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Kurlander JE, Laine L, Kim HM, Roberts CB, Saffar D, Myers A, Holleman R, Gao Y, Shank M, Nelson R, Forman J, Helfrich CD, Krein SL, Saini SD, Yang YX. Impact of large scale, multicomponent intervention to reduce proton pump inhibitor overuse in integrated healthcare system: difference-in-difference study. BMJ 2024; 385:e076484. [PMID: 38604668 PMCID: PMC11007585 DOI: 10.1136/bmj-2023-076484] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE To determine how a large scale, multicomponent, pharmacy based intervention to reduce proton pump inhibitor (PPI) overuse affected prescribing patterns, healthcare utilization, and clinical outcomes. DESIGN Difference-in-difference study. SETTING US Veterans Affairs Healthcare System, in which one regional network implemented the overuse intervention and all 17 others served as controls. PARTICIPANTS All individuals receiving primary care from 2009 to 2019. INTERVENTION Limits on PPI refills for patients without a documented indication for long term use, voiding of PPI prescriptions not recently filled, facilitated electronic prescribing of H2 receptor antagonists, and education for patients and clinicians. MAIN OUTCOME MEASURES The primary outcome was the percentage of patients who filled a PPI prescription per 6 months. Secondary outcomes included percentage of days PPI gastroprotection was prescribed in patients at high risk for upper gastrointestinal bleeding, percentage of patients who filled either a PPI or H2 receptor antagonist prescription, hospital admission for acid peptic disease in older adults appropriate for PPI gastroprotection, primary care visits for an upper gastrointestinal diagnosis, upper endoscopies, and PPI associated clinical conditions. RESULTS The number of patients analyzed per interval ranged from 192 607 to 250 349 in intervention sites and from 3 775 953 to 4 360 868 in control sites, with 26% of patients receiving PPIs before the intervention. The intervention was associated with an absolute reduction of 7.3% (95% confidence interval -7.6% to -7.0%) in patients who filled PPI prescriptions, an absolute reduction of 11.3% (-12.0% to -10.5%) in PPI use among patients appropriate for gastroprotection, and an absolute reduction of 5.72% (-6.08% to -5.36%) in patients who filled a PPI or H2 receptor antagonist prescription. No increases were seen in primary care visits for upper gastrointestinal diagnoses, upper endoscopies, or hospital admissions for acid peptic disease in older patients appropriate for gastroprotection. No clinically significant changes were seen in any PPI associated clinical conditions. CONCLUSIONS The multicomponent intervention was associated with reduced PPI use overall but also in patients appropriate for gastroprotection, with minimal evidence of either clinical benefits or harms.
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Affiliation(s)
- Jacob E Kurlander
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Loren Laine
- Yale School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Hyungjin Myra Kim
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Christopher B Roberts
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Darcy Saffar
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Aimee Myers
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Robert Holleman
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Yuqing Gao
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Michelle Shank
- Department of Veterans Affairs, Pharmacy Services, Washington, DC, USA (retired)
| | - Richard Nelson
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jane Forman
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Christian D Helfrich
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA
| | - Sarah L Krein
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Sameer D Saini
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Yu-Xiao Yang
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Donovan LM, McDowell JA, Pannick AP, Pai J, Bais AF, Plumley R, Wai TH, Grunwald GK, Josey K, Sayre GG, Helfrich CD, Zeliadt SB, Hoerster KD, Ma J, Au DH. Protocol for a pragmatic trial testing a self-directed lifestyle program targeting weight loss among patients with obstructive sleep apnea (POWER Trial). Contemp Clin Trials 2023; 135:107378. [PMID: 37935303 DOI: 10.1016/j.cct.2023.107378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/23/2023] [Accepted: 11/03/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND Obesity comprises the single greatest reversible risk factor for obstructive sleep apnea (OSA). Despite the potential of lifestyle-based weight loss services to improve OSA severity and symptoms, these programs have limited reach. POWER is a pragmatic trial of a remote self-directed weight loss care among patients with OSA. METHODS POWER randomizes 696 patients with obesity (BMI 30-45 kg/m2) and recent diagnosis or re-confirmation of OSA 1:1 to either a self-directed weight loss intervention or usual care. POWER tests whether such an intervention improves co-primary outcomes of weight and sleep-related quality of life at 12 months. Secondary outcomes include sleep symptoms, global ratings of change, and cardiovascular risk scores. Finally, consistent with a hybrid type 1 approach, the trial embeds an implementation process evaluation. We will use quantitative and qualitative methods including budget impact analyses and qualitative interviews to assess barriers to implementation. CONCLUSIONS The results of POWER will inform population health approaches to the delivery of weight loss care. A remote self-directed program has the potential to be disseminated widely with limited health system resources and likely low-cost.
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Affiliation(s)
- Lucas M Donovan
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; University of Washington, Seattle, WA, USA.
| | - Jennifer A McDowell
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Anna P Pannick
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - James Pai
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; Tulane University, New Orleans, LA, USA
| | - Anthony F Bais
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Robert Plumley
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | | | | | | | - George G Sayre
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Christian D Helfrich
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; University of Washington, Seattle, WA, USA
| | - Steven B Zeliadt
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; University of Washington, Seattle, WA, USA
| | - Katherine D Hoerster
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; University of Washington, Seattle, WA, USA
| | - Jun Ma
- University of Illinois Chicago, Chicago, IL, USA
| | - David H Au
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; University of Washington, Seattle, WA, USA
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Shalev L, Helfrich CD, Ellen M, Avirame K, Eitan R, Rose AJ. Bridging language barriers in developing valid health policy research tools: insights from the translation and validation process of the SHEMESH questionnaire. Isr J Health Policy Res 2023; 12:36. [PMID: 38008722 PMCID: PMC10680279 DOI: 10.1186/s13584-023-00583-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/12/2023] [Indexed: 11/28/2023] Open
Abstract
BACKGROUND The use of research tools developed and validated in one cultural and linguistic context to another often faces challenges. One major challenge is poor performance of the tool in the new context. This potentially impact the legitimacy of health policy research conducted with informal adaptations of existing tools which have not been subjected to formal validation. Best practices exist to guide researchers in adapting and validating research tools effectively. We present here, as an extended example, our validation of the SHEMESH questionnaire ('Organizational Readiness to Change Assessment'; In Hebrew: 'SHE'elon Muchanut Ergunit le'SHinuy'), a Hebrew-language version of the Organizational Readiness to Change Assessment (ORCA). SHEMESH is tailored to support implementation science projects, whose aim is to promote a more rapid and complete adoption of evidence-based health policies and practices. METHODS The SHEMESH included originally eleven questions from the Evidence (item 1-4) and Context (items 5-11) domains. We validated SHEMESH through the following steps: 1. Professional translation to Hebrew and discussion of the translation by multidisciplinary committee; 2. Back-translation into English by a different translator to detect discrepancies; 3. Eleven cognitive interviews with psychiatric emergency department physicians and nurses; and 4. Pilot testing and psychometric analyses, including Cronbach's alpha for subscales and factor analyses. RESULTS Following translation and cognitive interviews, SHEMESH was administered to 222 psychiatrists and nurses. Pearson correlation showed significant and strong correlations of items 1-4 to the Evidence construct and items 6-11 to the Context construct. Item 5 did not correlate with the other items, and therefore was removed from the other psychometric procedures and eventually from the SHEMESH. Factor analysis with the remaining 10 items yielded two factors, which together explained a total of 69.7% of variance. Cronbach's Alpha scores for the two subscales were high (Evidence, 0.887, and Context, 0.852). CONCLUSIONS This multi-step validation process of the SHEMESH questionnaire may serve as a comprehensive guideline for others who are willing to adapt research tools that were developed in other languages. Practically, SHEMESH has been validated for use in implementation science research projects in Israel.
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Affiliation(s)
- Ligat Shalev
- Braun School of Public Health and Community Medicine, Hebrew University of Jerusalem, Ein Kerem Campus, 91120, Jerusalem, Israel.
| | - Christian D Helfrich
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA
| | - Moriah Ellen
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O.B. 653, 84105, Beer-Sheva, Israel
| | - Keren Avirame
- Psychiatric Division, Sourasky Medical Center, 14 Weizmann Street, Tel Aviv-Yafo, Israel
| | - Renana Eitan
- Psychiatric Division, Sourasky Medical Center, 14 Weizmann Street, Tel Aviv-Yafo, Israel
| | - Adam J Rose
- Braun School of Public Health and Community Medicine, Hebrew University of Jerusalem, Ein Kerem Campus, 91120, Jerusalem, Israel
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O'Connor AW, Helfrich CD, Nelson KM, Sears JM, Jensen PK, Engstrom C, Wong ES. Full practice authority and burnout among primary care nurse practitioners. Nurs Outlook 2023; 71:102056. [PMID: 37856902 DOI: 10.1016/j.outlook.2023.102056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 09/15/2023] [Accepted: 09/15/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Full practice authority (FPA) improves clinical autonomy for nurse practitioners (NPs). Autonomy may reduce burnout. PURPOSE Estimate the effect of changing from reduced or restricted practice authority to FPA on NP burnout. METHODS In this quasi-experimental study, we compared NP burnout before (2016) and after (2018) a Veterans Health Administration (VHA) regulation authorized NP FPA. Burnout proportions were estimated for VHA facilities by aggregating responses to the VHA's All Employee Survey from 1,352 primary care NPs. DISCUSSION Seventy-seven percent of facilities changed to FPA postregulation. Burnout was six points lower among NPs in facilities that changed to FPA compared to facilities that had FPA prior to the regulation; however, this association was not statistically significant. CONCLUSION NPs are increasingly working under independent practice. While changing to FPA did not reduce NP burnout, this association may vary by health care setting or when burnout is measured for individuals or teams.
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Affiliation(s)
- Allyson W O'Connor
- Department of Health Systems and Population Health, University of Washington, Seattle, WA.
| | - Christian D Helfrich
- Department of Health Systems and Population Health, University of Washington, Seattle, WA; Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA
| | - Karin M Nelson
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA
| | - Jeanne M Sears
- Department of Health Systems and Population Health, University of Washington, Seattle, WA; Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA; Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - Penny Kaye Jensen
- Office of Nursing Service, Department of Veterans Affairs, Washington, DC
| | - Christine Engstrom
- Office of Nursing Service, Department of Veterans Affairs, Washington, DC
| | - Edwin S Wong
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA
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Ives J, Bagchi S, Soo S, Barrow C, Akgün KM, Erlandson KM, Goetz M, Griffith M, Gross R, Hulgan T, Moanna A, Soo Hoo GW, Weintrob A, Wongtrakool C, Adams SV, Sayre G, Helfrich CD, Au DH, Crothers K. Design and methods of a randomized trial testing "Advancing care for COPD in people living with HIV by implementing evidence-based management through proactive E-consults (ACHIEVE)". Contemp Clin Trials 2023; 132:107303. [PMID: 37481201 PMCID: PMC10528346 DOI: 10.1016/j.cct.2023.107303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 05/31/2023] [Accepted: 07/19/2023] [Indexed: 07/24/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is one of the most common comorbid diseases among aging people with HIV (PWH) and is often mismanaged. To address this gap, we are conducting the study, "Advancing care for COPD in people living with HIV by Implementing Evidence-based management through proactive E-consults (ACHIEVE)." This intervention optimizes COPD management by promoting effective, evidence-based care and de-implementing inappropriate therapies for COPD in PWH receiving care at Veteran Affairs (VA) medical centers. Study pulmonologists are proactively supporting ID providers managing a population of PWH who have COPD, offering real-time evidence-based recommendations tailored to each patient. We are leveraging VA clinical and informatics infrastructures to communicate recommendations between the study team and clinical providers through the electronic health record (EHR) as an E-consult. If effective, ACHIEVE could serve as a model of effective, efficient COPD management among PWH receiving care in VA. This paper outlines the rationale and methodology of the ACHIEVE trial, one of a series of studies funded by the National Heart, Lung, and Blood Institute (NHLBI) within the ImPlementation REsearCh to DEvelop Interventions for People Living with HIV (PRECluDE) consortium to study chronic disease comorbidities in HIV populations.
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Affiliation(s)
- Jennifer Ives
- Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States of America.
| | - Subarna Bagchi
- Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States of America.
| | - Sherilynn Soo
- Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States of America.
| | - Cera Barrow
- Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States of America.
| | - Kathleen M Akgün
- VA Connecticut Healthcare System, West Haven, CT, United States of America; Yale University, New Haven, CT, United States of America.
| | - Kristine M Erlandson
- Department of Medicine, University of Colorado Denver-Anschutz Medical Campus, Aurora, CO, United States of America.
| | - Matthew Goetz
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System Los Angeles, CA, United States of America; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America.
| | - Matthew Griffith
- Department of Medicine, University of Colorado Denver-Anschutz Medical Campus, Aurora, CO, United States of America; Department of Medicine, VA Eastern Colorado Health Care System, Aurora, CO, United States of America.
| | - Robert Gross
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States of America; Department of Medicine (Infectious Diseases), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America.
| | - Todd Hulgan
- Tennessee Valley Veterans Health System/Nashville Veterans Affairs Hospital, Nashville, TN, United States of America; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America.
| | - Abeer Moanna
- Department of Medicine, Atlanta VA Healthcare System, Decatur, GA, United States of America; Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States of America.
| | - Guy W Soo Hoo
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System Los Angeles, CA, United States of America; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America.
| | - Amy Weintrob
- Department of Medicine, Infectious Diseases Section, Washington DC Veterans Affairs Medical Center, Washington, DC, United States of America.
| | - Cherry Wongtrakool
- Department of Medicine, Atlanta VA Healthcare System, Decatur, GA, United States of America; Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States of America.
| | - Scott V Adams
- Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States of America.
| | - George Sayre
- Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States of America.
| | - Christian D Helfrich
- Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States of America.
| | - David H Au
- Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington School of Medicine, Seattle, WA, United States of America.
| | - Kristina Crothers
- Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington School of Medicine, Seattle, WA, United States of America.
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O’Connor AW, Wong ES, Nelson KM, Sears JM, Helfrich CD. Patient Enrollment Growth and Burnout in Primary Care at the Veterans Health Administration. J Gen Intern Med 2023; 38:1689-1696. [PMID: 36697928 PMCID: PMC10212874 DOI: 10.1007/s11606-023-08034-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 12/30/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Patient enrollment levels at Veterans Health Administration (VHA) facilities change based on Veteran demand for care, potentially affecting demands on staff. Effects on burnout in the primary care workforce associated with increases or decreases in enrollment are unknown. OBJECTIVE Estimate associations between patient enrollment and burnout. DESIGN In this serial cross-sectional study, VHA patient enrollment and workforce data from 2014 to 2018 were linked to burnout estimates for 138 VHA facilities. The VHA's annual All Employee Survey provided burnout estimates. PARTICIPANTS A total of 82,421 responses to the 2014-2018 All Employee Surveys by primary care providers (PCPs), including physicians, nurse practitioners, and physician assistants; nurses; clinical associates; and administrative clerks were included. Respondents identified as patient-aligned care team members. MAIN MEASURES Independent variables were (1) the ratio of enrollment to PCPs at VHA facilities and (2) the year-over-year change in enrollment per PCP. Burnout was measured as the annual proportion of staff at VHA facilities who reported emotional exhaustion and/or depersonalization. Each primary care role was analyzed independently. KEY RESULTS Overall enrollment decreased from 1553 enrollees per PCP in 2014 to 1442 enrollees per PCP in 2018 across VHA facilities. Forty-three facilities experienced increased enrollment (mean of 1524 enrollees/PCP in 2014 to 1668 in 2018) and 95 facilities experienced decreased enrollment (mean of 1566 enrollees/PCP in 2014 to 1339 in 2018). Burnout decreased for all primary care roles. PCP burnout was highest, decreasing from a facility-level mean of 51.7% in 2014 to 43.8% in 2018. Enrollment was not significantly associated with burnout for any role except nurses, for whom a 1% year-over-year increase in enrollment was associated with a 0.2 percentage point increase in burnout (95% CI: 0.1 to 0.3). CONCLUSIONS Studies assessing changes in organizational-level predictors are rare in burnout research. Patient enrollment predicted burnout only among nurses in primary care.
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Affiliation(s)
- Allyson W. O’Connor
- Department of Health Systems and Population Health, University of Washington, Seattle, WA USA
| | - Edwin S. Wong
- Department of Health Systems and Population Health, University of Washington, Seattle, WA USA
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA USA
| | - Karin M. Nelson
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA USA
- Department of Medicine, University of Washington, Seattle, WA USA
| | - Jeanne M. Sears
- Department of Health Systems and Population Health, University of Washington, Seattle, WA USA
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA USA
- Harborview Injury Prevention and Research Center, Seattle, WA USA
- Institute for Work and Health, Toronto, Ontario Canada
| | - Christian D. Helfrich
- Department of Health Systems and Population Health, University of Washington, Seattle, WA USA
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA USA
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Kononowech J, Hagedorn H, Hall C, Helfrich CD, Lambert-Kerzner AC, Miller SC, Sales AE, Damschroder L. Correction: Mapping the organizational readiness to change assessment to the Consolidated Framework for Implementation Research. Implement Sci Commun 2023; 4:32. [PMID: 36945073 PMCID: PMC10029170 DOI: 10.1186/s43058-023-00415-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Affiliation(s)
- Jennifer Kononowech
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd, Ann Arbor, MI, USA.
| | - Hildi Hagedorn
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, 1 Veterans Drive, Minneapolis, MN, USA
- Department of Psychiatry, University of Minnesota School of Medicine, 606 24Th Ave S, Minneapolis, MN, USA
| | - Carmen Hall
- Gusek Hall Consulting, 1362 Ryan Ave. W Ste 101, Roseville, MN, USA
| | - Christian D Helfrich
- Seattle-Denver Center of Innovation, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, USA
- School of Public Health, University of Washington, 1959 NE Pacific St, Seattle, WA, USA
| | - Anne C Lambert-Kerzner
- Department of Surgery, University of Colorado Anschutz Medical Campus, 12631 East 17Th Avenue, Aurora, CO, USA
| | - Susan C Miller
- Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 S. Main Street, Providence, RI, USA
| | - Anne E Sales
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd, Ann Arbor, MI, USA
- Department of Learning Health Sciences, University of Michigan Medical School, 300 N. Ingalls Street, Ann Arbor, MI, USA
| | - Laura Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd, Ann Arbor, MI, USA
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Naranjo D, Doll J, Maynard C, Beaver K, Bansal A, Helfrich CD. Practice Pattern Variation in Adoption of New and Evolving Percutaneous Coronary Intervention Procedures. J Interv Cardiol 2023; 2023:2488045. [PMID: 37181493 PMCID: PMC10175015 DOI: 10.1155/2023/2488045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/22/2023] [Accepted: 04/13/2023] [Indexed: 05/16/2023] Open
Abstract
Objective Assess factors contributing to variation in the use of new and evolving diagnostic and interventional procedures for percutaneous coronary intervention (PCI). Background Evidence-based practices for PCI have the potential to improve outcomes but are variably adopted. Finding possible drivers of PCI procedure-use variability is key for efforts aimed at establishing more uniform practice. Methods Veterans Affairs Clinical Assessment, Reporting, and Tracking Program data were used to estimate a proportion of variation attributable to hospital-, operator-, and patient-level factors across (a) radial arterial access, (b) intravascular imaging/optical coherence tomography, and (c) atherectomy for PCI. We used random-effects models with hospital, operator, and patient random effects. Overlap between levels generated cumulative variability estimates greater than 100%. Results A total of 445 operators performed 95,391 PCI procedures across 73 hospitals from 2011 to 2018. The rates of all procedures increased over this time. 24.45% of variability in the use of radial access was attributable to the hospital, 53.04% to the operator, and 57.83% to patient-level characteristics. 9.06% of the variability in intravascular imaging use was attributable to the hospital, 43.92% to the operator, and 21.20% to the patient. Lastly, 20.16% of the variability in use of atherectomy was attributed to the hospital, 34.63% to the operator, and 57.50% to the patient. Conclusions The use of radial access, intracoronary imaging, and atherectomy is influenced by patient, operator, and hospital factors, but patient and operator-level effects predominate. Efforts to increase the use of evidence-based practices for PCI should consider interventions at these levels.
