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Nevedal AL, Widerquist MAO, Reardon CM, Arasim M, Jackson GL, White B, Burns M, Fix GM, DeLaughter K, Cutrona SL, Gifford AL, Jasuja GK, Hogan TP, King HA, Henderson B, Damschroder LJ. Understanding pathways from implementation to sustainment: a longitudinal, mixed methods analysis of promising practices implemented in the Veterans Health Administration. Implement Sci 2024; 19:34. [PMID: 38715094 PMCID: PMC11075255 DOI: 10.1186/s13012-024-01361-z] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 04/12/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND The Veterans Health Administration (VHA) is the United States largest learning health system. The Diffusion of Excellence (DoE) program is a large-scale model of diffusion that identifies and diffuses evidence-informed practices across VHA. During the period of 2016-2021, 57 evidence-informed practices were implemented across 82 VHA facilities. This setting provides a unique opportunity to understand sustainment determinants and pathways. Our objective was to characterize the longitudinal pathways of practices as they transition from initial implementation to long-term sustainment at each facility. METHODS A longitudinal, mixed-methods evaluation of 82 VHA facilities. Eighty-two facility representatives, chosen by leadership as points-of-contact for 57 DoE practices, were eligible for post-implementation interviews and annual sustainment surveys. Primary outcomes (implementation, sustainment), and secondary outcomes (institutionalization, effectiveness, anticipated sustainment) at four time-points were collected. We performed descriptive statistics and directed content analysis using Hailemariam et al.'s factors influencing sustainment. RESULTS After approximately five years post-implementation (e.g., 2021 sustainment outcomes), of the 82 facilities, about one-third fully sustained their practice compared to one-third that did not fully sustain their practice because it was in a "liminal" stage (neither sustained nor discontinued) or permanently discontinued. The remaining one-third of facilities had missing 2021 sustainment outcomes. A higher percentage of facilities (70%) had inconsistent primary outcomes (changing over time) compared to facilities (30%) with consistent primary outcomes (same over time). Thirty-four percent of facilities with sustained practices reported resilience since they overcame implementation and sustainment barriers. Facilities with sustained practices reported more positive secondary outcomes compared to those that did not sustain their practice. Key factors facilitating practice sustainment included: demonstrating practice effectiveness/benefit, sufficient organizational leadership, sufficient workforce, and adaptation/alignment with local context. Key factors hindering practice sustainment included: insufficient workforce, not able to maintain practice fidelity/integrity, critical incidents related to the COVID-19 pandemic, organizational leadership did not support sustainment of practice, and no ongoing support. CONCLUSIONS We identified diverse pathways from implementation to sustainment, and our data underscore that initial implementation outcomes may not determine long-term sustainment outcomes. This longitudinal evaluation contributes to understanding impacts of the DoE program, including return on investment, achieving learning health system goals, and insights into achieving high-quality healthcare in VHA.
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Affiliation(s)
- Andrea L Nevedal
- Center for Clinical Management Research (CCMR), Veterans Affairs Ann Arbor Healthcare System, 2215 Fuller Rd, Mail Stop 152, Ann Arbor, MI, 48105, USA.
| | - Marilla A Opra Widerquist
- Center for Clinical Management Research (CCMR), Veterans Affairs Ann Arbor Healthcare System, 2215 Fuller Rd, Mail Stop 152, Ann Arbor, MI, 48105, USA
| | - Caitlin M Reardon
- Center for Clinical Management Research (CCMR), Veterans Affairs Ann Arbor Healthcare System, 2215 Fuller Rd, Mail Stop 152, Ann Arbor, MI, 48105, USA
| | - Maria Arasim
- Center for Clinical Management Research (CCMR), Veterans Affairs Ann Arbor Healthcare System, 2215 Fuller Rd, Mail Stop 152, Ann Arbor, MI, 48105, USA
| | - George L Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Brandolyn White
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Madison Burns
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Gemmae M Fix
- Center for Healthcare Organization & Implementation Research (CHOIR), Bedford & Boston Veterans Affairs Medical Centers, Bedford & Boston, MA, USA
- Section of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA
| | - Kathryn DeLaughter
- Center for Healthcare Organization & Implementation Research (CHOIR), Bedford & Boston Veterans Affairs Medical Centers, Bedford & Boston, MA, USA
| | - Sarah L Cutrona
- Center for Healthcare Organization & Implementation Research (CHOIR), Bedford & Boston Veterans Affairs Medical Centers, Bedford & Boston, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Division of General Internal Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Allen L Gifford
- Center for Healthcare Organization & Implementation Research (CHOIR), Bedford & Boston Veterans Affairs Medical Centers, Bedford & Boston, MA, USA
- Section of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA
| | - Guneet K Jasuja
- Center for Healthcare Organization & Implementation Research (CHOIR), Bedford & Boston Veterans Affairs Medical Centers, Bedford & Boston, MA, USA
- Section of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA
| | - Timothy P Hogan
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Center for Healthcare Organization & Implementation Research (CHOIR), Bedford & Boston Veterans Affairs Medical Centers, Bedford & Boston, MA, USA
| | - Heather A King
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Division of General Internal Medicine, Duke University, Durham, NC, USA
| | - Blake Henderson
- Innovation Ecosystem, United States Veterans Health Administration, Washington, DC, USA
| | - Laura J Damschroder
- Center for Clinical Management Research (CCMR), Veterans Affairs Ann Arbor Healthcare System, 2215 Fuller Rd, Mail Stop 152, Ann Arbor, MI, 48105, USA
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Ramos K, King HA, Gladney MN, Woolson SL, Coffman C, Bosworth HB, Porter LS, Hastings SN. Understanding veterans' experiences with lung cancer and psychological distress: A multimethod approach. Psychol Serv 2024:2024-59433-001. [PMID: 38436646 DOI: 10.1037/ser0000839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Psychological distress while coping with cancer is a highly prevalent and yet underrecognized and burdensome adverse effect of cancer diagnosis and treatment. Left unaddressed, psychological distress can further exacerbate poor mental health, negatively influence health management behaviors, and lead to a worsening quality of life. This multimethod study primarily focused on understanding veterans' psychological distress and personal experiences living with lung cancer (an underrepresented patient population). In a sample of 60 veterans diagnosed with either nonsmall cell lung cancer (NSCLC) or small cell lung cancer (SCLC), we found that distress is common across clinical psychology measures of depression (37% [using the Patient Health Questionnaire, PHQ-9 measure]), anxiety (35% [using the Generalized Anxiety Disorder, GAD-7 measure]), and cancer-related posttraumatic stress (13% [using the Posttraumatic Stress Symptom Checklist measure]). A total of 23% of the sample endorsed distress scores on two or more mental health screeners. Using a broader cancer-specific distress measure (National Comprehensive Cancer Network), 67% of our sample scored above the clinical cutoff (i.e., ≥ 3), and in the follow-up symptom checklist of the National Comprehensive Cancer Network measure, a majority endorsed feeling sadness (75%), worry (73%), and depression (60%). Qualitative analysis with a subset of 25 veterans highlighted that psychological distress is common, variable in nature, and quite bothersome. Future research should (a) identify veterans at risk for distress while living with lung cancer and (b) test supportive mental health interventions to target psychological distress among this vulnerable veteran population. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
- Katherine Ramos
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
| | - Heather A King
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
| | - Micaela N Gladney
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
| | - Sandra L Woolson
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
| | - Cynthia Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
| | - Hayden B Bosworth
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
| | - Laura S Porter
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
| | - S Nicole Hastings
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System
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Ezem N, Lewinski AA, Miller J, King HA, Oakes M, Monk L, Starks MA, Granger CB, Bosworth HB, Blewer AL. Factors influencing support for the implementation of community-based out-of-hospital cardiac arrest interventions in high- and low-performing counties. Resusc Plus 2024; 17:100550. [PMID: 38304635 PMCID: PMC10831164 DOI: 10.1016/j.resplu.2024.100550] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/21/2023] [Accepted: 01/06/2024] [Indexed: 02/03/2024] Open
Abstract
Aim of the study Survival to hospital discharge from out-of-hospital cardiac arrest (OHCA) after receiving treatment from emergency medical services (EMS) is less than 10% in the United States. Community-focused interventions improve survival rates, but there is limited information on how to gain support for new interventions or program activities within these populations. Using data from the RAndomized Cluster Evaluation of Cardiac ARrest Systems (RACE-CARS) trial, we aimed to identify the factors influencing emergency response agencies' support in implementing an OHCA intervention. Methods North Carolina counties were stratified into high-performing or low-performing counties based on the county's cardiac arrest volume, percent of bystander-cardiopulmonary resuscitation (CPR) performed, patient survival to hospital discharge, cerebral performance in patients after cardiac arrest, and perceived engagement in the RACE-CARS project. We randomly selected 4 high-performing and 3 low-performing counties and conducted semi-structured qualitative interviews with emergency response stakeholders in each county. Results From 10/2021 to 02/2022, we completed 29 interviews across the 7 counties (EMS (n = 9), telecommunications (n = 7), fire/first responders (n = 7), and hospital representatives (n = 6)). We identified three themes salient to community support for OHCA intervention: (1) initiating support at emergency response agencies; (2) obtaining support from emergency response agency staff (senior leadership and emergency response teams); and (3) and maintaining support. For each theme, we described similarities and differences by high- and low-performing county. Conclusions We identified techniques for supporting effective engagement of emergency response agencies in community-based interventions for OHCA improving survival rates. This work may inform future programs and initiatives around implementation of community-based interventions for OHCA.
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Affiliation(s)
- Natalie Ezem
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Allison A. Lewinski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
- School of Nursing, Duke University, Durham, NC, United States
| | - Julie Miller
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Heather A King
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Megan Oakes
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
| | - Lisa Monk
- Duke Clinical Research Institute, Durham, NC, United States
| | - Monique A. Starks
- Duke Clinical Research Institute, Durham, NC, United States
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Christopher B. Granger
- School of Nursing, Duke University, Durham, NC, United States
- Duke Clinical Research Institute, Durham, NC, United States
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Hayden B. Bosworth
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
- School of Nursing, Duke University, Durham, NC, United States
- Duke Clinical Research Institute, Durham, NC, United States
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC, United States
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, United States
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Audrey L. Blewer
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
- School of Nursing, Duke University, Durham, NC, United States
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC, United States
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Jackson GL, Fix GM, White BS, Cutrona SL, Reardon CM, Damschroder LJ, Burns M, DeLaughter K, Opra Widerquist MA, Arasim M, Lindquist J, Gifford AL, King HA, Kaitz J, Jasuja GK, Hogan TP, Lopez JCF, Henderson B, Fitzgerald BA, Goetschius A, Hagan D, McCoy C, Seelig A, Nevedal A. Diffusion of excellence: evaluating a system to identify, replicate, and spread promising innovative practices across the Veterans health administration. Front Health Serv 2024; 3:1223277. [PMID: 38420338 PMCID: PMC10900518 DOI: 10.3389/frhs.2023.1223277] [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] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 11/20/2023] [Indexed: 03/02/2024]
Abstract
Introduction The Veterans Health Administration (VHA) Diffusion of Excellence (DoE) program provides a system to identify, replicate, and spread promising practices across the largest integrated healthcare system in the United States. DoE identifies innovations that have been successfully implemented in the VHA through a Shark Tank style competition. VHA facility and regional directors bid resources needed to replicate promising practices. Winning facilities/regions receive external facilitation to aid in replication/implementation over the course of a year. DoE staff then support diffusion of successful practices across the nationwide VHA. Methods Organized around the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework, we summarize results of an ongoing long-term mixed-methods implementation evaluation of DoE. Data sources include: Shark Tank application and bid details, tracking practice adoptions through a Diffusion Marketplace, characteristics of VHA facilities, focus groups with Shark Tank bidders, structured observations of DoE events, surveys of DoE program participants, and semi-structured interviews of national VHA program office leaders, VHA healthcare system/facility executives, practice developers, implementation teams and facilitators. Results In the first eight Shark Tanks (2016-2022), 3,280 Shark Tank applications were submitted; 88 were designated DoE Promising Practices (i.e., practices receive facilitated replication). DoE has effectively spread practices across the VHA, with 1,440 documented instances of adoption/replication of practices across the VHA. This includes 180 adoptions/replications in facilities located in rural areas. Leadership decisions to adopt innovations are often based on big picture considerations such as constituency support and linkage to organizational goals. DoE Promising Practices that have the greatest national spread have been successfully replicated at new sites during the facilitated replication process, have close partnerships with VHA national program offices, and tend to be less expensive to implement. Two indicators of sustainment indicate that 56 of the 88 Promising Practices are still being diffused across the VHA; 56% of facilities originally replicating the practices have sustained them, even up to 6 years after the first Shark Tank. Conclusion DoE has developed a sustainable process for the identification, replication, and spread of promising practices as part of a learning health system committed to providing equitable access to high quality care.
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Affiliation(s)
- George L. Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
- Advancing Implementation and Improvement Science Program, Peter O’Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Gemmae M. Fix
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
- Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
- Department of Health Law, Policy & Management, Boston University, Boston, MA, United States
| | - Brandolyn S. White
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
| | - Sarah L. Cutrona
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
- Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Caitlin M. Reardon
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Laura J. Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Madison Burns
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
| | - Kathryn DeLaughter
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
| | | | - Maria Arasim
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Jennifer Lindquist
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
| | - Allen L. Gifford
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
- Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
- Department of Health Law, Policy & Management, Boston University, Boston, MA, United States
| | - Heather A. King
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
- Department of Population Health Sciences, Duke University, Durham, NC, United States
- Division of General Internal Medicine, Duke University, Durham, NC, United States
| | - Jenesse Kaitz
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
| | - Guneet K. Jasuja
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
- Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
- Department of Health Law, Policy & Management, Boston University, Boston, MA, United States
| | - Timothy P. Hogan
- Advancing Implementation and Improvement Science Program, Peter O’Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
| | - Jaifred Christian F. Lopez
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
- Department of Population Health Sciences, Duke University, Durham, NC, United States
| | - Blake Henderson
- VHA Innovation Ecosystem, Office of Healthcare Innovation and Learning, United States Veterans Health Administration, Washington, DC, United States
| | - Blaine A. Fitzgerald
- VHA Innovation Ecosystem, Office of Healthcare Innovation and Learning, United States Veterans Health Administration, Washington, DC, United States
| | - Amber Goetschius
- VHA Innovation Ecosystem, Office of Healthcare Innovation and Learning, United States Veterans Health Administration, Washington, DC, United States
| | - Danielle Hagan
- VHA Innovation Ecosystem, Office of Healthcare Innovation and Learning, United States Veterans Health Administration, Washington, DC, United States
| | - Carl McCoy
- VHA Innovation Ecosystem, Office of Healthcare Innovation and Learning, United States Veterans Health Administration, Washington, DC, United States
| | - Alex Seelig
- Agile Six Applications, Inc., San Diego, CA, United States
| | - Andrea Nevedal
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
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Peracca SB, Lachica O, Lamkin RP, Jackson GL, Mohr DC, King HA, Whited JD, Fonseca AS, Morris IJ, Gifford AL, Weinstock MA, Oh DH. Implementation of Direct-to-Patient Mobile Teledermatology in VA. J Gen Intern Med 2024; 39:97-105. [PMID: 38252250 PMCID: PMC10937882 DOI: 10.1007/s11606-023-08480-1] [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: 05/01/2023] [Accepted: 10/12/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Innovative technology can enhance patient access to healthcare but must be successfully implemented to be effective. OBJECTIVE We evaluated Department of Veterans Affairs' (VA's) implementation of My VA Images, a direct-to-patient asynchronous teledermatology mobile application enabling established dermatology patients to receive follow-up care remotely instead of in-person. DESIGN /PARTICIPANTS/APPROACH Following pilot testing at 3 facilities, the app was introduced to 28 facilities (4 groups of 7) every 3 months using a stepped-wedge cluster-randomized design. Using the Organizational Theory of Implementation Effectiveness, we examined the app's implementation using qualitative and quantitative data consisting of encounter data from VA's corporate data warehouse; app usage from VA's Mobile Health database; bi-monthly reports from facility representatives; phone interviews with clinicians; and documented communications between the operational partner and facility staff. KEY RESULTS Implementation policies and practices included VA's vision to expand home telehealth and marketing/communication strategies. The COVID-19 pandemic dominated the implementation climate by stressing staffing, introducing competing demands, and influencing stakeholder attitudes to the app, including its fit to their values. These factors were associated with mixed implementation effectiveness, defined as high quality consistent use. Nineteen of 31 exposed facilities prepared to use the app; 10 facilities used it for actual patient care, 7 as originally intended. Residents, nurse practitioners, and physician assistants were more likely than attendings to use the app. Facilities exposed to the app pre-pandemic were more likely to use and sustain the new process. CONCLUSIONS Considerable heterogeneity existed in implementing mobile teledermatology, despite VA's common mission, integrated healthcare system, and stakeholders' broad interest. Identifying opportunities to target favorable facilities and user groups (such as teaching facilities and physician extenders, respectively) while addressing internal implementation barriers including incomplete integration with the electronic health record as well as inadequate staffing may help optimize the initial impact of direct-to-patient telehealth. The COVID pandemic was a notable extrinsic barrier. CLINICAL TRIALS REGISTRATION NCT03241589.
