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Uscher-Pines L, McCullough CM, Sousa JL, Lee SD, Ober AJ, Camacho D, Kapinos KA. Changes in In-Person, Audio-Only, and Video Visits in California's Federally Qualified Health Centers, 2019-2022. JAMA 2023; 329:1219-1221. [PMID: 37039799 PMCID: PMC10091174 DOI: 10.1001/jama.2023.1307] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
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Schulson LB, Predmore Z, Sousa JL, McCullough CM, Magit A, Lerner C, Chinnock R, Barkley S, Marcin JP, McGuire T, Browne MA, Uscher-Pines L. Perceptions of Pediatric Endocrinologists and Neurologists on the Drivers of Telehealth Use. Acad Pediatr 2023; 23:271-278. [PMID: 35940573 DOI: 10.1016/j.acap.2022.07.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/22/2022] [Accepted: 07/30/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the extent and drivers of telehealth use variation across clinicians within the same pediatric subspecialties. METHODS In this mixed methods study, 8 pediatric medical groups in California shared data for eleven subspecialties. We calculated the proportion of total visits delivered via telehealth by medical group for each subspecialty and identified the 8 most common International Classification of Diseases 10 diagnoses for telehealth and in-person visits in endocrinology and neurology. We conducted semi-structured interviews with 32 pediatric endocrinologists and neurologists and applied a positive deviance approach comparing high versus low utilizers to identify factors that influenced their level of telehealth use. RESULTS In 2019, medical groups that submitted quantitative data conducted 1.8 million visits with 549,306 unique pediatric patients. For 3 subspecialties, there was relatively little variation in telehealth use across medical groups: urology (mean: 16.5%, range: 9%-23%), orthopedics (mean: 7.2%, range: 2%-14%), and cardiology (mean: 11.2%, range: 2%-24%). The remaining subspecialties, including neurology (mean: 58.6%, range: 8%-93%) and endocrinology (mean: 49.5%, range: 24%-92%), exhibited higher levels of variation. For both neurology and endocrinology, the top diagnoses treated in-person were similar to those treated via telehealth. There was limited consensus on which clinical conditions were appropriate for telehealth. High telehealth utilizers were more comfortable conducting telehealth visits for new patients and often worked in practices with innovations to support telehealth. CONCLUSIONS Clinicians perceive that telehealth may be appropriate for a range of clinical conditions when the right supports are available.
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Affiliation(s)
- Lucy B Schulson
- RAND Corporation, Health Care (LB Schulson, Z Predmore, and JL Sousa), Boston, Mass; General Internal Medicine, Boston University School of Medicine (LB Schulson), Boston, Mass.
| | - Zachary Predmore
- RAND Corporation, Health Care (LB Schulson, Z Predmore, and JL Sousa), Boston, Mass
| | - Jessica L Sousa
- RAND Corporation, Health Care (LB Schulson, Z Predmore, and JL Sousa), Boston, Mass
| | | | - Anthony Magit
- UC San Diego Department of Otolaryngology, Rady Children's Hospital San Diego (A Magit), San Diego, Calif
| | - Carlos Lerner
- Department of Pediatrics, UCLA Mattel Children's Hospital (C Lerner), Los Angeles, Calif
| | - Richard Chinnock
- Department of Pediatrics, Loma Linda University Health (R Chinnock), Loma Linda, Calif
| | - Steven Barkley
- Department of Neonatology, Cottage Children's Medical Center (S Barkley), Santa Barbara, Calif
| | - James P Marcin
- Pediatric Intensive Care, UC Davis Children's Hospital (JP Marcin), Sacramento, Calif
| | - Troy McGuire
- Division of General Pediatrics, Children's Hospital Los Angeles (T McGuire), Los Angeles, Calif
| | - Michael-Anne Browne
- Department of Pediatrics, Stanford Children's Health (M-A Browne), Palo Alto, Calif
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Uscher-Pines L, Arora N, Jones M, Lee A, Sousa JL, McCullough CM, Lee S, Martineau M, Predmore Z, Whaley CM, Ober AJ. Experiences of Health Centers in Implementing Telehealth Visits for Underserved Patients During the COVID-19 Pandemic: Results from the Connected Care Accelerator Initiative. Rand Health Q 2022; 9:2. [PMID: 36238021 PMCID: PMC9519102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
