Does engagement matter? The impact of patient and community engagement on implementation of cardiovascular health materials in primary care settings

BACKGROUND

Engaging patients and community members in healthcare implementation, research and evaluation has become more popular over the past two decades. Despite the growing interest in patient engagement, there is scant evidence of its impact and importance. Boot Camp Translation (BCT) is one evidence-based method of engaging communities in research. The purpose of this report is to describe the uptake by primary care practices of cardiovascular disease prevention materials produced through four different local community engagement efforts using BCT.

METHODS

EvidenceNOW Southwest (ENSW) was a randomized trial to increase cardiovascular disease (CVD) prevention in primary care practices. Because of its study design, Four BCTs were conducted, and the materials created were made available to participating practices in the "enhanced" study arm. As a result, ENSW offered one of the first opportunities to explore the impact of the BCT method by describing the uptake by primary care practices of health messages and materials created locally using the BCT process. Analysis compared uptake of locally translated BCT products vs. all other products among practices based on geography, type of practice, and local BCT.

RESULTS

Within the enhanced arm of the study that included BCT, 69 urban and 13 rural practices participated with 9 being federally qualified community health centers, 14 hospital owned and 59 clinician owned. Sixty-three practices had 5 or fewer clinicians. Two hundred and ten separate orders for materials were placed by 43 of the 82 practices. While practices ordered a wide variety of BCT products, they were more likely to order materials developed by their local BCT.

CONCLUSIONS

In this study, patients and community members generated common and unique messages and materials for cardiovascular disease prevention relevant to their regional and community culture. Primary care practices preferred the materials created in their region. The greater uptake of locally created materials over non-local materials supports the use of patient engagement methods such as BCT to increase the implementation and delivery of guideline-based care. Yes, patient and community engagement matters.

TRIAL REGISTRATION AND IRB

Trial registration was prospectively registered on July 31, 2015 at ClinicalTrials.gov (NCT02515578, protocol identifier 15-0403). The project was approved by the Colorado Multiple Institutional Review Board and the University of New Mexico Human Research Protections Office.

Why Family Medicine Program Directors Leave Their Position

BACKGROUND AND OBJECTIVES

Family medicine residency program directors (PD) oversee the training of every new family physician in the United States. The median tenure of family medicine PDs is 4.5 years, and factors relating to length of tenure and reasons for departure are not well known. This exploratory study examined why family medicine PDs leave their position.

METHODS

We conducted in-depth interviews with family medicine PDs who recently left their director position. Semistructured and structured questions asked about their PD experience and factors contributing to stepping away from the PD role. We analyzed answers quantitatively and qualitatively.

RESULTS

When comparing cases with longer (>6 years) and shorter tenures (≤6 years), 25 PDs described differing pathways but few major differences in why they left the position. The two groups were distinguished more by their similarities than their differences. The majority left voluntarily due to a combination of factors, not a single factor. Most PDs left the position because of their desire and opportunities to move up, move over, or move on, and not because of dissatisfaction with the job. Succession plans helped with PD decisions to leave the position, knowing that the program was in good hands.

CONCLUSIONS

Family medicine PDs left the position due to multiple factors primarily related to career pathway choices and not solely due to demands of the job. Additional research with PDs of very short tenures and long tenures may yield further details about sustaining PDs in residency education to successfully train the next generation of family physicians.

Primary Care Practices' Ability to Report Electronic Clinical Quality Measures in the EvidenceNOW Southwest Initiative to Improve Heart Health

IMPORTANCE

The capability and capacity of primary care practices to report electronic clinical quality measures (eCQMs) are questionable.

OBJECTIVE

To determine how quickly primary care practices can report eCQMs and the practice characteristics associated with faster reporting.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study examined an initiative (EvidenceNOW Southwest) to enhance primary care practices' ability to adopt evidence-based cardiovascular care approaches: aspirin prescribing, blood pressure control, cholesterol management, and smoking cessation (ABCS). A total of 211 primary care practices in Colorado and New Mexico participating in EvidenceNOW Southwest between February 2015 and December 2017 were included.

INTERVENTIONS

Practices were instructed on eCQM specifications that could be produced by an electronic health record, a registry, or a third-party platform. Practices received 9 months of support from a practice facilitator, a clinical health information technology advisor, and the research team. Practices were instructed to report their baseline ABCS eCQMs as soon as possible.

MAIN OUTCOMES AND MEASURES

The main outcome was time to report the ABCS eCQMs. Cox proportional hazards models were used to examine practice characteristics associated with time to reporting.

