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Sperl-Hillen JM, Haapala JL, Dehmer SP, Chumba LN, Ekstrom HL, Truitt AR, Asche SE, Werner AM, Rehrauer DJ, Pankonin MA, Pawloski PA, O'Connor PJ. Protocol of a patient randomized clinical trial to improve medication adherence in primary care. Contemp Clin Trials 2024; 136:107385. [PMID: 37956792 PMCID: PMC10922408 DOI: 10.1016/j.cct.2023.107385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 09/25/2023] [Accepted: 11/03/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Enhanced awareness of poor medication adherence could improve patient care. This article describes the original and adapted protocols of a randomized trial to improve medication adherence for cardiometabolic conditions. METHODS The original protocol entailed a cluster randomized trial of 28 primary care clinics allocated to either (i) medication adherence enhanced chronic disease care clinical decision support (eCDC-CDS) integrated within the electronic health record (EHR) or (ii) usual care (non-enhanced CDC-CDS). Enhancements comprised (a) electronic interfaces printed for patients and clinicians at primary care encounters that encouraged discussion about specific medication adherence issues that were identified, and (b) pharmacist phone outreach. Study subjects were individuals who at an index visit were aged 18-74 years and not at evidence-based care goals for hypertension (HTN), diabetes mellitus (DM), or lipid management, along with low medication adherence (proportion of days covered [PDC] <80%) for a corresponding medication. The primary study outcomes were improved medication adherence and clinical outcomes (BP and A1C) at 12 months. Protocol adaptation became imperative in response to major implementation challenges: (a) the availability of EHR system-wide PDC calculations that superseded our ability to limit PDC adherence information solely to intervention clinics; (b) the unforeseen closure of pharmacies committed to conducting the pharmacist outreach; and (c) disruptions and clinic closures due to the Covid-19 pandemic. CONCLUSION This manuscript details the protocol of a study to assess whether enhanced awareness of medication adherence issues in primary care settings could improve patient outcomes. The need for protocol adaptation arose in response to multiple implementation challenges.
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Affiliation(s)
| | | | | | | | | | | | | | - Ann M Werner
- HealthPartners Institute, Bloomington, MN, United States
| | - Dan J Rehrauer
- HealthPartners Health Plan, Bloomington, MN, United States; HealthPartners Medical Group, Bloomington, MN, United States
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Boston D, Larson AE, Sheppler CR, O'Connor PJ, Sperl-Hillen JM, Hauschildt J, Gold R. Does Clinical Decision Support Increase Appropriate Medication Prescribing for Cardiovascular Risk Reduction? J Am Board Fam Med 2023; 36:777-788. [PMID: 37704387 PMCID: PMC10680997 DOI: 10.3122/jabfm.2022.220391r2] [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: 11/17/2022] [Revised: 01/30/2023] [Accepted: 05/25/2023] [Indexed: 09/15/2023] Open
Abstract
PURPOSE To assess the impact of a clinical decision support (CDS) system's recommendations on prescribing patterns targeting cardiovascular disease (CVD) when the recommendations are prioritized in order from greatest to least benefit toward overall CVD risk reduction. METHODS Secondary analysis of trial data from September 20, 2018, to March 15, 2020, where 70 community health center clinics were cluster-randomized to the CDS intervention (42 clinics; 8 organizations) or control group (28 clinics; 7 organizations). Included patients were medication-naïve and aged 40 to 75 years with ≥1 uncontrolled cardiovascular disease risk factor, with known diabetes or cardiovascular disease, or ≥10% 10-year reversible CVD risk. RESULTS Among eligible encounters with 29,771 patients, the probability of prescribing a medication targeting hypertension was greater at intervention clinic encounters when CDS was used (34.9% [95% CI, 31.5 to 38.3]) versus dismissed (29.6% [95% CI, 26.7 to 32.6]; P < .001), but not when compared with control clinic encounters (34.9% [95% CI, 31.1 to 38.7]; P = .998). Prescribing for dyslipidemia was significantly higher at intervention encounters where the CDS system was used (11.3% [95% CI, 9.3 to 13.3]) compared with dismissed (7.7% [95% CI, 6.1 to 9.3]; P = .003) and to control encounters (8.7% [95% CI, 7.0 to 10.4]; P = .044); smoking cessation medication showed a similar pattern. Except for dyslipidemia, prescribing rates increased according to their prioritization. CONCLUSIONS Use of this CDS system was associated with significantly higher prescribing targeting most cardiovascular risk factors. These results highlight how displaying prioritized actions to reduce reversible CVD risk could improve risk management. TRIAL REGISTRATION ClinicalTrials.gov, NCT03001713, https://clinicaltrials.gov/.