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Affiliation(s)
- Diana Naranjo
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jacob Doll
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, US Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Charles Maynard
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, US Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
| | - Kristine Beaver
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, US Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
| | - Aasthaa Bansal
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
- Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - Christian D. Helfrich
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, US Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
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9
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O'Connor AW, Helfrich CD, Nelson KM, Sears JM, Singh H, Wong ES. Changes in electronic notification volume and primary care provider burnout. Am J Manag Care 2023; 29:57-63. [PMID: 36716155 DOI: 10.37765/ajmc.2023.89304] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Electronic health record (EHR) inbox notifications can be burdensome for primary care providers (PCPs), potentially contributing to burnout. We estimated the association between changes in the quantities of EHR inbox notifications and PCP burnout. STUDY DESIGN In this observational study, we tested the association between the percent change in daily inbox notification volumes and PCP burnout after an initiative to reduce low-value notifications at the Veterans Health Administration (VHA). METHODS The VHA initiative resulted in increases and decreases in notification volumes for PCPs. For each facility, the proportion of PCPs reporting burnout was estimated using VHA All Employee Survey responses before and after the initiative in 2016 and 2018, respectively. Survey responses were aggregated for 6459 PCPs (physicians, nurse practitioners, and physician assistants) at 138 VHA facilities. Fixed effects regression models estimated the association of small and large increases and small and large decreases in notifications on burnout. RESULTS Daily inbox notifications per PCP decreased by a mean (SD) of 5.9% (30.1%) across study facilities, from a mean (SD) of 128 (52) notifications to 114 (44) notifications after the initiative. Fifty-one percent of facilities experienced reductions in notifications, 30% experienced no change, and 20% experienced increased notifications. PCP burnout was not significantly associated with any level of increase or decrease in notifications. CONCLUSIONS Changes in notification volumes alone did not predict PCP burnout. Future research to reduce burnout might still address EHR notification volumes, but as part of a broader set of strategies that consider the other stressors that PCPs experience.
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Affiliation(s)
| | - Christian D Helfrich
- University of Washington, 3980 15th Ave NE, Fourth Floor, Box 351621, Seattle, WA 98195.
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10
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Sanchez A, Elizondo-Alzola U, Pijoan JI, Mediavilla MM, Pablo S, Sainz de Rozas R, Lekue I, Gonzalez-Larragan S, Llarena M, Larrañaga O, Helfrich CD, Grandes G. Applying the behavior change wheel to design de-implementation strategies to reduce low-value statin prescription in primary prevention of cardiovascular disease in primary care. Front Med (Lausanne) 2022; 9:967887. [PMID: 36314033 PMCID: PMC9606599 DOI: 10.3389/fmed.2022.967887] [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] [Received: 06/13/2022] [Accepted: 09/26/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction A substantial proportion of individuals with low cardiovascular risk receive inappropriate statin prescription for primary prevention of cardiovascular disease (CVD) instead of the evidence-based recommendations to promote healthy lifestyle behaviors. This study reports on the structured process performed to design targeted de-implementation strategies to reduce inappropriate prescription of statins and to increase healthy lifestyle promotion in low cardiovascular risk patients in Primary Care (PC). Methods A formative study was conducted based on the Theoretical Domains Framework and the Behavior Change Wheel (BCW). It comprised semi-structured interviews with PC professionals to define the problem in behavioral terms; focus groups with Family Physicians and patients to identify the determinants (barriers and facilitators) of inappropriate statin prescription and of healthy lifestyle promotion practice; mapping of behavioral change interventions operationalized as de-implementation strategies for addressing identified determinants; and consensus techniques for prioritization of strategies based on perceived effectiveness, feasibility and acceptability. Results Identified key determinants of statin prescription and healthy lifestyle promotion were: the lack of time and clinical inertia, external resources, patients' preferences and characteristics, limitation of available clinical tools and guidelines, social pressures, fears about negative consequences of not treating, and lack of skills and training of professionals. Fourteen potential de-implementation strategies were mapped to the identified determinants and the following were prioritized: 1) non-reflective decision assistance strategies based on reminders and decision support tools for helping clinical decision-making; 2) decision information strategies based on the principles of knowledge dissemination (e.g., corporative diffusion of evidence-based Clinical Practice Guidelines and Pathways for CVD primary prevention); 3) reflective decision-making restructuring strategies (i.e., audit and feedback provided along with intention formation interventions). Conclusions This study supports the usefulness of the BCW to guide the design and development of de-implementation strategies targeting the determinants of clinicians' decision-making processes to favor the abandonment of low-value practices and the uptake of those recommended for CVD primary prevention in low-risk patients. Further research to evaluate the feasibility and effectiveness of selected strategies is warranted. Clinical trial registration Sanchez A. De-implementation of Low-value Pharmacological Prescriptions (De-imFAR). ClinicalTrials.gov, Identifier: NCT04022850. Registered July 17, 2019. In: ClinicalTrials.gov. Bethesda (MD): U.S. National Library of Medicine (NLM). Available from: https://www.clinicaltrials.gov/ct2/show/NCT04022850.
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Affiliation(s)
- Alvaro Sanchez
- Primary Care Research Unit of Bizkaia, Biocruces Bizkaia Health Research Institute, Basque Health Service-Osakidetza, Barakaldo, Spain,*Correspondence: Alvaro Sanchez
| | - Usue Elizondo-Alzola
- Primary Care Research Unit of Bizkaia, Biocruces Bizkaia Health Research Institute, Basque Health Service-Osakidetza, Barakaldo, Spain
| | - Jose I. Pijoan
- Clinical Epidemiology Unit, Biocruces Bizkaia Health Research Institute, Basque Health Service-Osakidetza, Barakaldo, Spain
| | - Marta M. Mediavilla
- Primary Care Research Unit of Bizkaia, Biocruces Bizkaia Health Research Institute, Basque Health Service-Osakidetza, Barakaldo, Spain
| | - Susana Pablo
- Primary Care Research Unit of Bizkaia, Biocruces Bizkaia Health Research Institute, Basque Health Service-Osakidetza, Barakaldo, Spain
| | - Rita Sainz de Rozas
- Primary Care Pharmacy Unit, Ezkerraldea-Enkarterri-Cruces Integrated Health Organization, Basque Health Service-Osakidetza, Barakaldo, Spain
| | - Itxasne Lekue
- Primary Care Pharmacy Unit, Ezkerraldea-Enkarterri-Cruces Integrated Health Organization, Basque Health Service-Osakidetza, Barakaldo, Spain
| | - Susana Gonzalez-Larragan
- Department of Health Science Library, Biocruces Bizkaia Health Research Institute, Basque Health Service-Osakidetza, Barakaldo, Spain
| | - Marta Llarena
- Primary Care Research Unit of Bizkaia, Biocruces Bizkaia Health Research Institute, Basque Health Service-Osakidetza, Barakaldo, Spain
| | - Olatz Larrañaga
- Primary Care Research Unit of Bizkaia, Biocruces Bizkaia Health Research Institute, Basque Health Service-Osakidetza, Barakaldo, Spain
| | - Christian D. Helfrich
- VA Puget Sound Health Care System, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States,Department of Health Services, University of Washington School of Public Health, Seattle, WA, United States
| | - Gonzalo Grandes
- Primary Care Research Unit of Bizkaia, Biocruces Bizkaia Health Research Institute, Basque Health Service-Osakidetza, Barakaldo, Spain
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11
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Edelman EJ, Gan G, Dziura J, Esserman D, Porter E, Becker WC, Chan PA, Cornman DH, Helfrich CD, Reynolds J, Yager JE, Morford KL, Muvvala SB, Fiellin DA. Effect of Implementation Facilitation to Promote Adoption of Medications for Addiction Treatment in US HIV Clinics: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2236904. [PMID: 36251291 PMCID: PMC9577676 DOI: 10.1001/jamanetworkopen.2022.36904] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/30/2022] [Indexed: 11/30/2022] Open
Abstract
Importance Medications for addiction treatment (MAT) are inconsistently offered in HIV clinics. Objective To evaluate the impact of implementation facilitation (hereafter referred to as "facilitation"), a multicomponent implementation strategy, on increasing provision of MAT for opioid use disorder (MOUD), alcohol use disorder (MAUD), and tobacco use disorder (MTUD). Design, Setting, and Participants Conducted from July 26, 2016, through July 25, 2020, the Working with HIV Clinics to adopt Addiction Treatment using Implementation Facilitation (WHAT-IF?) study used an unblinded, stepped wedge design to sequentially assign each of 4 HIV clinics in the northeastern US to cross over from control (ie, baseline practices) to facilitation (ie, intervention) and then evaluation and maintenance periods every 6 months. Participants were adult patients with opioid, alcohol, or tobacco use disorder. Data analysis was performed from August 2020 to September 2022. Interventions Multicomponent facilitation. Main Outcomes and Measures Outcomes, assessed using electronic health record data, were provision of MAT among patients with opioid, alcohol, or tobacco use disorder during the evaluation (primary outcome) and maintenance periods compared with the control period. Results Among 3647 patients, the mean (SD) age was 49 (12) years, 1814 (50%) were Black, 781 (22%) were Hispanic, and 1407 (39%) were female; 121 (3%) had opioid use disorder, 126 (3%) had alcohol use disorder, and 420 (12%) had tobacco use disorder. Compared with the control period, there was no increase in provision of MOUD with facilitation during the evaluation period (243 patients [27%; 95% CI, 22%-32%] vs 135 patients [28%; 95% CI, 22%-35%]; P = .59) or maintenance period (198 patients [29%; 95% CI, 22%-36%]; P = .48). The change in provision of MAUD from the control period to the evaluation period was not statistically significant (251 patients [8%; 95% CI, 5%-12%] vs 112 patients [13%; 95% CI, 8%-21%]; P = .11); however, the difference increased and became significant during the maintenance period (180 patients [17%; 95% CI, 12%-24%]; P = .009). There were significant increases in provision of MTUD with facilitation during both the evaluation (810 patients [33%; 95% CI, 30%-36%] vs 471 patients [40%; 95% CI, 36%-45%]; P = .005) and maintenance (643 patients [38%; 95% CI, 34%-41%]; P = .047) periods. Conclusions and Relevance In this randomized clinical trial, facilitation led to increased provision of MTUD, delayed improvements in MAUD, and no improvements in MOUD in HIV clinics. Enhanced strategies, potentially including clinic and patient incentives, especially for MOUD, may be needed to further increase provision of MAT in HIV clinics. Trial Registration ClinicalTrials.gov Identifier: NCT02907944.
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Affiliation(s)
- E. Jennifer Edelman
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut
| | - Geliang Gan
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, Connecticut
| | - James Dziura
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Denise Esserman
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, Connecticut
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Elizabeth Porter
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - William C. Becker
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven
| | - Philip A. Chan
- Department of Medicine, Brown University, Providence, Rhode Island
| | - Deborah H. Cornman
- Institute for Collaboration on Health, Intervention, and Policy (InCHIP), University of Connecticut, Storrs
| | | | - Jesse Reynolds
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, Connecticut
| | | | - Kenneth L. Morford
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Srinivas B. Muvvala
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - David A. Fiellin
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
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12
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Fishleder S, Harris JR, Petrescu-Prahova M, Kohn M, Helfrich CD. Development and Feasibility Testing of the Clinical-Community Linkage Self-Assessment Survey for Community Organizations. Front Public Health 2022; 10:797468. [PMID: 35669755 PMCID: PMC9163549 DOI: 10.3389/fpubh.2022.797468] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 04/05/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction Clinical-community linkages (CCLs) can improve health, but few instruments exist to evaluate these partnerships. To address this gap, we develop and test the Clinical-Community Linkage Self-Assessment Survey (CCL Self-Assessment). Materials and Methods We built on an existing framework and conducted a literature review to guide the design of our survey, and obtained feedback from academic, clinical, and community-based experts. To pretest the instrument, we conducted 10 think-aloud interviews with community-based health-promotion organizations. We performed feasibility testing with 38 staff from 20 community organizations, followed by criterion-validity testing. Results The 15-item final instrument includes five domains: Nature of the Relationship, Communication, Referral Process, Feedback Loop, and Timeliness. Expert feedback included keeping the CCL Self-Assessment brief and actionable. Think-aloud interviews produced a range of revisions related to item wording, instructions, brevity, and formatting. Feasibility testing showed high response rate and ease of administration. Sites scoring high on the CCL Self-Assessment also scored high on the criterion measure. Discussion We demonstrate feasibility, as well as face, content, construct, and criterion validity. Initial results suggest the CCL Self-Assessment survey may be used by community organizations to identify strengths and weaknesses of their linkages. Next steps include additional statistical validation and testing to determine how the CCL Self-Assessment survey works in the field as well as providing specific tools to improve linkages.
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Affiliation(s)
- Sarah Fishleder
- Health Promotion Research Center, Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States
- *Correspondence: Sarah Fishleder
| | - Jeffrey R. Harris
- Health Promotion Research Center, Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States
| | - Miruna Petrescu-Prahova
- Health Promotion Research Center, Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States
| | - Marlana Kohn
- Health Promotion Research Center, Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States
| | - Christian D. Helfrich
- US Department of Veterans Affairs Health Services Research & Development, Washington, DC, United States
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13
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Harris JR, M. Kava C, Gary Chan KC, Kohn MJ, Hammerback K, Parrish AT, Helfrich CD, Hannon PA. Pathways to Employee Outcomes in a Workplace Health Promotion Program. Am J Health Promot 2022; 36:662-672. [PMID: 34983199 PMCID: PMC9012684 DOI: 10.1177/08901171211066898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE This study examined the relationship between employee outcomes and employer implementation of evidence-based interventions (EBIs) for chronic disease prevention. DESIGN Cross-sectional samples collected at 3 time points in a cluster-randomized, controlled trial of a workplace health promotion program to promote 12 EBIs. SETTING King County, WA. SAMPLE Employees of 63 small, low-wage workplaces. MEASURES Employer EBI implementation; 3 types of employee outcomes: perceived implementation of EBIs; perceived employer support for health; and health-related behaviors, perceived stress, depression risk, and presenteeism. ANALYSIS Intent-to-treat and correlation analyses using generalized estimating equations. We tested bivariate associations along potential paths from EBI implementation, through perceived EBI implementation and perceived support for health, to several employee health-related outcomes. RESULTS The intent-to-treat analysis found similar employee health-related behaviors in intervention and control workplaces at 15 and 24 months. Workplaces implemented varying combinations of EBIs, however, and bivariate associations were significant for 4 of the 6 indicators of physical activity and healthy eating, as well as perceived stress, depression risk, and presenteeism. We did not find significant positive associations for cancer screening and tobacco cessation. CONCLUSION Our findings support broader dissemination of EBIs for physical activity and healthy eating, as well as more focus on improving employer support for employee health. They also suggest we need better interventions for cancer screening and tobacco cessation.
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Affiliation(s)
- Jeffrey R. Harris
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Christine M. Kava
- Department of Health Systems and Population Health, University of Washington, Seattle
| | | | - Marlana J. Kohn
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Kristen Hammerback
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Amanda T. Parrish
- Department of Health Systems and Population Health, University of Washington, Seattle
| | | | - Peggy A. Hannon
- Department of Health Systems and Population Health, University of Washington, Seattle
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14
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Doll JA, Beaver K, Naranjo D, Waldo SW, Maynard C, Helfrich CD, Rao SV. Trends in Arterial Access Site Selection and Bleeding Outcomes Following Coronary Procedures, 2011-2018. Circ Cardiovasc Qual Outcomes 2022; 15:e008359. [PMID: 35272504 DOI: 10.1161/circoutcomes.121.008359] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Prior studies of radial access for cardiac catheterization have focused on early adopters of the technique, and some have described a risk/treatment paradox of low radial access use among high bleeding risk patients. This study aimed to determine (1) trends in radial access use over time, (2) if increasing use of radial access is driven by new invasive and interventional cardiologists (operators) or existing operators changing their practice, and (3) if increasing radial rates are associated with lower bleeding rates and elimination of the risk/treatment paradox. METHODS In this cross-sectional study using data from the Clinical Assessment, Reporting, and Tracking Program, we calculated radial access rates and risk-adjusted postprocedural bleeding rates of patients undergoing diagnostic angiography or percutaneous coronary intervention (PCI) between 2011 and 2018 in Veterans Affairs hospitals. We used separate bleeding risk models for diagnostic angiography and PCI and assessed temporal trends with the Kendall Tau-b test. RESULTS Among 253 179 diagnostic angiograms and 93 614 PCIs, radial access rates increased over time for both diagnostic (17.5%-60.4%; P<0.01)) and PCI procedures (14.0%-51.8%; P<0.01). Existing operators and new operators increased their use at similar rates, but new operators entered practice with higher baseline rates. Nearly all operators used radial access at least once in 2018. Overall adjusted rates of bleeding declined, a trend that was significant for diagnostic angiography (2.4%-1.4%, P=0.02) but not PCI (3.4%-2.5%, P=0.20). Femoral access patients had a higher predicted risk for bleeding. CONCLUSIONS A steady rise in radial access for diagnostic angiography and PCI was driven by increasing use among existing operators and high use by new operators. While this was associated with decreasing bleeding rates, a risk/treatment paradox for access site selection persists; patients at higher bleeding risk were still more likely to receive femoral access.