RESULTS

Practices were predominantly clinician owned (48%) and in urban or suburban areas (71%). Practices required a median (interquartile range) of 8.2 (4.6-11.9) months to report any ABCS eCQM. Time to report differed by eCQM: practices reported blood pressure management the fastest (median [interquartile range], 7.8 [3.5-10.4] months) and cholesterol management the slowest (median [interquartile range], 10.5 [6.6 to >12] months) (log-rank P < .001). In multivariable models, the blood pressure eCQM was reported more quickly by practices that participated in accountable care organizations (hazard ratio [HR], 1.88; 95% CI, 1.40-2.53; P < .001) or participated in a quality demonstration program (HR, 1.58; 95% CI, 1.14-2.18; P = .006). The cholesterol eCQM was reported more quickly by practices that used clinical guidelines for cardiovascular disease management (HR, 1.35; 95% CI, 1.18-1.53; P < .001). Compared with Federally Qualified Health Centers, hospital-owned practices had greater ability to report blood pressure eCQMs (HR, 2.66; 95% CI, 95% CI, 1.73-4.09; P < .001), and clinician-owned practices had less ability to report cholesterol eCQMs (HR, 0.52; 95% CI, 0.35-0.76; P < .001).

CONCLUSIONS AND RELEVANCE

In this study, time to report eCQMs varied by measure and practice type, with very few practices reporting quickly. Practices took longer to report a new cholesterol measure than other measures. Programs that require eCQM reporting should consider the time and effort practices must exert to produce reports. Practices may benefit from additional support to succeed in new programs that require eCQM reporting.

Colorado Residency PCMH Project: Results From a 6-Year Transformation Effort

BACKGROUND AND OBJECTIVES

Our objective was to describe the results of a 6-year patient-centered medical home (PCMH) transformation program in 11 Colorado primary care residency practices.

METHODS

We used a parallel qualitative and quantitative evaluation including cross-sectional surveys of practice staff and clinicians, group and individual interviews, meeting notes, and longitudinal practice facilitator field notes. Survey analyses assessed change over time, adjusting for practice-level random effects. Qualitative data analysis used iterative template coding and matrix analyses to synthesize data over time and across cases.

RESULTS

There were significant improvements in clinicians' self-reported routine delivery of patient-centered care, team-based care, self-management support, and use of information systems (P&lt;.0001). Clinicians and staff reported significant gains in practice change culture (P=.001). Self-reported practice-level assessments pointed to additional significant improvements in quality improvement (QI) processes, continuity of care, self-management support/care coordination, and the use of data and population management (P≤.0215). Practices and their practice facilitators reported important changes in how practices operated, significantly improving their QI processes, shared leadership, change culture, and achieving Level III PCMH NCQA Recognition. Important barriers to further progress remain, including inadequate payment models, inflexible staff roles, and difficult access to clinical data.

CONCLUSIONS

The success of these 11 primary care residency practices in making significant improvements in their delivery of patient-centered care, team-based care, self-management support, and use of information systems took time, effort, and external support. Further practice redesign for advanced primary care models will take sustained sources of well-aligned support, flexibility, shared leadership, and partnerships across residency programs for collaborative learning to assist in their transformation efforts.

Supporting primary care practices in building capacity to use health information data

Introduction:

Our objective was to describe essential support resources and strategies in order to advance the pace and scope of the use of health information technology (HIT) data.

Background and Context:

Primary data were collected between January 2011 and October 2012. The primary study population comprised 51 primary care practices enrolled in the Colorado Beacon Consortium in western Colorado.

Methods:

We used qualitative methods embedded in a mixed-method evaluation: monthly narrative reports from practices; interviews with providers and staff; and focused, group discussions with quality improvement (QI) advisors and staff from the Health Information Technology Regional Extension Center.

Findings:

Practices valued effective support strategies to assist with using HIT, including the following: translating rules and regulations into individual practice settings; facilitating peer-to-peer connections; providing processes and tools for practice improvement; maintaining accountability and momentum; and providing local electronic health record (EHR) technical expertise. Benefits of support included improved quality measures, operational improvements, increased provider and staff engagement, and deeper understanding of EHR data.

Discussion:

The findings affirm the utility of practice facilitation for HIT-focused aims with personalized attention and cross-fertilization among practices for improvements. Facilitation to sustain ongoing improvements and prepare for future HIT-intensive improvement activities was highly valued. In addition to the general practice facilitator, an EHR technical expert was critical to improving practice capacity to use electronic clinical data. Collaborative learning expands the pool of mentors and teachers, who can further translate their own lessons into practical advice for their peers, yielding the emergence of a stronger sense of community among the practices.

