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Yarborough BJH, Stumbo SP, Coleman MJ, Ling Grant DS, Hulsey J, Shaw JL, Ahmedani BK, Bruschke C, Carson CPA, Cooper R, Firemark A, Hulst D, Massimino S, Miller-Matero LR, Swanson JR, Leonard A, Westphal J, Coleman KJ. Suicide-related care among patients who have experienced an opioid-involved overdose. Gen Hosp Psychiatry 2023; 85:8-18. [PMID: 37717389 PMCID: PMC10840798 DOI: 10.1016/j.genhosppsych.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/26/2023] [Accepted: 09/08/2023] [Indexed: 09/19/2023]
Abstract
OBJECTIVE Our objective was to describe suicide prevention care for individuals prescribed opioids or with opioid use disorder (OUD) and identify opportunities for improving this care. METHODS Adult patients (n = 65) from four health systems with an opioid-involved overdose and clinicians (n = 21) who had contact with similar patients completed 30-60-min semi-structured interviews. A community advisory board contributed to development of all procedures, and interpretation and summary of findings. RESULTS Patients were mostly female (59%), White (63%) and non-Hispanic (77%); 52 were prescribed opioids, 49% had diagnosed OUD, and 42% experienced an intentional opioid-involved overdose. Findings included: 1) when prescribed an opioid or treated for OUD, suicide risks were typically not discussed; 2) 35% of those with an intentional opioid-involved overdose and over 80% with an unintentional overdose reported no discussion of suicidal ideation when treated for the overdose; and 3) suicide-related follow-up care was uncommon among those with unintentional overdoses despite suicidal ideation being reported by >20%. Clinicians reported that when prescribing opioids or treating OUD, post-overdose suicide-related screening or counseling was not done routinely. CONCLUSIONS There were several opportunities to tailor suicide prevention care for patients who were treated for opioid-involved overdoses within health systems.
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Affiliation(s)
| | - Scott P Stumbo
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | | | - Deborah S Ling Grant
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | | | | | - Brian K Ahmedani
- Center for Health Policy & Health Services Research, Henry Ford Health, Detroit, MI, USA
| | - Cambria Bruschke
- Kaiser Permanente, National Mental Health and Wellness, Oakland, CA, USA
| | | | - Rachael Cooper
- Shatterproof, National Stigma Initiative, Madison, WI, USA
| | - Alison Firemark
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Douglas Hulst
- Depression and Bipolar Support Alliance, Chicago, IL, USA
| | - Stefan Massimino
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Lisa R Miller-Matero
- Center for Health Policy & Health Services Research, Henry Ford Health, Detroit, MI, USA
| | - Jon R Swanson
- Kaiser Foundation Health Plan, Ethics and Compliance, Care Delivery & Quality Compliance, Pasadena, CA, USA
| | | | - Joslyn Westphal
- Center for Health Policy & Health Services Research, Henry Ford Health, Detroit, MI, USA
| | - Karen J Coleman
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA.
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Ling Grant DS, Munoz-Plaza C, Chang JM, Amundsen BI, Hechter RC. Transgender Care Experiences, Barriers, and Recommendations for Improvement in a Large Integrated Health Care System in the United States. Transgend Health 2023; 8:437-443. [PMID: 37810943 PMCID: PMC10551753 DOI: 10.1089/trgh.2021.0181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose Transgender individuals who pursue gender affirmation medical procedures often need to navigate a complex health system and interact with multiple health care providers in primary and specialty care. We sought to better understand patient, provider, and system level barriers to transgender care in a large integrated health care system in California. Methods Three 90-min focus groups were conducted with 13 transgender individuals who received specialty care between April and August 2018 in Kaiser Permanente Southern California. Results Participants cited common adversities such as misgendering and system-wide insensitivity during health care encounters and low levels of understanding of their transgender experience among primary care providers. Provider-patient relationship improvements were recommended for pre- and postsurgical care and service-provider sensitivity training. Suggestions include better care coordination, reducing redundancy in clearance for specialty care services, and enhancing patient support for navigation of gender affirmation services. Participants requested careful consideration when implementing systemwide routine processes such as using pronouns and names when calling patients in for visits or describing procedures on service invoices. Conclusions Education and training programs for improving transgender care competency and enhancing care coordination between primary care and specialty care for transgender patients are warranted. Including transgender voices with lived-experience as active stakeholders in ongoing efforts such as community advisory boards to identify care gaps may facilitate patient-centered and culturally sensitive transgender care and increased patient satisfaction. Policy Implications There is a need for systematic training for transgender care competent providers and enhancement of care coordination between primary care and specialty care.