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Affiliation(s)
- Sara B Peracca
- Dermatology Service (190), San Francisco VA Health Care System, 4150 Clement Street, San Francisco, CA, 94121, USA
| | - Olevie Lachica
- Dermatology Service (190), San Francisco VA Health Care System, 4150 Clement Street, San Francisco, CA, 94121, USA
| | - Rebecca P Lamkin
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA, 02130, USA
| | - George L Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA, 02130, USA
- Department of Health Law, Policy & Management, School of Public Health, Boston University, 715 Albany Street, Boston, MA, 02118, USA
| | - Heather A King
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University, 215 Morris Street, Durham, NC, 27701, USA
- Division of General Internal Medicine, Duke University School of Medicine, 6301 Herndon Road, Durham, NC, 27713, USA
| | - John D Whited
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Division of General Internal Medicine, Duke University School of Medicine, 6301 Herndon Road, Durham, NC, 27713, USA
| | - Allene S Fonseca
- Department of Dermatology, Wayne State University, 18101 Oakwood Boulevard #402, Dearborn, MI, 48124, USA
| | - Isis J Morris
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
| | - Allen L Gifford
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA, 02130, USA
- Department of Health Law, Policy & Management, School of Public Health, Boston University, 715 Albany Street, Boston, MA, 02118, USA
- Section of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, 72 E Concord Street, Boston, MA, 02118, USA
| | - Martin A Weinstock
- Department of Dermatology and Epidemiology, Brown University, 593 Eddy Street, Providence, RI, 02903, USA
- Center for Dermatoepidemiology, Providence VA Medical Center, 830 Chalkstone Avenue, Providence, RI, 02908, USA
| | - Dennis H Oh
- Dermatology Service (190), San Francisco VA Health Care System, 4150 Clement Street, San Francisco, CA, 94121, USA.
- Department of Dermatology, University of California San Francisco, 1701 Divisadero Street, San Francisco, CA, 94115, USA.
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6
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Kheterpal MK, Borre ED, Cheema U, Nicholas MW, Cooner EW, Phinney D, Gagnon K, Zullig LL, King HA, Malcolm EJ, Chen SC. Implementation evaluation of a teledermatology virtual clinic at an academic medical center. Implement Sci Commun 2023; 4:130. [PMID: 37891695 PMCID: PMC10612341 DOI: 10.1186/s43058-023-00508-1] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 10/04/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Teledermatology (TD) is an evidence-based practice that may increase access to dermatologic care. We sought to use the Exploration, Preparation, Implementation, and Sustainment (EPIS) and the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) frameworks to evaluate implementation of TD at Duke. METHODS The EPIS and RE-AIM frameworks were deployed to design and implement a TD program that leveraged the strengths of the Duke University Health System and addressed previously reported barriers to implementation of store-and-forward and synchronous TD models. In the resultant hybrid TD model, trained primary care providers (PCPs) sent e-comm referrals with clinical and dermatoscopic images to dermatology. These e-consults were reviewed asynchronously and patients were scheduled for a synchronous video visit with dermatology within days. Dermatologists managed the patient plan. This hybrid TD model was piloted at four primary care clinics. Pertinent outcomes from a TD-adapted RE-AIM framework were tracked using electronic health record data. Patient satisfaction was assessed using a post-video visit survey (n = 18). Implementation barriers and facilitators were also collected through provider surveys (n = 24 PCPs, n = 10 dermatologists, n = 10 dermatology residents). RESULTS At four PCP clinics throughout 9/1/2021-4/30/2022, there were 218 TD referrals. Video visits occurred on average 7.5 ± 0.5 days after referral and 18/18 patients completing the post-visit survey were satisfied. Adoption varied between clinics, with one placing 22% of all dermatology referrals as TD and another placing 2%. The primary PCP barriers to TD were time burdens, lack of fit in clinic flow, and discomfort with image taking. Top-endorsed potential facilitating interventions included allowing for rash referrals without dermoscopy and assurance for clinical evaluation within 3 days. CONCLUSIONS The use of implementation science frameworks allowed for identification of system and contextual strengths which informed the hybrid TD pilot. Barriers and facilitating interventions will provide guidance for expansion and ongoing maintenance of TD.
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Affiliation(s)
- Meenal K Kheterpal
- Department of Dermatology, Duke University Medical Center, DUMC Box 3135, Durham, NC, 27710, USA.
| | - Ethan D Borre
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | | | - Matilda W Nicholas
- Department of Dermatology, Duke University Medical Center, DUMC Box 3135, Durham, NC, 27710, USA
| | - Edward W Cooner
- Duke Primary Care, Duke University School of Medicine, Durham, NC, USA
| | - Donna Phinney
- Duke Telehealth Office, Duke University Health System, Durham, NC, USA
| | - Kelly Gagnon
- Performance Services, Duke University Health System, Durham, NC, USA
| | - Leah L Zullig
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
| | - Heather A King
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Elizabeth J Malcolm
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Suephy C Chen
- Department of Dermatology, Duke University Medical Center, DUMC Box 3135, Durham, NC, 27710, USA
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7
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Evans SR, Patel R, Hamasaki T, Howard-Anderson J, Kinamon T, King HA, Collyar D, Cross HR, Chambers HF, Fowler VG, Boucher HW. The Future Ain't What It Used to Be…Out With the Old…In With the Better: Antibacterial Resistance Leadership Group Innovations. Clin Infect Dis 2023; 77:S321-S330. [PMID: 37843122 PMCID: PMC10578048 DOI: 10.1093/cid/ciad538] [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] [Indexed: 10/17/2023] Open
Abstract
Clinical research networks conduct important studies that would not otherwise be performed by other entities. In the case of the Antibacterial Resistance Leadership Group (ARLG), such studies include diagnostic studies using master protocols, controlled phage intervention trials, and studies that evaluate treatment strategies or dynamic interventions, such as sequences of empiric and definitive therapies. However, the value of a clinical research network lies not only in the results from these important studies but in the creation of new approaches derived from collaborative thinking, carefully examining and defining the most important research questions for clinical practice, recognizing and addressing common but suboptimal approaches, and anticipating that the standard approaches of today may be insufficient for tomorrow. This results in the development and implementation of new methodologies and tools for the design, conduct, analyses, and reporting of research studies. These new methodologies directly impact the studies conducted within the network and have a broad and long-lasting impact on the field, enhancing the scientific value and efficiency of generations of research studies. This article describes innovations from the ARLG in diagnostic studies, observational studies, and clinical trials evaluating interventions for the prevention and treatment of antibiotic-resistant bacterial infections.
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Affiliation(s)
- Scott R Evans
- George Washington University Biostatistics Center, Rockville, Maryland, USA
| | - Robin Patel
- Division of Clinical Microbiology and Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Jessica Howard-Anderson
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Tori Kinamon
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Heather A King
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Health Services Research and Development, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | | | - Heather R Cross
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Henry F Chambers
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Vance G Fowler
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Helen W Boucher
- Tufts University School of Medicine and Tufts Medicine, Boston, Massachusetts, USA
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8
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Ballengee LA, King HA, Simon C, Lentz TA, Allen KD, Stanwyck C, Gladney M, George SZ, Hastings SN. Partner engagement for planning and development of non-pharmacological care pathways in the AIM-Back trial. Clin Trials 2023; 20:463-472. [PMID: 37269070 PMCID: PMC10524642 DOI: 10.1177/17407745231178789] [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] [Indexed: 06/04/2023]
Abstract
BACKGROUND/AIMS Embedded pragmatic clinical trials are increasingly recommended for non-pharmacological pain care research due to their focus on examining intervention effectiveness within real-world settings. Engagement with patients, health care providers, and other partners is essential, yet there is limited guidance for how to use engagement to meaningfully inform the design of interventions to be tested in pain-related pragmatic clinical trials. This manuscript aims to describe the process and impacts of partner input on the design of two interventions (care pathways) for low back pain currently being tested in an embedded pragmatic trial in the Veterans Affairs health care system. METHODS Sequential cohort design for intervention development was followed. Engagement activities were conducted with 25 participants between November 2017 and June 2018. Participants included representatives from multiple groups: clinicians, administrative leadership, patients, and caregivers. RESULTS Partner feedback led to several changes in each of the care pathways to improve patient experience and usability. Major changes to the sequenced care pathway included transitioning from telephone-based delivery to a flexible telehealth model, increased specificity about pain modulation activities, and reduction of physical therapy visits. Major changes to the pain navigator pathway included transitioning from a traditional stepped care model to one that offers care in a feedback loop, increased flexibility regarding pain navigator provider type, and increased specificity for patient discharge criteria. Centering patient experience emerged as a key consideration from all partner groups. CONCLUSION Diverse input is important to consider before implementing new interventions in embedded pragmatic trials. Partner engagement can increase acceptability of new care pathways to patients and providers and enhance uptake of effective interventions by health systems. TRIAL REGISTRATION NCT#04411420. Registered on 2 June 2020.
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Affiliation(s)
- Lindsay A Ballengee
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Heather A King
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Corey Simon
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Trevor A Lentz
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Kelli D Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Medicine and Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Catherine Stanwyck
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Micaela Gladney
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Steven Z George
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - S Nicole Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Center for the Study of Aging, Duke University School of Medicine, Durham, NC, USA
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9
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Ming DY, Wong W, Jones KA, Antonelli RC, Gujral N, Gonzales S, Rogers U, Ratliff W, Shah N, King HA. Feasibility of Implementation of a Mobile Digital Personal Health Record to Coordinate Care for Children and Youth With Special Health Care Needs in Primary Care: Protocol for a Mixed Methods Study. JMIR Res Protoc 2023; 12:e46847. [PMID: 37728977 PMCID: PMC10551780 DOI: 10.2196/46847] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Electronic health record (EHR)-integrated digital personal health records (PHRs) via Fast Healthcare Interoperability Resources (FHIR) are promising digital health tools to support care coordination (CC) for children and youth with special health care needs but remain widely unadopted; as their adoption grows, mixed methods and implementation research could guide real-world implementation and evaluation. OBJECTIVE This study (1) evaluates the feasibility of an FHIR-enabled digital PHR app for CC for children and youth with special health care needs, (2) characterizes determinants of implementation, and (3) explores associations between adoption and patient- or family-reported outcomes. METHODS This nonrandomized, single-arm, prospective feasibility trial will test an FHIR-enabled digital PHR app's use among families of children and youth with special health care needs in primary care settings. Key app features are FHIR-enabled access to structured data from the child's medical record, families' abilities to longitudinally track patient- or family-centered care goals, and sharing progress toward care goals with the child's primary care provider via a clinician dashboard. We shall enroll 40 parents or caregivers of children and youth with special health care needs to use the app for 6 months. Inclusion criteria for children and youth with special health care needs are age 0-16 years; primary care at a participating site; complex needs benefiting from CC; high hospitalization risk in the next 6 months; English speaking; having requisite technology at home (internet access, Apple iOS mobile device); and an active web-based EHR patient portal account to which a parent or caregiver has full proxy access. Digital prescriptions will be used to disseminate study recruitment materials directly to eligible participants via their existing EHR patient portal accounts. We will apply an intervention mixed methods design to link quantitative and qualitative (semistructured interviews and family engagement panels with parents of children and youth with special health care needs) data and characterize implementation determinants. Two CC frameworks (Pediatric Care Coordination Framework; Patient-Centered Medical Home) and 2 evaluation frameworks (Consolidated Framework for Implementation Research; Technology Acceptance Model) provide theoretical foundations for this study. RESULTS Participant recruitment began in fall 2022, before which we identified >300 potentially eligible patients in EHR data. A family engagement panel in fall 2021 generated formative feedback from family partners. Integrated analysis of pretrial quantitative and qualitative data informed family-centered enhancements to study procedures. CONCLUSIONS Our findings will inform how to integrate an FHIR-enabled digital PHR app for children and youth with special health care needs into clinical care. Mixed methods and implementation research will help strengthen implementation in diverse clinical settings. The study is positioned to advance knowledge of how to use digital health innovations for improving care and outcomes for children and youth with special health care needs and their families. TRIAL REGISTRATION ClinicalTrials.gov NCT05513235; https://clinicaltrials.gov/study/NCT05513235. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/46847.
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Affiliation(s)
- David Y Ming
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Willis Wong
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Kelley A Jones
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Richard C Antonelli
- Department of Pediatrics, Boston Children's Hospital, Harvard School of Medicine, Boston, MA, United States
| | - Nitin Gujral
- Innovation and Digital Health Accelerator, Boston Children's Hospital, Boston, MA, United States
| | - Sarah Gonzales
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Ursula Rogers
- AI Health, Duke University School of Medicine, Durham, NC, United States
| | - William Ratliff
- Duke Institute for Health Innovation, Duke University School of Medicine, Durham, NC, United States
| | - Nirmish Shah
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Heather A King
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veteran Affairs Health Care System, Durham, NC, United States
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10
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Cutrona SL, White L, Miano D, Damschroder LJ, Hogan TP, Gifford AL, White B, King HA, Opra Widerquist MA, Orvek E, DeLaughter K, Nevedal AL, Reardon CM, Henderson B, Vega R, Jackson GL. Supporting Veteran's Administration Medical Center Directors' Decisions When Adopting Innovative Practices: Development and Implementation of the "QuickView" and "WishList" Tools. Perm J 2023; 27:79-91. [PMID: 37545198 PMCID: PMC10502382 DOI: 10.7812/tpp/23.008] [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] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Background Since 2015, the Veterans Health Administration (VHA) Diffusion of Excellence Program has supported spread of practices developed by frontline employees. Shark Tank-style competitions encourage "Sharks" nationwide (VHA medical center/regional directors) to bid for the opportunity to implement practices at their institutions. Methods The authors evaluated bidding strategies (2016-2020), developing the "QuickView" practice comparator to promote informed bidding. Program leaders distributed QuickView and revised versions in subsequent competitions. Our team utilized in-person observation, online chats after the competition, bidder interviews, and bid analysis to evaluate QuickView use. Bids were ranked based on demonstrated understanding of resources required for practice implementation. Results Sharks stated that QuickView supported preparation before the competition and suggested improvements. Our revised tool reported necessary staff time and incorporated a "WishList" from practice finalists detailing minimum requirements for successful implementation. Bids from later years reflected increased review of facilities' current states before the competition and increased understanding of the resources needed for implementation. Percentage of bids describing local need for the practice rose from 2016 to 2020: 4.7% (6/127); 62.1% (54/87); 78.3% (36/46); 80.6% (29/36); 89.7% (26/29). Percentage of bids committing specific resources rose following QuickView introduction: 81.1% (103/127) in 2016, 69.0% (60/87) in 2017, then 73.9% (34/46) in 2018, 88.9% (32/36) in 2019, and 89.7% (26/29) in 2020. Discussion In the years following QuickView/WishList implementation, bids reflected increased assessment before the competition of both local needs and available resources. Conclusion Selection of a new practice for implementation requires an understanding of local need, necessary resources, and fit. QuickView and WishList appear to support these determinations.
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Affiliation(s)
- Sarah L Cutrona
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Lindsay White
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford, MA, USA
| | - Danielle Miano
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford, MA, USA
| | - Laura J Damschroder
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Timothy P Hogan
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford, MA, USA
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA
| | - Allen L Gifford
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford, MA, USA
- Section of General Internal Medicine, Department of Health Law, Policy & Management, Boston University, Boston, MA, USA
| | - Brandolyn White
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA
| | - Heather A King
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Division of General Internal Medicine, and Department of Family Medicine and Community Health, Duke University, Durham, NC, USA
| | | | - Elizabeth Orvek
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Kathryn DeLaughter
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford, MA, USA
| | - Andrea L Nevedal
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Caitlin M Reardon
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Blake Henderson
- Diffusion of Excellence, Office of Discovery, Education and Affiliate Networks, VHA, Washington, DC, USA
| | - Ryan Vega
- Office of Discovery, Education and Affiliate Networks, VHA, Bedford, MA, USA
| | - George L Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Division of General Internal Medicine, and Department of Family Medicine and Community Health, Duke University, Durham, NC, USA
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11
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Midboe AM, Javier SJ, Salsbury SA, Katsovich L, Burgess DJ, King HA, Taylor SL, Martino S, Mayer JM, Wallace RB, Der-Martirosian C, Kerns RD. Impact of COVID-19 pandemic on nonpharmacological pain management trials in military and veteran healthcare settings: an evaluation informed by implementation science. Transl Behav Med 2023; 13:601-611. [PMID: 37030012 PMCID: PMC10415731 DOI: 10.1093/tbm/ibad015] [Citation(s) in RCA: 1] [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] [Subscribe] [Scholar Register] [Indexed: 04/10/2023] Open
Abstract
The coronavirus disease (COVID-19) pandemic disrupted healthcare and clinical research, including a suite of 11 pragmatic clinical trials (PCTs), across clinics within the Department of Veterans Affairs (VA) and the Department of Defense (DOD). These PCTs were designed to evaluate an array of nonpharmacological treatments and models of care for treatment of patients with pain and co-occurring conditions. The aims of the study are to (a) describe modifications to PCTs and interventions to address the evolving pandemic and (b) describe the application of implementation science methods for evaluation of those PCT modifications. The project used a two-phase, sequential, mixed-methods design. In Phase I, we captured PCT disruptions and modifications via a Research Electronic Data Capture questionnaire, using Periodic Reflections methods as a guide. In Phase II, we utilized the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) taxonomy to develop a focus group interview guide and checklist that would provide more in-depth data than Phase I. Data were analyzed using directed content analysis. Phase I revealed that all PCTs made between two and six trial modifications. Phase II, FRAME-guided analyses showed that the key goals for modifying interventions were increasing treatment feasibility and decreasing patient exposure to COVID-19, while preserving intervention core elements. Context (format) modifications led eight PCTs to modify parts of the interventions for virtual delivery. Content modifications added elements to enhance patient safety; tailored interventions for virtual delivery (counseling, exercise, mindfulness); and modified interventions involving manual therapies. Implementation science methods identified near-real-time disruptions and modifications to PCTs focused on pain management in veteran and military healthcare settings.