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Affiliation(s)
- Jacob A Doll
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, US Department of Veterans Affairs (VA) Puget Sound Health Care System, WA (J.A.D., K.B., C.M., C.D.H.).,Division of Cardiology, Department of Medicine (J.A.D.), University of Washington, Seattle.,CART Program, VHA Office of Quality and Patient Safety, Washington DC (J.A.D., S.W.W.)
| | - Kristine Beaver
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, US Department of Veterans Affairs (VA) Puget Sound Health Care System, WA (J.A.D., K.B., C.M., C.D.H.)
| | | | - Stephen W Waldo
- CART Program, VHA Office of Quality and Patient Safety, Washington DC (J.A.D., S.W.W.).,VA Eastern Colorado Health Care System, Aurora, CO (S.W.W.).,Division of Cardiology, Department of Medicine, University of Colorado, Aurora (S.W.W.)
| | - Charles Maynard
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, US Department of Veterans Affairs (VA) Puget Sound Health Care System, WA (J.A.D., K.B., C.M., C.D.H.)
| | - Christian D Helfrich
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, US Department of Veterans Affairs (VA) Puget Sound Health Care System, WA (J.A.D., K.B., C.M., C.D.H.).,Department of Health Services, School of Public Health (C.D.H.), University of Washington, Seattle
| | - Sunil V Rao
- US Department of Veterans Affairs (VA) Health Care System, Durham, NC (S.V.R.)
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15
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Sterling R, Rinne ST, Reddy A, Moldestad M, Kaboli P, Helfrich CD, Henrikson NB, Nelson KM, Kaminetzky C, Wong ES. Identifying and Prioritizing Workplace Climate Predictors of Burnout Among VHA Primary Care Physicians. J Gen Intern Med 2022; 37:87-94. [PMID: 34327656 PMCID: PMC8321506 DOI: 10.1007/s11606-021-07006-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 06/25/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Burnout, or job-related stress, affects more than half of all US physicians, with primary care physicians (PCPs) experiencing some of the highest rates in medicine. Our study analyzes national survey data to identify and prioritize workplace climate predictors of burnout among PCPs within a large integrated health system. DESIGN Observational study of annual survey data from the Veterans Health Administration (VHA) All Employee Survey (AES) for 2013-2017. AES response rate ranged from 56 to 60% during the study period. Independent and dependent variables were measured from separate random samples. In total, 8,456 individual-level responses among PCPs at 110 VHA practice sites were aggregated at the facility level by reporting year. We used the semi-automated LASSO procedure to identify workplace climate measures that were more influential in predicting burnout and assessed relative importance using the Shapely value decomposition. PARTICIPANTS VHA employees that self-identify as PCPs. MAIN MEASURES Dependent variables included two dichotomous measures of burnout: emotional exhaustion and depersonalization. Independent measures included 30 survey measures related to dimensions of workplace climate (e.g., workload, leadership, satisfaction). RESULTS We identified seven influential workplace climate predictors of emotional exhaustion and nine predictors of depersonalization. With few exceptions, higher agreement/satisfaction scores for predictors were associated with a lower likelihood of burnout. The majority of explained variation in emotional exhaustion was attributable to perceptions of workload (32.6%), organization satisfaction (28.2%), and organization support (19.4%). The majority of explained variation in depersonalization was attributable to workload (25.3%), organization satisfaction (22.9%), and connection to VHA mission (20.7%). CONCLUSION Identifying the relative importance of workplace climate is important for the allocation of health organization resources to mitigate and prevent burnout within the PCP workplace. In a context of limited resources, efforts to reduce perceived workload and improve organization satisfaction may represent the biggest leverage points for health organizations to address physician burnout.
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Affiliation(s)
- Ryan Sterling
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.
| | - Seppo T Rinne
- VA Center for Healthcare Organization and Implementation Research, Bedford, MA, USA
| | - Ashok Reddy
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Megan Moldestad
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Peter Kaboli
- Iowa City VA Medical Center and University of Iowa, Iowa City, IA, USA
| | - Christian D Helfrich
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
| | | | - Karin M Nelson
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Catherine Kaminetzky
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Edwin S Wong
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
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16
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Duan KI, Helfrich CD, Rao SV, Neely EL, Sulc CA, Naranjo D, Wong ES. Cost analysis of a coaching intervention to increase use of transradial percutaneous coronary intervention. Implement Sci Commun 2021; 2:123. [PMID: 34706775 PMCID: PMC8554885 DOI: 10.1186/s43058-021-00219-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 09/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The transradial approach (TRA) to cardiac catheterization is safer than the traditional transfemoral approach (TFA), with similar clinical effectiveness. However, adoption of TRA remains low, representing less than 50% of catheterization procedures in 2015. Peer coaching is one approach to facilitate implementation; however, the costs of this strategy for cardiac procedures such as TRA are unclear. METHODS We conducted an activity-based costing analysis (ABC) of a multi-center, hybrid type III implementation trial of a coaching intervention designed to increase the use of TRA. We identified the key activities of the intervention and determined the personnel, resources, and time needed to complete each activity. The personnel cost per hour and the activity duration were then used to estimate the cost of each activity and the total variable cost of the implementation. Fixed costs related to designing and running the implementation were calculated separately. All costs are reported in 2019 constant US dollars. RESULTS The total cost of the coaching intervention implementation was $374,863. Of the total cost, $367,752 were variable costs due to travel, preparatory work, in-person coaching, post-intervention evaluation, and administrative time. We estimated fixed costs of $7112. The mean marginal cost of implementing the intervention at only one additional medical center was $52,536. CONCLUSIONS We provide granular cost estimates of a conceptually rooted implementation strategy designed to increase the uptake of TRA for cardiac catheterization. We estimate that implementation costs stemming from the coaching approach would be offset after the conversion of approximately 409 to 1363 catheterizations from TFA to TRA. Our estimates provide benchmarks of the expected costs of implementing evidence-based, but expertise-intensive, cardiac procedures. TRIAL REGISTRATION ISRCTN, ISRCTN66341299 . Registered 7 July 2020-retrospectively registered.
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Affiliation(s)
- Kevin I Duan
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA, USA. .,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, 1959 Northeast Pacific Street, Box 356522, Seattle, WA, 98195, USA.
| | - Christian D Helfrich
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Sunil V Rao
- Durham VA Health Care System, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Emily L Neely
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Christine A Sulc
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Diana Naranjo
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Edwin S Wong
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
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Beaver K, Naranjo D, Doll J, Maynard C, Taylor L, Plomondon M, Waldo S, Helfrich CD, Rao SV. Design and baseline results of a coaching intervention for implementation of trans-radial access in percutaneous coronary intervention. Contemp Clin Trials 2021; 111:106606. [PMID: 34710590 DOI: 10.1016/j.cct.2021.106606] [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] [Received: 07/02/2021] [Revised: 10/18/2021] [Accepted: 10/21/2021] [Indexed: 10/20/2022]
Abstract
Trans-radial artery access (TRA) for cardiac catheterization and percutaneous coronary intervention has many advantages over trans-femoral artery access (TFA), but implementation has been slow. The steep learning curve, logistical issues, and radiation exposure have been documented as barriers to implementation. Although many cardiac catheterization laboratories have overcome these barriers, we lack evidence on effective implementation strategies. Our objective is to test a team-based coaching intervention that targets the learning curve and other barriers to increase use of TRA. We use a stepped-wedge cluster-randomized trial to test a coaching intervention in Department of Veterans Affairs cardiac catheterization laboratories. The coaching intervention comprises team-based didactic instruction with live observation at a TRA-proficient lab, followed by a visit from a cardiologist and catheterization laboratory nurse coaching team. Interview and survey data are collected from participants to test and adapt an implementation science framework known as the Promoting Action on Research Implementation in Health Services (PARIHS) framework. This study is designed to test the effectiveness of the coaching intervention on TRA implementation, inform changes to the coaching intervention itself, and test and adapt the PARIHS framework in practice. While the benefits of TRA, including increased clinical efficiency, patient comfort, and reduced patient complications, are well understood, the underlying drivers of TRA adoption and sustained practice are not. Findings from this trial can inform future research to facilitate change in the cardiac catheterization laboratory.
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Affiliation(s)
- Kristine Beaver
- Department of Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way S-152, Seattle, WA 98018, United States of America.
| | - Diana Naranjo
- Department of Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way S-152, Seattle, WA 98018, United States of America
| | - Jacob Doll
- Department of Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way S-152, Seattle, WA 98018, United States of America
| | - Charles Maynard
- Department of Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way S-152, Seattle, WA 98018, United States of America
| | - Leslie Taylor
- Department of Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way S-152, Seattle, WA 98018, United States of America
| | - Mary Plomondon
- Department of Veterans Affairs Eastern Colorado Health Care System, 1055 Clermont St, Denver, CO 80220, United States of America; Clinical Assessment Reporting and Tracking Program, Department of Veterans Affairs Office of Quality and Patient Safety, 810 Vermont Avenue NW, Washington, DC 20420, United States of America
| | - Stephen Waldo
- Department of Veterans Affairs Eastern Colorado Health Care System, 1055 Clermont St, Denver, CO 80220, United States of America; Clinical Assessment Reporting and Tracking Program, Department of Veterans Affairs Office of Quality and Patient Safety, 810 Vermont Avenue NW, Washington, DC 20420, United States of America
| | - Christian D Helfrich
- Department of Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way S-152, Seattle, WA 98018, United States of America
| | - Sunil V Rao
- Department of Veterans Affairs Durham Health Care System, 508 Fulton Street Durham, NC 27705, United States of America
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18
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Schuttner L, Haraldsson B, Maynard C, Helfrich CD, Reddy A, Parikh T, Nelson KM, Wong E. Factors Associated With Low-Value Cancer Screenings in the Veterans Health Administration. JAMA Netw Open 2021; 4:e2130581. [PMID: 34677595 PMCID: PMC8536952 DOI: 10.1001/jamanetworkopen.2021.30581] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
IMPORTANCE Most clinical practice guidelines recommend stopping cancer screenings when risks exceed benefits, yet low-value screenings persist. The Veterans Health Administration focuses on improving the value and quality of care, using a patient-centered medical home model that may affect cancer screening behavior. OBJECTIVE To understand rates and factors associated with outpatient low-value cancer screenings. DESIGN, SETTING, AND PARTICIPANTS This cohort study assessed the receipt of low-value cancer screening and associated factors among 5 993 010 veterans. Four measures of low-value cancer screening defined by validated recommendations of practices to avoid were constructed using administrative data. Patients with cancer screenings in 2017 at Veterans Health Administration primary care clinics were included. Excluded patients had recent symptoms or historic high-risk diagnoses that may affect test appropriateness (eg, melena preceding colonoscopy). Data were analyzed from December 23, 2019, to June 21, 2021. EXPOSURES Receipt of cancer screening test. MAIN OUTCOMES AND MEASURES Low-value screenings were defined as occurring for average-risk patients outside of guideline-recommended ages or if the 1-year mortality risk estimated using a previously validated score was at least 50%. Factors evaluated in multivariable regression models included patient, clinician, and clinic characteristics and patient-centered medical home domain performance for team-based care, access, and continuity previously developed from administrative and survey data. RESULTS Of 5 993 010 veterans (mean [SD] age, 63.1 [16.8] years; 5 496 976 men [91.7%]; 1 027 836 non-Hispanic Black [17.2%] and 4 539 341 non-Hispanic White [75.7%] race and ethnicity) enrolled in primary care, 903 612 of 4 647 479 men of average risk (19.4%) underwent prostate cancer screening; 299 765 of 5 770 622 patients of average risk (5.2%) underwent colorectal cancer screening; 21 930 of 469 045 women of average risk (4.7%) underwent breast cancer screening; and 65 511 of 458 086 women of average risk (14.3%) underwent cervical cancer screening. Of patients screened, low-value testing was rare for 3 cancers, with receipt of a low-value test in 633 of 21 930 of women screened for breast cancer (2.9%), 630 of 65 511 of women screened for cervical cancer (1.0%), and 6790 of 299 765 of patients screened for colorectal cancer (2.3%). However, 350 705 of 4 647 479 of screened men (7.5%) received a low-value prostate cancer test. Patient race and ethnicity, sociodemographic factors, and illness burden were significantly associated with likelihood of receipt of low-value tests among screened patients. No single patient-, clinician-, or clinic-level factor explained the receipt of a low-value test across cancer screening cohorts. CONCLUSIONS AND RELEVANCE This large cohort study found that low-value breast, cervical, and colorectal cancer screenings were rare in the Veterans Health Administration, but more than one-third of patients screened for prostate cancer were tested outside of clinical practice guidelines. Guideline-discordant care has quality implications and is not consistently explained by associated multilevel factors.
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Affiliation(s)
- Linnaea Schuttner
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | | | - Charles Maynard
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Christian D. Helfrich
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Ashok Reddy
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Toral Parikh
- Department of Medicine, University of Washington, Seattle
- Geriatrics and Extended Care, VA Puget Sound Healthcare System
| | - Karin M. Nelson
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Edwin Wong
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
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Ailabouni NJ, Reeve E, Helfrich CD, Hilmer SN, Wagenaar BH. Leveraging implementation science to increase the translation of deprescribing evidence into practice. Res Social Adm Pharm 2021; 18:2550-2555. [PMID: 34147372 DOI: 10.1016/j.sapharm.2021.05.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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: 12/16/2020] [Revised: 04/29/2021] [Accepted: 05/31/2021] [Indexed: 11/28/2022]
Abstract
Implementation science may address some of the limitations that impede the translation of deprescribing recommendations into practice and policy. Application of principles and standard terminologies from implementation science could improve understanding and interpretation of deprescribing research findings. As such, in this commentary we propose three main avenues to help achieve this. These include: The application of these concepts derived from implementation science could help inform future deprescribing needs for clinicians and researchers. Ultimately, this could help ensure the quality use of medications and examination of meaningful outcomes in deprescribing studies. This could result in more consistent and widespread translation of deprescribing evidence into practice and policy across various healthcare settings.
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Affiliation(s)
- Nagham J Ailabouni
- University of South Australia, UniSA: Clinical and Health Sciences, Quality Use of Medicines and Pharmacy Research Centre (QUMPRC), Adelaide, SA, Australia.
| | - Emily Reeve
- University of South Australia, UniSA: Clinical and Health Sciences, Quality Use of Medicines and Pharmacy Research Centre (QUMPRC), Adelaide, SA, Australia; Dalhousie University and Nova Scotia Health Authority, Geriatric Medicine Research, Faculty of Medicine, And College of Pharmacy Halifax, Canada
| | - Christian D Helfrich
- University of Washington, School of Public Health, Veterans Administration Puget Sound Health Care System, Seattle, WA, USA
| | - Sarah N Hilmer
- Kolling Institute of Medical Research, Royal North Shore Hospital and Northern Clinical School, Faculty of Medicine and Health, University of Sydney, St Leonards, New South Wales, Australia
| | - Bradley H Wagenaar
- University of Washington, Department of Global Health, Seattle, WA, USA; University of Washington, Department of Epidemiology, Seattle, WA, USA
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20
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Kononowech J, Hagedorn H, Hall C, Helfrich CD, Lambert-Kerzner AC, Miller SC, Sales AE, Damschroder L. Mapping the organizational readiness to change assessment to the Consolidated Framework for Implementation Research. Implement Sci Commun 2021; 2:19. [PMID: 33581728 PMCID: PMC7881456 DOI: 10.1186/s43058-021-00121-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 02/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Implementation researchers recognize the influential role of organizational factors and, thus, seek to assess these factors using quantitative measurement instruments. However, researchers are hindered by instruments that measure similar constructs but rely on different nomenclature and/or definitions. The Consolidated Framework for Implementation Research (CFIR) provides a taxonomy of constructs derived from prior frameworks and empirical studies of implementation-related constructs. The CFIR includes constructs based on the original Promoting Action on Research Implementation in Health Services (PARiHS) framework which highlights the key roles of strength of evidence for a specific evidence-based intervention (EBI), favorability of organizational context for change, and capacities to facilitate implementation of the EBI. Although the CFIR is among the most frequently used implementation frameworks, it does not include quantitative measures. The Organizational Resource and Context Assessment (ORCA) is a quantitative measurement instrument that was developed based on PARiHS, assessing its three domains. Factors within these three domains are conceptually similar to constructs in the CFIR but do not match directly. The aim of this work was to map ORCA survey items to CFIR constructs to enable direct comparisons and syntheses of findings across studies using the CFIR and/or ORCA. METHODS Two distinct, independent research teams, each used rigorous constant comparative techniques with deliberation and consensus to map individual items from the ORCA to the five domains and 39 constructs of CFIR. RESULTS ORCA items were mapped primarily to three of five CFIR domains: Inner Setting, Process, and Intervention Characteristics. The two research teams agreed on 88% of mappings at the higher domain level; at the lower construct level, their mappings aligned for 62.2% of the ORCA items. CONCLUSIONS Mapping results reveal that the ORCA focuses measurement prominently on Inner Setting, Process, and Intervention Characteristics. This mapping guide can help improve consistency in measurement and reporting, enabling more efficient comparison and synthesis of findings that use either the ORCA instrument or the CFIR framework. The guide helps advance implementation science utilizing mixed methods by providing CFIR users with quantitative measures for selected constructs and enables ORCA users to map their findings to CFIR constructs.