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Affiliation(s)
- Deborah S Ling Grant
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Corrine Munoz-Plaza
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - John M Chang
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Britta I Amundsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Rulin C Hechter
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
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Hechter RC, Pak KJ, Chang CK, Xie F, Gray PL, Ling Grant DS, Barreras JL, Zhou H. Chronic and Sustained High-Dose Opioid Use in an Integrated Health System. Am J Prev Med 2023; 64:167-174. [PMID: 36653099 DOI: 10.1016/j.amepre.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 09/09/2022] [Accepted: 09/13/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain released in 2016 had led to decreases in opioid prescribing. This study sought to examine chronic and sustained high-dose prescription opioid use in an integrated health system. METHODS A serial cross-sectional study was conducted in 2021 to estimate the annual age-adjusted prevalence and incidence of chronic and high-dose opioid use among demographically diverse noncancer adults in an integrated health system in Southern California during 2013-2020. Interrupted time-series analysis with segmented regression was conducted to estimate changes in the trends in annual rates before (2013-2015) and after (2017-2020) the 2016 guideline, treating 2016 as a wash-out period. RESULTS Prevalence and incidence of chronic use and sustained high-dose use had started to decrease after a health system intervention program before the 2016 Centers for Disease Control and Prevention guideline release and continued to decline after the guideline. Among those with sustained high-dose use, there was a substantial decrease in persons with an average daily dosage ≥90 morphine milligram equivalent and concurrent benzodiazepine use. An accelerated decrease in prevalent chronic use after the guideline was observed (slope change: -11.1 [95% CI= -20.3, -1.9] users/10,000 person-years, p=0.03). The incidence of chronic use and sustained high-dose use continued to decrease after the guideline release but at a slower pace. CONCLUSIONS Implementing evidence-based prescribing guidelines was associated with a decrease in chronic and sustained high-dose prescription opioid use.
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Affiliation(s)
- Rulin C Hechter
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California.
| | - Katherine J Pak
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Craig K Chang
- Southern California Permanente Medical Group, Kaiser Permanente, Panorama City, California
| | - Fagen Xie
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Patricia L Gray
- Clinical Pharmacy Operations, Kaiser Permanente, Riverside, California
| | - Deborah S Ling Grant
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Joanna L Barreras
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Hui Zhou
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
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Negriff S, Sidell M, Nau C, Sharp AL, Koebnick C, Contreras R, Grant DSL, Kim JK, Hechter RC. Factors Associated With Firearm Injury Among Pediatric Members of a Large Integrated Healthcare System. Acad Pediatr 2022; 23:604-609. [PMID: 36122825 DOI: 10.1016/j.acap.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 09/07/2022] [Accepted: 09/10/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND AND OBJECTIVES Few studies have tested multiple socio-ecological risk factors assocated with firearm injury among pediatric populations and distinguished self-inflicted from non-self-inflicted injury. To address this gap, the current study examined demographic, individual psychosocial, and neighborhood variables as risk factors for firearm injury among a large cohort of children and adolescents. METHODS Retrospective cohort study. Data were obtained from the electronic health records of a large integrated healthcare system. The cohort included children <18 years with at least one clinical encounter between January 1, 2010 and December 31, 2018. Poisson regression was used to examine demographic (age, gender, race and ethnicity, Medicaid status), psychosocial (depression, substance use disorder, medical comorbidities), and neighborhood education variables as potential risk factors for non-self-inflicted and self-inflicted firearm injuries. RESULTS For non-self-inflicted injury, the highest relative risk was found for children age 12-17 years old compared to 0-5 year olds (RR = 37.57); other risk factors included male gender, Black and Hispanic race and ethnicity (compared to White race), being a Medicaid recipient, lower neighborhood education, and substance use disorder diagnosis. For self-inflicted injury, only age 12-17 years old and male gender were associated with increased risk. CONCLUSIONS These results reinforce the established higher risk for firearm injury among adolescent males, highlight differences between self-inflicted and non-self-inflicted injuries, and the need to consider demographic, psychosocial, and neighborhood variables as risk factors to inform interventions aimed to reduce firearm injuries among children and adolescents.
