sharing this information with their Veterans Affairs (VA) provider and 9.6% sharing with their non-VA provider. CONCLUSION Although veterans are transferring important medical information from their personal health records, increased education and awareness are needed to increase use. Personal health records have the potential to improve continuity of care. However, more research is needed on both the barriers to adoption as well as the actual impact on patient health outcomes and well-being.
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Affiliation(s)
- Carolyn L Turvey
- Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa 42286, USA.
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Wakefield BJ, Hayes J, Boren SA, Pak Y, Davis JW. Strain and satisfaction in caregivers of veterans with chronic illness. Res Nurs Health 2011; 35:55-69. [DOI: 10.1002/nur.21456] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2011] [Indexed: 11/08/2022]
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Young LB, Foster L, Silander A, Wakefield BJ. Home Telehealth: Patient Satisfaction, Program Functions, and Challenges for the Care Coordinator. J Gerontol Nurs 2011; 37:38-46. [DOI: 10.3928/00989134-20110706-02] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Accepted: 02/10/2011] [Indexed: 11/20/2022]
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Koopman RJ, Kochendorfer KM, Moore JL, Mehr DR, Wakefield DS, Yadamsuren B, Coberly JS, Kruse RL, Wakefield BJ, Belden JL. A diabetes dashboard and physician efficiency and accuracy in accessing data needed for high-quality diabetes care. Ann Fam Med 2011; 9:398-405. [PMID: 21911758 PMCID: PMC3185474 DOI: 10.1370/afm.1286] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We compared use of a new diabetes dashboard screen with use of a conventional approach of viewing multiple electronic health record (EHR) screens to find data needed for ambulatory diabetes care. METHODS We performed a usability study, including a quantitative time study and qualitative analysis of information-seeking behaviors. While being recorded with Morae Recorder software and "think-aloud" interview methods, 10 primary care physicians first searched their EHR for 10 diabetes data elements using a conventional approach for a simulated patient, and then using a new diabetes dashboard for another. We measured time, number of mouse clicks, and accuracy. Two coders analyzed think-aloud and interview data using grounded theory methodology. RESULTS The mean time needed to find all data elements was 5.5 minutes using the conventional approach vs 1.3 minutes using the diabetes dashboard (P <.001). Physicians correctly identified 94% of the data requested using the conventional method, vs 100% with the dashboard (P <.01). The mean number of mouse clicks was 60 for conventional searching vs 3 clicks with the diabetes dashboard (P <.001). A common theme was that in everyday practice, if physicians had to spend too much time searching for data, they would either continue without it or order a test again. CONCLUSIONS Using a patient-specific diabetes dashboard improves both the efficiency and accuracy of acquiring data needed for high-quality diabetes care. Usability analysis tools can provide important insights into the value of optimizing physician use of health information technologies.
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Affiliation(s)
- Richelle J Koopman
- Curtis W. and Ann H. Long Department of Family and Community Medicine, University of Missouri, School of Medicine, Columbia, Missouri 65212, USA.
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