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Affiliation(s)
- Jennifer Kononowech
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd, Ann Arbor, MI, USA.
| | - Hildi Hagedorn
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, 1 Veterans Drive, Minneapolis, MN, USA
- Department of Psychiatry, University of Minnesota School of Medicine, 606 24th Ave S, Minneapolis, MN, USA
| | - Carmen Hall
- Gusek Hall Consulting, 1362 Ryan Ave. W Ste 101, Roseville, MN, USA
| | - Christian D Helfrich
- Seattle-Denver Center of Innovation, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, USA
- School of Public Health, University of Washington, 1959 NE Pacific St, Seattle, WA, USA
| | - Anne C Lambert-Kerzner
- Department of Surgery, University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue, Aurora, CO, USA
| | - Susan C Miller
- Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 S. Main Street, Providence, RI, USA
| | - Anne E Sales
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd, Ann Arbor, MI, USA
- Department of Learning Health Sciences, University of Michigan Medical School, 300 N. Ingalls Street, Ann Arbor, MI, USA
| | - Laura Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd, Ann Arbor, MI, USA
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21
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Winchester DE, Merritt J, Waheed N, Norton H, Manja V, Shah NR, Helfrich CD. Implementation of appropriate use criteria for cardiology tests and procedures: a systematic review and meta-analysis. Eur Heart J Qual Care Clin Outcomes 2021; 7:34-41. [PMID: 32232436 DOI: 10.1093/ehjqcco/qcaa029] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/23/2020] [Accepted: 03/26/2020] [Indexed: 11/13/2022]
Abstract
AIMS The American College of Cardiology appropriate use criteria (AUC) provide clinicians with evidence-informed recommendations for cardiac care. Adopting AUC into clinical workflows may present challenges, and there may be specific implementation strategies that are effective in promoting effective use of AUC. We sought to assess the effect of implementing AUC in clinical practice. METHODS AND RESULTS We conducted a meta-analysis of studies found through a systematic search of the MEDLINE, Web of Science, Cochrane, or CINAHL databases. Peer-reviewed manuscripts published after 2005 that reported on the implementation of AUC for a cardiovascular test or procedure were included. The main outcome was to determine if AUC implementation was associated with a reduction in inappropriate/rarely appropriate care. Of the 18 included studies, the majority used pre/post-cohort designs; few (n = 3) were randomized trials. Most studies used multiple strategies (n = 12, 66.7%). Education was the most common individual intervention strategy (n = 13, 72.2%), followed by audit and feedback (n = 8, 44.4%) and computerized physician order entry (n = 6, 33.3%). No studies reported on formal use of stakeholder engagement or 'nudges'. In meta-analysis, AUC implementation was associated with a reduction in inappropriate/rarely appropriate care (odds ratio 0.62, 95% confidence interval 0.49-0.78). Funnel plot suggests the possibility of publication bias. CONCLUSION We found most published efforts to implement AUC observed reductions in inappropriate/rarely appropriate care. Studies rarely explored how or why the implementation strategy was effective. Because interventions were infrequently tested in isolation, it is difficult to make observations about their effectiveness as stand-alone strategies. STUDY REGISTRATION PROSPERO 2018 CRD42018091602. Available from https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018091602.
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Affiliation(s)
- David E Winchester
- Cardiology Section, Malcom Randall VAMC, 1601 SW Archer Rd 111-D, Gainesville, FL, USA.,Division of Cardiovascular Medicine, University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Justin Merritt
- Division of Cardiovascular Medicine, University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Nida Waheed
- Department of Internal Medicine, University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Hannah Norton
- University of Florida College of Medicine, Health Science Center Library, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Veena Manja
- Department of Surgery, University of California Davis, 2315 Stockton Blvd, Sacramento, CA 95817, USA.,VA Northern California Health Care System, 10535 Hospital Way, Mather, CA 95655, USA
| | - Nishant R Shah
- Department of Medicine, Providence VA Medical Center, Brown University Warren Alpert Medical School, 830 Chalkstone Ave, Providence, RI 02908, USA.,Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 S Main St, Providence, RI 02903, USA
| | - Christian D Helfrich
- Seattle-Denver Center for Innovation in Veteran-Centered and Value-Driven Care, 1660 S. Columbian Way Mailstop S-152 Seattle, WA 98108, USA
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22
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Affiliation(s)
- Christian D Helfrich
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA.
| | - Lucy A Savitz
- Health Research Kaiser Permanente Northwest Region, Center for Health Research, Kaiser Permanente School of Medicine, Oregon Health & Science University - Portland State University School of Public Health, Portland, OR, USA
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23
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Goebel MC, Trautner BW, Wang Y, Van JN, Dillon LM, Patel PK, Drekonja DM, Graber CJ, Shukla BS, Lichtenberger P, Helfrich CD, Sales A, Grigoryan L. Organizational readiness assessment in acute and long-term care has important implications for antibiotic stewardship for asymptomatic bacteriuria. Am J Infect Control 2020; 48:1322-1328. [PMID: 32437753 DOI: 10.1016/j.ajic.2020.04.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Prior to implementing an antibiotic stewardship intervention for asymptomatic bacteriuria (ASB), we assessed institutional barriers to change using the Organizational Readiness to Change Assessment. METHODS Surveys were self-administered on paper in inpatient medicine and long-term care units at 4 Veterans Affairs facilities. Participants included providers, nurses, and pharmacists. The survey included 7 subscales: evidence (perceived strength of evidence) and six context subscales (favorability of organizational context). Responses were scored on a 5-point Likert-type scale. RESULTS One hundred four surveys were completed (response rate = 69.3%). Overall, the evidence subscale had the highest score; the resources subscale (mean 2.8) was significantly lower than other subscales (P < .001). Scores for budget and staffing resources were lower than scores for training and facility resources (P < .001 for both). Pharmacists had lower scores than providers for the staff culture subscale (P = .04). The site with the lowest scores for resources (mean 2.4) also had lower scores for leadership and lower pharmacist effort devoted to stewardship. CONCLUSIONS Although healthcare professionals endorsed the evidence about nontreatment of ASB, perceived barriers to antibiotic stewardship included inadequate resources and leadership support. These findings provide targets for tailoring the stewardship intervention to maximize success.
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Parikh TJ, Stryczek KC, Gillespie C, Sayre GG, Feemster L, Udris E, Majerczyk B, Rinne ST, Wiener RS, Au DH, Helfrich CD. Provider anticipation and experience of patient reaction when deprescribing guideline discordant inhaled corticosteroids. PLoS One 2020; 15:e0238511. [PMID: 32941462 PMCID: PMC7498097 DOI: 10.1371/journal.pone.0238511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 08/18/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction Despite evidence of possible patient harm and substantial costs, medication overuse is persistent. Patient reaction is one potential barrier to deprescribing, but little research has assessed this in specific instances of medication discontinuation. We sought to understand Veteran and provider experience when de-implementing guideline-discordant use of inhaled corticosteroids (ICS) in those with mild-to-moderate chronic obstructive pulmonary disease (COPD). Methods We conducted a mixed-methods analysis in a provider-randomized quality improvement project testing a proactive electronic-consultation from pulmonologists recommending ICS discontinuation when appropriate. PCPs at two Veterans Health Administration healthcare systems were included. We completed interviews with 16 unexposed providers and 6 intervention-exposed providers. We interviewed 9 patients within 3 months after their PCP proposed ICS discontinuation. We conducted inductive and deductive content analysis of qualitative data to explore an emergent theme of patient reaction. Forty-eight PCPs returned surveys (24 exposed and 24 unexposed, response rate: 35%). Results The unexposed providers anticipated their patients might resist ICS discontinuation because it seems counterintuitive to stop something that is working, patient’s fear of worsening symptoms, or if the prescription was initiated by another provider. Intervention-exposed providers reported similar experiences in post-intervention interviews. Unexposed providers anticipated that patients may accept ICS discontinuation, citing tactical use of patient-centered care strategies. This was echoed by intervention-exposed providers who had successfully discontinued an ICS. Veterans reported acceding to their providers out of trust or deference to their advanced training, even after describing an ICS as a ‘security blanket’. Our survey findings supported the subthemes from our interviews. Among providers who proposed discontinuation of an ICS, 76% reported that they were able to discontinue it or switch to another more appropriate medication. Conclusions While PCPs anticipated that patients would resist discontinuing an ICS, interviews with patient and intervention-exposed PCPs along with surveys suggest that patients were receptive to this change.
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Affiliation(s)
- Toral J. Parikh
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States of America
- Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, Washington, United States of America
- * E-mail:
| | | | - Chris Gillespie
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, United States of America
| | - George G. Sayre
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States of America
- Department of Health Services, School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Laura Feemster
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States of America
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, United States of America
| | - Edmunds Udris
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States of America
| | - Barbara Majerczyk
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States of America
| | - Seppo T. Rinne
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, United States of America
- The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, United States of America
- The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - David H. Au
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States of America
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, United States of America
| | - Christian D. Helfrich
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States of America
- Department of Health Services, School of Public Health, University of Washington, Seattle, Washington, United States of America
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25
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Fishleder S, Petrescu-Prahova M, Harris JR, Leroux B, Bennett K, Helfrich CD, Kohn M, Hannon P. Predictors of Improvement in Physical Function in Older Adults in an Evidence-Based Physical Activity Program (EnhanceFitness). J Geriatr Phys Ther 2020; 42:230-242. [PMID: 29979352 DOI: 10.1519/jpt.0000000000000202] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND PURPOSE Declines in strength, flexibility, and balance in older adults can lead to injuries and loss of independence and are particularly common in those of greater age and in worse health. EnhanceFitness (EF) is a nationally disseminated, evidence-based group exercise program for older adults that has been shown to improve function through cardiovascular, strength, flexibility, and balance exercises. This article examines changes in, and predictors of, participant physical function from baseline through 2 program cycles of EF as measured by 3 physical function tests: arm curls, chair stands, and 8-foot up-and-go. METHODS We analyzed data on participants who attended at least 2 consecutive 16-week program cycles between January 2005 and June 2016. We ran 3 random-effects linear regression models, 1 for each physical function test, and accounted for missing data and clustering by class site. Independent variables included attendance, demographics, and health status. RESULTS AND DISCUSSION A total of 7483 participants completed baseline and 2 sets of follow-up physical function tests. For all 3 physical function tests, participants showed some degree of improved physical function at each follow-up, and greater program attendance predicted clinically significant improvements. Some participants had less improvement: females, those less active at baseline, older than 75 years, not married or partnered, or in fair or poor health, those who had experienced at least 1 fall, and those with a disability. CONCLUSION EnhanceFitness program providers may need to implement additional measures to support the participants who could benefit most from EF, such as targeting messaging, coordinating with referring providers to emphasize attendance and general activity in specific participants, and offering additional support to groups who show less improvement during classes. The evidence presented here may inform clinical decision making for older adult patients and increase health care provider confidence in EF and similar exercise programs, thereby providing a mechanism to maintain and continue functional gains made in clinical or rehabilitation settings.
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Affiliation(s)
- Sarah Fishleder
- Health Promotion Research Center, University of Washington, Seattle.,Department of Health Services, University of Washington, Seattle
| | - Miruna Petrescu-Prahova
- Health Promotion Research Center, University of Washington, Seattle.,Department of Health Services, University of Washington, Seattle
| | - Jeffrey R Harris
- Health Promotion Research Center, University of Washington, Seattle.,Department of Health Services, University of Washington, Seattle
| | - Brian Leroux
- Department of Biostatistics, University of Washington, Seattle.,Department of Oral Health Sciences, University of Washington, Seattle
| | - Kimberly Bennett
- Department of Rehabilitative Medicine, University of Washington, Seattle
| | | | - Marlana Kohn
- Health Promotion Research Center, University of Washington, Seattle
| | - Peggy Hannon
- Health Promotion Research Center, University of Washington, Seattle.,Department of Health Services, University of Washington, Seattle
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Brown MC, Harris JR, Hammerback K, Kohn MJ, Parrish AT, Chan GK, Ornelas IJ, Helfrich CD, Hannon PA. Development of a Wellness Committee Implementation Index for Workplace Health Promotion Programs in Small Businesses. Am J Health Promot 2020; 34:614-621. [PMID: 32077300 PMCID: PMC7305966 DOI: 10.1177/0890117120906967] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To construct a wellness committee (WC) implementation index and determine whether this index was associated with evidence-based intervention implementation in a workplace health promotion program. DESIGN Secondary data analysis of the HealthLinks randomized controlled trial. SETTING Small businesses assigned to the HealthLinks plus WC study arm. SAMPLE Small businesses (20-200 employees, n = 23) from 6 low-wage industries in King County, Washington. MEASURES Wellness committee implementation index (0%-100%) and evidence-based intervention implementation (0%-100%). ANALYSIS We used descriptive and bivariate statistics to describe worksites' organizational characteristics. For the primary analyses, we used generalized estimating equations with robust standard errors to assess the association between WC implementation index and evidence-based intervention implementation over time. RESULTS Average WC implementation index scores were 60% at 15 months and 38% at 24 months. Evidence-based intervention scores among worksites with WCs were 27% points higher at 15 months (64% vs 37%, P < .001) and 36% points higher at 24 months (55% vs 18%, P < .001). Higher WC implementation index scores were positively associated with evidence-based intervention implementation scores over time (P < .001). CONCLUSION Wellness committees may play an essential role in supporting evidence-based intervention implementation among small businesses. Furthermore, the degree to which these WCs are engaged and have leadership support, a set plan or goals, and multilevel participation may influence evidence-based intervention implementation and maintenance over time.
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Affiliation(s)
- Meagan C. Brown
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA
| | - Jeffrey R. Harris
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA
| | - Kristen Hammerback
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA
| | - Marlana J. Kohn
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA
| | - Amanda T. Parrish
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA
| | - Gary K. Chan
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA
| | - India J. Ornelas
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA
| | - Christian D. Helfrich
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA
| | - Peggy A. Hannon
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA
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Gamble-George JC, Longenecker CT, Webel AR, Au DH, Brown AF, Bosworth H, Crothers K, Cunningham WE, Fiscella KA, Hamilton AB, Helfrich CD, Ladapo JA, Luque A, Tobin JN, Wyatt GE. ImPlementation REsearCh to DEvelop Interventions for People Living with HIV (the PRECluDE consortium): Combatting chronic disease comorbidities in HIV populations through implementation research. Prog Cardiovasc Dis 2020; 63:79-91. [PMID: 32199901 PMCID: PMC7237329 DOI: 10.1016/j.pcad.2020.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 03/11/2020] [Indexed: 02/08/2023]
Abstract
Antiretroviral therapy (ART) prevented premature mortality and improved the quality of life among people living with the human immunodeficiency virus (PLWH), such that now more than half of PLWH in the United States are 50 years of age and older. Increased longevity among PLWH has resulted in a significant rise in chronic, comorbid diseases. However, the implementation of guideline-based interventions for preventing, treating, and managing such age-related, chronic conditions among the HIV population is lacking. The PRECluDE consortium supported by the Center for Translation Research and Implementation Science at the National Heart, Lung, and Blood Institute catalyzes implementation research on proven-effective interventions for co-occurring heart, lung, blood, and sleep diseases and conditions among PLWH. These collaborative research studies use novel implementation frameworks with HIV, mental health, cardiovascular, and pulmonary care to advance comprehensive HIV and chronic disease healthcare in a variety of settings and among diverse populations.
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Affiliation(s)
- Joyonna Carrie Gamble-George
- Health Scientist Administrator and AAAS Science and Technology Policy Fellow, Implementation Science Branch (ISB), Center for Translation Research and Implementation Science (CTRIS), National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), U.S. Department of Health and Human Services, Bethesda, MD 20892, United States of America; Office of Science Policy (OSP), Office of the Director (OD), National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD 20892, United States of America.
| | - Christopher T Longenecker
- Department of Medicine, Case Western Reserve University School of Medicine, University Hospitals Harrington Heart and Vascular Institute, Cleveland, OH 44106, United States of America
| | - Allison R Webel
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH 44106, United States of America
| | - David H Au
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington School of Medicine, Seattle, WA 98195, United States of America; Seattle-Denver Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, United States of America
| | - Arleen F Brown
- Department of Medicine, Division of General Internal Medicine and Health Services Research (GIM and HSR), David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, United States of America; GIM and HSR, Olive View-UCLA Medical Center Sylmar, Los Angeles, CA 90095, United States of America; Community Engagement and Research Program, UCLA Clinical and Translational Science Institute, Los Angeles, CA 90095, United States of America
| | - Hayden Bosworth
- Department of Medicine, Duke University School of Medicine, Durham, NC 27701, United States of America; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC 27701, United States of America; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC 27701, United States of America
| | - Kristina Crothers
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington School of Medicine, Seattle, WA 98195, United States of America; Pulmonary and Critical Care Section, VA Puget Sound Health Care System, Seattle, WA 98108, United States of America
| | - William E Cunningham
- Department of Medicine, GIM and HSR, David Geffen School of Medicine, UCLA, Los Angeles, CA 90095, United States of America; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA 90095, United States of America
| | - Kevin A Fiscella
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY 14620, United States of America; Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY 14620, United States of America; Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, NY 14620, United States of America; Center for Communication and Disparities Research, University of Rochester Medical Center, Rochester, NY 14620, United States of America; Greater Rochester Practice-Based Research Network, Clinical and Translational Science Institute (CTSI), University of Rochester Medical Center, Rochester, NY 14642, United States of America
| | - Alison B Hamilton
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90095, United States of America; VA Health Services Research and Development (HSR&D) Service, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, North Hills, CA 91343, United States of America
| | - Christian D Helfrich
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA 98101, United States of America; Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Administration (VA) Puget Sound Health Care System, Seattle, WA 98108, United States of America
| | - Joseph A Ladapo
- Department of Medicine, GIM and HSR, David Geffen School of Medicine, UCLA, Los Angeles, CA 90095, United States of America; Department of Population Health, New York University (NYU) Grossman School of Medicine, New York, NY 10016, United States of America
| | - Amneris Luque
- HIV Clinical Services, Parkland Health and Hospital System, Dallas, TX 75235, United States of America; Department of Internal Medicine, University of Texas (UT) Southwestern Medical Center, Dallas, TX 75390, United States of America
| | - Jonathan N Tobin
- Clinical Directors Network, Inc. (CDN), New York, NY 10018; Community-Engaged Research, The Rockefeller University Center for Clinical and Translational Science, New York, NY 10065, United States of America
| | - Gail E Wyatt
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90095, United States of America; Sexual Health Programs, UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90095, United States of America; The Center for Culture, Trauma, and Mental Health Disparities, UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90024, United States of America; University of Cape Town, Rondebosch, Cape Town 7701, South Africa
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Sanchez A, Pijoan JI, Pablo S, Mediavilla M, de Rozas RS, Lekue I, Gonzalez-Larragan S, Lantaron G, Argote J, García-Álvarez A, Latorre PM, Helfrich CD, Grandes G. Addressing low-value pharmacological prescribing in primary prevention of CVD through a structured evidence-based and theory-informed process for the design and testing of de-implementation strategies: the DE-imFAR study. Implement Sci 2020; 15:8. [PMID: 31969175 PMCID: PMC6977270 DOI: 10.1186/s13012-020-0966-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 01/06/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND De-implementation or abandonment of ineffective or low-value healthcare is becoming a priority research field globally due to the growing empirical evidence of the high prevalence of such care and its impact in terms of patient safety and social inefficiency. Little is known, however, about the factors, barriers, and facilitators involved or about interventions that are effective in promoting and accelerating the de-implementation of low-value healthcare. The De-imFAR study seeks to carry out a structured, evidence-based, and theory-informed process involving the main stakeholders (clinicians, managers, patients, and researchers) for the design, deployment, and assessment of de-implementation strategies for reducing low-value pharmacological prescribing. METHODS A phase I formative study using a systematic and comprehensive framework based on theory and evidence for the design of implementation strategies-specifically, the Behavior Change Wheel (BCW)-will be conducted to design and model de-implementation strategies to favor reductions in low-value pharmacological prescribing of statins in primary prevention of cardiovascular disease (CVD) by main stakeholders (clinicians, managers, patients, and researchers) in a collegiate way. Subsequently, a phase II comparative hybrid trial will be conducted to assess the feasibility and potential effectiveness of at least one active de-implementation strategy to reduce low-value pharmacological prescribing of statins in primary prevention of CVD compared to the usual procedures for dissemination of clinical practice guidelines ("what-not-to-do" recommendations). A mixed-methods evaluation will be used: quantitative for the results of the implementation at the professional level (e.g., adoption, reach and implementation or execution of the recommended clinical practice); and qualitative to determine the feasibility and perceived impact of the de-implementation strategies from the clinicians' perspective, and patients' experiences related to the clinical care received. DISCUSSION The DE-imFAR study aims to generate valid scientific knowledge about the design and development of de-implementation strategies using theory- and evidence-based methodologies suggested by implementation science. It will explore the effectiveness of these strategies and their acceptability among clinicians, policymakers, and patients. Its ultimate goal is to maximize the quality and efficiency of our health system by abandoning low-value pharmacological prescribing. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT04022850. Registered 17 July 2019.