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Affiliation(s)
- Amanda M Midboe
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA 94025, USA
- Department of Public Health Sciences, School of Medicine, University of California, Davis, CA 95616, USA
| | - Sarah J Javier
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA 94025, USA
- Department of Public Health Sciences, School of Medicine, University of California, Davis, CA 95616, USA
| | - Stacie A Salsbury
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, IA 52803, USA
| | - Lily Katsovich
- Department of Psychiatry, Yale University, New Haven, CT 06511, USA
- Departments of Neurology, Yale University, New Haven, CT 06511, USA
- Departments of Psychology, Yale University, New Haven, CT 06511, USA
| | - Diana J Burgess
- VA HSR&D Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Health Care System, Minneapolis, MN 55417, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Heather A King
- VA HSR&D Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC 27701, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC 27701, USA
| | - Stephanie L Taylor
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Greater Los Angeles VA Healthcare System, Los Angeles, CA 90073, USA
- Department of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
- Department of Health Policy and Management, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Steve Martino
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06511, USA
- VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - John M Mayer
- The Vert Mooney Research (DBA US Spine & Sport Foundation), San Diego, CA 92111, USA
| | - Robert B Wallace
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA 52242, USA
| | - Claudia Der-Martirosian
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Greater Los Angeles VA Healthcare System, Los Angeles, CA 90073, USA
| | - Robert D Kerns
- Department of Psychiatry, Yale University, New Haven, CT 06511, USA
- Departments of Neurology, Yale University, New Haven, CT 06511, USA
- Departments of Psychology, Yale University, New Haven, CT 06511, USA
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT 06516, USA
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12
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Zullig LL, Raska W, McWhirter G, Sherman SE, Makarov D, Becker D, King HA, Pura J, Jeffreys AS, Danus S, Passero V, Goldstein KM, Kelley MJ. Veterans Health Administration National TeleOncology Service. JCO Oncol Pract 2023; 19:e504-e510. [PMID: 36649579 PMCID: PMC10113113 DOI: 10.1200/op.22.00455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 10/19/2022] [Accepted: 11/28/2022] [Indexed: 01/18/2023] Open
Abstract
PURPOSE As the largest integrated health care system in the United States, the Veterans Health Administration (VA) is a leader in telehealth-delivered care. All 10 million Veterans cared for within the VA are eligible for telehealth. The VA cares for approximately 46,000 Veteran patients with newly diagnosed cancer and an estimated 400,000 prevalent cases annually. With nearly 38% of VA health care system users residing in rural areas and only 44% of rural counties having an oncologist, many Veterans lack local access to specialized cancer services. METHODS We describe the VA's National TeleOncology (NTO) Service. NTO was established to provide Veterans with the opportunity for specialized treatment regardless of geographical location. Designed as a hub-and-spoke model, VA oncologists from across the country can provide care to patients at spoke sites. Spoke sites are smaller and rural VA medical centers that are less able to independently provide the full range of services available at larger facilities. In addition to smaller rural spoke sites, NTO also provides subspecialized oncology care to Veterans located in larger VA medical facilities that do not have subspecialties available or that have limited capacity. RESULTS As of fiscal year 2021, 23 clinics are served by or engaged in planning for delivery of NTO and there are 24 physicians providing care through the NTO virtual hub. Most NTO physicians continue to provide patient care in separate traditional in-person clinics. Approximately 4,300 unique Veterans have used NTO services. Approximately half (52%) of Veterans using NTO lived in rural areas. Most of these Veterans had more than one remote visit through NTO. CONCLUSION NTO is a state-of-the-art model that has the potential to revolutionize the way cancer care is delivered, which should improve the experience of Veterans receiving cancer care.
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Affiliation(s)
- Leah L. Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
| | - Whitney Raska
- Department of Veterans Affairs, National Oncology Program, Washington, DC
| | - Gina McWhirter
- Department of Veterans Affairs, National Oncology Program, Washington, DC
| | - Scott E. Sherman
- VA New York Harbor Healthcare System, New York, NY
- Department of Population Health, New York University Grossman School of Medicine, New York, NY
| | - Danil Makarov
- VA New York Harbor Healthcare System, New York, NY
- Department of Population Health, New York University Grossman School of Medicine, New York, NY
- Department of Urology, New York University Grossman School of Medicine, New York, NY
| | - Daniel Becker
- VA New York Harbor Healthcare System, New York, NY
- Perlmutter Cancer Center, New York University Grossman School of Medicine, New York, NY
| | - Heather A. King
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
- Division of General Internal Medicine, Duke University, Durham, NC
| | - John Pura
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
| | - Amy S. Jeffreys
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
| | - Susanne Danus
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
| | - Vida Passero
- Division of Hematology/Oncology, University of Pittsburgh, Pittsburgh, PA
- Department of Hematology/Oncology, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Karen M. Goldstein
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- Division of General Internal Medicine, Duke University, Durham, NC
| | - Michael J. Kelley
- Department of Veterans Affairs, National Oncology Program, Washington, DC
- Division of Medical Oncology, Duke University Medical Center, Durham, NC
- Hematology-Oncology, Durham Veterans Affairs Health Care System, Durham, NC
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13
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Kheterpal M, Borre ED, Nicholas MW, Cooner EW, Phinney D, Gagnon K, Zullig LL, King HA, Malcolm EJ, Chen SC. Implementation Evaluation of a Teledermatology Virtual Clinic at an Academic Medical Center. Res Sq 2023:rs.3.rs-2558425. [PMID: 36909611 PMCID: PMC10002841 DOI: 10.21203/rs.3.rs-2558425/v1] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Background Teledermatology (TD) is an evidence-based practice that may increase access to dermatologic care. We sought to evaluate implementation of TD at four Duke primary care practices. Methods We implemented a hybrid TD program where trained primary care providers (PCPs) sent referrals with clinical and dermatoscopic images to dermatology. Patients were seen by dermatologists over video visit within days, and dermatologists managed the patient plan. We evaluated implementation using the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework using electronic health record data. Implementation barriers and facilitators were collected through surveys (n = 24 PCPs, n = 10 dermatologists, n = 10 dermatology residents). Results At four PCP clinics throughout 9/1/2021-4/30/2022 there were 218 TD referrals. Video visits occurred on average 7.5 days after referral and 18/18 patients completing the post-visit survey were satisfied. Adoption varied between clinics, with one placing 22% of all dermatology referrals as TD and another placing 2%. The primary PCP barriers to TD were time burdens, lack of fit in clinic flow, and discomfort with image taking. Top-endorsed potential facilitating interventions included allowing for rash referrals without dermoscopy and assurance for clinical evaluation within 3 days. Conclusions Addressing TD process fit into PCP clinic flow and reducing time burdens may increase PCP uptake of TD.
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Reardon CM, Damschroder L, Opra Widerquist MA, Arasim M, Jackson GL, White B, Cutrona SL, Fix GM, Gifford AL, DeLaughter K, King HA, Henderson B, Vega R, Nevedal AL. Sustainment of diverse evidence-informed practices disseminated in the Veterans Health Administration (VHA): initial development and piloting of a pragmatic survey tool. Implement Sci Commun 2023; 4:6. [PMID: 36647162 PMCID: PMC9842210 DOI: 10.1186/s43058-022-00386-z] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/18/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND There are challenges associated with measuring sustainment of evidence-informed practices (EIPs). First, the terms sustainability and sustainment are often falsely conflated: sustainability assesses the likelihood of an EIP being in use in the future while sustainment assesses the extent to which an EIP is (or is not) in use. Second, grant funding often ends before sustainment can be assessed. The Veterans Health Administration (VHA) Diffusion of Excellence (DoE) program is one of few large-scale models of diffusion; it seeks to identify and disseminate practices across the VHA system. The DoE sponsors "Shark Tank" competitions, in which leaders bid on the opportunity to implement a practice with approximately 6 months of implementation support. As part of an ongoing evaluation of the DoE, we sought to develop and pilot a pragmatic survey tool to assess sustainment of DoE practices. METHODS In June 2020, surveys were sent to 64 facilities that were part of the DoE evaluation. We began analysis by comparing alignment of quantitative and qualitative responses; some facility representatives reported in the open-text box of the survey that their practice was on a temporary hold due to COVID-19 but answered the primary outcome question differently. As a result, the team reclassified the primary outcome of these facilities to Sustained: Temporary COVID-Hold. Following this reclassification, the number and percent of facilities in each category was calculated. We used directed content analysis, guided by the Consolidated Framework for Implementation Research (CFIR), to analyze open-text box responses. RESULTS A representative from forty-one facilities (64%) completed the survey. Among responding facilities, 29/41 sustained their practice, 1/41 partially sustained their practice, 8/41 had not sustained their practice, and 3/41 had never implemented their practice. Sustainment rates increased between Cohorts 1-4. CONCLUSIONS The initial development and piloting of our pragmatic survey allowed us to assess sustainment of DoE practices. Planned updates to the survey will enable flexibility in assessing sustainment and its determinants at any phase after adoption. This assessment approach can flex with the longitudinal and dynamic nature of sustainment, including capturing nuances in outcomes when practices are on a temporary hold. If additional piloting illustrates the survey is useful, we plan to assess the reliability and validity of this measure for broader use in the field.
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Affiliation(s)
- Caitlin M. Reardon
- grid.413800.e0000 0004 0419 7525Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, USA
| | - Laura Damschroder
- grid.413800.e0000 0004 0419 7525Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, USA
| | - Marilla A. Opra Widerquist
- grid.413800.e0000 0004 0419 7525Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, USA
| | - Maria Arasim
- grid.413800.e0000 0004 0419 7525Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, USA
| | - George L. Jackson
- grid.512153.1Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, USA ,grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University, Durham, USA ,grid.26009.3d0000 0004 1936 7961Division of General Internal Medicine, Duke University, Durham, USA ,grid.26009.3d0000 0004 1936 7961Department of Family Medicine & Community Health, Duke University, Durham, USA
| | - Brandolyn White
- grid.512153.1Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, USA
| | - Sarah L. Cutrona
- Center for Healthcare Organization & Implementation Research (CHOIR), Bedford & Boston VA Medical Centers, Bedford, USA ,Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, USA ,grid.168645.80000 0001 0742 0364Division of General Internal Medicine, University of Massachusetts Medical School, Worcester, USA
| | - Gemmae M. Fix
- Center for Healthcare Organization & Implementation Research (CHOIR), Bedford & Boston VA Medical Centers, Bedford, USA ,grid.189504.10000 0004 1936 7558Section of General Internal Medicine, Boston University School of Medicine, Boston, USA
| | - Allen L. Gifford
- Center for Healthcare Organization & Implementation Research (CHOIR), Bedford & Boston VA Medical Centers, Bedford, USA ,grid.189504.10000 0004 1936 7558Section of General Internal Medicine, Boston University School of Medicine, Boston, USA ,grid.189504.10000 0004 1936 7558Department of Health Law, Policy & Management, Boston University, Boston, USA
| | - Kathryn DeLaughter
- Center for Healthcare Organization & Implementation Research (CHOIR), Bedford & Boston VA Medical Centers, Bedford, USA ,Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, USA
| | - Heather A. King
- grid.512153.1Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, USA ,grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University, Durham, USA ,grid.26009.3d0000 0004 1936 7961Division of General Internal Medicine, Duke University, Durham, USA
| | - Blake Henderson
- grid.239186.70000 0004 0481 9574Innovation Ecosystem, United States Veterans Health Administration, Washington, D.C., USA
| | - Ryan Vega
- grid.239186.70000 0004 0481 9574Innovation Ecosystem, United States Veterans Health Administration, Washington, D.C., USA
| | - Andrea L. Nevedal
- grid.413800.e0000 0004 0419 7525Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, USA
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15
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Peracca SB, Fonseca AS, Lachica O, Jackson GL, Morris IJ, King HA, Misitzis A, Whited JD, Mohr DC, Lamkin RP, Gifford AL, Weinstock MA, Oh DH. Organizational Readiness for Patient-Facing Mobile Teledermatology to Care for Established Veteran Patients in the United States. Telemed J E Health 2023; 29:72-80. [PMID: 35612465 DOI: 10.1089/tmj.2022.0009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Purpose: To improve patient access to skin care, the Department of Veterans Affairs (VA) developed a patient-facing asynchronous mobile teledermatology application (app), which allows patients to follow up remotely with dermatologists. To understand how the app would be received in VA, we examined Organizational Readiness for Change (ORC), an important prelude to effective implementation, which includes the shared resolve and collective ability of organizational members to implement a change. Methods: We used a mixed-methods multiple case study approach to assess ORC at three VA facilities. Data derived from a site process call, surveys, and semistructured telephone interviews of VA staff, field notes, and administrative data. Results: Participants at all three facilities supported the intervention and recognized the value of using the app to increase patients' access to dermatologists, but expressed concerns largely related to disruption of the pre-existing clinical workflow. Participants at the facility most actively using the app had the highest overall ORC score and reported the most facilitators. Facility leadership support when guided by a clinical champion minimized barriers by recognizing the complexities of health care provision at specialty clinics. Discussion: While provider buy-in remained a barrier, leadership, guided by the clinical champion, played a critical role instituting implementation strategies. The strong association between the ORC survey score and the presence of facilitators and barriers suggests that the ORC survey may be a rapid, convenient, and effective tool for health care systems to identify favorable sites for wider implementation of mobile telehealth care. Clinical Trials Identifier: NCT03241589.
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Affiliation(s)
- Sara B Peracca
- Dermatology Service, San Francisco VA Health Care System, San Francisco, California, USA
| | - Allene S Fonseca
- Center for Dermatoepidemiology, Providence VA Medical Center, Providence, Rhode Island, USA.,Department of Dermatology and Epidemiology, Brown University, Providence, Rhode Island, USA
| | - Olevie Lachica
- Dermatology Service, San Francisco VA Health Care System, San Francisco, California, USA
| | - George L Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA.,Department of Population Health Science, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Medicine, Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - Isis J Morris
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
| | - Heather A King
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA.,Department of Population Health Science, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Medicine, Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Angelica Misitzis
- Center for Dermatoepidemiology, Providence VA Medical Center, Providence, Rhode Island, USA.,Department of Dermatology and Epidemiology, Brown University, Providence, Rhode Island, USA
| | - John D Whited
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA.,Department of Medicine, Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research (CHOIR), Veterans Affairs Boston Health Care System, Boston, Massachusetts, USA.,Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Rebecca P Lamkin
- Center for Healthcare Organization and Implementation Research (CHOIR), Veterans Affairs Boston Health Care System, Boston, Massachusetts, USA
| | - Allen L Gifford
- Center for Healthcare Organization and Implementation Research (CHOIR), Veterans Affairs Boston Health Care System, Boston, Massachusetts, USA.,Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts, USA.,Department of Medicine, Section of General Internal Medicine, School of Medicine, Boston University, Boston, Massachusetts, USA
| | - Martin A Weinstock
- Center for Dermatoepidemiology, Providence VA Medical Center, Providence, Rhode Island, USA.,Department of Dermatology and Epidemiology, Brown University, Providence, Rhode Island, USA
| | - Dennis H Oh
- Dermatology Service, San Francisco VA Health Care System, San Francisco, California, USA.,Department of Dermatology, University of California at San Francisco, San Francisco, California, USA
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16
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Yip O, Dhaini S, Esser J, Siqeca F, Mendieta MJ, Huber E, Zeller A, De Geest S, Deschodt M, Zúñiga F, Zullig LL, King HA, Urfer P, Vounatsou P, Obas K, Briel M, Schwenkglenks M, Quinto C, Blozik E. Health and social care of home-dwelling frail older adults in Switzerland: a mixed methods study. BMC Geriatr 2022; 22:857. [PMID: 36376806 PMCID: PMC9663289 DOI: 10.1186/s12877-022-03552-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/14/2022] [Indexed: 11/16/2022] Open
Abstract
Background Home-dwelling frail older adults are often faced with multimorbidity and complex care needs, requiring health and social care systems that support frail older adults to age in place. The objective of this paper was to investigate the types of formal health and social care as well as informal care and social support used by home-dwelling frail older adults; whether they perceive their support as sufficient; and their experience with and preferences for care and support. Methods Using an explanatory sequential mixed methods design, we first conducted a secondary analysis of a subset of cross-sectional data from the ImplemeNtation of a community-baSed care Program for home dwelling senIoR citizEns (INSPIRE) population survey using descriptive analysis. Subsequently, we analyzed existing data from interviews in the parent study to help explain the survey results using applied thematic analysis. Results were organized according to adapted domains and concepts of the SELFIE framework and integrated via a joint display table. Results Of the parent population survey respondents, 2314 older adults indicating frailty were included in the quantitative arm of this study. Interview data was included from 7 older adults who indicated frailty. Support from health and social, formal and informal caregivers is diverse and anticipated to increase (e.g., for ‘care and assistance at home’ and ‘meal services’). Informal caregivers fulfilled various roles and while some older adults strongly relied on them for support, others feared burdening them. Most participants (93.5%) perceived their overall support to meet their needs; however, findings suggest areas (e.g., assessment of overall needs) which merit attention to optimize future care. Conclusions Given the anticipated demand for future care and support, we recommend efforts to prevent fragmentation between health and social as well as formal and informal care. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03552-z.