In early 2020, as the coronavirus disease 2019 (COVID-19) pandemic emerged, widespread social-distancing efforts suspended much of the delivery of nonurgent health care. Telehealth proved to be a viable alternative to in-person care, at least on a temporary basis, and utilization skyrocketed. Many Federally Qualified Health Centers (FQHCs) serving low-income patients started delivering telehealth visits in high volume in March 2020 to help maintain access to care. This sudden and dramatic change in health care delivery posed numerous challenges. Health centers had to quickly make changes to technology, workflows, and staffing to accommodate telehealth visits. To support health centers in these efforts, the California Health Care Foundation established the Connected Care Accelerator (CCA) program, a quality improvement initiative that was launched in July 2020. RAND researchers evaluated the progress of FQHCs that participated in the CCA initiative by investigating changes in telehealth utilization and health center staff experiences with implementation. In this research, researchers review recent literature on telehealth implementation in safety net settings. They also present new information on the experiences of the 45 CCA health centers, drawing from data on visit trends, interviews with health center leaders, and surveys of health center providers and staff. Telehealth has the potential to increase access to care and deliver care that is more convenient and patient-centered; however, ongoing research is needed to ensure that telehealth is implemented in a way that ensures high-quality care and health equity.
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Ober AJ, Hunter SB, McCullough CM, Leamon I, McCreary M, Beas I, Montero A, Tarn DM, Bromley E, Hurley B, Sheehe J, Martinez J, Watkins KE. Opioid Use Disorder Among Clients of Community Mental Health Clinics: Prevalence, Characteristics, and Treatment Willingness. Psychiatr Serv 2022; 73:271-279. [PMID: 34281359 PMCID: PMC8770719 DOI: 10.1176/appi.ps.202000818] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors examined the prevalence of co-occurring opioid use disorder and willingness to engage in treatment among clients of eight Los Angeles County Department of Mental Health outpatient clinics. METHODS Adults presenting for an appointment over a 2-week period were invited to complete a voluntary, anonymous health survey. Clients who indicated opioid use in the past year were offered a longer survey assessing probable opioid use disorder. Willingness to take medication and receive treatment also was assessed. RESULTS In total, 3,090 clients completed screening. Among these, 8% had a probable prescription (Rx) opioid use disorder and 2% a probable heroin use disorder. Of the clients with probable Rx opioid use or heroin use disorder, 49% and 25% were female, respectively. Among those with probable Rx opioid use disorder, 43% were Black, 33% were Hispanic, and 12% were White, and among those with probable heroin use disorder, 24% were Black, 22% were Hispanic, and 39% were White. Seventy-eight percent of those with Rx opioid use disorder had never received any treatment, and 82% had never taken a medication for this disorder; 39% of those with heroin use disorder had never received any treatment, and 39% had never received a medication. The strongest predictor of willingness to take a medication was believing that it would help stop opioid use (buprenorphine, β=13.54, p=0.003, and naltrexone long-acting injection, β=15.83, p<0.001). CONCLUSIONS These findings highlight the need to identify people with opioid use disorder and to educate clients in mental health settings about medications for these disorders.
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Affiliation(s)
| | | | | | - Isabel Leamon
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407
| | | | - Ivan Beas
- David Geffen School of Medicine at UCLA
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Simmons MM, Osilla KC, Miranda J, Paddock SM, McCullough CM. Understanding the characteristics of Latino individuals with first-time DUI offenses to facilitate effective interventions. J Ethn Subst Abuse 2021; 22:337-349. [PMID: 34365912 DOI: 10.1080/15332640.2021.1943096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Literature shows that Latinos who drink are more likely to experience alcohol-related consequences and less likely to seek care for alcohol misuse than Whites. We aim to understand characteristics, consumption patterns, and openness to treatment among Latino first-time offenders driving under the influence. Latino participants were significantly younger (29.0 years) than non-Latinos (37.7 years). In adjusted models, Latino participants were significantly more likely than non-Latinos to binge drink, but there were no significant group differences in amount of alcohol consumed in a typical week. There was no significant difference in incidence of alcohol-related consequences, readiness to change drinking, and driving behaviors in this sample.