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Affiliation(s)
- Sonya Negriff
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, CA USA (S Negriff, M Sidell, C Nau, AL Sharp, C Koebnick, R Contreras, DSL Grant, and RC Hechter); Kaiser Permanente Bernard J. Tyson School of Medicine Department of Health Systems Science, Pasadena, CA USA (S Negriff, C Nau, AL Sharp, and RC Hechter).
| | - Margo Sidell
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, CA USA (S Negriff, M Sidell, C Nau, AL Sharp, C Koebnick, R Contreras, DSL Grant, and RC Hechter)
| | - Claudia Nau
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, CA USA (S Negriff, M Sidell, C Nau, AL Sharp, C Koebnick, R Contreras, DSL Grant, and RC Hechter); Kaiser Permanente Bernard J. Tyson School of Medicine Department of Health Systems Science, Pasadena, CA USA (S Negriff, C Nau, AL Sharp, and RC Hechter)
| | - Adam L Sharp
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, CA USA (S Negriff, M Sidell, C Nau, AL Sharp, C Koebnick, R Contreras, DSL Grant, and RC Hechter); Kaiser Permanente Bernard J. Tyson School of Medicine Department of Health Systems Science, Pasadena, CA USA (S Negriff, C Nau, AL Sharp, and RC Hechter); Kaiser Permanente Bernard J. Tyson School of Medicine Department of Clinical Science, Pasadena, CA USA (AL Sharp)
| | - Corinna Koebnick
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, CA USA (S Negriff, M Sidell, C Nau, AL Sharp, C Koebnick, R Contreras, DSL Grant, and RC Hechter)
| | - Richard Contreras
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, CA USA (S Negriff, M Sidell, C Nau, AL Sharp, C Koebnick, R Contreras, DSL Grant, and RC Hechter)
| | - Deborah S Ling Grant
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, CA USA (S Negriff, M Sidell, C Nau, AL Sharp, C Koebnick, R Contreras, DSL Grant, and RC Hechter)
| | - Johnathan K Kim
- Kaiser Permanente Southern California Department of Psychiatry, Riverside, CA USA (JK Kim)
| | - Rulin C Hechter
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, CA USA (S Negriff, M Sidell, C Nau, AL Sharp, C Koebnick, R Contreras, DSL Grant, and RC Hechter); Kaiser Permanente Bernard J. Tyson School of Medicine Department of Health Systems Science, Pasadena, CA USA (S Negriff, C Nau, AL Sharp, and RC Hechter)
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Grant DSL, Scott RD, Harrison TN, Cheetham TC, Chang SC, Hsu JWY, Wei R, Boklage SH, Romo-LeTourneau V, Reynolds K. Trends in Lipid Screening Among Adults in an Integrated Health Care Delivery System, 2009-2015. J Manag Care Spec Pharm 2018; 24:1090-1101. [PMID: 30063170 PMCID: PMC10397736 DOI: 10.18553/jmcp.2018.18100] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Lipid screening determines eligibility for statins and other cardiovascular risk reduction interventions. OBJECTIVE To examine trends in lipid screening among adults aged ≥20 years in a large, multiethnic, integrated health care delivery system in southern California. METHODS Temporal trends in lipid screening were examined from 2009 to 2015 with an index date of September 30 of each year. Lipid screening was defined as the proportion of eligible members each year who (a) had ever been screened among those aged 20-39 years and (b) had been screened in the previous 6 years for those aged ≥ 40 years. Trends were analyzed by age, gender, and the presence of atherosclerotic cardiovascular disease (ASCVD) or diabetes without ASCVD status. RESULTS More than 2 million individuals were included each year: 5%-6% had ASCVD (includes those with diabetes), 7%-8% had diabetes without ASCVD, and 87% had neither condition. Among the entire population, lipid screening increased from 79.8% in 2009 to 82.6% in 2015 (P < 0.0001). Among those with ASCVD or diabetes, lipid screening was 99% across all years. Among those without ASCVD or DM, screening increased from 76.9% in 2009 to 80.0% in 2015 (P < 0.0001), with higher screening among women compared with men and lower screening among individuals younger than 55 