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17
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Malcolm EJ, Brandon Z, Wilson LE, Shoup JP, King HA, Lewinski A, Greiner MA, Malone S, Miller J, Keenan RT, Tarrant TK, Phinney D, Cho A, Bosworth HB, Shah K. eConsults' Impact on Care Access and Wait Times in Rheumatology. J Clin Rheumatol 2022; 28:147-154. [PMID: 35067514 DOI: 10.1097/rhu.0000000000001825] [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] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVE A growing number of health systems have implemented eConsults to improve access to specialty advice, but few studies have described their use in rheumatology or impact on visit wait times. We evaluated the uptake of an eConsult program and its impact on wait times for in-person rheumatology visits. METHODS In this quality improvement project, we analyzed electronic health record data from 4 intervention clinics and 4 comparison clinics, 12 months before and after implementation of an eConsult program. We compared median wait time for rheumatology appointments using a pre-post difference-in-differences analysis and quantile regression, adjusting for patient age, race, sex, clinic pair, and primary insurance payer. We also interviewed 11 primary care providers from the intervention clinics and conducted a rheumatology provider focus group (n = 4) to elucidate experiences with the program. RESULTS Rheumatologists recommended management in primary care or referral to another specialty for 41% of eConsults, reducing initial demand for in-person visits. The median wait times dropped in the intervention and the comparison clinics (42 and 25 days, respectively). Intervention clinic median wait time dropped 17 days more than comparison clinics, and this was nonstatistically significant (p = 0.089). eConsults fit provider care tasks best for triage or initial workup for diagnosis, and less well when tests required interpretation, or when back and forth communication was needed to manage the patient's condition. CONCLUSIONS Implementation of eConsults for rheumatology was associated with reduced wait times for rheumatology appointments and supported primary care providers in the triage and workup for a substantial portion of patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Julie Miller
- From the Duke University School of Medicine, Durham
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18
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King HA, Doernberg SB, Grover K, Miller J, Oakes M, Wang TW, McFatrich M, Ruffin F, Staman K, Lane HG, Rader A, Sund Z, Bosworth HB, Reeve BB, Fowler VG, Holland TL. Patients' Experiences With Staphylococcus aureus and Gram-Negative Bacterial Bloodstream Infections: Results From Cognitive Interviews to Inform Assessment of Health-Related Quality of Life. Open Forum Infect Dis 2022; 9:ofab622. [PMID: 35106313 PMCID: PMC8801228 DOI: 10.1093/ofid/ofab622] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/06/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We previously conducted a concept elicitation study on the impact of Staphylococcus aureus and gram-negative bacterial bloodstream infections (SAB/GNB) on health-related quality of life (HRQoL) from the patient's perspective and found significant impacts on HRQoL, particularly in the physical and functional domains. Using this information and following guidance on the development of patient-reported outcome (PRO) measures, we determined which combination of measures and items (ie, specific questions) would be most appropriate in a survey assessing HRQoL in bloodstream infections. METHODS We selected a variety of measures/items from the Patient-Reported Outcomes Measurement Information System (PROMIS) representing different domains. We purposefully sampled patients ~6-12 weeks post-SAB/GNB and conducted 2 rounds of cognitive interviews to refine the survey by exploring patients' understanding of items and answer selection as well as relevance for capturing HRQoL. RESULTS We interviewed 17 SAB/GNB patients. Based on the first round of cognitive interviews (n = 10), we revised the survey. After round 2 of cognitive interviewing (n = 7), we finalized the survey to include 10 different PROMIS short forms/measures of the most salient HRQoL domains and 2 adapted questions (41 items total) that were found to adequately capture HRQoL. CONCLUSIONS We developed a survey from well-established PRO measures that captures what matters most to SAB/GNB patients as they recover. This survey, uniquely tailored to bloodstream infections, can be used to assess these meaningful, important HRQoL outcomes in clinical trials and in patient care. Engaging patients is crucial to developing treatments for bloodstream infections.
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Affiliation(s)
- Heather A King
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sarah B Doernberg
- University of California San Francisco Department of Medicine, San Francisco, California, USA
| | - Kiran Grover
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Julie Miller
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Megan Oakes
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Tsai-Wei Wang
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Molly McFatrich
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Felicia Ruffin
- Department of Medicine, Duke University, Durham North Carolina, USA
| | - Karen Staman
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Hannah G Lane
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Abigail Rader
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Zoë Sund
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Hayden B Bosworth
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Bryce B Reeve
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Vance G Fowler
- Department of Medicine, Duke University, Durham North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Thomas L Holland
- Department of Medicine, Duke University, Durham North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
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19
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King HA, Shepherd-Banigan M, Chapman JG, Bruening R, Decosimo KP, Van Houtven CH. Use of motivational techniques to enhance unpaid caregiver engagement in a tailored skills training intervention. Aging Ment Health 2022; 26:337-344. [PMID: 33325259 PMCID: PMC10424086 DOI: 10.1080/13607863.2020.1855103] [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] [Received: 11/06/2019] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The Helping Invested Families Improve Veterans' Experiences Study (HI-FIVES) evaluated a skills training program to support family caregivers of cognitively or functionally impaired persons. HI-FIVES demonstrated sustained improvements in caregivers' and patients' experiences of VA care. The aim of this distinct, secondary qualitative study was to explore the potential processes related to the individual tailored skills-based telephone training underpinning HI-FIVES intervention effects. We explored topics caregivers selected, characteristics of action items created, patterns of action or inaction, and barriers to action item completion across topics. METHODS Qualitative data was analysed from 118 dyads randomized into the HI-FIVES intervention which included three weekly facilitated training calls covering five education topics and action items developed by caregivers for each topic. Qualitative analysis of text responses to questions from the training calls was used. RESULTS Three of the top four most selected topics were caregiver-oriented and caregivers created an action item most often for self-care topics. Caregiver-oriented topics also had the highest action item completion rates. The majority of action items created met SMART guidelines for goal setting and simple structure. With regard to barriers to action item completion, caregivers commonly reported still contemplating/pending. CONCLUSION Our findings identify motivational interviewing as an effective technique to identify critical intervention content and address barriers to achieving caregiving goals. We suggest that caregivers felt more empowered to create and complete an action item when they had more control over completing the action item, such as in topics related to their own self-care.
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Affiliation(s)
- Heather A. King
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | | | - Rebecca Bruening
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Kasey P. Decosimo
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Courtney H. Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
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20
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Wortmann JH, Nieuwsma JA, King HA, Fernandez P, Jackson GL, Smigelsky MA, Cantrell W, Meador KG. Collaborative spiritual care for moral injury in the veterans Affairs Healthcare System (VA): Results from a national survey of VA chaplains. J Health Care Chaplain 2021; 28:S9-S24. [PMID: 34825859 DOI: 10.1080/08854726.2021.2004847] [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: 10/19/2022]
Abstract
The psychospiritual nature of moral injury invites consideration regarding how chaplains understand the construct and provide care. To identify how chaplains in the VA Healthcare System conceptualize moral injury, we conducted an anonymous online survey (N = 361; 45% response rate). Chaplains responded to a battery of items and provided free-text definitions of moral injury that generally aligned with key elements in the existing literature, though with different emphases. Over 90% of chaplain respondents indicated that they encounter moral injury in their chaplaincy care, and a similar proportion agreed that chaplains and mental health professionals should collaborate in providing care for moral injury. Over one-third of chaplain respondents reported offering or planning to offer a moral injury group. Separately, nearly one-quarter indicated present or planned collaboration with mental health to provide groups that in some manner address moral injury. Previous training in evidence-based and collaborative care approaches appears to contribute to the likelihood of providing integrated psychosocial-spiritual care. Results and future directions are discussed, including a description of moral injury that may be helpful to understand present areas of emphasis in VA chaplains' care for moral injury.
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Affiliation(s)
- Jennifer H Wortmann
- Integrative Mental Health, Veterans Affairs Healthcare System, Durham, NC, USA.,VA Mid-Atlantic MIRECC, Durham Veterans Affairs Healthcare System, Durham, NC, USA
| | - Jason A Nieuwsma
- Integrative Mental Health, Veterans Affairs Healthcare System, Durham, NC, USA.,VA Mid-Atlantic MIRECC, Durham Veterans Affairs Healthcare System, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Healthcare System, Durham, NC, USA
| | - Heather A King
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Healthcare System, Durham, NC, USA.,Department of Population Health Sciences, Duke University, Durham, NC, USA.,Division of General Internal Medicine, Duke University, Durham, NC, USA
| | - Paola Fernandez
- Integrative Mental Health, Veterans Affairs Healthcare System, Durham, NC, USA.,VA Mid-Atlantic MIRECC, Durham Veterans Affairs Healthcare System, Durham, NC, USA.,Department of Psychology, University of South Alabama, Mobile, AL, USA
| | - George L Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Healthcare System, Durham, NC, USA.,Department of Population Health Sciences, Duke University, Durham, NC, USA.,Division of General Internal Medicine, Duke University, Durham, NC, USA.,Department of Family Medicine and Community Health, Duke University, Durham, NC, USA
| | - Melissa A Smigelsky
- Integrative Mental Health, Veterans Affairs Healthcare System, Durham, NC, USA.,VA Mid-Atlantic MIRECC, Durham Veterans Affairs Healthcare System, Durham, NC, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Healthcare System, Durham, NC, USA
| | - William Cantrell
- Integrative Mental Health, Veterans Affairs Healthcare System, Durham, NC, USA.,VA Mid-Atlantic MIRECC, Durham Veterans Affairs Healthcare System, Durham, NC, USA
| | - Keith G Meador
- Integrative Mental Health, Veterans Affairs Healthcare System, Durham, NC, USA.,VA Mid-Atlantic MIRECC, Durham Veterans Affairs Healthcare System, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Vanderbilt University, Nashville, TN, USA.,Center for Biomedical Ethics and Society, Vanderbilt University, Nashville, TN, USA.,Department of Health Policy, Vanderbilt University, Nashville, TN, USA.,Graduate Department of Religion, Vanderbilt University, Nashville, TN, USA
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21
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Lewinski AA, Shapiro A, Bosworth HB, Crowley MJ, McCant F, Howard T, Jeffreys AS, McConnell E, Tanabe P, Barcinas S, Coffman CJ, King HA. Veterans' Interpretation of Diabetes Distress in Diabetes Self-Management: Findings From Cognitive Interviews. Sci Diabetes Self Manag Care 2021; 47:391-403. [PMID: 34559032 DOI: 10.1177/26350106211043487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The purpose of this project was to identify additional facets of diabetes distress (DD) in veterans that may be present due to the veteran's military-related experience. METHODS The study team completed cognitive interviews with veterans with type 2 diabetes mellitus (T2DM) to examine how they answered the Diabetes Distress Scale (DD Scale), a tool that assesses DD. The DD Scale was used because of its strong associations with self-management challenges, physician-related distress, and clinical outcomes. RESULTS The veterans sample (n= 15) was 73% male, mean age of 61 (SD = 8.6), 53% Black, 53% with glycosylated hemoglobin level <9%, and 67% with prescribed insulin. The DD Scale is readily understood by veterans and interpreted. Thematic analysis indicated additional domains affecting DD and T2DM self-management, including access to care, comorbidities, disruptions in routine, fluctuations in emotions and behaviors, interactions with providers, lifelong nature of diabetes, mental health concerns, military as culture, personal characteristics, physical limitations, physical pain, sources of information and support, spirituality, and stigma. CONCLUSIONS This study describes how a veteran's military experience may contribute to DD in the context of T2DM self-management. Findings indicate clinicians and researchers should account for additional domains when developing self-management interventions and discussing self-management behaviors with individuals with T2DM.
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Affiliation(s)
- Allison A Lewinski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina.,School of Nursing, Duke University, Durham, North Carolina
| | - Abigail Shapiro
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Hayden B Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina.,School of Nursing, Duke University, Durham, North Carolina.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.,Department of Medicine, Division of General Internal Medicine, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina
| | - Matthew J Crowley
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Division of Endocrinology, Diabetes and Metabolism, Duke University School of Medicine, Durham, North Carolina
| | - Felicia McCant
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Teresa Howard
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Amy S Jeffreys
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Eleanor McConnell
- School of Nursing, Duke University, Durham, North Carolina.,Geriatric Research, Education and Clinical Center, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Paula Tanabe
- School of Nursing, Duke University, Durham, North Carolina.,Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Cynthia J Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Heather A King
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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22
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King HA, Doernberg SB, Miller J, Grover K, Oakes M, Ruffin F, Gonzales S, Rader A, Neuss MJ, Bosworth HB, Sund Z, Drennan C, Hill-Rorie JM, Shah P, Winn L, Fowler VG, Holland TL. Patients' Experiences With Staphylococcus aureus and Gram-negative Bacterial Bloodstream Infections: A Qualitative Descriptive Study and Concept Elicitation Phase To Inform Measurement of Patient-reported Quality of Life. Clin Infect Dis 2021; 73:237-247. [PMID: 32445467 DOI: 10.1093/cid/ciaa611] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 01/03/2020] [Accepted: 05/18/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Although Staphylococcus aureus and gram-negative bacterial bloodstream infections (SAB/GNB) cause substantial morbidity, little is known regarding patient perceptions' of their impact on quality of life (QOL). Guidance for assessing QOL and disease-specific measures are lacking. We conducted a descriptive qualitative study to gain an in-depth understanding of patients' experiences with SAB/GNB and concept elicitation phase to inform a patient-reported QOL outcome measure. METHODS We conducted prospective one-time, in-depth, semi-structured, individual, qualitative telephone interviews 6- 8 weeks following bloodstream infection with either SAB or GNB. Patients were enrolled in an institutional registry (tertiary academic medical center) for SAB or GNB. Interviews were audio-recorded, transcribed, and coded. Directed content analysis identified a priori and emergent themes. Theme matrix techniques were used to facilitate analysis and presentation. RESULTS Interviews were completed with 30 patients with SAB and 31 patients with GNB. Most patients were at or near the end of intravenous antibiotic treatment when interviewed. We identified 3 primary high-level concepts: impact on QOL domains, time as a critical index, and sources of variability across patients. Across both types of bloodstream infection, the QOL domains most impacted were physical and functional, which was particularly evident among patients with SAB. CONCLUSIONS SAB/GNB impact QOL among survivors. In particular, SAB had major impacts on multiple QOL domains. A combination of existing, generic measures that are purposefully selected and disease-specific items, if necessary, could best capture these impacts. Engaging patients as stakeholders and obtaining their feedback is crucial to conducting patient-centered clinical trials and providing patient-centered care.