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Osilla KC, Paddock SM, McCullough CM, Jonsson L, Watkins KE. Randomized Clinical Trial Examining Cognitive Behavioral Therapy for Individuals With a First-Time DUI Offense. Alcohol Clin Exp Res 2019; 43:2222-2231. [PMID: 31472028 DOI: 10.1111/acer.14161] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 07/29/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Driving under the influence (DUI) programs are a unique setting to reduce disparities in treatment access to those who may not otherwise access treatment. Providing evidence-based therapy in these programs may help prevent DUI recidivism. METHODS We conducted a randomized clinical trial of 312 participants enrolled in 1 of 3 DUI programs in California. Participants were 21 and older with a first-time DUI offense who screened positive for at-risk drinking in the past year. Participants were randomly assigned to a 12-session manualized cognitive behavioral therapy (CBT) or usual care (UC) group and then surveyed 4 and 10 months later. We conducted intent-to-treat analyses to test the hypothesis that participants receiving CBT would report reduced impaired driving, alcohol consumption (drinks per week, abstinence, and binge drinking), and alcohol-related negative consequences. We also explored whether race/ethnicity and gender moderated CBT findings. RESULTS Participants were 72.3% male and 51.7% Hispanic, with an average age of 33.2 (SD = 12.4). Relative to UC, participants receiving CBT had lower odds of driving after drinking at the 4- and 10-month follow-ups compared to participants receiving UC (odds ratio [OR] = 0.37, p = 0.032, and OR = 0.29, p = 0.065, respectively). This intervention effect was more pronounced for females at 10-month follow-up. The remaining 4 outcomes did not significantly differ between UC versus CBT at 4- and 10-month follow-ups. Participants in both UC and CBT reported significant within-group reductions in 2 of 5 outcomes, binge drinking and alcohol-related consequences, at 10-month follow-up (p < 0.001). CONCLUSIONS In the short-term, individuals receiving CBT reported significantly lower rates of repeated DUI than individuals receiving UC, which may suggest that learning cognitive behavioral strategies to prevent impaired driving may be useful in achieving short-term reductions in impaired driving.
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Ober AJ, Watkins KE, McCullough CM, Setodji CM, Osilla K, Hunter SB. Patient predictors of substance use disorder treatment initiation in primary care. J Subst Abuse Treat 2018; 90:64-72. [PMID: 29866385 PMCID: PMC6336395 DOI: 10.1016/j.jsat.2018.04.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [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: 10/09/2017] [Revised: 04/07/2018] [Accepted: 04/08/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Primary care clinics are opportune settings in which to deliver substance use disorder (SUD) treatment, but little is known about which patients initiate treatment in these settings. METHODS Using secondary data from a RCT that aimed to integrate SUD treatment into a federally qualified health center (FQHC) using an organizational readiness and collaborative care (CC) intervention, we examined patient-level predictors of initiation of evidence-based practices for opioid and/or alcohol use disorders (OAUDs): a brief behavioral treatment (BT) based on motivational interviewing and cognitive behavioral therapy and medication-assisted treatment (MAT) (extended-release injectable naltrexone (XR-NTX) for patients with an alcohol use disorder or opioid use disorder and buprenorphine/naloxone (BUP/NX) for patients with an opioid use disorder). Using the Andersen model of health care access, we tested bivariate and multivariate logistic regression models to assess associations between patient factors and initiation of BT and MAT. RESULTS Twenty-three percent of all participants (N = 392) received BT and 13% received MAT. In the multivariate model examining factors associated with initiation of BT, being of "other" or "multiple" races compared with being White (OR = 0.45, CI = 0.22, 0.92), being homeless (OR = 0.45, CI = 0.21, 0.97) and having been arrested within 