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Affiliation(s)
- David Boston
- From the OCHIN Inc., PO Box 5426, Portland, OR (DB, AEL, JH, RG); Kaiser Permanente Northwest, Center for Health Research, 3800 N Interstate Ave, Portland, OR (CRS); HealthPartners Institute, 8170 33rd Ave So 23301a, Minneapolis, MN (PJOC, JMSH).
| | - Annie E Larson
- From the OCHIN Inc., PO Box 5426, Portland, OR (DB, AEL, JH, RG); Kaiser Permanente Northwest, Center for Health Research, 3800 N Interstate Ave, Portland, OR (CRS); HealthPartners Institute, 8170 33rd Ave So 23301a, Minneapolis, MN (PJOC, JMSH)
| | - Christina R Sheppler
- From the OCHIN Inc., PO Box 5426, Portland, OR (DB, AEL, JH, RG); Kaiser Permanente Northwest, Center for Health Research, 3800 N Interstate Ave, Portland, OR (CRS); HealthPartners Institute, 8170 33rd Ave So 23301a, Minneapolis, MN (PJOC, JMSH)
| | - Patrick J O'Connor
- From the OCHIN Inc., PO Box 5426, Portland, OR (DB, AEL, JH, RG); Kaiser Permanente Northwest, Center for Health Research, 3800 N Interstate Ave, Portland, OR (CRS); HealthPartners Institute, 8170 33rd Ave So 23301a, Minneapolis, MN (PJOC, JMSH)
| | - JoAnn M Sperl-Hillen
- From the OCHIN Inc., PO Box 5426, Portland, OR (DB, AEL, JH, RG); Kaiser Permanente Northwest, Center for Health Research, 3800 N Interstate Ave, Portland, OR (CRS); HealthPartners Institute, 8170 33rd Ave So 23301a, Minneapolis, MN (PJOC, JMSH)
| | - Jennifer Hauschildt
- From the OCHIN Inc., PO Box 5426, Portland, OR (DB, AEL, JH, RG); Kaiser Permanente Northwest, Center for Health Research, 3800 N Interstate Ave, Portland, OR (CRS); HealthPartners Institute, 8170 33rd Ave So 23301a, Minneapolis, MN (PJOC, JMSH)
| | - Rachel Gold
- From the OCHIN Inc., PO Box 5426, Portland, OR (DB, AEL, JH, RG); Kaiser Permanente Northwest, Center for Health Research, 3800 N Interstate Ave, Portland, OR (CRS); HealthPartners Institute, 8170 33rd Ave So 23301a, Minneapolis, MN (PJOC, JMSH)
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Rossom RC, Crain AL, Waring S, Sperl-Hillen JM, Hooker SA, Miley K, O'Connor PJ. Differential Effects of an Intervention to Reduce Cardiovascular Risk for Patients With Bipolar Disorder, Schizoaffective Disorder, or Schizophrenia: A Randomized Clinical Trial. J Clin Psychiatry 2023; 84:22m14710. [PMID: 37428030 PMCID: PMC10793875 DOI: 10.4088/jcp.22m14710] [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] [Indexed: 07/11/2023]
Abstract
Objective: To measure the impact of a clinical decision support (CDS) tool on total modifiable cardiovascular risk at 12 months separately for outpatients with 3 subtypes of serious mental illness (SMI) identified via ICD-9 and ICD-10 codes: bipolar disorder, schizoaffective disorder, and schizophrenia. Methods: This cluster-randomized pragmatic clinical trial was active from March 2016 to September 2018; data were analyzed from April 2021 to September 2022. Clinicians and patients from 78 primary care clinics participated. All 8,922 adult patients aged 18-75 years with diagnosed SMI, at least 1 cardiovascular risk factor not at goal, and an index and follow-up visit during the study period were included. The CDS tool provided a summary of modifiable cardiovascular risk and personalized treatment recommendations. Results: Intervention patients had 4% relative reduction in total modifiable cardiovascular risk at 12 months compared to controls (relative risk ratio = 0.96; 95% CI, 0.94 to 0.98), with similar intervention benefits for all 3 SMI subtypes. At index, 10-year cardiovascular risk was higher for patients with schizophrenia (mean [SD] = 11.3% [9.2%]) than for patients with bipolar disorder (8.5% [8.9%]) or schizoaffective disorder (9.4% [8.1%]), while 30-year cardiovascular risk was highest for patients with schizoaffective disorder (44% with 2 or more major cardiovascular risk factors, compared to 40% for patients with schizophrenia and 37% for patients with bipolar disorder). Smoking was highly prevalent (47%), and mean (SD) BMI was 32.7 (7.9). Conclusions: This CDS intervention produced a clinically and statistically significant 4% relative reduction in total modifiable cardiovascular risk for intervention patients versus controls at 12 months, an effect observed across all 3 SMI subtypes and attributable to the aggregate impact of small changes in multiple cardiovascular risk factors. Trial Registration: ClinicalTrials.gov Identifier: NCT02451670.