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Affiliation(s)
- Heather A King
- Duke University School of Medicine, Department of Population Health Sciences, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Duke University School of Medicine, Division of General Internal Medicine, Durham, North Carolina, USA
| | - Sarah B Doernberg
- University of California, San Francisco, Department of Medicine, San Francisco, California, USA
| | - Julie Miller
- Duke University School of Medicine, Department of Population Health Sciences, Durham, North Carolina, USA
| | - Kiran Grover
- Duke University School of Medicine, Department of Population Health Sciences, Durham, North Carolina, USA
| | - Megan Oakes
- Duke University School of Medicine, Department of Population Health Sciences, Durham, North Carolina, USA
| | - Felicia Ruffin
- Duke University, Department of Medicine, Durham North Carolina, USA
| | - Sarah Gonzales
- Duke University School of Medicine, Department of Population Health Sciences, Durham, North Carolina, USA
| | - Abigail Rader
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael J Neuss
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hayden B Bosworth
- Duke University School of Medicine, Department of Population Health Sciences, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Zoë Sund
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | | | - Pratik Shah
- Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Laura Winn
- Duke University School of Medicine, Department of Population Health Sciences, Durham, North Carolina, USA
| | - Vance G Fowler
- Duke University, Department of Medicine, Durham North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Thomas L Holland
- Duke University, Department of Medicine, Durham North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
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23
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Perry KR, King HA, Parker R, Steinhauser KE. Coordinating assessment of spiritual needs: a cross-walk of narrative and psychometric assessment tools used in palliative care. J Health Care Chaplain 2021; 28:365-377. [PMID: 33909546 DOI: 10.1080/08854726.2021.1904653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Addressing spiritual needs of patients in healthcare settings improves patient experiences and clinical outcomes; however, non-chaplain providers typically assess spiritual needs differently (quantitative psychometric) than healthcare chaplains (long form narrative) and thus there is little shared language or cross-disciplinary evaluation frameworks across disciplines. This discrepancy impedes the provision of both team-based and patient-centered care. This paper used scoping review methodology to illustrate the overlap between narrative and psychometric assessment tools, comparing four narrative tools against eight psychometric tools. The SpNQ-120 and Brief RCOPE demonstrated consistent domain coverage across the four chaplain narrative tools. This work provides preliminary resources to aid clinicians and researchers in choosing an appropriate tool. Additionally, for those who do not work closely with chaplains, it provides a sense of what domains chaplains prioritize, from their professional and lived experience, in assessing the spiritual life of the patient. This improves interdisciplinary communication, and therefore, patient care.
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Affiliation(s)
- Kathleen R Perry
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA
| | - Heather A King
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA.,Department of Population and Health Sciences, Duke University Medical Center, Durham, NC, USA.,Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Ryan Parker
- Chaplain Service, Durham VA Health Care System, Durham, NC, USA
| | - Karen E Steinhauser
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA.,Department of Population and Health Sciences, Duke University Medical Center, Durham, NC, USA.,Department of Medicine, Duke University Medical Center, Durham, NC, USA
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24
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Peracca SB, Fonseca A, Hines A, King HA, Grenga AM, Jackson GL, Whited JD, Chapman JG, Lamkin R, Mohr DC, Gifford A, Weinstock MA, Oh DH. Implementation of Mobile Teledermatology: Challenges and Opportunities. Telemed J E Health 2021; 27:1416-1422. [PMID: 33691074 DOI: 10.1089/tmj.2020.0500] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: While teledermatology is well-established in the Department of Veterans Affairs (VA), its implementation is far from complete. To facilitate consultative teledermatology and extend its reach, VA introduced a mobile teledermatology application (app) at three VA sites. Methods: We evaluated the initial implementation process using a mixed-methods, multiple case study approach to assess organizational readiness for change (ORC), which included examining facilitators, barriers, and contextual factors that affected implementation. We conducted: (1) group interviews and bimonthly reports to understand site processes; (2) semistructured interviews and surveys of individual participants representing a range of implementation roles; and (3) a review of internal organizational documents. We identified themes from interviews using an iterative process, and computed an ORC score based on surveys. Results: Forty-three individuals participated in the study. Qualitative data from all sites, corroborated by survey data available from one site, revealed a high readiness for change with an ORC score of 4.2, where 5 = maximal readiness for change. Facilitators included support from leadership and clinical champions, active telehealth programs, and an understanding and appreciation of the program and the resources needed. At all sites, however, technical issues negatively affected adoption; these included a suboptimal information technology infrastructure, which led to the inoperability of the app at two sites, and technical inefficiencies related to users' unfamiliarity with new devices and inconsistent internet access. Conclusions: Although a strong commitment to change and a confidence to effect change existed, these alone were insufficient to surmount barriers to implementation effectiveness. Clinical Trials Registration: NCT03241589.
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Affiliation(s)
- Sara B Peracca
- Dermatology Service, San Francisco VA Health Care System, San Francisco, California, USA
| | - Allene Fonseca
- Center for Dermatoepidemiology, Providence VA Medical Center, Providence, Rhode Island, USA.,Department of Dermatology and Epidemiology, Brown University, Providence, Rhode Island, USA
| | - Aliya Hines
- VA Ann Arbor Health Care System, Ann Arbor, Michigan, USA
| | - Heather A King
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA.,Department of Population Health Science, Duke University School of Medicine, Durham, North Carolina, USA.,Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andrea M Grenga
- Center for Dermatoepidemiology, Providence VA Medical Center, Providence, Rhode Island, USA
| | - George L Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA.,Department of Population Health Science, Duke University School of Medicine, Durham, North Carolina, USA.,Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - John D Whited
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA.,Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer G Chapman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
| | - Rebecca Lamkin
- Center for Healthcare Organization and Implementation Research (CHOIR), Veterans Affairs Boston Health Care System, Boston, Massachusetts, USA
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research (CHOIR), Veterans Affairs Boston Health Care System, Boston, Massachusetts, USA.,Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Allen Gifford
- Center for Healthcare Organization and Implementation Research (CHOIR), Veterans Affairs Boston Health Care System, Boston, Massachusetts, USA.,Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts, USA.,Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts, USA
| | - Martin A Weinstock
- Center for Dermatoepidemiology, Providence VA Medical Center, Providence, Rhode Island, USA.,Department of Dermatology and Epidemiology, Brown University, Providence, Rhode Island, USA
| | - Dennis H Oh
- Dermatology Service, San Francisco VA Health Care System, San Francisco, California, USA.,Department of Dermatology, University of California at San Francisco, San Francisco, California, USA
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25
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Jackson GL, Cutrona SL, White BS, Reardon CM, Orvek E, Nevedal AL, Lindquist J, Gifford AL, White L, King HA, DeLaughter K, Houston TK, Henderson B, Vega R, Kilbourne AM, Damschroder LJ. Merging Implementation Practice and Science to Scale Up Promising Practices: The Veterans Health Administration (VHA) Diffusion of Excellence (DoE) Program. Jt Comm J Qual Patient Saf 2020; 47:217-227. [PMID: 33549485 DOI: 10.1016/j.jcjq.2020.11.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 11/23/2020] [Accepted: 11/23/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The Veterans Health Administration (VHA) Diffusion of Excellence (DoE) program developed and manages a framework for identification, replication, and diffusion of promising practices throughout the nation's largest integrated health care system. DoE identifies promising practices through a "Shark Tank" competition with winning bidders receiving external implementation facilitation. DoE further supports diffusion of successful practices across the VHA. METHODS This article presents results of a mixed methods implementation evaluation of DoE, focusing on program reach, program participation and decisions to adopt innovative practices, implementation processes, and practice sustainment. Data sources include practice adoption metrics, focus groups with bidders (two focus groups), observations of DoE events (seven events), surveys of stakeholders (five separate surveys), and semistructured interviews of facility directors, practice developers, implementation teams, and facilitators (133 participants). RESULTS In the first four Shark Tank cohorts (2016-2018), 1,676 practices were submitted; 47 were designated Gold Status Practices (practices with facilitated implementation). Motivation for participation varied. Generally, staff led projects targeting problems they felt passionate about, facility directors focused on big-picture quality metrics and getting middle manager support, and frontline staff displayed variable motivation to implement new projects. Approximately half of facilitated implementation efforts were successful; barriers included insufficient infrastructure, staff, and resources. At the facility level, 73.3% of facilities originating or receiving facilitated implementation support have maintained the practice. VHA-wide, 834 decisions to adopt these practices were made. CONCLUSION DoE has resulted in the identification of many candidate practices, promoted adoption of promising practices by facility directors, and supported practice implementation and diffusion across the VHA.
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26
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Nieuwsma JA, Brancu M, Wortmann J, Smigelsky MA, King HA, Meador KG. Screening for moral injury and comparatively evaluating moral injury measures in relation to mental illness symptomatology and diagnosis. Clin Psychol Psychother 2020; 28:239-250. [PMID: 32830386 DOI: 10.1002/cpp.2503] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 11/09/2022]
Abstract
Moral injury merits further study to clarify its identification, prevalence, assessment and intersection with psychosocial and psychiatric problems. The present study investigated the screening potential of the Brief Moral Injury Screen (BMIS) in a sample of post-9/11 veterans (N = 315) and comparatively evaluated how this tool, the Moral Injury Events Scale (MIES), and the Moral Injury Questionnaire-Military Version (MIQ-M) relate to psychiatric diagnoses and mental illness symptom severity. Those who endorsed failing to prevent or doing something morally wrong had the highest symptomatology scores on measures of posttraumatic stress disorder, depression, suicidality, alcohol abuse and drug abuse, followed by those who reported solely witnessing a moral injury event. Posttraumatic stress disorder and depressive symptoms correlated most strongly with scores on the MIQ-M; suicidality, alcohol abuse and drug abuse scores correlated most strongly with scores on the BMIS and MIQ-M. Moral injury, as measured by three scales, was robustly correlated with worse outcomes on various symptom measures. The three scales appear to differentially predict mental illness symptomatology and diagnoses, with the BMIS predicting suicidality and alcohol and drug abuse as well as better than other measures.
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Affiliation(s)
- Jason A Nieuwsma
- Department of Veterans Affairs, Mental Health and Chaplaincy, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Mira Brancu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA.,VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, North Carolina, USA
| | - Jennifer Wortmann
- Department of Veterans Affairs, Mental Health and Chaplaincy, Durham, North Carolina, USA
| | - Melissa A Smigelsky
- Department of Veterans Affairs, Mental Health and Chaplaincy, Durham, North Carolina, USA
| | - Heather A King
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina, USA
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- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, North Carolina, USA
| | - Keith G Meador
- Department of Veterans Affairs, Mental Health and Chaplaincy, Durham, North Carolina, USA.,Department of Psychiatry and Preventative Medicine, Center for Biomedical Ethics and Society, & Graduate Department of Religion, Vanderbilt University, Nashville, Tennessee, USA
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27
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Nevedal AL, Reardon CM, Jackson GL, Cutrona SL, White B, Gifford AL, Orvek E, DeLaughter K, White L, King HA, Henderson B, Vega R, Damschroder L. Implementation and sustainment of diverse practices in a large integrated health system: a mixed methods study. Implement Sci Commun 2020; 1:61. [PMID: 32885216 PMCID: PMC7427879 DOI: 10.1186/s43058-020-00053-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 06/18/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND One goal of health systems seeking to evolve into learning health systems is to accelerate the implementation and sustainment of evidence-based practices (EBPs). As part of this evolution, the Veterans Health Administration (VHA) developed the Innovation Ecosystem, which includes the Diffusion of Excellence (DoE), a program that identifies and diffuses Gold Status Practices (GSPs) across facilities. The DoE hosts an annual "Shark Tank" competition in which leaders bid on the opportunity to implement a GSP with 6 months of implementation support. Over 750 diverse practices were submitted in cohorts 2 and 3 of Shark Tank; 23 were designated GSPs and were implemented in 31 VA networks or facilities. As part of a national evaluation of the DoE, we identified factors contributing to GSP implementation and sustainment. METHODS Our sequential mixed methods evaluation of cohorts 2 and 3 of Shark Tank included semi-structured interviews with at least one representative from 30/31 implementing teams (N = 78/105 people invited) and survey responses from 29/31 teams (N = 39/47 invited). Interviews focused on factors influencing implementation and future sustainment. Surveys focused on sustainment 1.5-2 years after implementation. The Consolidated Framework for Implementation Research (CFIR) informed data collection and directed content analysis. Ordinal scales were developed inductively to rank implementation and sustainment outcomes. RESULTS Over 50% of teams (17/30) successfully implemented their GSP within the 6-month implementation period. Despite extensive implementation support, significant barriers related to centralized decision-making, staffing, and resources led to partial (n = 6) or no (n = 7) implementation for the remaining teams. While 12/17 initially successful implementation teams reported sustained use of their GSP, over half of the initially unsuccessful teams (n = 7/13) also reported sustained GSP use 1.5 years after the initial implementation period. When asked at 6 months, 18/27 teams with complete data accurately anticipated their future sustainability based on reported sustainment an average of 1.5 years later. CONCLUSIONS Most teams implemented within 6 months and/or sustained their GSP 1.5 years later. High levels of implementation and sustainment across diverse practices and teams suggest that VHA's DoE is a successful large-scale model of diffusion. Team predictions about sustainability after the first 6 months of implementation provide a promising early assessment and point of intervention to increase sustainability.
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Affiliation(s)
- Andrea L. Nevedal
- Center for Innovation to Implementation, VHA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025 USA
| | - Caitlin M. Reardon
- Center for Clinical Management Research, VHA Ann Arbor Healthcare System, 2215 Fuller Rd., 152, Ann Arbor, MI 48105 USA
| | - George L. Jackson
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VHA Health Care System, HSR&D (152) Suite 600, 411 West Chapel Hill Street, Durham, NC 27701 USA
- Department of Population Health Sciences and Division of General Internal Medicine, Duke University School of Medicine, 215 Morris Street, Durham, NC 27701 USA
| | - Sarah L. Cutrona
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VHA Medical Centers, 200 Springs Road (152), Building 70, Bedford, MA 01730 USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, The Albert Sherman Center, Worcester, MA 01605 USA
| | - Brandolyn White
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VHA Health Care System, HSR&D (152) Suite 600, 411 West Chapel Hill Street, Durham, NC 27701 USA
| | - Allen L. Gifford
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VHA Medical Centers, 200 Springs Road (152), Building 70, Bedford, MA 01730 USA
- Section of General Internal Medicine & Department of Health Law, Policy & Management, Boston University, 715 Albany St., Talbot Building, T2W, Boston, MA 02118 USA
| | - Elizabeth Orvek
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VHA Medical Centers, 200 Springs Road (152), Building 70, Bedford, MA 01730 USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, The Albert Sherman Center, Worcester, MA 01605 USA
| | - Kathryn DeLaughter
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VHA Medical Centers, 200 Springs Road (152), Building 70, Bedford, MA 01730 USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, The Albert Sherman Center, Worcester, MA 01605 USA
| | - Lindsay White
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VHA Medical Centers, 200 Springs Road (152), Building 70, Bedford, MA 01730 USA
| | - Heather A. King
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VHA Health Care System, HSR&D (152) Suite 600, 411 West Chapel Hill Street, Durham, NC 27701 USA
- Department of Population Health Sciences and Division of General Internal Medicine, Duke University School of Medicine, 215 Morris Street, Durham, NC 27701 USA
| | - Blake Henderson
- Diffusion of Excellence, VHA Innovation Ecosystem, 810 Vermont Avenue NW, Washington, DC, 20420 USA
| | - Ryan Vega
- VHA Office of Discovery, Education and Affiliate Networks, 810 Vermont Avenue NW, Washington, DC, 20420 USA
| | - Laura Damschroder
- Center for Clinical Management Research, VHA Ann Arbor Healthcare System, 2215 Fuller Rd., 152, Ann Arbor, MI 48105 USA
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28
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Voils CI, King HA, Thorpe CT, Blalock DV, Kronish IM, Reeve BB, Boatright C, Gellad ZF. Content Validity and Reliability of a Self-Report Measure of Medication Nonadherence in Hepatitis C Treatment. Dig Dis Sci 2019; 64:2784-2797. [PMID: 31037593 DOI: 10.1007/s10620-019-05621-7] [Citation(s) in RCA: 14] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 04/08/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND Nonadherence to direct-acting agents (DAAs) for hepatitis C (HCV) decreases viral response. To measure nonadherence to DAAs, a reliable, valid, and easily implemented method is needed. AIMS The goals of this study were to refine a previously validated (in patients with hypertension) self-report measure of extent of nonadherence and reasons for nonadherence in the context of DAAs and to obtain initial evidence of content validity and reliability. METHODS Phase I involved two focus groups with patients with HCV (n = 12) and one focus group with prescribers of HCV medications (n = 6) to establish content validity of reasons for nonadherence. Subsequent cognitive interviews with patients (n = 11) were conducted to refine items. Phase II was a prospective cohort study involving weekly administration of the refined measure by telephone to patients (n = 75) who are prescribed DAAs to evaluate reliability and consistency with viral response. RESULTS In the cohort study, internal consistency ranged from acceptable (α = .69) to very high (α = 1.00) across time points and was quite high on average (α = .91). Across the 75 participants, there were 895 measurement occasions; of those, nonadherence was reported on only 27 occasions (3%), all of which occurred in the first 12 weeks. These 27 occasions represented 19 (26%) different individuals. At 12 weeks, 1 (1%) of patients had a detectable HCV viral load; at 12-24 weeks posttreatment, 4 (5%) had a sustained viral response. Nonadherent patients reported an average of 1.41 reasons for nonadherence. CONCLUSIONS This multi-method study established content validity of reasons for nonadherence and reliability of extent of nonadherence. High rates of adherence and viral response were consistent with previous studies using other nonadherence measurement methods.