90 days of baseline (OR = 0.21 CI = 0.63, 0.69) were associated with significantly lower odds of initiating BT. Greater self-stigma (OR = 1.60, CI = 1.06, 2.42), receiving MAT (OR = 5.52, CI = 2.34, 12.98), and having received the CC study intervention (OR = 12.95, CI = 5.91, 28.37) were associated with higher odds of initiating BT. In the multivariate model examining patient factors associated with initiating MAT, older age (OR = 1.07, CI = 1.03, 1.11), female gender (OR = 3.05, CI = 1.25, 7.46), having a diagnosis of heroin abuse or dependence (with or without alcohol abuse or dependence compared with have a diagnosis of alcohol dependence only (OR = 3.03, CI = 1.17, 7.86), and having received at least one session of BT (OR = 6.42, CI = 2.59, 15.94), were associated with higher odds of initiating MAT. CONCLUSIONS Individuals who initiate BT for OAUDs in a FQHC are less likely to be homeless and more likely to have greater self-stigma. Those who receive MAT are more likely to be of older age, female, and to have a diagnosis of heroin abuse or dependence, with or without concomitant alcohol abuse or dependence, rather than alcohol abuse or dependence alone. Receiving collaborative care (e.g., a warm handoff, and follow-up by a care coordinator) may be critical to initiating BT. Receiving at least one session of BT is associated with higher odds of receiving MAT, and receiving MAT is associated with higher odds of receiving BT. The Andersen model of health care access provides some insight into who initiates BT and MAT for OAUD treatment in FQHC-based primary care; further research is needed to explore system-level factors that may also influence treatment initiation.
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Affiliation(s)
- Allison J Ober
- RAND Corporation, 1776 Main Street Santa Monica, CA 90407, USA.
| | | | | | | | - Karen Osilla
- RAND Corporation, 1776 Main Street Santa Monica, CA 90407, USA.
| | - Sarah B Hunter
- RAND Corporation, 1776 Main Street Santa Monica, CA 90407, USA.
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Hunter SB, Ober AJ, McCullough CM, Storholm ED, Iyiewuare PO, Pham C, Watkins KE. Sustaining alcohol and opioid use disorder treatment in primary care: a mixed methods study. Implement Sci 2018; 13:83. [PMID: 29914524 PMCID: PMC6006923 DOI: 10.1186/s13012-018-0777-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 06/07/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Efforts to integrate substance use disorder treatment into primary care settings are growing. Little is known about how well primary care settings can sustain treatment delivery to address substance use following the end of implementation support. METHODS Data from two clinics operated by one multi-site federally qualified health center (FQHC) in the US, including administrative data, staff surveys, interviews, and focus groups, were used to gather information about changes in organizational capacity related to alcohol and opioid use disorder (AOUD) treatment delivery during and after a multi-year implementation intervention was executed. Treatment practices from the intervention period were compared to practices after the intervention period to examine whether the practices were sustained. Data from staff surveys and interviews were used to examine the factors related to sustainment. RESULTS The two clinics sustained multiple components of AOUD care 1 year following the end of implementation support, including care coordination, psychotherapy, and medication-assisted treatment. Some of the practices were modified over time, for example, screening became less frequent by design, while use of care coordination and psychotherapy for AOUDs expanded. Participants identified staff training and funding for medications as key challenges to sustaining treatment. CONCLUSIONS Following a multi-year implementation intervention, a large FQHC continued to deliver AOUD treatment. Access to external funding and staff support appeared to be critical elements for sustaining care over time. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT01810159.
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Affiliation(s)
- Sarah B Hunter
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407-2138, USA.