Conclusions:

Using HIT more effectively in primary care will require sustained, focused efforts by practices as regulations, incentives and HIT evolve. Ongoing support for community-based practice facilitators; collaborative learning; and local, personalized EHR advisors will help practices care for patients while more effectively deploying HIT to improve care.

Engaging communities in education and research: PBRNs, AHEC, and CTSA

BACKGROUND

Community engagement has become a prominent element in medical research and is an important component of the Clinical and Translational Science Awards program. Area Health Education Centers engage communities in education and workforce development.

METHODS

Engaging Communities in Education and Research (ECER) is a successful collaboration among the Colorado Area Health Education Center (AHEC), the Colorado Clinical Translational Science Institute, and Shared Network of Collaborative Ambulatory Practices and Partners--Colorado's practice-based research collaborative. The ECER Conference is an annual conference of community members, health care providers, clinical preceptors, AHEC board members, university faculty, primary care investigators, program administrators, and community organization leaders.

RESULTS

Over 1,000 people have participated in the ECER Conference representing all regions of Colorado. Several projects from the "new ideas" breakout session have been developed and completed. Six-month follow-up provided evidence of numerous new collaborations, campus-community partnerships, and developing research projects. Several new collaborations highlight the long-term nature of building on relationships started at the ECER Conference.

DISCUSSION AND CONCLUSION

ECER has been a successful collaboration to develop and support campus-community collaborations in Colorado. Although seemingly just a simple 3-day conference, we have found that this event has lead to many important partnerships.

A standardized reporting system for assessment of diverse public health programs

State public health agencies face challenges when monitoring the efforts and effects of public health programs that use disparate strategies and address various diseases, locations, and populations. The external evaluators of a complex portfolio of grant funding sought a standardized reporting framework and tool that could be used for all grants in the portfolio, without having to redesign it for each disease or intervention approach. Evaluators iteratively reviewed grant-funded projects to identify common project delivery strategies, then developed and implemented a common reporting framework and spreadsheet-based data capture tool. Evaluators provided training, technical assistance, and ongoing data reviews. During 2 fiscal years, 103 public health programs throughout Colorado submitted quarterly reports; agencies funded to implement these programs ranged from small community-based organizations to university- and hospital-affiliated groups in urban and rural settings. Aggregated reports supported estimates of program reach by strategy and by disease area, and the system supported production of summary descriptions of program implementation. Standardized language and expectations for reporting helped to align grant applications and work plans with reporting tools. A common language and standardized reporting tool can be used for diverse projects in a comprehensive evaluation framework. Decentralized data collection using common spreadsheet software enabled the aggregation of common data elements across multiple programs and projects. Further refinements could enable wider dissemination of common reporting criteria and expectations.

Designing a cardiovascular disease prevention web site for Latinos: qualitative community feedback

Latinos are the largest minority group in the United States, yet there is currently a lack of Web sites that focus on Latino health. This article shares qualitative research results obtained from Latinos, with a focus on creating a culturally sensitive, bilingual, interactive, computer-based cardiovascular disease risk assessment and behavioral goal-setting program. This project is a substudy of the Latinos Using Cardio Health Actions to Reduce Risk (LUCHAR) grant, a 5-year trial, funded by the National Heart, Lung, and Blood Institute, whose primary aim is the primary prevention of cardiovascular disease in Latinos. Ten focus groups, five in English and five in Spanish, were conducted at six community sites with trained, bilingual facilitators in Denver, Colorado. Results from the focus groups are used to make recommendations on how to develop a culturally sensitive cardiovascular health care Web site for Latinos.

Stopping the error cascade: a report on ameliorators from the ASIPS collaborative

OBJECTIVE

To present a novel examination of how error cascades are stopped (ameliorated) before they affect patients.

DESIGN

Qualitative analysis of reported errors in primary care.

SETTING

Over a three-year period, clinicians and staff in two practice-based research networks voluntarily reported medical errors to a primary care patient safety reporting system, Applied Strategies for Improving Patient Safety (ASIPS). The authors found a number of reports where the error was corrected before it had an adverse impact on the patient.

RESULTS

Of 754 codeable reported events, 60 were classified as ameliorated events. In these events, a participant stopped the progression of the event before it reached or affected the patient. Ameliorators included doctors, nurses, pharmacists, diagnostic laboratories and office staff. Additionally, patients or family members may be ameliorators by recognising the error and taking action. Ameliorating an event after an initial error requires an opportunity to catch the error by systems, chance or attentiveness. Correcting the error before it affects the patient requires action either directed by protocols and systems or by vigilance, power to change course and perseverance on the part of the ameliorator.