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Affiliation(s)
- Rebecca C Rossom
- HealthPartners Institute, Minneapolis, Minnesota (Rossom, Crain, Sperl-Hillen, Hooker, Miley, O'Connor)
| | - A Lauren Crain
- HealthPartners Institute, Minneapolis, Minnesota (Rossom, Crain, Sperl-Hillen, Hooker, Miley, O'Connor)
| | | | - JoAnn M Sperl-Hillen
- HealthPartners Institute, Minneapolis, Minnesota (Rossom, Crain, Sperl-Hillen, Hooker, Miley, O'Connor)
| | - Stephanie A Hooker
- HealthPartners Institute, Minneapolis, Minnesota (Rossom, Crain, Sperl-Hillen, Hooker, Miley, O'Connor)
| | - Kathleen Miley
- HealthPartners Institute, Minneapolis, Minnesota (Rossom, Crain, Sperl-Hillen, Hooker, Miley, O'Connor)
| | - Patrick J O'Connor
- HealthPartners Institute, Minneapolis, Minnesota (Rossom, Crain, Sperl-Hillen, Hooker, Miley, O'Connor)
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Hauschildt J, Lyon-Scott K, Sheppler CR, Larson AE, McMullen C, Boston D, O'Connor PJ, Sperl-Hillen JM, Gold R. Adoption of shared decision-making and clinical decision support for reducing cardiovascular disease risk in community health centers. JAMIA Open 2023; 6:ooad012. [PMID: 36909848 PMCID: PMC10005607 DOI: 10.1093/jamiaopen/ooad012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 01/13/2023] [Accepted: 02/14/2023] [Indexed: 03/12/2023] Open
Abstract
Objective Electronic health record (EHR)-based shared decision-making (SDM) and clinical decision support (CDS) systems can improve cardiovascular disease (CVD) care quality and risk factor management. Use of the CV Wizard system showed a beneficial effect on high-risk community health center (CHC) patients' CVD risk within an effectiveness trial, but system adoption was low overall. We assessed which multi-level characteristics were associated with system use. Materials and Methods Analyses included 80 195 encounters with 17 931 patients with high CVD risk and/or uncontrolled risk factors at 42 clinics in September 2018-March 2020. Data came from the CV Wizard repository and EHR data, and a survey of 44 clinic providers. Adjusted, mixed-effects multivariate Poisson regression analyses assessed factors associated with system use. We included clinic- and provider-level clustering as random effects to account for nested data. Results Likelihood of system use was significantly higher in encounters with patients with higher CVD risk and at longer encounters, and lower when providers were >10 minutes behind schedule, among other factors. Survey participants reported generally high satisfaction with the system but were less likely to use it when there were time constraints or when rooming staff did not print the system output for the provider. Discussion CHC providers prioritize using this system for patients with the greatest CVD risk, when time permits, and when rooming staff make the information readily available. CHCs' financial constraints create substantial challenges to addressing barriers to improved system use, with health equity implications. Conclusion Research is needed on improving SDM and CDS adoption in CHCs. Trial Registration ClinicalTrials.gov, NCT03001713, https://clinicaltrials.gov/.