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Affiliation(s)
- Corrine I Voils
- William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, WI, 53705, USA. .,Department of Surgery, University of Wisconsin School of Medicine and Public Health, K6/100 Clinical Science Center, 600 Highland Ave, Madison, WI, 53792, USA.
| | - Heather A King
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 411 W. Chapel Hill St., Suite 600, Durham, NC, 27701, USA.,Department of Population and Health Sciences, Duke University Medical Center, Duke Box 104023, 2200 West Main St, Office #771, Durham, NC, 27705, USA.,Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, 27599, USA
| | - Dan V Blalock
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 411 W. Chapel Hill St., Suite 600, Durham, NC, 27701, USA.,Department of Psychiatry, Duke University Medical Center, Durham, NC, USA
| | - Ian M Kronish
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th Street, PH9-311, New York, NY, 10032, USA
| | - Bryce B Reeve
- Department of Population and Health Sciences, Duke University Medical Center, Duke Box 104023, 2200 West Main St, Office #771, Durham, NC, 27705, USA
| | - Colleen Boatright
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 411 W. Chapel Hill St., Suite 600, Durham, NC, 27701, USA
| | - Ziad F Gellad
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 411 W. Chapel Hill St., Suite 600, Durham, NC, 27701, USA.,Duke Clinical Research Institute, 2400 Pratt Street, Rm 0311 Terrace Level, Durham, NC, 27705, USA
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29
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Van Houtven CH, Smith VA, Lindquist JH, Chapman JG, Hendrix C, Hastings SN, Oddone EZ, King HA, Shepherd-Banigan M, Weinberger M. Family Caregiver Skills Training to Improve Experiences of Care: a Randomized Clinical Trial. J Gen Intern Med 2019; 34:2114-2122. [PMID: 31388914 PMCID: PMC6816649 DOI: 10.1007/s11606-019-05209-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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: 08/27/2018] [Revised: 04/03/2019] [Accepted: 06/14/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of Helping Invested Families Improve Veterans' Experiences Study (HI-FIVES), a skills training program for caregivers of persons with functional or cognitive impairments. DESIGN A two-arm RCT. SETTING Single Veterans Affairs Medical Center. PARTICIPANTS Patients and their primary caregivers referred in the past 6 months to home and community-based services or geriatrics clinic. INTERVENTION All caregivers received usual care. Caregivers in HI-FIVES also received five training calls and four group training sessions. MAIN MEASURES Cumulative patient days at home 12 months post-randomization, defined as days not in an emergency department, inpatient hospital, or post-acute facility. Secondary outcomes included patients' total VA health care costs, caregiver and patient rating of the patient's experience of VA health care, and caregiver depressive symptoms. RESULTS Of 241 dyads, caregivers' (patients') mean age was 61 (73) years, 54% (53%) Black and 89% (4%) female. HI-FIVES was associated with a not statistically significant 9% increase in the rate of days at home (95% CI 0.72, 1.65; mean difference 1 day over 12 months). No significant differences were observed in health care costs or caregiver depressive symptoms. Model-estimated mean baseline patient experience of VA care (scale of 0-10) was 8.43 (95% CI 8.16, 8.70); the modeled mean difference between HI-FIVES and controls at 3 months was 0.29 (p = .27), 0.31 (p = 0.26) at 6 months, and 0.48 (p = 0.03) at 12 months. For caregivers, it was 8.34 (95% CI 8.10, 8.57); the modeled mean difference at 3 months was 0.28 (p = .18), 0.53 (p < .01) at 6 months, and 0.46 (p = 0.054) at 12 months. CONCLUSIONS HI-FIVES did not increase patients' days at home; it showed sustained improvements in caregivers' and patients' experience of VA care at clinically significant levels, nearly 0.5 points. The training holds promise in increasing an important metric of care quality-reported experience with care.
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Affiliation(s)
- Courtney Harold Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA.
- Department of Population Health Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA.
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA.
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jennifer H Lindquist
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA
| | - Jennifer G Chapman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA
| | - Cristina Hendrix
- School of Nursing, Duke University Medical Center, 307 Trent Drive, Box 102400, Durham, NC, 27710, USA
- Geriatric Research, Education and Clinical Center, Durham VA Medical Center, Durham, NC, USA
| | - Susan Nicole Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Geriatric Research, Education and Clinical Center, Durham VA Medical Center, Durham, NC, USA
- Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA
| | - Eugene Z Oddone
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Heather A King
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1101A McGavran-Greenberg Hall, Campus Box 7411, Chapel Hill, NC, 27599, USA
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Done N, Oh DH, Weinstock MA, Whited JD, Jackson GL, King HA, Peracca SB, Elwy AR, Prentice JC. VA Telederm study: protocol for a stepped-wedge cluster randomised trial to compare access to care for a mobile app versus a workstation-based store-and-forward teledermatology process. BMJ Open 2018; 8:e022218. [PMID: 30552249 PMCID: PMC6303588 DOI: 10.1136/bmjopen-2018-022218] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Teledermatology has emerged as an important strategy to enhance access to high-quality skin care. VA Telederm is a provider-facing, web-based mobile app designed to integrate into the existing teledermatology workflow in the US Veterans Health Administration (VHA). In this study, we will conduct a systematic evaluation of VA Telederm on access outcomes in VHA facilities using a pragmatic trial guided by clinical and operational leaders. METHODS AND ANALYSIS The study is a prospective, stepped-wedge cluster randomised trial with cross-sectional exposure and outcome measurement via retrospective database analysis of administrative records. Each cluster is a VHA facility deemed eligible for the trial. We assign the intervention using a cluster-level balanced randomisation scheme based on facility size, baseline teledermatology uptake and geographic location. The trial will test whether patients receiving dermatological care at participating facilities will have better access compared with patients receiving care through the current standard process. The primary outcomes proxy for patient-level access to dermatology services, including (1) consult completion time for teledermatology consults; (2) appointment completion time for new dermatology consults; and (3) travel distance for dermatology services. As secondary outcomes, we will assess facility-level adoption outcomes, that is, the number of dermatology encounters and the proportion of teledermatology consults out of all dermatology encounters. To account for secular trends in outcomes and for correlation across individuals within clusters, we will assess the impact of the intervention using generalised linear mixed regression models. DISCUSSION Streamlining the current practice for store-and-forward teledermatology in the VHA can improve access to expert dermatological care for US veterans. The lessons learnt in this trial could validate the use of mobile technology for consultative store-and-forward dermatology in a large healthcare organisation. The results may also be of interest to other medical specialties assessing the merits of implementing mobile telehealth. PROTOCOL VERSION Version 3; 7 November 2018. TRIAL REGISTRATION NUMBER NCT03241589; Pre-results.
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Affiliation(s)
- Nicolae Done
- US Department of Veterans Affairs, Center for Access Policy, Evaluation and Research, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Dennis H Oh
- Department of Research and Development, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | - Martin A Weinstock
- Center for Dermatoepidemiology, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - John D Whited
- Durham Veterans Affairs Medical Centre, Duke University, Durham, North Carolina, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - George L Jackson
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Heather A King
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Sara B Peracca
- Department of Research and Development, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - A Rani Elwy
- Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
- Department of Veterans Affairs Boston Medical Center, Center for Healthcare Organization and Implementation Research, Boston, Massachusetts, USA
| | - Julia C Prentice
- US Department of Veterans Affairs, Center for Access Policy, Evaluation and Research, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
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Moss JM, Bryan WE, Wilkerson LM, King HA, Jackson GL, Owenby RK, Van Houtven CH, Stevens MB, Powers J, Vaughan CP, Hung WW, Hwang U, Markland AD, Sloane R, Knaack W, Hastings SN. An Interdisciplinary Academic Detailing Approach to Decrease Inappropriate Medication Prescribing by Physician Residents for Older Veterans Treated in the Emergency Department. J Pharm Pract 2017; 32:167-174. [PMID: 29277130 DOI: 10.1177/0897190017747424] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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
OBJECTIVE To evaluate the impact of an academic detailing intervention delivered as part of a quality improvement project by a physician-pharmacist pair on (1) self-reported confidence in prescribing for older adults and (2) rates of potentially inappropriate medications (PIMs) prescribed to older adults by physician residents in a Veteran Affairs emergency department (ED). METHODS This quality improvement project at a single site utilized a questionnaire that assessed knowledge of Beers Criteria, self-perceived barriers to appropriate prescribing in older adults, and self-rated confidence in ability to prescribe in older adults which was administered to physician residents before and after academic detailing delivered during their emergency medicine rotation. PIM rates in the resident cohort who received the academic detailing were compared to residents who did not receive the intervention. RESULTS Sixty-three residents received the intervention between February 2013 and December 2014. At baseline, approximately 50% of the residents surveyed reported never hearing about nor using the Beers Criteria. A significantly greater proportion of residents agreed or strongly agreed in their abilities to identify drug-disease interactions and to prescribe the appropriate medication for the older adult after receiving the intervention. The resident cohort who received the educational intervention was less likely to prescribe a PIM when compared to the untrained resident cohort with a rate ratio of 0.73 ( P < .0001). CONCLUSION Academic detailing led by a physician-pharmacist pair resulted in improved confidence in physician residents' ability to prescribe safely in an older adult ED population and was associated with a statistically significant decrease in PIM rates.
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Affiliation(s)
- Jason M Moss
- 1 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, NC, USA.,2 Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, USA
| | - William E Bryan
- 3 Pharmacy Service, Veterans Affairs Health Care System, Durham, NC, USA
| | - Loren M Wilkerson
- 4 Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Heather A King
- 5 Center for Health Services Research in Primary Care, Veterans Affairs Health Care System, Durham, NC, USA.,6 Duke University School of Medicine, Durham, NC, USA
| | - George L Jackson
- 5 Center for Health Services Research in Primary Care, Veterans Affairs Health Care System, Durham, NC, USA.,6 Duke University School of Medicine, Durham, NC, USA
| | - Ryan K Owenby
- 3 Pharmacy Service, Veterans Affairs Health Care System, Durham, NC, USA
| | - Courtney H Van Houtven
- 5 Center for Health Services Research in Primary Care, Veterans Affairs Health Care System, Durham, NC, USA.,6 Duke University School of Medicine, Durham, NC, USA
| | - Melissa B Stevens
- 7 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Atlanta/Decatur, GA, USA.,8 Emory University School of Medicine, Atlanta/Decatur, GA, USA
| | - James Powers
- 9 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Nashville, TN, USA.,10 Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Camille P Vaughan
- 7 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Atlanta/Decatur, GA, USA.,8 Emory University School of Medicine, Atlanta/Decatur, GA, USA
| | - William W Hung
- 11 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Bronx, NY, USA.,12 Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
| | - Ula Hwang
- 11 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Bronx, NY, USA.,12 Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
| | | | - Richard Sloane
- 1 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, NC, USA.,14 Department of Duke Aging Center, Duke University Medical Center, Durham, NC, USA
| | - William Knaack
- 15 Division of General Internal Medicine, Veterans Affairs Health Care System, Durham, NC, USA
| | - Susan Nicole Hastings
- 1 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, NC, USA.,5 Center for Health Services Research in Primary Care, Veterans Affairs Health Care System, Durham, NC, USA.,6 Duke University School of Medicine, Durham, NC, USA
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Nieuwsma JA, King HA, Jackson GL, Bidassie B, Wright LW, Cantrell WC, Bates MJ, Rhodes JE, White BS, Gatewood SJL, Meador KG. Implementing Integrated Mental Health and Chaplain Care in a National Quality Improvement Initiative. Psychiatr Serv 2017; 68:1213-1215. [PMID: 29191144 PMCID: PMC5726535 DOI: 10.1176/appi.ps.201700397] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This column describes the development, implementation, and outcomes of a quality improvement learning collaborative that aimed to better integrate chaplaincy with mental health care services at 14 participating health care facilities evenly distributed across the U.S. Department of Veterans Affairs and Department of Defense. Teams of health care chaplains and mental health professionals from participating sites sought to improve cross-disciplinary service integration in six key domains: screening, referrals, assessment, communication and documentation, cross-disciplinary training, and role clarification. Chaplains and mental health providers across all facilities at participating sites were significantly more likely post-collaboration to report having a clear understanding of how to collaborate and to report using a routine process for screening patients who could benefit from seeing a professional from the other discipline. Foundational efforts to enhance cross-disciplinary awareness and screening practices between chaplains and mental health professionals appear particularly promising.
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Affiliation(s)
- Jason A Nieuwsma
- Dr. Nieuwsma, Dr. King, Dr. Jackson, Dr. Bidassie, Ms. Wright, Rev. Cantrell, Ms. White, and Dr. Meador are with the U.S. Department of Veterans Affairs (VA). Dr. Nieuwsma, Dr. King, and Dr. Jackson are also with Duke University Medical Center, Durham, North Carolina, and Dr. Meador is also with Vanderbilt University, Nashville, Tennessee. Dr. Bates, Dr. Rhodes, and Ms. Gatewood are with the Department of Defense (DoD), Arlington, Virginia
| | - Heather A King
- Dr. Nieuwsma, Dr. King, Dr. Jackson, Dr. Bidassie, Ms. Wright, Rev. Cantrell, Ms. White, and Dr. Meador are with the U.S. Department of Veterans Affairs (VA). Dr. Nieuwsma, Dr. King, and Dr. Jackson are also with Duke University Medical Center, Durham, North Carolina, and Dr. Meador is also with Vanderbilt University, Nashville, Tennessee. Dr. Bates, Dr. Rhodes, and Ms. Gatewood are with the Department of Defense (DoD), Arlington, Virginia
| | - George L Jackson
- Dr. Nieuwsma, Dr. King, Dr. Jackson, Dr. Bidassie, Ms. Wright, Rev. Cantrell, Ms. White, and Dr. Meador are with the U.S. Department of Veterans Affairs (VA). Dr. Nieuwsma, Dr. King, and Dr. Jackson are also with Duke University Medical Center, Durham, North Carolina, and Dr. Meador is also with Vanderbilt University, Nashville, Tennessee. Dr. Bates, Dr. Rhodes, and Ms. Gatewood are with the Department of Defense (DoD), Arlington, Virginia
| | - Balmatee Bidassie
- Dr. Nieuwsma, Dr. King, Dr. Jackson, Dr. Bidassie, Ms. Wright, Rev. Cantrell, Ms. White, and Dr. Meador are with the U.S. Department of Veterans Affairs (VA). Dr. Nieuwsma, Dr. King, and Dr. Jackson are also with Duke University Medical Center, Durham, North Carolina, and Dr. Meador is also with Vanderbilt University, Nashville, Tennessee. Dr. Bates, Dr. Rhodes, and Ms. Gatewood are with the Department of Defense (DoD), Arlington, Virginia
| | - Laura W Wright
- Dr. Nieuwsma, Dr. King, Dr. Jackson, Dr. Bidassie, Ms. Wright, Rev. Cantrell, Ms. White, and Dr. Meador are with the U.S. Department of Veterans Affairs (VA). Dr. Nieuwsma, Dr. King, and Dr. Jackson are also with Duke University Medical Center, Durham, North Carolina, and Dr. Meador is also with Vanderbilt University, Nashville, Tennessee. Dr. Bates, Dr. Rhodes, and Ms. Gatewood are with the Department of Defense (DoD), Arlington, Virginia
| | - William C Cantrell
- Dr. Nieuwsma, Dr. King, Dr. Jackson, Dr. Bidassie, Ms. Wright, Rev. Cantrell, Ms. White, and Dr. Meador are with the U.S. Department of Veterans Affairs (VA). Dr. Nieuwsma, Dr. King, and Dr. Jackson are also with Duke University Medical Center, Durham, North Carolina, and Dr. Meador is also with Vanderbilt University, Nashville, Tennessee. Dr. Bates, Dr. Rhodes, and Ms. Gatewood are with the Department of Defense (DoD), Arlington, Virginia
| | - Mark J Bates
- Dr. Nieuwsma, Dr. King, Dr. Jackson, Dr. Bidassie, Ms. Wright, Rev. Cantrell, Ms. White, and Dr. Meador are with the U.S. Department of Veterans Affairs (VA). Dr. Nieuwsma, Dr. King, and Dr. Jackson are also with Duke University Medical Center, Durham, North Carolina, and Dr. Meador is also with Vanderbilt University, Nashville, Tennessee. Dr. Bates, Dr. Rhodes, and Ms. Gatewood are with the Department of Defense (DoD), Arlington, Virginia
| | - Jeffrey E Rhodes
- Dr. Nieuwsma, Dr. King, Dr. Jackson, Dr. Bidassie, Ms. Wright, Rev. Cantrell, Ms. White, and Dr. Meador are with the U.S. Department of Veterans Affairs (VA). Dr. Nieuwsma, Dr. King, and Dr. Jackson are also with Duke University Medical Center, Durham, North Carolina, and Dr. Meador is also with Vanderbilt University, Nashville, Tennessee. Dr. Bates, Dr. Rhodes, and Ms. Gatewood are with the Department of Defense (DoD), Arlington, Virginia
| | - Brandolyn S White
- Dr. Nieuwsma, Dr. King, Dr. Jackson, Dr. Bidassie, Ms. Wright, Rev. Cantrell, Ms. White, and Dr. Meador are with the U.S. Department of Veterans Affairs (VA). Dr. Nieuwsma, Dr. King, and Dr. Jackson are also with Duke University Medical Center, Durham, North Carolina, and Dr. Meador is also with Vanderbilt University, Nashville, Tennessee. Dr. Bates, Dr. Rhodes, and Ms. Gatewood are with the Department of Defense (DoD), Arlington, Virginia
| | - Shannon J L Gatewood
- Dr. Nieuwsma, Dr. King, Dr. Jackson, Dr. Bidassie, Ms. Wright, Rev. Cantrell, Ms. White, and Dr. Meador are with the U.S. Department of Veterans Affairs (VA). Dr. Nieuwsma, Dr. King, and Dr. Jackson are also with Duke University Medical Center, Durham, North Carolina, and Dr. Meador is also with Vanderbilt University, Nashville, Tennessee. Dr. Bates, Dr. Rhodes, and Ms. Gatewood are with the Department of Defense (DoD), Arlington, Virginia
| | - Keith G Meador
- Dr. Nieuwsma, Dr. King, Dr. Jackson, Dr. Bidassie, Ms. Wright, Rev. Cantrell, Ms. White, and Dr. Meador are with the U.S. Department of Veterans Affairs (VA). Dr. Nieuwsma, Dr. King, and Dr. Jackson are also with Duke University Medical Center, Durham, North Carolina, and Dr. Meador is also with Vanderbilt University, Nashville, Tennessee. Dr. Bates, Dr. Rhodes, and Ms. Gatewood are with the Department of Defense (DoD), Arlington, Virginia
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Kinsinger LS, Anderson C, Kim J, Larson M, Chan SH, King HA, Rice KL, Slatore CG, Tanner NT, Pittman K, Monte RJ, McNeil RB, Grubber JM, Kelley MJ, Provenzale D, Datta SK, Sperber NS, Barnes LK, Abbott DH, Sims KJ, Whitley RL, Wu RR, Jackson GL. Implementation of Lung Cancer Screening in the Veterans Health Administration. JAMA Intern Med 2017; 177:399-406. [PMID: 28135352 DOI: 10.1001/jamainternmed.2016.9022] [Citation(s) in RCA: 241] [Impact Index Per Article: 34.4] [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: 12/14/2022]
Abstract
IMPORTANCE The US Preventive Services Task Force recommends annual lung cancer screening (LCS) with low-dose computed tomography for current and former heavy smokers aged 55 to 80 years. There is little published experience regarding implementing this recommendation in clinical practice. OBJECTIVES To describe organizational- and patient-level experiences with implementing an LCS program in selected Veterans Health Administration (VHA) hospitals and to estimate the number of VHA patients who may be candidates for LCS. DESIGN, SETTING, AND PARTICIPANTS This clinical demonstration project was conducted at 8 academic VHA hospitals among 93 033 primary care patients who were assessed on screening criteria; 2106 patients underwent LCS between July 1, 2013, and June 30, 2015. INTERVENTIONS Implementation Guide and support, full-time LCS coordinators, electronic tools, tracking database, patient education materials, and radiologic and nodule follow-up guidelines. MAIN OUTCOMES AND MEASURES Description of implementation processes; percentages of patients who agreed to undergo LCS, had positive findings on results of low-dose computed tomographic scans (nodules to be tracked or suspicious findings), were found to have lung cancer, or had incidental findings; and estimated number of VHA patients who met the criteria for LCS. RESULTS Of the 4246 patients who met the criteria for LCS, 2452 (57.7%) agreed to undergo screening and 2106 (2028 men and 78 women; mean [SD] age, 64.9 [5.1] years) underwent LCS. Wide variation in processes and patient experiences occurred among the 8 sites. Of the 2106 patients screened, 1257 (59.7%) had nodules; 1184 of these patients (56.2%) required tracking, 42 (2.0%) required further evaluation but the findings were not cancer, and 31 (1.5%) had lung cancer. A variety of incidental findings, such as emphysema, other pulmonary abnormalities, and coronary artery calcification, were noted on the scans of 857 patients (40.7%). CONCLUSIONS AND RELEVANCE It is estimated that nearly 900 000 of a population of 6.7 million VHA patients met the criteria for LCS. Implementation of LCS in the VHA will likely lead to large numbers of patients eligible for LCS and will require substantial clinical effort for both patients and staff.