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Affiliation(s)
- Alvaro Sanchez
- Primary Care Research Unit, BioCruces Bizkaia Health Research Institute, Basque Healthcare Service, Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Jose Ignacio Pijoan
- Clinical Epidemiology Unit, Hospital Universitario de Cruces. BioCruces Bizkaia Health Research Institute, Basque Healthcare Service-Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Susana Pablo
- Primary Care Research Unit, BioCruces Bizkaia Health Research Institute, Basque Healthcare Service, Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Marta Mediavilla
- Primary Care Research Unit, BioCruces Bizkaia Health Research Institute, Basque Healthcare Service, Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Rita Sainz de Rozas
- Primary Care Pharmacy Unit, Ezkerraldea-Enkarterri-Cruces Integrated Health Organization – Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Itxasne Lekue
- Primary Care Pharmacy Unit, Barakaldo-Sestao Integrated Health Organization–Osakidetza, Antonio Miranda Etorbidea, E-48902 Barakaldo, Spain
| | - Susana Gonzalez-Larragan
- Department of Health Science Library, Cruces University Hospital-Osakidetza, Biocruces Bizkaia Health Research Institute, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Gaspar Lantaron
- Healthcare Integration Directorate, Ezkerraldea-Enkarterri-Cruces Integrated Health Organization–Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Jon Argote
- Healthcare Integration Directorate, Barakaldo-Sestao Integrated Health Organization–Osakidetza, Antonio Miranda Etorbidea, E-48902 Barakaldo, Spain
| | - Arturo García-Álvarez
- Primary Care Research Unit, BioCruces Bizkaia Health Research Institute, Basque Healthcare Service, Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Pedro Maria Latorre
- Primary Care Research Unit, BioCruces Bizkaia Health Research Institute, Basque Healthcare Service, Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Christian D. Helfrich
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care VA Puget Sound Health Care System, Seattle, USA
- Department of Health Services, University of Washington School of Public Health, Seattle, USA
| | - Gonzalo Grandes
- Primary Care Research Unit, BioCruces Bizkaia Health Research Institute, Basque Healthcare Service, Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
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Stryczek K, Lea C, Gillespie C, Sayre G, Wanner S, Rinne ST, Wiener RS, Feemster L, Udris E, Au DH, Helfrich CD. De-implementing Inhaled Corticosteroids to Improve Care and Safety in COPD Treatment: Primary Care Providers' Perspectives. J Gen Intern Med 2020; 35:51-56. [PMID: 31396814 PMCID: PMC6957635 DOI: 10.1007/s11606-019-05193-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 12/21/2018] [Accepted: 05/23/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is among the most common medical diagnoses among Veterans. More than 50% of Veterans diagnosed with mild-to-moderate COPD are prescribed inhaled corticosteroids despite recommendations for use restricted to patients with frequent exacerbations. OBJECTIVE We explored primary care providers' experiences prescribing inhaled corticosteroids among patients with mild-to-moderate COPD as part of a quality improvement initiative. DESIGN We used a sequential mixed-methods evaluation approach to understand factors influencing primary care providers' inhaled corticosteroid prescribing for patients with mild-to-moderate COPD. Participants were recruited to participate in qualitative interviews and structured surveys. PARTICIPANTS We used a purposive sample of primary care providers from 13 primary care clinics affiliated with two urban Veteran Health Administration healthcare systems. MAIN MEASURES Interviews were transcribed and analyzed using content analysis. Qualitative findings informed a subsequent survey. Surveys were administered through REDCap and analyzed descriptively. Key qualitative and quantitative findings were compared. KEY RESULTS Participants reported they were unaware of current evidence and recommendations for prescribing inhaled corticosteroids; for example, 46% of providers reported they were unaware of risks of pneumonia. Providers reported they are generally unable to keep up with the current literature due to the broad scope of primary care practice. We also found primary care providers may be reluctant to change inherited prescriptions, even if they thought inhaled corticosteroid therapy might not be appropriate. CONCLUSIONS Inhaled corticosteroid prescribing in this patient population is partly due to primary care providers' lack of knowledge about the potential harms and availability of alternative therapies. Our findings suggest that efforts to expand access by increasing the number of prescribing providers a patient potentially sees could make it more difficult to de-implement harmful prescriptions. Our findings also corroborate prior findings that awareness of current evidence-based guidelines is likely an important part of medical overuse.
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Affiliation(s)
- Krysttel Stryczek
- VA Northeast Ohio Healthcare System, Cleveland, OH, USA.,Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Colby Lea
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Chris Gillespie
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, USA
| | - George Sayre
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA
| | | | - Seppo T Rinne
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, USA.,The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, USA.,The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | - Laura Feemster
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Edmunds Udris
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - David H Au
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Christian D Helfrich
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA. .,Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA.
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Hannon PA, Hammerback K, Kohn MJ, Kava CM, Gary Chan KC, Parrish AT, Allen C, Helfrich CD, Mayotte C, Beresford SA, Harris JR. Disseminating Evidence-Based Interventions in Small, Low-Wage Worksites: A Randomized Controlled Trial in King County, Washington (2014-2017). Am J Public Health 2019; 109:1739-1746. [PMID: 31622155 DOI: 10.2105/ajph.2019.305313] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. To determine whether (1) participating in HealthLinks, and (2) adding wellness committees to HealthLinks increases worksites' evidence-based intervention (EBI) implementation.Methods. We developed HealthLinks to disseminate EBIs to small, low-wage worksites. From 2014 to 2017, we conducted a site-randomized trial in King County, Washington, with 68 small worksites (20-200 employees). We assigned worksites to 1 of 3 arms: HealthLinks, HealthLinks plus wellness committee (HealthLinks+), or delayed control. At baseline, 15 months, and 24 months, we assessed worksites' EBI implementation on a 0% to 100% scale and employees' perceived support for their health behaviors.Results. Postintervention EBI scores in both intervention arms (HealthLinks and HealthLinks+) were significantly higher than in the control arm at 15 months (51%, 51%, and 23%, respectively) and at 24 months (33%, 37%, and 24%, respectively; P < .001). Employees in the intervention arms perceived greater support for their health at 15 and 24 months than did employees in control worksites.Conclusions. HealthLinks is an effective strategy for disseminating EBIs to small worksites in low-wage industries.Public Health Implications. Future research should focus on scaling up HealthLinks, improving EBI maintenance, and measuring impact of these on health behavior.
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Affiliation(s)
- Peggy A Hannon
- Peggy A. Hannon, Kristen Hammerback, Marlana J. Kohn, Christine M. Kava, Amanda T. Parrish, Claire Allen, Caitlin Mayotte, and Jeffrey R. Harris are with the Department of Health Services, University of Washington, Seattle. Kwun C. Gary Chan is with the Department of Biostatistics, University of Washington, Seattle. Christian D. Helfrich is with VA Puget Sound Health Care System, Seattle, WA. Shirley A. Beresford is with the Department of Epidemiology, University of Washington, Seattle
| | - Kristen Hammerback
- Peggy A. Hannon, Kristen Hammerback, Marlana J. Kohn, Christine M. Kava, Amanda T. Parrish, Claire Allen, Caitlin Mayotte, and Jeffrey R. Harris are with the Department of Health Services, University of Washington, Seattle. Kwun C. Gary Chan is with the Department of Biostatistics, University of Washington, Seattle. Christian D. Helfrich is with VA Puget Sound Health Care System, Seattle, WA. Shirley A. Beresford is with the Department of Epidemiology, University of Washington, Seattle
| | - Marlana J Kohn
- Peggy A. Hannon, Kristen Hammerback, Marlana J. Kohn, Christine M. Kava, Amanda T. Parrish, Claire Allen, Caitlin Mayotte, and Jeffrey R. Harris are with the Department of Health Services, University of Washington, Seattle. Kwun C. Gary Chan is with the Department of Biostatistics, University of Washington, Seattle. Christian D. Helfrich is with VA Puget Sound Health Care System, Seattle, WA. Shirley A. Beresford is with the Department of Epidemiology, University of Washington, Seattle
| | - Christine M Kava
- Peggy A. Hannon, Kristen Hammerback, Marlana J. Kohn, Christine M. Kava, Amanda T. Parrish, Claire Allen, Caitlin Mayotte, and Jeffrey R. Harris are with the Department of Health Services, University of Washington, Seattle. Kwun C. Gary Chan is with the Department of Biostatistics, University of Washington, Seattle. Christian D. Helfrich is with VA Puget Sound Health Care System, Seattle, WA. Shirley A. Beresford is with the Department of Epidemiology, University of Washington, Seattle
| | - Kwun C Gary Chan
- Peggy A. Hannon, Kristen Hammerback, Marlana J. Kohn, Christine M. Kava, Amanda T. Parrish, Claire Allen, Caitlin Mayotte, and Jeffrey R. Harris are with the Department of Health Services, University of Washington, Seattle. Kwun C. Gary Chan is with the Department of Biostatistics, University of Washington, Seattle. Christian D. Helfrich is with VA Puget Sound Health Care System, Seattle, WA. Shirley A. Beresford is with the Department of Epidemiology, University of Washington, Seattle
| | - Amanda T Parrish
- Peggy A. Hannon, Kristen Hammerback, Marlana J. Kohn, Christine M. Kava, Amanda T. Parrish, Claire Allen, Caitlin Mayotte, and Jeffrey R. Harris are with the Department of Health Services, University of Washington, Seattle. Kwun C. Gary Chan is with the Department of Biostatistics, University of Washington, Seattle. Christian D. Helfrich is with VA Puget Sound Health Care System, Seattle, WA. Shirley A. Beresford is with the Department of Epidemiology, University of Washington, Seattle
| | - Claire Allen
- Peggy A. Hannon, Kristen Hammerback, Marlana J. Kohn, Christine M. Kava, Amanda T. Parrish, Claire Allen, Caitlin Mayotte, and Jeffrey R. Harris are with the Department of Health Services, University of Washington, Seattle. Kwun C. Gary Chan is with the Department of Biostatistics, University of Washington, Seattle. Christian D. Helfrich is with VA Puget Sound Health Care System, Seattle, WA. Shirley A. Beresford is with the Department of Epidemiology, University of Washington, Seattle
| | - Christian D Helfrich
- Peggy A. Hannon, Kristen Hammerback, Marlana J. Kohn, Christine M. Kava, Amanda T. Parrish, Claire Allen, Caitlin Mayotte, and Jeffrey R. Harris are with the Department of Health Services, University of Washington, Seattle. Kwun C. Gary Chan is with the Department of Biostatistics, University of Washington, Seattle. Christian D. Helfrich is with VA Puget Sound Health Care System, Seattle, WA. Shirley A. Beresford is with the Department of Epidemiology, University of Washington, Seattle
| | - Caitlin Mayotte
- Peggy A. Hannon, Kristen Hammerback, Marlana J. Kohn, Christine M. Kava, Amanda T. Parrish, Claire Allen, Caitlin Mayotte, and Jeffrey R. Harris are with the Department of Health Services, University of Washington, Seattle. Kwun C. Gary Chan is with the Department of Biostatistics, University of Washington, Seattle. Christian D. Helfrich is with VA Puget Sound Health Care System, Seattle, WA. Shirley A. Beresford is with the Department of Epidemiology, University of Washington, Seattle
| | - Shirley A Beresford
- Peggy A. Hannon, Kristen Hammerback, Marlana J. Kohn, Christine M. Kava, Amanda T. Parrish, Claire Allen, Caitlin Mayotte, and Jeffrey R. Harris are with the Department of Health Services, University of Washington, Seattle. Kwun C. Gary Chan is with the Department of Biostatistics, University of Washington, Seattle. Christian D. Helfrich is with VA Puget Sound Health Care System, Seattle, WA. Shirley A. Beresford is with the Department of Epidemiology, University of Washington, Seattle
| | - Jeffrey R Harris
- Peggy A. Hannon, Kristen Hammerback, Marlana J. Kohn, Christine M. Kava, Amanda T. Parrish, Claire Allen, Caitlin Mayotte, and Jeffrey R. Harris are with the Department of Health Services, University of Washington, Seattle. Kwun C. Gary Chan is with the Department of Biostatistics, University of Washington, Seattle. Christian D. Helfrich is with VA Puget Sound Health Care System, Seattle, WA. Shirley A. Beresford is with the Department of Epidemiology, University of Washington, Seattle
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Parikh TJ, Helfrich CD, Quiñones AR, Marshall-Fabien GL, Makaroun LK, Black MA, Thielke SM. Cost-related delay in filling prescriptions and health care ratings among medicare advantage recipients. Medicine (Baltimore) 2019; 98:e16469. [PMID: 31374008 PMCID: PMC6708951 DOI: 10.1097/md.0000000000016469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
Despite higher health care needs, older adults often have limited and fixed income. Approximately a quarter of them report not filling or delaying prescription medications due to cost (cost-related prescription delay, CRPD). To ascertain the association between CRPD and satisfaction with health care, secondary analysis of the 2012 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare Advantage Survey was performed.Regression models quantified the association between CRPD and rating of personal doctor, specialist, and overall health care. Models were adjusted for demographic, health-related, and socioeconomic characteristics. 274,996 Medicare Advantage enrollees were mailed the CAHPS survey, of which 101,910 (36.8%) returned a survey that had responses to all the items we analyzed. CRPD was assessed by self-report of delay in filling prescriptions due to cost. Health care ratings were on a 0-10 scale. A score ≤ 5 was considered a poor rating of care.In unadjusted models, CRPD more than doubled the relative risk (RR) for poor ratings of personal doctor (RR 2.34), specialist (RR 2.14), and overall health care (RR 2.40). Adjusting for demographics and health status slightly reduced the RRs to 1.9, but adjusting for low-income subsidy and lack of insurance for medications did not make a difference.CRPD is independently associated with poor ratings of medical care, regardless of health, financial or insurance status. Providers might reduce patients' financial stress and improve patient satisfaction by explicitly discussing prescription cost and incorporating patient priorities when recommending treatments.
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Affiliation(s)
- Toral J Parikh
- Department of Gerontology and Geriatric Medicine, University of Washington, Health Services Research and Development, VA Puget Sound Health Care System
| | - Christian D Helfrich
- Department of Health Services, University of Washington, Health Services Research and Development, VA Puget Sound Health Care System
| | - Ana R Quiñones
- Department of Family Medicine, Oregon Health & Science University
| | | | - Lena K Makaroun
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
| | | | - Stephen M Thielke
- Department of Psychiatry and Behavioral Sciences, University of Washington, Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System
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Abstract
Ensuring equitable access to quality health care historically has focused on gaps in care, where patients fail to receive the high-value care that will benefit them, something termed underuse. But providing high-quality health care sometimes requires reducing low-value care that delivers no benefit or where known harms outweigh expected benefits. These situations represent health care overuse. The process involved in reducing low-value care is known as de-implementation. In this article, we argue that de-implementation is critical for advancing equity for several reasons. First, medical overuse is associated with patient race, ethnicity, and socioeconomic status. In some cases, the result is even double jeopardy, where racial and ethnic minorities are at higher risk of both overuse and underuse. In these cases, more traditional efforts focused exclusively on underuse ignore half of the problem. Second, overuse of preventive care and screening is often greater for more socioeconomically advantaged patients. Within insured populations, this means more socioeconomically disadvantaged patients subsidize overuse. Finally, racial and ethnic minorities may have different experiences of overuse than Whites in the United States. This may make efforts to de-implement overuse particularly fraught. We therefore provide several actions for closing current research gaps, including: adding subgroup analyses in studies of medical overuse; specifying and measuring potential mechanisms related to equity (eg, double jeopardy vs thermostat models of overuse); and testing de-implementation strategies that may mitigate bias.