years. CONCLUSIONS Consistently high rates of lipid screening were observed among individuals with ASCVD or diabetes. In individuals without these conditions, screening increased over time. However, there is room to further increase screening rates in adults younger than 55 years. DISCLOSURES This manuscript and research work was supported by a contractual agreement between the Southern California Permanente Medical Group and Regeneron Pharmaceuticals and Sanofi U.S. Researchers from Regeneron and Sanofi collaborated on the study design, interpretation of data, and writing of the manuscript. Ling Grant, Harrison, Chang, Hsu, Cheetham, Wei, and Reynolds are employed by Kaiser Permanente Southern California. Scott is employed by Southern California Permanente Medical Group. Boklage is employed by Regeneron, and Romo-LeTourneau is employed by Sanofi. Preliminary results from this study were presented at the American Heart Association Scientific Sessions; November 12-16, 2016; New Orleans, LA.
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Affiliation(s)
- Deborah S Ling Grant
- 1 Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena
| | - Ronald D Scott
- 2 Southern California Permanente Medical Group, Los Angeles
| | - Teresa N Harrison
- 1 Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena
| | - T Craig Cheetham
- 3 Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena, and Western University College of Pharmacy, Pomona, California
| | - Shen-Chih Chang
- 1 Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena
| | - Jin-Wen Y Hsu
- 1 Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena
| | - Rong Wei
- 1 Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena
| | | | | | - Kristi Reynolds
- 1 Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena
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Hechter RC, Qian L, Luo Y, Ling Grant DS, Baxter R, Klein NP, Valdez Nunley K, Aukes L, Hogea C, Krishnarajah G, Patterson BJ, Im TM, Tseng HF. Impact of an electronic medical record reminder on hepatitis B vaccine initiation and completion rates among insured adults with diabetes mellitus. Vaccine 2018; 37:195-201. [PMID: 29958736 DOI: 10.1016/j.vaccine.2018.06.035] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/14/2018] [Accepted: 06/16/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The Advisory Committee on Immunization Practices recommends Hepatitis B (HepB) vaccine for previously unvaccinated adults <60 years with diabetes mellitus. This observational retrospective cohort study assessed the impact of implementing electronic provider reminders on HepB vaccine initiation and 3-dose series completion rates among insured adults with diabetes aged 19-59 years old. RESEARCH DESIGN AND METHODS Difference-in-difference (DID) analyses compared changes in vaccine initiation and completion rates (ratio of the rate ratio [RRR] and 95% confidence interval [CI]) during 12 months pre- and post-implementation between intervention and control sites. We examined trends in vaccine initiation and completion rates by plotting monthly rates during the study period. We also calculated the overall HepB vaccine coverage rates with 95% CI among all adults with diabetes aged 19-59 years old at the start and end date of the study period. RESULTS Baseline HepB vaccine initiation and completion rates were similar at both the intervention and control sites. Gender, age, and race/ethnicity distributions within both sites were similar during the 12 months pre- and post-implementation. DID analyses demonstrated statistically significant differences in the changes of the annual vaccine initiation rates (RRR: 70.7, 95% CI: 62.8-79.6) and the third dose completion rates (RRR = 18.7, 95% CI: 14.2-24.8) between the two sites. The coverage increased significantly at the intervention site while it remained low at the control site. CONCLUSIONS Use of provider reminders is highly effective in increasing both HepB vaccine initiation and series completion rates among adults with diabetes.