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Affiliation(s)
- Linda S Kinsinger
- Veterans Health Administration National Center for Health Promotion and Disease Prevention, Durham, North Carolina
| | - Charles Anderson
- Veterans Health Administration National Radiology Program Office, Durham, North Carolina
| | - Jane Kim
- Veterans Health Administration National Center for Health Promotion and Disease Prevention, Durham, North Carolina
| | - Martha Larson
- Veterans Health Administration National Center for Health Promotion and Disease Prevention, Durham, North Carolina
| | - Stephanie H Chan
- Veterans Health Administration National Center for Health Promotion and Disease Prevention, Durham, North Carolina
| | - Heather A King
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Kathryn L Rice
- Department of Medicine, Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota
| | - Christopher G Slatore
- Department of Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Nichole T Tanner
- Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina
| | - Kathleen Pittman
- Veterans Health Administration National Center for Health Promotion and Disease Prevention, Durham, North Carolina
| | - Robert J Monte
- Pittsburgh Veterans Engineering Resource Center, Pittsburgh, Pennsylvania
| | - Rebecca B McNeil
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Janet M Grubber
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Michael J Kelley
- Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Veterans Health Administration National Oncology Program, Durham, North Carolina
| | - Dawn Provenzale
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Santanu K Datta
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Nina S Sperber
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Lottie K Barnes
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina
| | - David H Abbott
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina
| | - Kellie J Sims
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina
| | - Richard L Whitley
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina
| | - R Ryanne Wu
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - George L Jackson
- Durham Veterans Affairs Health Services Research and Development Center of Innovation, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina
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Crowley MJ, Olsen MK, Woolson SL, King HA, Oddone EZ, Bosworth HB. Baseline Antihypertensive Drug Count and Patient Response to Hypertension Medication Management. J Clin Hypertens (Greenwich) 2016; 18:322-8. [PMID: 26370918 PMCID: PMC4792789 DOI: 10.1111/jch.12669] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 07/24/2015] [Accepted: 07/26/2015] [Indexed: 12/20/2022]
Abstract
Telemedicine-based medication management improves hypertension control, but has been evaluated primarily in patients with low antihypertensive drug counts. Its impact on patients taking three or more antihypertensive agents is not well-established. To address this evidence gap, the authors conducted an exploratory analysis of an 18-month, 591-patient trial of telemedicine-based hypertension medication management. Using general linear models, the effect of medication management on blood pressure for patients taking two or fewer antihypertensive agents at study baseline vs those taking three or more was compared. While patients taking two or fewer antihypertensive agents had a significant reduction in systolic blood pressure with medication management, those taking three or more had no such response. The between-subgroup effect difference was statistically significant at 6 months (-6.4 mm Hg [95% confidence interval, -12.2 to -0.6]) and near significant at 18 months (-6.0 mm Hg [95% confidence interval, -12.2 to 0.2]). These findings suggest that baseline antihypertensive drug count may impact how patients respond to hypertension medication management and emphasize the need to study management strategies specifically in patients taking three or more antihypertensive medications.
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Affiliation(s)
- Matthew J. Crowley
- Center for Health Services Research in Primary CareDurham VA Medical CenterDurhamNC
- Division of Endocrinology, Diabetes, and MetabolismDepartment of MedicineDuke UniversityDurhamNC
| | - Maren K. Olsen
- Center for Health Services Research in Primary CareDurham VA Medical CenterDurhamNC
- Department of Biostatistics and BioinformaticsDuke University Medical CenterDurhamNC
| | - Sandra L. Woolson
- Center for Health Services Research in Primary CareDurham VA Medical CenterDurhamNC
| | - Heather A. King
- Center for Health Services Research in Primary CareDurham VA Medical CenterDurhamNC
- Division of General Internal MedicineDepartment of MedicineDuke UniversityDurhamNC
| | - Eugene Z. Oddone
- Center for Health Services Research in Primary CareDurham VA Medical CenterDurhamNC
- Division of General Internal MedicineDepartment of MedicineDuke UniversityDurhamNC
| | - Hayden B. Bosworth
- Center for Health Services Research in Primary CareDurham VA Medical CenterDurhamNC
- Division of General Internal MedicineDepartment of MedicineDuke UniversityDurhamNC
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Gallagher P, King HA, Haga SB, Orlando LA, Joy SV, Trujillo GM, Scott WM, Bembe M, Creighton DL, Cho AH, Ginsburg GS, Vorderstrasse A. Patient beliefs and behaviors about genomic risk for type 2 diabetes: implications for prevention. J Health Commun 2015; 20:728-735. [PMID: 25844569 DOI: 10.1080/10810730.2015.1018563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Type 2 diabetes is a major health burden in the United States, and population trends suggest this burden will increase. High interest in, and increased availability of, testing for genetic risk of type 2 diabetes presents a new opportunity for reducing type 2 diabetes risk for many patients; however, to date, there is little evidence that genetic testing positively affects type 2 diabetes prevention. Genetic information may not fit patients' illness representations, which may reduce the chances of risk-reducing behavior changes. The present study aimed to examine illness representations in a clinical sample who are at risk for type 2 diabetes and interested in genetic testing. The authors used the Common Sense Model to analyze survey responses of 409 patients with type 2 diabetes risk factors. Patients were interested in genetic testing for type 2 diabetes risk and believed in its importance. Most patients believed that genetic factors are important to developing type 2 diabetes (67%), that diet and exercise are effective in preventing type 2 diabetes (95%), and that lifestyle changes are more effective than drugs (86%). Belief in genetic causality was not related to poorer self-reported health behaviors. These results suggest that patients' interest in genetic testing for type 2 diabetes might produce a teachable moment that clinicians can use to counsel behavior change.
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McVay MA, King HA, Jeffreys AS, Coffman CJ, Voils CI. Mechanisms of patient health behavior change in a randomized controlled trial of a spouse-assisted intervention. PSYCHOL HEALTH MED 2015; 20:753-66. [PMID: 25774698 DOI: 10.1080/13548506.2015.1020817] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Spouse-assisted interventions can improve health behaviors, but mechanisms of action are unknown. This study evaluated mediators of dietary and physical activity outcomes during a spouse-assisted intervention to improve low-density lipoprotein cholesterol. This is a secondary analysis of data from a randomized controlled trial comparing usual care (n = 128) to a spouse-assisted lifestyle change intervention (n = 127) comprising nine monthly goal setting telephone calls to participants and support planning calls to spouses over 11 months. Structural equation modeling was used to examine if the intervention influenced the putative mediators of participant self-efficacy and perceived spousal support at 6 months (i.e. action test); if changes in putative mediators at 6 months were associated with changes in diet and physical activity outcomes at 11 months (i.e. conceptual test); and if treatment condition effects on outcomes at 11 months were mediated by its effects on the 6-month putative mediators (i.e. indirect effects test). Participants were 94.9% male, 64.9% white and were 61.3 years old on average. The action test showed that the intervention increased dietary self-efficacy (p < .001) and perceived spousal support for diet (p < .001) and physical activity (p < .01) at 6 months. The conceptual test showed that increases in participant physical activity self-efficacy at 6 months were associated with increases in physical activity frequency (p = .01) and duration (p = .04) at 11 months; other putative mediators were not associated with changes in outcomes at 11 months. The indirect effects tests did not support a mediating role for self-efficacy or perceived spousal support. Intervention-induced changes in spousal support and dietary self-efficacy did not translate into behavior change. Other mechanisms may be driving behavior change.
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Affiliation(s)
- Megan A McVay
- a Center for Health Services Research in Primary Care , Durham VA Medical Center , Durham , NC 27705 , USA
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Wu RR, Kinsinger LS, Provenzale D, King HA, Akerly P, Barnes LK, Datta SK, Grubber JM, Katich N, McNeil RB, Monte R, Sperber NR, Atkins D, Jackson GL. Implementation of new clinical programs in the VHA healthcare system: the importance of early collaboration between clinical leadership and research. J Gen Intern Med 2014; 29 Suppl 4:825-30. [PMID: 25355086 PMCID: PMC4239283 DOI: 10.1007/s11606-014-3026-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [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] [Indexed: 11/25/2022]
Abstract
Collaboration between policy, research, and clinical partners is crucial to achieving proven quality care. The Veterans Health Administration has expended great efforts towards fostering such collaborations. Through this, we have learned that an ideal collaboration involves partnership from the very beginning of a new clinical program, so that the program is designed in a way that ensures quality, validity, and puts into place the infrastructure necessary for a reliable evaluation. This paper will give an example of one such project, the Lung Cancer Screening Demonstration Project (LCSDP). We will outline the ways that clinical, policy, and research partners collaborated in design, planning, and implementation in order to create a sustainable model that could be rigorously evaluated for efficacy and fidelity. We will describe the use of the Donabedian quality matrix to determine the necessary characteristics of a quality program and the importance of the linkage with engineering, information technology, and clinical paradigms to connect the development of an on-the-ground clinical program with the evaluation goal of a learning healthcare organization. While the LCSDP is the example given here, these partnerships and suggestions are salient to any healthcare organization seeking to implement new scientifically proven care in a useful and reliable way.
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Affiliation(s)
- R Ryanne Wu
- Health Services Research & Development (HSR&D) Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, HSR&D Services (152), 508 Fulton Street, Durham, NC, 27705, USA,
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Sperber NR, King HA, Steinhauser K, Ammarell N, Danus S, Powers BJ. Scheduled telephone visits in the veterans health administration patient-centered medical home. BMC Health Serv Res 2014; 14:145. [PMID: 24690086 PMCID: PMC3976456 DOI: 10.1186/1472-6963-14-145] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 03/18/2014] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The Veterans Health Administration (VHA) patient-centered medical home model, Patient Aligned Care Teams (PACT), includes telephone visits to improve care access and efficiency. Scheduled telephone visits can replace in-person care for some focused issues, and more information is needed to understand how this mode can best work for primary care. We conducted a study at the beginning of PACT implementation to elicit stakeholder views on this mode of healthcare delivery, including potential facilitators and barriers. METHODS We conducted focus groups with primary care patients (n = 3 groups), providers (n = 2 groups) and staff (n = 2 groups). Questions were informed by Donabedian's framework to evaluate and improve healthcare quality. Content analysis and theme matrix techniques were used to explore themes. Content was assigned a positive or negative valuation to indicate whether it was a facilitator or barrier. PACT principles were used as an organizing framework to present stakeholder responses within the context of the VHA patient-centered medical home program. RESULTS Scheduled telephone visits could potentially improve care quality and efficiency, but stakeholders were cautious. Themes were identified relating to the following PACT principles: comprehensiveness, patient-centeredness, and continuity of care. In sum, scheduled telephone visits were viewed as potentially beneficial for routine care not requiring physical examination, and patients and providers suggested using them to evaluate need for in-person care; however, visits would need to be individualized, with patients able to discontinue if not satisfied. Patients and staff asserted that providers would need to be kept in the loop for continuity of care. Additionally, providers and staff emphasized needing protected time for these calls. CONCLUSION These findings inform development of scheduled telephone visits as part of patient-centered medical homes by providing evidence about areas that may be leveraged to most effectively implement this mode of care. Presenting this service as enhanced care, with ability to triage need for in-person clinic visits and consequently provide more frequent contact, may most adequately meet different stakeholder expectations. In this way, scheduled telephone visits may serve as both a substitute for in-person care for certain situations and a supplement to in-person interaction.