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Affiliation(s)
- Christian D Helfrich
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA
| | - Christine W Hartmann
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA
| | - Toral J Parikh
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA
| | - David H Au
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA
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Affiliation(s)
- Melanie D Whittington
- 1 VA Eastern Colorado Health Care System, Aurora, CO.,2 University of Colorado Anschutz Medical Campus, Aurora, CO
| | - P Michael Ho
- 1 VA Eastern Colorado Health Care System, Aurora, CO.,2 University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Christian D Helfrich
- 3 VA Puget Sound Health Care System, Seattle, WA.,4 University of Washington, Seattle, WA
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Helfrich CD, Kohn MJ, Stapleton A, Allen CL, Hammerback KE, Chan KCG, Parrish AT, Ryan DE, Weiner BJ, Harris JR, Hannon PA. Readiness to Change Over Time: Change Commitment and Change Efficacy in a Workplace Health-Promotion Trial. Front Public Health 2018; 6:110. [PMID: 29740572 PMCID: PMC5925216 DOI: 10.3389/fpubh.2018.00110] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [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: 01/14/2018] [Accepted: 04/03/2018] [Indexed: 11/13/2022] Open
Abstract
Introduction Organizational readiness to change may be a key determinant of implementation success and a mediator of the effectiveness of implementation interventions. If organizational readiness can be reliably and validly assessed at the outset of a change initiative, it could be used to assess the effectiveness of implementation-support activities by measuring changes in readiness factors over time. Methods We analyzed two waves of readiness-to-change survey data collected as part of a three-arm, randomized controlled trial to implement evidence-based health promotion practices in small worksites in low-wage industries. We measured five readiness factors: context (favorable broader conditions); change valence (valuing health promotion); information assessment (demands and resources to implement health promotion); change commitment (an intention to implement health promotion); and change efficacy (a belief in shared ability to implement health promotion). We expected commitment and efficacy to increase at intervention sites along with their self-reported effort to implement health promotion practices, termed wellness-program effort. We compared means between baseline and 15 months, and between intervention and control sites. We used linear regression to test whether intervention and control sites differed in their change-readiness scores over time. Results Only context and change commitment met reliability thresholds. Change commitment declined significantly for both control (-0.39) and interventions sites (-0.29) from baseline to 15 months, while context did not change for either. Only wellness program effort at 15 months, but not at baseline, differed significantly between control and intervention sites (1.20 controls, 2.02 intervention). Regression analyses resulted in two significant differences between intervention and control sites in changes from baseline to 15 months: (1) intervention sites exhibited significantly smaller change in context scores relative to control sites over time and (2) intervention sites exhibited significantly higher changes in wellness program effort relative to control sites. Discussion Contrary to our hypothesis, change commitment declined significantly at both Healthlinks and control sites, even as wellness-program effort increased significantly at HealthLinks sites. Regression to the mean may explain the decline in change commitment. Future research needs to assess whether baseline commitment is an independent predictor of wellness-program effort or an effect modifier of the HealthLinks intervention.
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Affiliation(s)
- Christian D Helfrich
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, WA, United States.,Department of Health Services, School of Public Health, University of Washington, Seattle, WA, United States
| | - Marlana J Kohn
- Health Promotion Research Center, A CDC Prevention Research Center, Department of Health Services, University of Washington, Seattle, WA, United States
| | - Austin Stapleton
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA, United States
| | - Claire L Allen
- Health Promotion Research Center, A CDC Prevention Research Center, Department of Health Services, University of Washington, Seattle, WA, United States
| | - Kristen Elizabeth Hammerback
- Health Promotion Research Center, A CDC Prevention Research Center, Department of Health Services, University of Washington, Seattle, WA, United States
| | - K C Gary Chan
- Health Promotion Research Center, A CDC Prevention Research Center, Department of Health Services, University of Washington, Seattle, WA, United States
| | - Amanda T Parrish
- Health Promotion Research Center, A CDC Prevention Research Center, Department of Health Services, University of Washington, Seattle, WA, United States
| | - Daron E Ryan
- Health Promotion Research Center, A CDC Prevention Research Center, Department of Health Services, University of Washington, Seattle, WA, United States
| | - Bryan J Weiner
- Health Promotion Research Center, A CDC Prevention Research Center, Department of Health Services, University of Washington, Seattle, WA, United States
| | - Jeffrey R Harris
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA, United States.,Health Promotion Research Center, A CDC Prevention Research Center, Department of Health Services, University of Washington, Seattle, WA, United States
| | - Peggy A Hannon
- Health Promotion Research Center, A CDC Prevention Research Center, Department of Health Services, University of Washington, Seattle, WA, United States
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Helfrich CD, Rose AJ, Hartmann CW, van Bodegom-Vos L, Graham ID, Wood SJ, Majerczyk BR, Good CB, Pogach LM, Ball SL, Au DH, Aron DC. How the dual process model of human cognition can inform efforts to de-implement ineffective and harmful clinical practices: A preliminary model of unlearning and substitution. J Eval Clin Pract 2018; 24:198-205. [PMID: 29314508 PMCID: PMC5900912 DOI: 10.1111/jep.12855] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 11/02/2017] [Accepted: 11/03/2017] [Indexed: 11/29/2022]
Abstract
RATIONALE AND OBJECTIVES One way to understand medical overuse at the clinician level is in terms of clinical decision-making processes that are normally adaptive but become maladaptive. In psychology, dual process models of cognition propose 2 decision-making processes. Reflective cognition is a conscious process of evaluating options based on some combination of utility, risk, capabilities, and/or social influences. Automatic cognition is a largely unconscious process occurring in response to environmental or emotive cues based on previously learned, ingrained heuristics. De-implementation strategies directed at clinicians may be conceptualized as corresponding to cognition: (1) a process of unlearning based on reflective cognition and (2) a process of substitution based on automatic cognition. RESULTS We define unlearning as a process in which clinicians consciously change their knowledge, beliefs, and intentions about an ineffective practice and alter their behaviour accordingly. Unlearning has been described as "the questioning of established knowledge, habits, beliefs and assumptions as a prerequisite to identifying inappropriate or obsolete knowledge underpinning and/or embedded in existing practices and routines." We hypothesize that as an unintended consequence of unlearning strategies clinicians may experience "reactance," ie, feel their professional prerogative is being violated and, consequently, increase their commitment to the ineffective practice. We define substitution as replacing the ineffective practice with one or more alternatives. A substitute is a specific alternative action or decision that either precludes the ineffective practice or makes it less likely to occur. Both approaches may work independently, eg, a substitute could displace an ineffective practice without changing clinicians' knowledge, and unlearning could occur even if no alternative exists. For some clinical practice, unlearning and substitution strategies may be most effectively used together. CONCLUSIONS By taking into account the dual process model of cognition, we may be able to design de-implementation strategies matched to clinicians' decision-making processes and avoid unintended consequence.
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Affiliation(s)
- Christian D Helfrich
- VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, USA.,Department of Health Services, University of Washington School of Public Health, Seattle, USA
| | - Adam J Rose
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, USA
| | - Christine W Hartmann
- Center for Healthcare Organization and Implementation Research (CHOIR) Bedford VA Medical Center, Bedford, USA.,Boston University School of Public Health, Boston, USA
| | - Leti van Bodegom-Vos
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Ian D Graham
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,Centre for Practice-Changing Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Suzanne J Wood
- Graduate Program in Health Services Administration, Department of Health Sciences, School of Public Health, University of Washington, Seattle, USA
| | - Barbara R Majerczyk
- VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, USA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh healthcare System, Department of Veterans Affairs, Pittsburgh, USA.,Medical Advisory Panel for Pharmacy Benefits Management, Department of Veterans Affairs, Washington, USA.,University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Leonard M Pogach
- Office of Specialty Care, Veterans Health Administration, Washington, USA.,VA New Jersey Health Care System, East Orange, USA
| | - Sherry L Ball
- Louis Stokes Cleveland VA Medical Center, Department of Veterans Affairs, Cleveland, USA
| | - David H Au
- VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, USA
| | - David C Aron
- Department of Medicine, Louis Stokes Cleveland VA Medical Center, Cleveland, USA.,Division of Clinical and Molecular Endocrinology and Adjunct Professor Dept. of Organizational Behavior, Weatherhead School of Management, Case Western Reserve University, Cleveland, USA
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Fishleder S, Petrescu-Prahova M, Harris JR, Steinman L, Kohn M, Bennett K, Helfrich CD. Bridging the Gap After Physical Therapy: Clinical-Community Linkages With Older Adult Physical Activity Programs. Innov Aging 2018; 2:igy006. [PMID: 30480131 PMCID: PMC6177034 DOI: 10.1093/geroni/igy006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Many barriers exist to older adult participation in physical activity, despite known benefits. Referrals from physical therapists (PTs) through clinical-community linkages offer novel, promising opportunities to increase older adult engagement in appropriate community-based physical activity programs. We assessed the capacity of PTs to participate in such linkages. RESEARCH DESIGN AND METHODS We collected qualitative data using semistructured phone interviews (n = 30) with PTs across 14 states. We conducted thematic analysis using a priori themes based on the 2008 Bridging Model of Etz and colleagues: capacity to assess patient risk, ability to provide brief counseling, capacity and ability to refer, and awareness of community resources. RESULTS Risk assessment and counseling were already part of routine practice for our respondents, but counseling could be further facilitated if PTs had more skills to engage less-motivated patients. PTs expressed a desire to refer their patients to community programs; however, barriers to referrals included lack of knowledge of and trust in community programs, and limited infrastructure for communicating with potential partners. DISCUSSION AND IMPLICATIONS PTs have the capacity to develop patient referral linkages with community-based physical activity programs. PT session length and content facilitates patient risk assessment and behavioral counseling. Integrating motivational techniques can help PTs engage less-motivated patients in physical activity. Systemic improvements should include innovations in communication infrastructure, identifying clinic-level champions, and in-person outreach initiated by organizations that deliver community physical activity programs.
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Affiliation(s)
| | | | | | | | | | - Kimberly Bennett
- Department of Rehabilitative Medicine, University of Washington, Seattle
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Kim LY, Rose DE, Soban LM, Stockdale SE, Meredith LS, Edwards ST, Helfrich CD, Rubenstein LV. Primary Care Tasks Associated with Provider Burnout: Findings from a Veterans Health Administration Survey. J Gen Intern Med 2018; 33:50-56. [PMID: 28948450 PMCID: PMC5756167 DOI: 10.1007/s11606-017-4188-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 08/30/2017] [Accepted: 09/07/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND The patient-centered medical home (PCMH) is a primary care delivery model predicated on shared responsibility for patient care among members of an interprofessional team. Effective task sharing may reduce burnout among primary care providers (PCPs). However, little is known about the extent to which PCPs share these responsibilities, and which, if any, of the primary care tasks performed independently by the PCPs (vs. shared with the team) are particularly associated with PCP burnout. A better understanding of the relationship between these tasks and their effects on PCP burnout may help guide focused efforts aimed at reducing burnout. OBJECTIVE To investigate (1) the extent to which PCPs share responsibility for 14 discrete primary care tasks with other team members, and (2) which, if any, of the primary care tasks performed by the PCPs (without reliance on team members) are associated with PCP burnout. DESIGN Secondary data analysis of Veterans Health Administration (VHA) survey data from two time periods. PARTICIPANTS 327 providers from 23 VA primary care practices within one VHA regional network. MAIN MEASURES The dependent variable was PCP report of burnout. Independent variables included PCP report of the extent to which they performed 14 discrete primary care tasks without reliance on team members; team functioning; and PCP-, clinic-, and system-level variables. KEY RESULTS In adjusted models, PCP reports of intervening on patient lifestyle factors and educating patients about disease-specific self-care activities, without reliance on their teams, were significantly associated with burnout (intervening on lifestyle: b = 4.11, 95% CI = 0.39, 7.83, p = 0.03; educating patients: b = 3.83, 95% CI = 0.33, 7.32, p = 0.03). CONCLUSIONS Performing behavioral counseling and self-management education tasks without relying on other team members for assistance was associated with PCP burnout. Expanding the roles of nurses and other healthcare professionals to assume responsibility for these tasks may ease PCP burden and reduce burnout.
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Affiliation(s)
- Linda Y Kim
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, Greater Los Angeles (GLA) Healthcare System, Los Angeles, CA, USA.
| | - Danielle E Rose
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, Greater Los Angeles (GLA) Healthcare System, Los Angeles, CA, USA
| | - Lynn M Soban
- Department of Nursing Research, Cedars-Sinai Health System, Los Angeles, CA, USA
| | - Susan E Stockdale
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, Greater Los Angeles (GLA) Healthcare System, Los Angeles, CA, USA.,Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA
| | - Lisa S Meredith
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, Greater Los Angeles (GLA) Healthcare System, Los Angeles, CA, USA.,RAND Corporation, Santa Monica, CA, USA
| | - Samuel T Edwards
- Section of General Internal Medicine, VA Portland Health Care System, Portland, OR, USA.,Division of General Internal Medicine and Geriatrics, Oregon Health and Sciences University, Portland, OR, USA.,Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Christian D Helfrich
- Seattle-Denver 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
| | - Lisa V Rubenstein
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, Greater Los Angeles (GLA) Healthcare System, Los Angeles, CA, USA.,RAND Corporation, Santa Monica, CA, USA
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Wang V, Maciejewski ML, Helfrich CD, Weiner BJ. Working smarter not harder: Coupling implementation to de-implementation. Healthc (Amst) 2017; 6:104-107. [PMID: 29279297 DOI: 10.1016/j.hjdsi.2017.12.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 12/09/2017] [Accepted: 12/12/2017] [Indexed: 10/18/2022]
Abstract
In this paper, we discuss de-implementation as an implicit part of implementation and organizational change, and consider its underlying processes of unlearning to discontinue or deviate from ineffective practice and learning to applying newer, more effective practices. We describe a typology of de-implementation that represents four types of change: partial reduction, complete reversal, substitution with related replacement and substitution with unrelated replacement of existing practice. We also explicate how learning and unlearning needed for effective change vary in these four types of de-implementation. Last, we propose coupling de-implementation and implementation efforts, which serve conceptual and logistical goals of organizational change.
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Affiliation(s)
- Virginia Wang
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System; Department of Population Health Sciences, Duke University School of Medicine; Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine.
| | - Matthew L Maciejewski
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System; Department of Population Health Sciences, Duke University School of Medicine; Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine.
| | - Christian D Helfrich
- Center for Health Services Research in Older Adults, VA Puget Sound Health Care System; Department of Health Services, School of Public Health, University of Washington, USA.
| | - Bryan J Weiner
- Department of Health Services, School of Public Health, University of Washington, USA; Department of Global Health, School of Public Health, University of Washington, USA.
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Helfrich CD, Simonetti JA, Clinton WL, Wood GB, Taylor L, Schectman G, Stark R, Rubenstein LV, Fihn SD, Nelson KM. The Association of Team-Specific Workload and Staffing with Odds of Burnout Among VA Primary Care Team Members. J Gen Intern Med 2017; 32:760-766. [PMID: 28233221 PMCID: PMC5481228 DOI: 10.1007/s11606-017-4011-4] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 01/11/2017] [Accepted: 02/02/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Work-related burnout is common in primary care and is associated with worse patient safety, patient satisfaction, and employee mental health. Workload, staffing stability, and team completeness may be drivers of burnout. However, few studies have assessed these associations at the team level, and fewer still include members of the team beyond physicians. OBJECTIVE To study the associations of burnout among primary care providers (PCPs), nurse care managers, clinical associates (MAs, LPNs), and administrative clerks with the staffing and workload on their teams. DESIGN We conducted an individual-level cross-sectional analysis of survey and administrative data in 2014. PARTICIPANTS Primary care personnel at VA clinics responding to a national survey. MAIN MEASURES Burnout was measured with a validated single-item survey measure dichotomized to indicate the presence of burnout. The independent variables were survey measures of team staffing (having a fully staffed team, serving on multiple teams, and turnover on the team), and workload both from survey items (working extended hours), and administrative data (patient panel overcapacity and average panel comorbidity). KEY RESULTS There were 4610 respondents (estimated response rate of 20.9%). The overall prevalence of burnout was 41%. In adjusted analyses, the strongest associations with burnout were having a fully staffed team (odds ratio [OR] = 0.55, 95% CI 0.47-0.65), having turnover on the team (OR = 1.67, 95% CI 1.43-1.94), and having patient panel overcapacity (OR = 1.19, 95% CI 1.01-1.40). The observed burnout prevalence was 30.1% lower (28.5% vs. 58.6%) for respondents working on fully staffed teams with no turnover and caring for a panel within capacity, relative to respondents in the inverse condition. CONCLUSIONS Complete team staffing, turnover among team members, and panel overcapacity had strong, cumulative associations with burnout. Further research is needed to understand whether improvements in these factors would lower burnout.