| | - Allison J Ober
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407-2138, USA
| | | | - Erik D Storholm
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407-2138, USA
| | | | - Chau Pham
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407-2138, USA
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Osilla KC, Watkins KE, D'Amico EJ, McCullough CM, Ober AJ. Effects of motivational interviewing fidelity on substance use treatment engagement in primary care. J Subst Abuse Treat 2018; 87:64-69. [PMID: 29471928 DOI: 10.1016/j.jsat.2018.01.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 01/15/2018] [Accepted: 01/17/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Primary care (PC) may be an opportune setting to engage patients with opioid and alcohol use disorders (OAUDs) in treatment. We examined whether motivational interviewing (MI) fidelity was associated with engagement in primary care-based OAUD treatment in an integrated behavioral health setting. METHODS We coded 42 first session therapy recordings and examined whether therapist MI global ratings and behavior counts were associated with patient engagement, defined as the patient receiving one shot of extended-release injectable naltrexone or any combination of at least two additional behavioral therapy, sublingual buprenorphine/naloxone prescriptions, or OAUD-related medical visits within 30days of their initial behavioral therapy visit. RESULTS Autonomy/support global ratings were higher in the non-engaged group (OR=0.28, 95%CI: 0.09-0.93; p=0.037). No other MI fidelity ratings were significantly associated with engagement. CONCLUSION We did not find positive associations between MI fidelity and engagement in primary care-based OAUD treatment. More research with larger samples is needed to examine how providing autonomy/support to patients who are not ready to change may affect engagement. PRACTICE IMPLICATIONS Training providers to strategically use MI to reinforce change as opposed to the status quo is needed. This may be especially important in primary care where patients may not be specifically seeking help for their OAUDs.
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Affiliation(s)
- Karen Chan Osilla
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407-2138, USA.
| | | | | | | | - Allison J Ober
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407-2138, USA
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Watkins KE, Ober AJ, Lamp K, Lind M, Setodji C, Osilla KC, Hunter SB, McCullough CM, Becker K, Iyiewuare PO, Diamant A, Heinzerling K, Pincus HA. Collaborative Care for Opioid and Alcohol Use Disorders in Primary Care: The SUMMIT Randomized Clinical Trial. JAMA Intern Med 2017; 177:1480-1488. [PMID: 28846769 PMCID: PMC5710213 DOI: 10.1001/jamainternmed.2017.3947] [Citation(s) in RCA: 130] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 06/24/2017] [Indexed: 11/14/2022]
Abstract
Importance Primary care offers an important and underutilized setting to deliver treatment for opioid and/or alcohol use disorders (OAUD). Collaborative care (CC) is effective but has not been tested for OAUD. Objective To determine whether CC for OAUD improves delivery of evidence-based treatments for OAUD and increases self-reported abstinence compared with usual primary care. Design, Setting, and Participants A randomized clinical trial of 377 primary care patients with OAUD was conducted in 2 clinics in a federally qualified health center. Participants were recruited from June 3, 2014, to January 15, 2016, and followed for 6 months. Interventions Of the 377 participants, 187 were randomized to CC and 190 were randomized to usual care; 77 (20.4%) of the participants were female, of whom 39 (20.9%) were randomized to CC and 38 (20.0%) were randomized to UC. The mean (SD) age of all respondents at baseline was 42 (12.0) years, 41(11.7) years for the CC group, and 43 (12.2) yearsfor the UC group. Collaborative care was a system-level intervention, designed to increase the delivery of either a 6-session brief psychotherapy treatment and/or medication-assisted treatment with either sublingual buprenorphine/naloxone for opioid use disorders or long-acting injectable naltrexone for alcohol use disorders. Usual care participants were told that the clinic provided OAUD treatment and given a number for appointment scheduling and list of community referrals. Main Outcomes and Measures The primary outcomes were use of any evidence-based treatment for OAUD and self-reported abstinence from opioids or alcohol at 6 months. The secondary outcomes included the Healthcare Effectiveness Data and Information Set (HEDIS) initiation and engagement measures, abstinence from other substances, heavy drinking, health-related quality of life, and consequences from OAUD. Results At 6 months, the proportion of participants who received any OAUD treatment was higher in the CC group compared with usual care (73 [39.0%] vs 32 [16.8%]; logistic model adjusted OR, 3.97; 95% CI, 2.32-6.79; P < .001). A higher proportion of CC participants reported abstinence from opioids or alcohol at 6 months (32.8% vs 22.3%); after linear probability model adjustment for covariates (β = 0.12; 95% CI, 0.01-0.23; P = .03). In secondary analyses, the proportion meeting the HEDIS initiation and engagement measures was also higher among CC participants (initiation, 31.6% vs 13.7%; adjusted OR, 3.54; 95% CI, 2.02-6.20; P < .001; engagement, 15.5% vs 4.2%; adjusted OR, 5.89; 95% CI, 2.43-14.32; P < .001) as was abstinence from opioids, cocaine, methamphetamines, marijuana, and any alcohol (26.3% vs 15.6%; effect estimate, β = 0.13; 95% CI, 0.03-0.23; P = .01). Conclusions and Relevance Among adults with OAUD in primary care, the SUMMIT collaborative care intervention resulted in significantly more access to treatment and abstinence from alcohol and drugs at 6 months, than usual care. Trial Registration clinicaltrials.gov Identifier: NCT01810159.