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Affiliation(s)
- Nina R Sperber
- Center for Health Services Research in Primary Care, Durham VAMC, Legacy Tower (NC Mutual Building) Suite 600, 411 West Chapel Hill Street, Durham, NC 27701, USA
- Department of Medicine, Division of General Internal Medicine, Duke University, 411 West Chapel Hill Street, Durham, NC 27701, USA
| | - Heather A King
- Center for Health Services Research in Primary Care, Durham VAMC, Legacy Tower (NC Mutual Building) Suite 600, 411 West Chapel Hill Street, Durham, NC 27701, USA
| | - Karen Steinhauser
- Center for Health Services Research in Primary Care, Durham VAMC, Legacy Tower (NC Mutual Building) Suite 600, 411 West Chapel Hill Street, Durham, NC 27701, USA
- Department of Medicine, Division of General Internal Medicine, Duke University, 411 West Chapel Hill Street, Durham, NC 27701, USA
| | - Natalie Ammarell
- Center for Health Services Research in Primary Care, Durham VAMC, Legacy Tower (NC Mutual Building) Suite 600, 411 West Chapel Hill Street, Durham, NC 27701, USA
| | - Susanne Danus
- Center for Health Services Research in Primary Care, Durham VAMC, Legacy Tower (NC Mutual Building) Suite 600, 411 West Chapel Hill Street, Durham, NC 27701, USA
| | - Benjamin J Powers
- Center for Health Services Research in Primary Care, Durham VAMC, Legacy Tower (NC Mutual Building) Suite 600, 411 West Chapel Hill Street, Durham, NC 27701, USA
- St. Luke’s Health System, 190 E Bannock St, Boise, ID 83712, USA
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Barrineau MJ, Zarit SH, King HA, Costanzo ES, Almeida DM. Daily well-being of cancer survivors: the role of somatic amplification. Psychooncology 2014; 23:1027-33. [PMID: 24615865 DOI: 10.1002/pon.3509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 01/18/2014] [Accepted: 01/31/2014] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The current study examined the role that somatic amplification plays in placing cancer survivors at an increased risk of impairments in daily well-being, specifically severity of physical symptoms, positive affect and negative affect. METHODS Participants were drawn from Midlife Development in the United States National Study of daily health and well-being (MIDUS) and the National Study of Daily Experiences (NSDE, Project 2). One hundred eleven individuals with a cancer history were compared with a matched comparison group of individuals who did not have a cancer history. RESULTS Results show that across both groups, somatic amplification is associated with higher negative affect and higher severity of physical symptoms. However, results also show that a somatic amplification by cancer status interaction predicts severity of physical symptoms. The significant interaction indicates that in the comparison group, level of physical symptom severity is the same regardless of whether the individual is high or low on somatic amplification. However, in the group of individuals with a cancer history, individuals who are high on somatic amplification report more severe physical symptoms than individuals who are low on somatic amplification. CONCLUSIONS These findings suggest that heightened attention to minor bodily symptoms impacts individuals with a cancer history differently than individuals who have not experienced cancer, and therefore, may have important implications for the manner in which continued care is provided to cancer survivors.
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Affiliation(s)
- Mary Jon Barrineau
- Department of Human Development and Family Studies, Penn State University, University Park, PA, USA
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Voils CI, King HA, Neelon B, Hoyle RH, Reeve BB, Maciejewski ML, Yancy WS. Characterizing weekly self-reported antihypertensive medication nonadherence across repeated occasions. Patient Prefer Adherence 2014; 8:643-50. [PMID: 24855340 PMCID: PMC4019621 DOI: 10.2147/ppa.s60715] [Citation(s) in RCA: 20] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Little is known about weekly variability in medication nonadherence both between and within persons. PURPOSE To characterize medication nonadherence across repeated, closely spaced occasions. METHODS This prospective cohort study comprised four unannounced telephone assessment occasions, each separated by approximately 2 weeks. On each occasion, adult outpatients taking at least a single antihypertensive medication completed a measure of extent of, and reasons for, nonadherence. RESULTS Two hundred and sixty-one participants completed 871 (83%) of 1,044 occasions. Nonadherence was reported on 152 (17.5%) of 871 occasions by 93 (36%) of 261 participants. The most commonly endorsed reasons for nonadherence were forgetting (39.5%), being busy (23.7%), and traveling (19.7%). Among 219 participants completing at least three occasions, 50% of the variability in extent of nonadherence was a result of within-person fluctuations, and 50% was a result of between-person differences. CONCLUSION Interventions to reduce nonadherence should be informed by variability in the extent of nonadherence and specific reasons for nonadherence.
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Affiliation(s)
- Corrine I Voils
- Health Services Research and Development, Durham Veterans Affairs Medical Center, NC, USA
- Department of Medicine, Duke University, NC, USA
- Correspondence: Corrine I Voils, Durham Veterans Affairs Medical Center, 508 Fulton St (152), Durham, NC 27705, USA, Tel +1 919 286 0411 ext 5196, Fax +1 919 416 5836, Email
| | - Heather A King
- Health Services Research and Development, Durham Veterans Affairs Medical Center, NC, USA
| | - Brian Neelon
- Health Services Research and Development, Durham Veterans Affairs Medical Center, NC, USA
- Department of Medicine, Duke University, NC, USA
| | - Rick H Hoyle
- Department of Psychology and Neuroscience, Duke University, NC, USA
| | - Bryce B Reeve
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, NC, USA
| | - Matthew L Maciejewski
- Health Services Research and Development, Durham Veterans Affairs Medical Center, NC, USA
- Department of Medicine, Duke University, NC, USA
| | - William S Yancy
- Health Services Research and Development, Durham Veterans Affairs Medical Center, NC, USA
- Department of Medicine, Duke University, NC, USA
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McVay MA, Jeffreys AS, King HA, Olsen MK, Voils CI, Yancy WS. The relationship between pretreatment dietary composition and weight loss during a randomised trial of different diet approaches. J Hum Nutr Diet 2013; 28 Suppl 2:16-23. [PMID: 24251378 DOI: 10.1111/jhn.12188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Identifying pretreatment dietary habits that are associated with weight-loss intervention outcomes could help guide individuals' selection of weight-loss approach among competing options. A pretreatment factor that may influence weight-loss outcomes is macronutrient intake. METHODS Overweight and obese Durham Veterans Affairs outpatients were randomised to a weight-loss intervention with a low-carbohydrate diet (n = 71) or orlistat medication therapy plus a low-fat diet (n = 73). Percentage fat, carbohydrate and protein intake prior to treatment were measured using 4-day food records. Linear mixed-effects models were used to determine whether pretreatment percentage macronutrient intake influenced weight trajectories and weight loss in each weight-loss condition. RESULTS Participant's mean age was 53 years, baseline body mass index was 39.3 kg m(-2) and 72% were male. A higher pretreatment percentage carbohydrate intake was associated with less rapid initial weight loss (P = 0.02) and less rapid weight regain (P = 0.03) in the low-carbohydrate diet condition but was not associated with weight trajectories in the orlistat plus low-fat diet condition. In both conditions, a higher pretreatment percentage fat intake was associated with more rapid weight regain (P < 0.01). Pretreatment percentage protein intake was not associated with weight trajectories. None of the pretreatment macronutrients were associated with weight loss on study completion in either condition. CONCLUSIONS Selection of a weight-loss approach on the basis of pretreatment macronutrient intake is unlikely to improve weight outcomes at the end of a 1-year treatment. However, pretreatment macronutrient intake may have implications for tailoring of interventions to slow weight regain after weight loss.
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Affiliation(s)
- M A McVay
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA; Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
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King HA, Trotter KW, Archer TK. Chromatin remodeling during glucocorticoid receptor regulated transactivation. Biochim Biophys Acta 2012; 1819:716-26. [PMID: 22425674 DOI: 10.1016/j.bbagrm.2012.02.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Revised: 02/24/2012] [Accepted: 02/28/2012] [Indexed: 12/21/2022]
Abstract
Steroid hormone receptor (SR) signaling leads to widespread changes in gene expression, and aberrant SR signaling can lead to malignancies including breast, prostate, and lung cancers. Chromatin remodeling is an essential component of SR signaling, and defining the process of chromatin and nucleosome remodeling during signaling is critical to the continued development of related therapies. The glucocorticoid receptor (GR) is a key SR that activates numerous promoters including the well defined MMTV promoter. The activation of MMTV by GR provides an excellent model for teasing apart the sequence of events between hormone treatment and changes in gene expression. Comparing hormone-induced transcription from stably integrated promoters with defined nucleosomal structure to that from transiently expressed, unstructured promoters permits key distinctions between interactions that require remodeling and those that do not. The importance of co-activators and histone modifications prior to remodeling and the formation of the preinitiation complex that follows can also be clarified by defining key transition points in the propagation of hormonal signals. Combined with detailed mapping of proteins along the promoter, a temporal and spatial understanding of the signaling and remodeling processes begins to emerge. In this review, we examine SR signaling with a focus on GR activation of the MMTV promoter. We also discuss the ATP-dependent remodeling complex SWI/SNF, which provides the necessary remodeling activity during GR signaling and interacts with several SRs. BRG1, the central ATPase of SWI/SNF, also interacts with a set of BAF proteins that help determine the specialized function and fine-tuned regulation of BRG1 remodeling activity. BRG1 regulation comes from its own subdomains as well as its interactive partners. In particular, the HSA domain region of BRG1 and unique features of its ATPase homology appear to play key roles in regulating remodeling function. Details of the inter-workings of this chromatin remodeling protein continue to be revealed and promise to improve our understanding of the mechanism of chromatin remodeling during steroid hormone signaling. This article is part of a Special Issue entitled: Chromatin in time and space.
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Affiliation(s)
- Heather A King
- Laboratory of Molecular Carcinogenesis, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC 27709, USA
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King HA, Hoelz A, Crane BR, Young MW. Structure of an enclosed dimer formed by the Drosophila period protein. J Mol Biol 2011; 413:561-72. [PMID: 21907720 DOI: 10.1016/j.jmb.2011.08.048] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Revised: 08/19/2011] [Accepted: 08/23/2011] [Indexed: 11/18/2022]
Abstract
Period (PER) is the major transcription inhibitor in metazoan circadian clocks and lies at the center of several feedback loops that regulate gene expression. Dimerization of Drosophila PER influences nuclear translocation, repressor activity, and behavioral rhythms. The structure of a central, 346-residue PER fragment reveals two associated PAS (Per-Arnt-Sim) domains followed by a protruding α-helical extension (αF). A closed, pseudo-symmetric dimer forms from a cross handshake interaction of the N-terminal PAS domain with αF of the opposing subunit. Strikingly, a shift of αF against the PAS β-sheet generates two alternative subunit interfaces in the dimer. Taken together with a previously reported PER structure in which αF extends, these data indicate that αF unlatches to switch association of PER with itself to its partner Timeless. The variable positions of the αF helix provide snapshots of a helix dissociation mechanism that has relevance to other PAS protein systems. Conservation of PER interaction residues among a family of PAS-AB-containing transcription factors suggests that contacts mediating closed PAS-AB dimers serve a general function.
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Affiliation(s)
- Heather A King
- Laboratory of Genetics, The Rockefeller University, New York, NY 10065, USA
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Cobbold LC, Wilson LA, Sawicka K, King HA, Kondrashov AV, Spriggs KA, Bushell M, Willis AE. Upregulated c-myc expression in multiple myeloma by internal ribosome entry results from increased interactions with and expression of PTB-1 and YB-1. Oncogene 2010; 29:2884-91. [PMID: 20190818 DOI: 10.1038/onc.2010.31] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The 5' untranslated region of the proto-oncogene c-myc contains an internal ribosome entry segment (IRES) and c-myc translation can therefore be initiated by internal ribosome entry as well as by cap-dependent mechanisms. It has been shown previously that in patients with multiple myeloma (MM) and in MM-derived cell lines there is a C to T mutation in the c-myc IRES that increases IRES activity and the corresponding synthesis of c-myc protein although it is not fully understood how this occurs. Our data show that two recently identified c-myc IRES trans-acting factors, Y-box binding protein 1 (YB-1) and polypyrimidine tract-binding protein 1 (PTB-1), bind more strongly (approximately 3.5- and 2-fold respectively) to the mutated version of the c-myc IRES and in vitro these proteins exert their effect synergistically to stimulate IRES activity of the mutant IRES 4.5-fold more than the wild-type version. Importantly, we show that there is a strong correlation between the expression of PTB-1, YB-1 and c-myc in MM-derived cell lines, suggesting that by reducing either PTB-1 or YB-1 protein levels it is possible to decrease c-myc expression and inhibit cell proliferation of MM-derived cell lines.
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Affiliation(s)
- L C Cobbold
- Centre for Biomolecular Sciences, School of Pharmacy, University of Nottingham, Nottingham, UK
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Abstract
Children and adolescents occasionally have back symptoms, but rarely come to a physician's office for more severe back pain. When a child or adolescent appears in the clinic with complaints of back pain, a careful detailed evaluation is appropriate. The incidence of findings in children with significant back pain is high; therefore, a detailed history, physical examination, and evaluation are needed. It is also legitimate to continue monitoring children even if no obvious cause is initially identified because often a diagnosis subsequently will be made.
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Affiliation(s)
- H A King
- Department of Orthopaedic Surgery, University of Washington, Seattle, Washington, USA
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Viola RW, King HA, Adler SM, Wilson CB. Delayed infection after elective spinal instrumentation and fusion. A retrospective analysis of eight cases. Spine (Phila Pa 1976) 1997; 22:2444-50; discussion 2450-1. [PMID: 9355228 DOI: 10.1097/00007632-199710150-00023] [Citation(s) in RCA: 135] [Impact Index Per Article: 5.0] [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] [Indexed: 02/05/2023]
Abstract
STUDY DESIGN A retrospective analysis of eight cases of delayed spinal infection after elective posterior or combined anterior and posterior spinal instrumentation and fusion. OBJECTIVES These cases are reviewed to identify risk factors for delayed spinal infection after elective instrumentation and to describe the treatment of this complication. SUMMARY OF BACKGROUND DATA Delayed spinal infection after elective spinal instrumentation and fusion is uncommon. This diagnosis is frequently difficult. METHODS Five cases seen in the senior author's practice and three referral cases are reviewed. RESULTS Of these eight cases, the organisms were Staphylococcus epidermidis in six cases, Propionibacterium acnes in one cases, and in the final patient, all intraoperative cultures were negative. Clinical presentations were variable; however, all patients reported back pain. Seven patients had elevated erythrocyte sedimentation rates, averaging 57 mm/hour. Only two had elevated white blood cell counts. No distant foci of infection were identified in any patient. Five-patients were found to have at least one pseudarthrosis. All patients were treated with debridement, instrumentation removal, and primary wound closure over drains followed by a minimum 6-week course of culture-directed postoperative antibiotics. At an average follow-up of 18 months, no patient has evidence of infection. CONCLUSIONS The diagnosis of delayed infection after elective spinal instrumentation and fusion requires a high index of suspicion. These infections may have been caused by intraoperative inoculation. All patients were successfully treated with debridement, instrumentation removal, and culture-directed postoperative antibiotics.
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Affiliation(s)
- R W Viola
- Department of Orthopaedics, University of Washington, Seattle, USA
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Rushall BS, King HA. Reply by Rushall and King to replies to their AJSMS (1994) article. Aust J Sci Med Sport 1994; 26:77. [PMID: 8665282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Powell ET, Krengel WF, King HA, Lagrone MO. Comparison of same-day sequential anterior and posterior spinal fusion with delayed two-stage anterior and posterior spinal fusion. Spine (Phila Pa 1976) 1994; 19:1256-9. [PMID: 8073318 DOI: 10.1097/00007632-199405310-00011] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [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] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This was a retrospective review. Short-term outcomes were compared based on two different surgical techniques. OBJECTIVES To determine the safety, efficacy, and cost effectiveness of two different surgical techniques of anterior and posterior spinal fusion for pediatric patients with spinal deformity. SUMMARY OF BACKGROUND DATA Brown et al, Floman et al, and Bradford et al have reported on combined anterior and posterior spine fusions with a 1-2-week recovery period between stages. However, advances in surgical and anesthetic techniques combined with the prohibitive cost of prolonged hospitalization and theoretical advantages in pulmonary function and nutrition have led to increasing use of combined anterior and posterior spinal fusion under one anesthetic. METHODS The authors reviewed records and radiographs of patients with pediatric spinal deformities who underwent anterior spine fusion/posterior spine fusion and instrumentation performed by the senior author (HAK) at one institution. RESULTS Same-day sequential anterior spine fusion/posterior spine fusion resulted in less blood loss (575 +/- 275 ml; P < or = 0.0045), shorter hospital stay (8.00 +/- 2.68 days; P < or = 0.0001), and reduced hospital costs ($18,762 +/- $4,925; P < or = 0.0001). Operative time and complication rate were not affected. CONCLUSIONS In selected patients with pediatric spinal deformity, experienced spinal surgeons can reduce blood loss, hospital stay, and costs by performing anterior and posterior spinal fusions sequentially under one anesthetic.
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Affiliation(s)
- E T Powell
- Children's Hospital and Medical Center, Seattle, Washington
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King HA. Analysis and treatment of type II idiopathic scoliosis. Orthop Clin North Am 1994; 25:225-37. [PMID: 8159397] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The evaluation and management of scoliosis curves depend on careful study and curve classification. This article discusses current concepts of curve classifications and analyzes Type II curves in particular in hopes of making it easier to manage these curves from both nonoperative and operative standpoints.
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Affiliation(s)
- H A King
- Northwest Spine Surgeons, Seattle, Washington
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Abstract
A 10-year-old girl with Williams syndrome (with characteristic facies and behavior, mental retardation, and growth disturbances) was seen with scoliosis, which, despite attempted bracing, rapidly progressed to 95 degrees and required surgical stabilization. Review of the entire literature on Williams syndrome revealed hallux valgus and little-finger clinodactyly as the most commonly mentioned orthopaedic manifestations, with only brief mention of spinal deformity. As awareness of Williams syndrome increases, spine surgeons must be aware of possible rapidly progressive scoliosis and kyphosis.
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Affiliation(s)
- W R Osebold
- Shriners Hospitals for Crippled Children, Spokane, Washington
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