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Affiliation(s)
- Christian D. Helfrich
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care VA Puget Sound Puget Sound Health Care System, US Department of Veterans Affairs, Seattle, WA USA
- Department of Health Services, University of Washington School of Public Health, Seattle, WA USA
| | - Joseph A. Simonetti
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care VA Puget Sound Puget Sound Health Care System, US Department of Veterans Affairs, Seattle, WA USA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA USA
| | - Walter L. Clinton
- Office of Analytics and Business Intelligence, US Department of Veterans Affairs, Seattle, WA USA
| | - Gordon B. Wood
- Office of Analytics and Business Intelligence, US Department of Veterans Affairs, Seattle, WA USA
| | - Leslie Taylor
- Office of Analytics and Business Intelligence, US Department of Veterans Affairs, Seattle, WA USA
| | | | - Richard Stark
- VA Office of Clinical Operations, Washington, DC USA
| | - Lisa V. Rubenstein
- Center for the Study of Healthcare Innovation, Implementation, & Policy, Greater Los Angeles VA, Sepulveda, CA USA
- UCLA School of Medicine, Los Angeles, CA USA
- RAND Corp, Santa Monica, CA USA
| | - Stephan D. Fihn
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care VA Puget Sound Puget Sound Health Care System, US Department of Veterans Affairs, Seattle, WA USA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA USA
- Office of Analytics and Business Intelligence, US Department of Veterans Affairs, Seattle, WA USA
| | - Karin M. Nelson
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care VA Puget Sound Puget Sound Health Care System, US Department of Veterans Affairs, Seattle, WA USA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA USA
- Office of Analytics and Business Intelligence, US Department of Veterans Affairs, Seattle, WA USA
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Winchester DE, Schmalfuss C, Helfrich CD, Beyth RJ. A specialty-specific, multimodality educational quality improvement initiative to deimplement rarely appropriate myocardial perfusion imaging. Open Heart 2017; 4:e000589. [PMID: 28674630 PMCID: PMC5471866 DOI: 10.1136/openhrt-2017-000589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 04/06/2017] [Accepted: 04/11/2017] [Indexed: 01/03/2023] Open
Abstract
Objective Investigations of Appropriate Use Criteria (AUC) education have shown a mixed effect on changing provider behaviour. At our facility, rarely appropriate myocardial perfusion imaging (MPI) differs by specialty; awareness of AUC is low. Our objective is to investigate if specialty-specific, multimodality education could reduce rarely appropriate MPI. Methods We designed education focused on the rarely appropriate MPI ordered most often by each specialty. We tracked appropriateness of MPI in three cohorts: pre, post (immediately after) and late-post (4 months after) intervention. Results A total of 889 MPI were evaluated (n=287 pre, n=313 post, n=289 late-post), 95.3% were men. Chest pain was the most common symptom (n=530, 59.6%), while 14.1% (n=125) had no symptoms. Rarely appropriate testing decreased from 4.9% to 1.3% and remained at 1.4% in the late-post cohort (p<0.0001). In logistic regression, lack of symptoms (OR 31.3, 95% CI 10.3 to 94.8, p≤0.0001) and being in the post or late-post cohorts (OR 0.27, 95% CI 0.11 to 0.68, p=0.006) were associated with rarely appropriate MPI. Preoperative MPI in patients with good exercise capacity was a common rarely appropriate indication. Ischaemia was not observed among patients with rarely appropriate indication for MPI. Conclusions In certain clinical settings, education may be an effective approach for deimplementing rarely appropriate MPI. The effect of education may be enhanced when focused on improving patient care, delivered by a peer, and needs assessment indicates low awareness of guidelines. Lack of symptoms and preoperative MPI continue to be the predominant rarely appropriate MPI ordered.
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Affiliation(s)
- David E Winchester
- Cardiology Section, Medical Service, Malcom Randall VA Medical Center, Gainesville, Florida, USA.,Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Carsten Schmalfuss
- Cardiology Section, Medical Service, Malcom Randall VA Medical Center, Gainesville, Florida, USA.,Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Rebecca J Beyth
- Geriatric Research Education and Clinical Centers (GRECC), Malcom Randall VA Medical Center, Gainesville, Florida, USA.,Division of General Internal Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
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Winchester DE, Schmalfuss C, Wymer DC, Helfrich CD, Beyth RJ. Abstract 017: Feasibility of Audit and Feedback for Reducing Rarely Appropriate Nuclear Myocardial Perfusion Imaging Among Veterans. Circ Cardiovasc Qual Outcomes 2017. [DOI: 10.1161/circoutcomes.10.suppl_3.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Appropriate Use Criteria (AUC) are complex documents which provide great detail on which patients are likely to benefit from a test. For providers who order a low volume of cardiac tests, regular application and navigation through the AUC may be difficult. Audit and feedback (A&F) has been proposed as an effective method for encouraging de-implementation of unnecessary testing. We hypothesized that the volume of myocardial perfusion imaging (MPI) ordered by most providers would make A&F ineffective.
Methods:
We performed a secondary analysis of data gathered for the evaluation of a program to reduce rarely appropriate MPI. Patients who underwent nuclear myocardial perfusion imaging (MPI) were rated using the AUC. Appropriateness rating was performed retrospectively by a nurse trained in application of the AUC. We extracted data on both the patient and the ordering provider from the medical record which accompanied the visit where the MPI was ordered. Patients were compared in two cohorts: those with rarely appropriate indications for MPI, and all others. We performed logistic regression to determine which patient and provider characteristics were associated with rarely appropriate MPI. We ranked the most common indications for rarely appropriate testing and calculated the mean number of MPI ordered by our providers.
Results:
A total of 889 cases over six months were included; 22 MPI (2.5%) were rated as rarely appropriate. A minority of patients had a prior myocardial infarction (n=127, 143%) or coronary revascularization (n=291, 32.7%). Chest pain was more common among appropriate or maybe appropriate MPI (n=528, 61.1% vs. n=1, 4.5%, P<0.0001) while lack of symptoms was more common among rarely appropriate MPI (n=18, 81.8% vs. 107, 12.4%, P<0.0001). In logistic regression, lack of symptoms was retained in association with rarely appropriate testing (odds ratio 31.6, 95% confidence interval 10.5-95.2, P<0.0001). The majority (59.1%) of rarely appropriate tests were accounted for with only 3 indications (#8, #71, and #67). A total of 219 providers ordered MPI during the study period, with an average of 4.1 MPI per provider, less than one MPI per provider per month. The greatest number of rarely appropriate tests from any single provider was 3.
Conclusions:
Within the setting of an educational program to reduce rarely appropriate MPI, the number of rarely appropriate MPI per provider was low. Lack of symptoms and indications including preoperative testing and screening in low risk patients were common drivers of rarely appropriate MPI. These data raise doubt about efficacy of a broadly applied program which provides individualized A&F. Efforts to increase awareness of common reasons for rarely appropriate testing may have greater impact.
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Rose AJ, Park A, Gillespie C, Van Deusen Lukas C, Ozonoff A, Petrakis BA, Reisman JI, Borzecki AM, Benedict AJ, Lukesh WN, Schmoke TJ, Jones EA, Morreale AP, Ourth HL, Schlosser JE, Mayo-Smith MF, Allen AL, Witt DM, Helfrich CD, McCullough MB. Results of a Regional Effort to Improve Warfarin Management. Ann Pharmacother 2016; 51:373-379. [PMID: 28367699 DOI: 10.1177/1060028016681030] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Improved anticoagulation control with warfarin reduces adverse events and represents a target for quality improvement. No previous study has described an effort to improve anticoagulation control across a health system. OBJECTIVE To describe the results of an effort to improve anticoagulation control in the New England region of the Veterans Health Administration (VA). METHODS Our intervention encompassed 8 VA sites managing warfarin for more than 5000 patients in New England (Veterans Integrated Service Network 1 [VISN 1]). We provided sites with a system to measure processes of care, along with targeted audit and feedback. We focused on processes of care associated with site-level anticoagulation control, including prompt follow-up after out-of-range international normalized ratio (INR) values, minimizing loss to follow-up, and use of guideline-concordant INR target ranges. We used a difference-in-differences (DID) model to examine changes in anticoagulation control, measured as percentage time in therapeutic range (TTR), as well as process measures and compared VISN 1 sites with 116 VA sites located outside VISN 1. RESULTS VISN 1 sites improved on TTR, our main indicator of quality, from 66.4% to 69.2%, whereas sites outside VISN 1 improved from 65.9% to 66.4% (DID 2.3%, P < 0.001). Improvement in TTR correlated strongly with the extent of improvement on process-of-care measures, which varied widely across VISN 1 sites. CONCLUSIONS A regional quality improvement initiative, using performance measurement with audit and feedback, improved TTR by 2.3% more than control sites, which is a clinically important difference. Improving relevant processes of care can improve outcomes for patients receiving warfarin.
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Affiliation(s)
- Adam J Rose
- 1 Bedford VA Medical Center, MA, USA.,2 Boston University School of Medicine, MA, USA
| | - Angela Park
- 3 New England Veterans Engineering Resource Center, Boston, MA, USA
| | | | - Carol Van Deusen Lukas
- 1 Bedford VA Medical Center, MA, USA.,4 Boston University School of Public Health, MA, USA
| | - Al Ozonoff
- 1 Bedford VA Medical Center, MA, USA.,5 Boston Children's Hospital, MA, USA.,6 Harvard Medical School, Boston, MA, USA
| | | | | | - Ann M Borzecki
- 1 Bedford VA Medical Center, MA, USA.,2 Boston University School of Medicine, MA, USA.,4 Boston University School of Public Health, MA, USA
| | | | - William N Lukesh
- 3 New England Veterans Engineering Resource Center, Boston, MA, USA
| | | | - Ellen A Jones
- 8 VA Central Western Massachusetts Healthcare System, Northampton, MA, USA
| | | | | | | | | | | | - Daniel M Witt
- 14 University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | - Christian D Helfrich
- 15 VA Portland Healthcare System, OR, USA.,16 VA Center for Veteran-Centered and Value-Driven Care, Seattle, WA, USA
| | - Megan B McCullough
- 1 Bedford VA Medical Center, MA, USA.,4 Boston University School of Public Health, MA, USA
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Hannon PA, Helfrich CD, Chan KG, Allen CL, Hammerback K, Kohn MJ, Parrish AT, Weiner BJ, Harris JR. Development and Pilot Test of the Workplace Readiness Questionnaire, a Theory-Based Instrument to Measure Small Workplaces' Readiness to Implement Wellness Programs. Am J Health Promot 2016; 31:67-75. [PMID: 26389975 DOI: 10.4278/ajhp.141204-quan-604] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To develop a theory-based questionnaire to assess readiness for change in small workplaces adopting wellness programs. DESIGN In developing our scale, we first tested items via "think-aloud" interviews. We tested the revised items in a cross-sectional quantitative telephone survey. SETTING The study setting comprised small workplaces (20-250 employees) in low-wage industries. SUBJECTS Decision-makers representing small workplaces in King County, Washington (think-aloud interviews, n = 9), and the United States (telephone survey, n = 201) served as study subjects. MEASURES We generated items for each construct in Weiner's theory of organizational readiness for change. We also measured workplace characteristics and current implementation of workplace wellness programs. ANALYSIS We assessed reliability by coefficient alpha for each of the readiness questionnaire subscales. We tested the association of all subscales with employers' current implementation of wellness policies, programs, and communications, and conducted a path analysis to test the associations in the theory of organizational readiness to change. RESULTS Each of the readiness subscales exhibited acceptable internal reliability (coefficient alpha range, .75-.88) and was positively associated with wellness program implementation ( p < .05). The path analysis was consistent with the theory of organizational readiness to change, except change efficacy did not predict change-related effort. CONCLUSION We developed a new questionnaire to assess small workplaces' readiness to adopt and implement evidence-based wellness programs. Our findings also provide empirical validation of Weiner's theory of readiness for change.
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Affiliation(s)
- Peggy A Hannon
- 1 Health Promotion Research Center (a CDC Prevention Research Center), Department of Health Services, University of Washington School of Public Health, Seattle, Washington
| | - Christian D Helfrich
- 2 Northwest Health Services Research & Development Center of Excellence, VA Puget Sound Health Care System, Seattle, Washington.,3 Department of Health Services, University of Washington School of Public Health, Seattle, Washington
| | - K Gary Chan
- 3 Department of Health Services, University of Washington School of Public Health, Seattle, Washington
| | - Claire L Allen
- 1 Health Promotion Research Center (a CDC Prevention Research Center), Department of Health Services, University of Washington School of Public Health, Seattle, Washington
| | - Kristen Hammerback
- 1 Health Promotion Research Center (a CDC Prevention Research Center), Department of Health Services, University of Washington School of Public Health, Seattle, Washington
| | - Marlana J Kohn
- 1 Health Promotion Research Center (a CDC Prevention Research Center), Department of Health Services, University of Washington School of Public Health, Seattle, Washington
| | - Amanda T Parrish
- 1 Health Promotion Research Center (a CDC Prevention Research Center), Department of Health Services, University of Washington School of Public Health, Seattle, Washington
| | - Bryan J Weiner
- 4 Department of Health Policy and Management, UNC Gillings Global School of Public Health, University of North Carolina-Chapel Hill
| | - Jeffrey R Harris
- 1 Health Promotion Research Center (a CDC Prevention Research Center), Department of Health Services, University of Washington School of Public Health, Seattle, Washington
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Schopfer DW, Takemoto S, Allsup K, Helfrich CD, Ho PM, Forman DE, Whooley MA. Notice of Retraction and Replacement. Schopfer DW, et al. Cardiac Rehabilitation Use Among Veterans With Ischemic Heart Disease. JAMA Intern Med. 2014;174(10):1687-1689. JAMA Intern Med 2016; 176:1726-1727. [PMID: 27723859 DOI: 10.1001/jamainternmed.2016.5831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- David W Schopfer
- Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California2Department of Medicine, University of California, San Francisco
| | - Steven Takemoto
- Department of Anesthesia, University of California, San Francisco
| | - Kelly Allsup
- Geriatric, Research, and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Christian D Helfrich
- Northwest Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
| | - P Michael Ho
- Division of Cardiology, Denver Veterans Affairs Medical Center, Denver, Colorado7Division of Cardiology, Department of Medicine, University of Colorado Health Sciences Center, Denver
| | - Daniel E Forman
- Geriatric, Research, and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania8Geriatric Cardiology Section, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania9Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mary A Whooley
- Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California2Department of Medicine, University of California, San Francisco10Department of Epidemiology and Biostatistics, University of California, San Francisco
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Helfrich CD, Sylling PW, Gale RC, Mohr DC, Stockdale SE, Joos S, Brown EJ, Grembowski D, Asch SM, Fihn SD, Nelson KM, Meredith LS. The facilitators and barriers associated with implementation of a patient-centered medical home in VHA. Implement Sci 2016; 11:24. [PMID: 26911135 PMCID: PMC4766632 DOI: 10.1186/s13012-016-0386-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 02/17/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The patient-centered medical home (PCMH) is a team-based, comprehensive model of primary care. When effectively implemented, PCMH is associated with higher patient satisfaction, lower staff burnout, and lower hospitalization for ambulatory care-sensitive conditions. However, less is known about what factors contribute to (or hinder) PCMH implementation. We explored the associations of specific facilitators and barriers reported by primary care employees with a previously validated, clinic-level measure of PCMH implementation, the Patient Aligned Care Team Implementation Progress Index (Pi(2)). METHODS We used a 2012 survey of primary care employees in the Veterans Health Administration to perform cross-sectional, respondent-level multinomial regressions. The dependent variable was the Pi(2) categorized as high implementation (top decile, 54 clinics, 235 respondents), medium implementation (middle eight deciles, 547 clinics, 4537 respondents), and low implementation (lowest decile, 42 clinics, 297 respondents) among primary care clinics. The independent variables were ordinal survey items rating 19 barriers to patient-centered care and 10 facilitators of PCMH implementation. For facilitators, we explored clinic Pi(2) score decile both as a function of respondent-reported availability of facilitators and of rating of facilitator helpfulness. RESULTS The availability of five facilitators was associated with higher odds of a respondent's clinic's Pi(2) scores being in the highest versus lowest decile: teamlet huddles (OR = 3.91), measurement tools (OR = 3.47), regular team meetings (OR = 2.88), information systems (OR = 2.42), and disease registries (OR = 2.01). The helpfulness of four facilitators was associated with higher odds of a respondent's clinic's Pi(2) scores being in the highest versus lowest decile. Six barriers were associated with significantly higher odds of a respondent's clinic's Pi(2) scores being in the lowest versus highest decile, with the strongest associations for the difficulty recruiting and retaining providers (OR = 2.37) and non-provider clinicians (OR = 2.17). Results for medium versus low Pi(2) score clinics were similar, with fewer, smaller significant associations, all in the expected direction. CONCLUSIONS A number of specific barriers and facilitators were associated with PCMH implementation, notably recruitment and retention of clinicians, team huddles, and local education. These findings can guide future research, and may help healthcare policy makers and leaders decide where to focus attention and limited resources.
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Affiliation(s)
- Christian D Helfrich
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound, U.S. Department of Veterans Affairs, 1660 Columbian Way, S-152, Seattle, 98108, WA, USA.
- Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA.
| | - Philip W Sylling
- Office of Analytics and Business Intelligence, U.S. Department of Veterans Affairs, Seattle, WA, USA
| | - Randall C Gale
- Center for Innovation to Implementation, VHA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
- Boston University School of Public Health, Boston, MA, USA
| | - Susan E Stockdale
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VHA Greater Los Angeles Health Care System, North Hills, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Sandra Joos
- Portland VHA Medical Center, VISN 20 Patient Aligned Care Team (PACT) Demonstration Laboratory, U.S. Department of Veterans Affairs, Portland, OR, USA
| | - Elizabeth J Brown
- Center for Evaluation of Patient Aligned Care Teams (CEPACT), Philadelphia Veterans Affairs Medical Center, Philadelphia, USA
- The Robert Wood Johnson Foundation Clinical Scholars Program, and the Department of Family and Community Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, USA
| | - David Grembowski
- Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA
| | - Steven M Asch
- Center for Innovation to Implementation, VHA Palo Alto Healthcare System, Menlo Park, CA, USA
- Stanford University School of Medicine, Palo Alto, CA, USA
| | - Stephan D Fihn
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound, U.S. Department of Veterans Affairs, 1660 Columbian Way, S-152, Seattle, 98108, WA, USA
- Office of Analytics and Business Intelligence, U.S. Department of Veterans Affairs, Seattle, WA, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Karin M Nelson
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound, U.S. Department of Veterans Affairs, 1660 Columbian Way, S-152, Seattle, 98108, WA, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Lisa S Meredith
- RAND Corporation, Santa Monica, CA, USA
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, Los Angeles, CA, USA
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Haverhals LM, Sayre G, Helfrich CD, Battaglia C, Aron D, Stevenson LD, Kirsh S, Ho M, Lowery J. E-consult implementation: lessons learned using consolidated framework for implementation research. Am J Manag Care 2015; 21:e640-e647. [PMID: 26760426 PMCID: PMC4717483] [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] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVES In 2011, the Veterans Health Administration (VHA) implemented electronic consults (e-consults) as an alternative to in-person specialty visits to improve access and reduce travel for veterans. We conducted an evaluation to understand variation in the use of the new e-consult mechanism and the causes of variable implementation, guided by the Consolidated Framework for Implementation Research (CFIR). STUDY DESIGN Qualitative case studies of 3 high- and 5 low-implementation e-consult pilot sites. Participants included e-consult site leaders, primary care providers, specialists, and support staff identified using a modified snowball sample. METHODS We used a 3-step approach, with a structured survey of e-consult site leaders to identify key constructs, based on the CFIR. We then conducted open-ended interviews, focused on key constructs, with all participants. Finally, we produced structured, site-level ratings of CFIR constructs and compared them between high- and low-implementation sites. RESULTS Site leaders identified 14 initial constructs. We conducted 37 interviews, from which 4 CFIR constructs distinguished high implementation e-consult sites: compatibility, networks and communications, training, and access to knowledge and information. For example, illustrating compatibility, a specialist at a high-implementation site reported that the site changed the order of consult options so that all specialties listed e-consults first to maintain consistency. High-implementation sites also exhibited greater agreement on constructs. CONCLUSIONS By using the CFIR to analyze results, we facilitate future synthesis with other findings, and we better identify common patterns of implementation determinants common across settings.