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Affiliation(s)
| | | | - Karen Lamp
- Venice Family Clinic, Los Angeles, California
| | - Mimi Lind
- Venice Family Clinic, Los Angeles, California
| | | | | | | | | | | | | | | | | | - Harold Alan Pincus
- RAND Corporation, Santa Monica, California
- Columbia University and New York-Presbyterian Hospital, New York
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McCullough CM, Wang JJ, Parsons AS, Shih SC. Quality measure performance in small practices before and after electronic health record adoption. EGEMS (Wash DC) 2015; 3:1131. [PMID: 25848635 PMCID: PMC4371508 DOI: 10.13063/2327-9214.1131] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Introduction: To date, little research has been published on the impact that the transition from paper-based record keeping to the use of electronic health records (EHR) has on performance on clinical quality measures. This study examines whether small, independent medical practices improved in their performance on nine clinical quality measures soon after adopting EHRs. Methods: Data abstracted by manual review of paper and electronic charts for 6,007 patients across 35 small, primary care practices were used to calculate rates of nine clinical quality measures two years before and up to two years after EHR adoption. Results: For seven measures, population-level performance rates did not change before EHR adoption. Rates of antithrombotic therapy and smoking status recorded increased soon after EHR adoption; increases in blood pressure control occurred later. Rates of hemoglobin A1c testing, BMI recorded, and cholesterol testing decreased before rebounding; smoking cessation intervention, hemoglobin A1c control and cholesterol control did not significantly change. Discussion: The effect of EHR adoption on performance on clinical quality measures is mixed. To improve performance, practices may need to develop new workflows and adapt to different documentation methods after EHR adoption. Conclusions: In the short term, EHRs may facilitate documentation of information needed for improving the delivery of clinical preventive services. Policies and incentive programs intended to drive improvement should include in their timelines consideration of the complexity of clinical tasks and documentation needed to capture performance on measures when developing timelines, and should also include assistance with workflow redesign to fully integrate EHRs into medical practice.
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Affiliation(s)
| | - Jason J Wang
- New York City Department of Health and Mental Hygiene
| | | | - Sarah C Shih
- New York City Department of Health and Mental Hygiene
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Wang JJ, Cha J, Sebek KM, McCullough CM, Parsons AS, Singer J, Shih SC. Factors related to clinical quality improvement for small practices using an EHR. Health Serv Res 2014; 49:1729-46. [PMID: 25287906 PMCID: PMC4254122 DOI: 10.1111/1475-6773.12243] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To analyze the impact of three primary care practice transformation program models on performance: Meaningful Use (MU), Patient-Centered Medical Home (PCMH), and a pay-for-performance program (eHearts). DATA SOURCES/STUDY SETTING Data for seven quality measures (QM) were retrospectively collected from 192 small primary care practices between October 2009 and October 2012; practice demographics and program participation status were extracted from in-house data. STUDY DESIGN Bivariate analyses were conducted to measure the impact of individual programs, and a Generalized Estimating Equation model was built to test the impact of each program alongside the others. DATA COLLECTION/EXTRACTION METHODS Monthly data were extracted via a structured query data network and were compared to program participation status, adjusting for variables including practice size and patient volume. Seven QMs were analyzed related to smoking prevention, blood pressure control, BMI, diabetes, and antithrombotic therapy. PRINCIPAL FINDINGS In bivariate analysis, MU practices tended to perform better on process measures, PCMH practices on more complex process measures, and eHearts practices on measures for which they were incentivized; in multivariate analysis, PCMH recognition was associated with better performance on more QMs than any other program. CONCLUSIONS Results suggest each of the programs can positively impact performance. In our data, PCMH appears to have the most positive impact.