CONCLUSION

Despite numerous individual and systematic methods to prevent errors, a system to prevent all potential errors is not feasible. However, a more pervasive culture of safety that builds on simple acts in addition to more costly and complex electronic systems may improve patient outcomes. Medical staff and patients who are encouraged to be vigilant, ask questions and seek solutions may correct otherwise inevitable wrongs.

Rural community members' perceptions of harm from medical mistakes: a High Plains Research Network (HPRN) Study

OBJECTIVE

The aim of this study was to learn about community members' definitions and types of harm from medical mistakes.

METHODS

Mixed methods study using community-based participatory research (CBPR). The High Plains Research Network (HPRN) with its Community Advisory Council (CAC) designed and distributed an anonymous survey through local community newspapers. Survey included open-ended questions on patients' experiences with medical mistakes and resultant harm. Qualitative analysis was performed by CAC and research team members on mistake descriptions and types of reported harm. Patient Safety Taxonomy coding was performed on a subset of surveys that contained actual medical errors.

RESULTS

A total of 286 surveys were returned, with 172 respondents (60%) reporting a total of 180 perceived medical mistakes. Quantitative analysis showed that 41% of perceived mistakes (n = 73) involved only unanticipated outcomes. Reported types of harm included emotional, financial, and physical harm. Reports suggest that perceived clinician indifference to unanticipated outcomes may lead to patients' loss of trust and belief that the unexpected outcome was a result of an error.

DISCUSSION

CBPR methodology is an important strategy to design and implement a community-based survey. Community members reported experiencing medical mistakes, most with harmful outcomes. The response they received by the medical community may have influenced their perception of mistake and harm.

Family physicians and youth tobacco-free education: outcomes of the Colorado Tar Wars program

BACKGROUND

Tar Wars is a national school-based tobacco-free education program operated by the American Academy of Family Physicians. The Tar Wars lesson uses an interactive 45-min session taught by volunteer family physicians in 4th- and 5th-grade classrooms and focuses on the short-term image-based consequences of tobacco use. In this study, we evaluated the effectiveness of the Tar Wars program in Colorado with both quantitative and qualitative measures.

METHODS

Students participating in the quantitative evaluation were tested before and after a Tar Wars teaching session using a 14-question test covering the short-term and image-based consequences of tobacco use, cost of smoking, tobacco advertising, and social norms of tobacco use. Qualitative evaluation of the program included guided telephone interviews and focus groups with participating students, teachers, and presenters.

RESULTS

Quantitative evaluation showed statistically significant improvement in correct responses for the 14 questions measured with an average increase in correct responses from 8.95 to 10.23. Three areas recommended by the Centers for Disease Control (CDC) for youth tobacco prevention showed greater change in correct responses, including cost of smoking, truth of tobacco advertising, and peer norms of tobacco use. Qualitative evaluation found that the overall message of the session was well received, that previously known tobacco information was reinforced by its presentation in a novel format, and that new information learned included cost of smoking, truth of tobacco advertising, and peer norms of tobacco use.

CONCLUSIONS

The Tar Wars lesson plan is effective in increasing students' understanding about the short-term consequences of tobacco use, cost of tobacco use, truth of tobacco advertising, and peer norms. Tar Wars meets the CDC guidelines as one component of effective comprehensive youth tobacco prevention.

Pharmacy clarification of prescriptions ordered in primary care: a report from the Applied Strategies for Improving Patient Safety (ASIPS) collaborative

INTRODUCTION

Prescription errors threaten patient safety and pharmacists often contact providers for prescription clarification. This study describes the principal reasons pharmacies call primary care practices to clarify prescriptions and subsequent implications for quality and patient safety improvement.

METHODS

A cross-sectional study of 22 primary care practices participating in a patient safety study was performed. Callbacks from pharmacies were logged for 2 weeks to determine reasons for callbacks, most frequently involved drug classes, whether issues were resolved on the same day of the call, and variability of callbacks among practice types. Analyses were performed using frequencies, t tests, and chi(2) tests.

RESULTS

Practices recorded 567 clarification calls, most frequently for prior authorization issues (n = 209; 37%), formulary issues (n = 148; 26%), and unclear/missing prescription dosages (n = 117; 21%). Drug classes most frequently requiring clarifications were gastrointestinal (n = 122; 21.7%), cardiovascular (n = 278; 13.9%), and analgesic/anesthetic (n = 74; 13.2%) agents. Issues were resolved on the same day 62% of the time. Residency practices averaged more issues per call (P < .001).

CONCLUSIONS

Clarification calls made to primary care practices involve administrative and clinical issues, potentially impacting patient safety. Pharmacy callback data can identify potential prescription concerns, thereby helping practices develop interventions aimed at reducing errors and improving patient safety.