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Affiliation(s)
- Rulin C Hechter
- Kaiser Permanente Southern California, 100 S. Los Robles, 2nd Floor, Pasadena, CA 91101, USA.
| | - Lei Qian
- Kaiser Permanente Southern California, 100 S. Los Robles, 2nd Floor, Pasadena, CA 91101, USA.
| | - Yi Luo
- Kaiser Permanente Southern California, 100 S. Los Robles, 2nd Floor, Pasadena, CA 91101, USA.
| | - Deborah S Ling Grant
- Kaiser Permanente Southern California, 100 S. Los Robles, 2nd Floor, Pasadena, CA 91101, USA.
| | - Roger Baxter
- Kaiser Permanente Northern California, 1 Kaiser Plaza, 16th Floor, Oakland, CA 94612, USA
| | - Nicola P Klein
- Kaiser Permanente Northern California, 1 Kaiser Plaza, 16th Floor, Oakland, CA 94612, USA.
| | - Karen Valdez Nunley
- Kaiser Permanente Northern California, 1 Kaiser Plaza, 16th Floor, Oakland, CA 94612, USA.
| | - Laurie Aukes
- Kaiser Permanente Northern California, 1 Kaiser Plaza, 16th Floor, Oakland, CA 94612, USA.
| | | | | | | | - Theresa M Im
- Kaiser Permanente Southern California, 100 S. Los Robles, 2nd Floor, Pasadena, CA 91101, USA.
| | - Hung Fu Tseng
- Kaiser Permanente Southern California, 100 S. Los Robles, 2nd Floor, Pasadena, CA 91101, USA.
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Harrison TN, Sacks DA, Parry C, Macias M, Ling Grant DS, Lawrence JM. Acceptability of Virtual Prenatal Visits for Women with Gestational Diabetes. Womens Health Issues 2017; 27:351-355. [PMID: 28153743 DOI: 10.1016/j.whi.2016.12.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 12/03/2016] [Accepted: 12/16/2016] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Gestational diabetes mellitus (GDM) is one of the most common complications of pregnancy. Current approaches to GDM management and education are labor intensive and costly. Telemedicine offers a potential solution to reduce the time and cost burden of prenatal care for women with GDM. METHODS We assessed the acceptability of a telemedicine intervention to transmit patients' weight, blood pressure, and blood glucose measurements from wireless devices to health care providers, and to alternate "virtual office visits" with office-based prenatal visits. We administered surveys to 70 Kaiser Permanente Southern California members with GDM to assess preferences for modalities of GDM care delivery and to understand perceptions of telemedicine. We subsequently conducted 10 qualitative interviews among women with GDM to elicit perceptions about confidence and comfort with receiving care telephonically and safety concerns. Data were coded and categorized using analytic induction. RESULTS Training on these devices would increase participants' confidence in using the equipment. Continuity of care was perceived as an important factor in facilitating confidence with near universal preference for having virtual visits with the same clinician. Most participants were not concerned with the safety of their baby or themselves during the weeks without an office visit. One participant expressed an unwillingness to participate in the intervention because of a perceived association between having a high-risk pregnancy and an increased risk of pregnancy loss. CONCLUSIONS As telemedicine becomes increasingly common in health care, feedback from end users will be essential in tailoring, communicating about, and supporting the uptake and success of such programs.
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Affiliation(s)
- Teresa N Harrison
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - David A Sacks
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Carly Parry
- Patient-Centered Outcomes Research Center, Improving Healthcare Systems Program, Washington, DC
| | - Mayra Macias
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Deborah S Ling Grant
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Jean M Lawrence
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California.
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