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Affiliation(s)
- Jason J Wang
- Primary Care Information Project (PCIP), NYC DOHMHLong Island City (Queens), NY 11101
| | - Jisung Cha
- Primary Care Information Project (PCIP), NYC DOHMHLong Island City (Queens), NY
| | - Kimberly M Sebek
- Primary Care Information Project (PCIP), NYC DOHMHLong Island City (Queens), NY
| | | | - Amanda S Parsons
- Department of Population and Community Health, Montefiore Medical CenterBronx, NY
| | - Jesse Singer
- Primary Care Information Project (PCIP), NYC DOHMHLong Island City (Queens), NY
| | - Sarah C Shih
- Primary Care Information Project (PCIP), NYC DOHMHLong Island City (Queens), NY
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Wang JJ, Winther CH, Cha J, McCullough CM, Parsons AS, Singer J, Shih SC. Patient-centered medical home and quality measurement in small practices. Am J Manag Care 2014; 20:481-489. [PMID: 25180435] [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: 06/03/2023]
Abstract
OBJECTIVES To assess performance on quality measures among small primary care practices that recently adopted an electronic health record (EHR), and how performance differs between practices that have achieved patient-centered medical home (PCMH) recognition and those that have not. STUDY DESIGN Retrospective cohort study. METHODS Comparison of practice characteristics and performance on quality measures across 150 independent practices from 2009 to 2011 by recognition status for Physician Practice Connections-PCMH. RESULTS PCMH-recognized practices performed significantly better than nonrecognized practices on 5 out of 7 clinical quality measures at baseline, and the differences were maintained over the 2-year study period. Both groups improved on all clinical quality measures. Though the magnitude of differences was small, PCMHrecognized practices had a higher number of patients diagnosed with hypertension and proportionally more black patients. A significant difference in PCMH-recognized practices is that they received, on average, 4 additional quality improvement visits compared with nonrecognized practices. CONCLUSIONS Among small practices that have adopted EHRs, practices with PCMH recognition consistently outperformed practices without recognition on most clinical quality measures. With adequate assistance, small, resource-strapped practices can continue to have higher performance on clinical quality measures.
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Affiliation(s)
- Jason J Wang
- New York City Department of Health and Mental Hygiene, Primary Care Information Project, 42-09 28th St, 12th Fl, Queens, NY 11101. E-mail: jwang5@health. nyc.gov
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Wang JJ, Sebek KM, McCullough CM, Amirfar SJ, Parsons AS, Singer J, Shih SC. Sustained improvement in clinical preventive service delivery among independent primary care practices after implementing electronic health record systems. Prev Chronic Dis 2013; 10:E130. [PMID: 23906330 PMCID: PMC3733479 DOI: 10.5888/pcd10.120341] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Studies showing sustained improvements in the delivery of clinical preventive services are limited. Fewer studies demonstrate sustained improvements among independent practices that are not affiliated with hospitals or integrated health systems. This study examines the continued improvement in clinical quality measures for a group of independent primary care practices using electronic health records (EHRs) and receiving technical support from a local public health agency. METHODS We analyzed clinical quality measure performance data from a cohort of primary care practices that implemented an EHR at least 3 months before October 2009, the study baseline. We assessed trends for 4 key quality measures: antithrombotic therapy, blood pressure control, smoking cessation intervention, and hemoglobin A1c (HbA1c) testing based on monthly summary data transmitted by the practices. RESULTS Of the 151 practices, 140 were small practices and 11 were community health centers; average time using an EHR was 13.7 months at baseline. From October 2009 through October 2011, average rates increased for antithrombotic therapy (from 58.4% to 74.8%), blood pressure control (from 55.3% to 64.1%), HbA1c testing (from 46.4% to 57.7%), and smoking cessation intervention (from 29.3% to 46.2%). All improvements were significant. CONCLUSION During 2 years, practices showed significant improvement in the delivery of several key clinical preventive services after implementing EHRs and receiving support services from a public health agency.