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Affiliation(s)
- Leah M Haverhals
- VA Eastern Colorado Health Care System, 1055 Clermont St, Research A151, Denver, CO 80220. E-mail:
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Battaglia C, Lambert-Kerzner A, Aron DC, Sayre GG, Ho PM, Haverhals L, Stevenson L, Kirsh S, Au DH, Helfrich CD. Evaluation of E-Consults in the VHA: Provider Perspectives. Fed Pract 2015; 32:42-48. [PMID: 30766078 PMCID: PMC6363293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
As VHA expands the use of e-consults, this study suggests that they often are more timely than are face-to-face consultations.
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Affiliation(s)
- Catherine Battaglia
- is a nurse scientist, is a health services researcher, is a physician, and is a health research specialist, all at VA Eastern Colorado Health Care System in Denver. is a physician and is a research health science specialist at Louis Stokes Cleveland VA Medical Center in Ohio. is a clinical consultant at the VA Office of Specialty Care Services in Washington, DC. is a research health science specialist and qualitative resources coordinator, is a physician, and is a research investigator, all at VA Puget Sound Health Care System in Seattle, Washington. Dr. Battaglia, Dr. Lambert-Kerzner, Dr. Sayre, Dr. Ho, Ms. Haverhals, Dr. Au, and Dr. Helfrich are affiliated with the VA's Seattle-Denver Center of Innovation. Dr. Battaglia, Dr. Lambert-Kerzner, and Dr. Ho have faculty appointments at the University of Colorado in Aurora. Dr. Aron is a professor at Case Western Reserve University in Cleveland, Ohio. Dr. Sayre, Dr. Au, and Dr. Helfrich have faculty appointments at the University of Washington in Seattle
| | - Anne Lambert-Kerzner
- is a nurse scientist, is a health services researcher, is a physician, and is a health research specialist, all at VA Eastern Colorado Health Care System in Denver. is a physician and is a research health science specialist at Louis Stokes Cleveland VA Medical Center in Ohio. is a clinical consultant at the VA Office of Specialty Care Services in Washington, DC. is a research health science specialist and qualitative resources coordinator, is a physician, and is a research investigator, all at VA Puget Sound Health Care System in Seattle, Washington. Dr. Battaglia, Dr. Lambert-Kerzner, Dr. Sayre, Dr. Ho, Ms. Haverhals, Dr. Au, and Dr. Helfrich are affiliated with the VA's Seattle-Denver Center of Innovation. Dr. Battaglia, Dr. Lambert-Kerzner, and Dr. Ho have faculty appointments at the University of Colorado in Aurora. Dr. Aron is a professor at Case Western Reserve University in Cleveland, Ohio. Dr. Sayre, Dr. Au, and Dr. Helfrich have faculty appointments at the University of Washington in Seattle
| | - David C Aron
- is a nurse scientist, is a health services researcher, is a physician, and is a health research specialist, all at VA Eastern Colorado Health Care System in Denver. is a physician and is a research health science specialist at Louis Stokes Cleveland VA Medical Center in Ohio. is a clinical consultant at the VA Office of Specialty Care Services in Washington, DC. is a research health science specialist and qualitative resources coordinator, is a physician, and is a research investigator, all at VA Puget Sound Health Care System in Seattle, Washington. Dr. Battaglia, Dr. Lambert-Kerzner, Dr. Sayre, Dr. Ho, Ms. Haverhals, Dr. Au, and Dr. Helfrich are affiliated with the VA's Seattle-Denver Center of Innovation. Dr. Battaglia, Dr. Lambert-Kerzner, and Dr. Ho have faculty appointments at the University of Colorado in Aurora. Dr. Aron is a professor at Case Western Reserve University in Cleveland, Ohio. Dr. Sayre, Dr. Au, and Dr. Helfrich have faculty appointments at the University of Washington in Seattle
| | - George G Sayre
- is a nurse scientist, is a health services researcher, is a physician, and is a health research specialist, all at VA Eastern Colorado Health Care System in Denver. is a physician and is a research health science specialist at Louis Stokes Cleveland VA Medical Center in Ohio. is a clinical consultant at the VA Office of Specialty Care Services in Washington, DC. is a research health science specialist and qualitative resources coordinator, is a physician, and is a research investigator, all at VA Puget Sound Health Care System in Seattle, Washington. Dr. Battaglia, Dr. Lambert-Kerzner, Dr. Sayre, Dr. Ho, Ms. Haverhals, Dr. Au, and Dr. Helfrich are affiliated with the VA's Seattle-Denver Center of Innovation. Dr. Battaglia, Dr. Lambert-Kerzner, and Dr. Ho have faculty appointments at the University of Colorado in Aurora. Dr. Aron is a professor at Case Western Reserve University in Cleveland, Ohio. Dr. Sayre, Dr. Au, and Dr. Helfrich have faculty appointments at the University of Washington in Seattle
| | - P Michael Ho
- is a nurse scientist, is a health services researcher, is a physician, and is a health research specialist, all at VA Eastern Colorado Health Care System in Denver. is a physician and is a research health science specialist at Louis Stokes Cleveland VA Medical Center in Ohio. is a clinical consultant at the VA Office of Specialty Care Services in Washington, DC. is a research health science specialist and qualitative resources coordinator, is a physician, and is a research investigator, all at VA Puget Sound Health Care System in Seattle, Washington. Dr. Battaglia, Dr. Lambert-Kerzner, Dr. Sayre, Dr. Ho, Ms. Haverhals, Dr. Au, and Dr. Helfrich are affiliated with the VA's Seattle-Denver Center of Innovation. Dr. Battaglia, Dr. Lambert-Kerzner, and Dr. Ho have faculty appointments at the University of Colorado in Aurora. Dr. Aron is a professor at Case Western Reserve University in Cleveland, Ohio. Dr. Sayre, Dr. Au, and Dr. Helfrich have faculty appointments at the University of Washington in Seattle
| | - Leah Haverhals
- is a nurse scientist, is a health services researcher, is a physician, and is a health research specialist, all at VA Eastern Colorado Health Care System in Denver. is a physician and is a research health science specialist at Louis Stokes Cleveland VA Medical Center in Ohio. is a clinical consultant at the VA Office of Specialty Care Services in Washington, DC. is a research health science specialist and qualitative resources coordinator, is a physician, and is a research investigator, all at VA Puget Sound Health Care System in Seattle, Washington. Dr. Battaglia, Dr. Lambert-Kerzner, Dr. Sayre, Dr. Ho, Ms. Haverhals, Dr. Au, and Dr. Helfrich are affiliated with the VA's Seattle-Denver Center of Innovation. Dr. Battaglia, Dr. Lambert-Kerzner, and Dr. Ho have faculty appointments at the University of Colorado in Aurora. Dr. Aron is a professor at Case Western Reserve University in Cleveland, Ohio. Dr. Sayre, Dr. Au, and Dr. Helfrich have faculty appointments at the University of Washington in Seattle
| | - Lauren Stevenson
- is a nurse scientist, is a health services researcher, is a physician, and is a health research specialist, all at VA Eastern Colorado Health Care System in Denver. is a physician and is a research health science specialist at Louis Stokes Cleveland VA Medical Center in Ohio. is a clinical consultant at the VA Office of Specialty Care Services in Washington, DC. is a research health science specialist and qualitative resources coordinator, is a physician, and is a research investigator, all at VA Puget Sound Health Care System in Seattle, Washington. Dr. Battaglia, Dr. Lambert-Kerzner, Dr. Sayre, Dr. Ho, Ms. Haverhals, Dr. Au, and Dr. Helfrich are affiliated with the VA's Seattle-Denver Center of Innovation. Dr. Battaglia, Dr. Lambert-Kerzner, and Dr. Ho have faculty appointments at the University of Colorado in Aurora. Dr. Aron is a professor at Case Western Reserve University in Cleveland, Ohio. Dr. Sayre, Dr. Au, and Dr. Helfrich have faculty appointments at the University of Washington in Seattle
| | - Susan Kirsh
- is a nurse scientist, is a health services researcher, is a physician, and is a health research specialist, all at VA Eastern Colorado Health Care System in Denver. is a physician and is a research health science specialist at Louis Stokes Cleveland VA Medical Center in Ohio. is a clinical consultant at the VA Office of Specialty Care Services in Washington, DC. is a research health science specialist and qualitative resources coordinator, is a physician, and is a research investigator, all at VA Puget Sound Health Care System in Seattle, Washington. Dr. Battaglia, Dr. Lambert-Kerzner, Dr. Sayre, Dr. Ho, Ms. Haverhals, Dr. Au, and Dr. Helfrich are affiliated with the VA's Seattle-Denver Center of Innovation. Dr. Battaglia, Dr. Lambert-Kerzner, and Dr. Ho have faculty appointments at the University of Colorado in Aurora. Dr. Aron is a professor at Case Western Reserve University in Cleveland, Ohio. Dr. Sayre, Dr. Au, and Dr. Helfrich have faculty appointments at the University of Washington in Seattle
| | - David H Au
- is a nurse scientist, is a health services researcher, is a physician, and is a health research specialist, all at VA Eastern Colorado Health Care System in Denver. is a physician and is a research health science specialist at Louis Stokes Cleveland VA Medical Center in Ohio. is a clinical consultant at the VA Office of Specialty Care Services in Washington, DC. is a research health science specialist and qualitative resources coordinator, is a physician, and is a research investigator, all at VA Puget Sound Health Care System in Seattle, Washington. Dr. Battaglia, Dr. Lambert-Kerzner, Dr. Sayre, Dr. Ho, Ms. Haverhals, Dr. Au, and Dr. Helfrich are affiliated with the VA's Seattle-Denver Center of Innovation. Dr. Battaglia, Dr. Lambert-Kerzner, and Dr. Ho have faculty appointments at the University of Colorado in Aurora. Dr. Aron is a professor at Case Western Reserve University in Cleveland, Ohio. Dr. Sayre, Dr. Au, and Dr. Helfrich have faculty appointments at the University of Washington in Seattle
| | - Christian D Helfrich
- is a nurse scientist, is a health services researcher, is a physician, and is a health research specialist, all at VA Eastern Colorado Health Care System in Denver. is a physician and is a research health science specialist at Louis Stokes Cleveland VA Medical Center in Ohio. is a clinical consultant at the VA Office of Specialty Care Services in Washington, DC. is a research health science specialist and qualitative resources coordinator, is a physician, and is a research investigator, all at VA Puget Sound Health Care System in Seattle, Washington. Dr. Battaglia, Dr. Lambert-Kerzner, Dr. Sayre, Dr. Ho, Ms. Haverhals, Dr. Au, and Dr. Helfrich are affiliated with the VA's Seattle-Denver Center of Innovation. Dr. Battaglia, Dr. Lambert-Kerzner, and Dr. Ho have faculty appointments at the University of Colorado in Aurora. Dr. Aron is a professor at Case Western Reserve University in Cleveland, Ohio. Dr. Sayre, Dr. Au, and Dr. Helfrich have faculty appointments at the University of Washington in Seattle
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Dolan ED, Mohr D, Lempa M, Joos S, Fihn SD, Nelson KM, Helfrich CD. Using a single item to measure burnout in primary care staff: a psychometric evaluation. J Gen Intern Med 2015; 30:582-7. [PMID: 25451989 PMCID: PMC4395610 DOI: 10.1007/s11606-014-3112-6] [Citation(s) in RCA: 303] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 07/25/2014] [Accepted: 11/07/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND Burnout affects nearly half of all U.S. nurses and physicians, and has been linked to poor outcomes such as worse patient safety. The most common measure of burnout is the well-validated Maslach Burnout Inventory (MBI). However, the MBI is proprietary and carries licensing fees, posing challenges to routine or repeated assessment. OBJECTIVE To compare a non-proprietary, single-item burnout measure to a single item from the MBI Emotional Exhaustion (MBI:EE) subscale that has been validated as a standalone burnout measure. DESIGN Cross-sectional online survey. PARTICIPANTS A sample of primary care providers (PCPs), registered nurses, clinical associates (e.g., licensed practical nurses (LPNs), medical technicians), and administrative clerks in the Veterans Health Administration surveyed in 2012. MAIN METHODS We compared a validated one-item version of the MBI:EE and a non-proprietary single-item burnout measure used in the Physician Work Life Study. We calculated kappa statistics, sensitivity and specificity, positive predictive (PPV) and negative predictive values (NPV), and area under the receiver operator curve (AUC). We conducted analyses stratified by occupation to determine the stability of the correlation between the two measures. KEY RESULTS We analyzed responses from 5,404 participants, including 1,769 providers and 1,380 registered nurses. The prevalence of burnout was 36.7% as measured on the single MBI:EE item and 38.5% as measured on the non-proprietary single-item measure. Relative to the MBI:EE, the non-proprietary single-item measure had a correlation of 0.79, sensitivity of 83.2%, specificity of 87.4%, and AUC of 0.93 (se = 0.004). Results were similar when stratified by respondent occupation. CONCLUSIONS A non-proprietary single-item measure served as a reliable substitute for the MBI:EE across occupations. Because it is non-proprietary and easy to interpret, it has logistical advantages over the one-item MBI.
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Affiliation(s)
- Emily D. Dolan
- />VA Puget Sound Health Services Research & Development Center of Innovation, US Department of Veterans Affairs, Seattle, WA USA
| | - David Mohr
- />Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA USA
- />Department of Health Policy and Management, Boston University School of Public Health, Boston, MA USA
| | - Michele Lempa
- />Philadelphia VA Medical Center, US Department of Veterans Affairs, Philadelphia, PA USA
| | - Sandra Joos
- />Portland VA Medical Center, VISN 20 PACT Demonstration Laboratory, US Department of Veterans Affairs, Portland, OR USA
- />Department of Medicine, Division of General Internal Medicine & Geriatrics, Oregon Health and Science University, Portland, OR USA
| | - Stephan D. Fihn
- />Office of Analytics and Business Intelligence, US Department of Veterans Affairs, Seattle, WA USA
- />Department of Medicine, University of Washington School of Medicine, Seattle, WA USA
| | - Karin M. Nelson
- />VA Puget Sound Health Services Research & Development Center of Innovation, US Department of Veterans Affairs, Seattle, WA USA
- />Department of Medicine, University of Washington School of Medicine, Seattle, WA USA
| | - Christian D. Helfrich
- />VA Puget Sound Health Services Research & Development Center of Innovation, US Department of Veterans Affairs, Seattle, WA USA
- />Department of Health Services, University of Washington School of Public Health, Seattle, WA USA
- />VA Ischemic Heart Disease Quality Enhancement Research Initiative Seattle Denver Center of Innovation for Veteran-Centered and Value-Driven Care, 1100 Olive Way, Suite 1400, Seattle, WA 98101 USA
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Gale RC, Asch SM, Taylor T, Nelson KM, Luck J, Meredith LS, Helfrich CD. The most used and most helpful facilitators for patient-centered medical home implementation. Implement Sci 2015; 10:52. [PMID: 25924611 PMCID: PMC4414441 DOI: 10.1186/s13012-015-0246-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 04/13/2015] [Indexed: 12/03/2022] Open
Abstract
Background Like other transformative healthcare initiatives, patient-centered medical home (PCMH) implementation requires substantial investments of time and resources. Even though PCMH and PCMH-like models are being implemented by multiple provider practices and health systems, little is known about what facilitates their implementation. The purpose of this study was to assess which PCMH-implementation resources are most widely used, by whom, and which resources primary care personnel find most helpful. Methods This study is an analysis of data from a cross-sectional survey of primary care personnel in the Veterans Health Administration in 2012, in which respondents were asked to rate whether they were aware of and accessed PCMH-implementation resources, and to rate their helpfulness. Logistic regression was used to produce odds ratios for the outcomes (1) resource use and (2) resource helpfulness. Respondents were nested within clinics, nested, in turn, within 135 parent hospitals. Results Teamlet huddles were the most widely accessed (80.4% accessed) and most helpful (90.4% rated helpful) resource; quality-improvement methods to conduct small tests of change were the least frequently accessed (42.4% accessed) resource though two-thirds (66.7%) of users reported as helpful. Supervisors were significantly more likely (ORs, 1.46 to 1.86) to use resources than non-supervisors but were less likely to rate the majority (8 out of 10) of resources as “somewhat/very helpful” than non-supervisors (ORs, 0.72 to 0.84). Longer-tenured employees tended to rate resources as more helpful. Conclusions These findings are the first in the PCMH literature that we are aware of that systematically assesses primary care staff’s access to and the helpfulness of PCMH implementation resources. Supervisors generally reported greater access to resources, relative to non-supervisors, but rated resources as less helpful, suggesting that information about them may not have been optimally disseminated. Knowing what resources primary care staff use and find helpful can inform administrators’ and policymakers’ investments in PCMH-implementation resources. The implications of our model extend beyond just PCMH implementation but also to considerations when providing implementation resources for other complex quality-improvement initiatives. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0246-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Randall C Gale
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 790 Willow Road, Menlo Park, CA, 94025, USA.
| | - Steven M Asch
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 790 Willow Road, Menlo Park, CA, 94025, USA. .,Division of General Medical Disciplines, Stanford University, Palo Alto, CA, USA.
| | - Thomas Taylor
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 790 Willow Road, Menlo Park, CA, 94025, USA.
| | - Karin M Nelson
- US Department of Veterans Affairs, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA. .,Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA. .,Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA.
| | - Jeff Luck
- College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA.
| | - Lisa S Meredith
- VA HSR&D Center for the Study of Healthcare Provider Behavior, Sepulveda, CA, USA. .,RAND Corporation, Santa Monica, CA, USA.
| | - Christian D Helfrich
- US Department of Veterans Affairs, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA. .,Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA.
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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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