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Affiliation(s)
- Jason J Wang
- New York City Department of Health and Mental Hygiene, Primary Care Information Project, 42-09 28th St, 12th Fl, Queens, NY 11101, USA.
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Shih SC, McCullough CM, Wang JJ, Singer J, Parsons AS. Health information systems in small practices. Improving the delivery of clinical preventive services. Am J Prev Med 2011; 41:603-9. [PMID: 22099237 DOI: 10.1016/j.amepre.2011.07.024] [Citation(s) in RCA: 21] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Revised: 05/25/2011] [Accepted: 07/08/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite strong evidence that clinical preventive services (CPS) reduce morbidity and mortality, CPS performance has not improved in adult primary care. In addition to implementing electronic health records (EHRs), key factors for improving CPS include providing actionable information at the point of care, technical support staff, and quality-improvement assistance. These resources are not typically available in small practices. PURPOSE Estimate the impact on CPS delivery after a software upgrade to embed a clinical decision support system and practice-level quality-improvement support services. METHODS Practices were recruited from the Primary Care Information Project, a citywide initiative assisting practices adopt health information technology. Data were collected in 2009 and 2010, and analyses were conducted in 2010 and 2011. Across two time periods, receipt of CPS was calculated for 56 practices. Period 1 measured CPS delivery 2-37 months following implementation of an EHR. Period 2 measured CPS delivery within the first 6 months after an EHR software upgrade. RESULTS Substantial increases in the delivery of selected CPS were observed after the EHR software upgrades. Blood pressure control for patients with hypertension increased from 46.0% to 54.8%. Breast cancer screening, recorded BMI, and HbA1c testing for patients with diabetes also increased. More than half of the practices increased their patients' blood pressure control, recorded BMI, breast cancer screening, and HbA1c screening by ≥5 percentage points. CONCLUSIONS Delivery of CPS can increase in small primary care practices that implement an EHR that includes comprehensive quality-improvement support.
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Affiliation(s)
- Sarah C Shih
- Primary Care Information Project, New York City Department of Health and Mental Hygiene, 42-09 28th Street,Queens, NY 11101-4132, USA.
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Abstract
A skin allograft retransplantation model was utilized to study the mechanism of immunological enhancement in a murine system. Enhancement was accomplished by treating allografted recipients with host antidonor serum (B6AF1 anti-B10.D2 alloantiserum). Grafts from enhanced or untreated hosts were retransplanted after seven days onto a second recipient. Enhanced retransplanted grafts had significantly prolonged survival as compared with unenhanced grafts. The survival of enhanced retransplanted grafts was as prolonged as that of primary skin grafts on antiserum-treated hosts. Splenocytes harvested from recipients of enhanced retransplanted allografts showed delayed and diminished development of T cell responses to graft alloantigens. Sensitization of the second recipient abrogated prolonged survival of enhanced retransplanted grafts. Also, enhancement prevented sensitization of allografted recipients. One interpretation of these studies suggests that a sensitization block is a sufficient mechanism of skin allograft enhancement. The site of action of antisera is within the graft itself. Decreased T cell responses in the host are indirect effects of diminished antigenicity of enhanced grafts. Further studies of immunological enhancement should be directed to the graft, not toward the graft recipient.
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Mercier MT, Hill JC, Wohn FK, McCullough CM, Nieland ME, Winger JA, Howard CB, Renwick S, Matheis DK, Smith AR. Electromagnetic dissociation of 59Co, 89Y, and 197Au targets by relativistic heavy ions to Z=26. Phys Rev C Nucl Phys 1986; 33:1655-1667. [PMID: 9953328 DOI: 10.1103/physrevc.33.1655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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Hill JC, Winger JA, McCullough CM, Smith AR, McCaslin JB, Karol PJ. Cross sections for the production of 11C in C targets by 20Ne and 56Fe at relativistic energies. Phys Rev C Nucl Phys 1986; 33:557-559. [PMID: 9953179 DOI: 10.1103/physrevc.33.557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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