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Affiliation(s)
| | | | | | - Annie E Larson
- OCHIN Inc., Research Department, Portland, Oregon 97228-5426, USA
| | - Carmit McMullen
- Kaiser Permanente Center for Health Research, Portland, Oregon 97227, USA
| | - David Boston
- OCHIN Inc., Research Department, Portland, Oregon 97228-5426, USA
| | - Patrick J O'Connor
- HealthPartners Institute, HealthPartners Center for Chronic Care Innovation, Bloomington, Minnesota 55425, USA
| | - JoAnn M Sperl-Hillen
- HealthPartners Institute, HealthPartners Center for Chronic Care Innovation, Bloomington, Minnesota 55425, USA
| | - Rachel Gold
- OCHIN Inc., Research Department, Portland, Oregon 97228-5426, USA.,Kaiser Permanente Center for Health Research, Portland, Oregon 97227, USA
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Rossom RC, Crain AL, O'Connor PJ, Wright E, Haller IV, Hooker SA, Sperl-Hillen JM, Olson A, Romagnoli K, Solberg L, Dehmer SP, Haapala J, Borgert-Spaniol C, Tusing L, Muegge J, Allen C, Ekstrom H, Huntley K, McCormack J, Bart G. Design of a pragmatic clinical trial to improve screening and treatment for opioid use disorder in primary care. Contemp Clin Trials 2023; 124:107012. [PMID: 36402275 PMCID: PMC9839646 DOI: 10.1016/j.cct.2022.107012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Opioid-related deaths continue to rise in the U.S. A shared decision-making (SDM) system to help primary care clinicians (PCCs) identify and treat patients with opioid use disorder (OUD) could help address this crisis. METHODS In this cluster-randomized trial, primary care clinics in three healthcare systems were randomized to receive or not receive access to an OUD-SDM system. The OUD-SDM system alerts PCCs and patients to elevated risk of OUD and supports OUD screening and treatment. It includes guidance on OUD screening and diagnosis, treatment selection, starting and maintaining patients on buprenorphine for waivered clinicians, and screening for common comorbid conditions. The primary study outcome is, of patients at high risk for OUD, the percentage receiving an OUD diagnosis within 30 days of index visit. Additional outcomes are, of patients at high risk for or with a diagnosis of OUD, (a) the percentage receiving a naloxone prescription, or (b) the percentage receiving a medication for OUD (MOUD) prescription or referral to specialty care within 30 days of an index visit, and (c) total days covered by a MOUD prescription within 90 days of an index visit. RESULTS The intervention started in April 2021 and continues through December 2023. PCCs and patients in 90 clinics are included; study results are expected in 2024. CONCLUSION This protocol paper describes the design of a multi-site trial to help PCCs recognize and treat OUD. If effective, this OUD-SDM intervention could improve screening of at-risk patients and rates of OUD treatment for people with OUD.
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Affiliation(s)
- Rebecca C Rossom
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - A Lauren Crain
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - Patrick J O'Connor
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - Eric Wright
- Geisinger Health, 100 North Academy Ave., Danville, PA 17822, United States of America.
| | - Irina V Haller
- Essentia Institute of Rural Health, 502 E 2nd St, Duluth, MN 55805, United States of America.
| | - Stephanie A Hooker
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - JoAnn M Sperl-Hillen
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - Anthony Olson
- Essentia Institute of Rural Health, 502 E 2nd St, Duluth, MN 55805, United States of America.
| | - Katrina Romagnoli
- Geisinger Health, 100 North Academy Ave., Danville, PA 17822, United States of America.
| | - Leif Solberg
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - Steven P Dehmer
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - Jacob Haapala
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - Caitlin Borgert-Spaniol
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - Lorraine Tusing
- Geisinger Health, 100 North Academy Ave., Danville, PA 17822, United States of America.
| | - Jule Muegge
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - Clayton Allen
- Essentia Institute of Rural Health, 502 E 2nd St, Duluth, MN 55805, United States of America.
| | - Heidi Ekstrom
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - Kristen Huntley
- National Institute on Drug Abuse, Center for the Clinical Trials Network, 16071 Industrial Dr, Gaithersburg, MD 20877, United States of America.
| | - Jennifer McCormack
- The Emmes Company, 401 N Washington St # 700, Rockville, MD 20850, United States of America.
| | - Gavin Bart
- Hennepin Healthcare Research Institute, 825 8th St S, Minneapolis, MN 55404, United States of America.
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Harry ML, Asche SE, Freitag LA, Sperl-Hillen JM, Saman DM, Ekstrom HL, Chrenka EA, Truitt AR, Allen CI, O'Connor PJ, Dehmer SP, Bianco JA, Elliott TE. Human Papillomavirus vaccination clinical decision support for young adults in an upper midwestern healthcare system: a clinic cluster-randomized control trial. Hum Vaccin Immunother 2022; 18:2040933. [PMID: 35302909 PMCID: PMC9009937 DOI: 10.1080/21645515.2022.2040933] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Human papillomavirus (HPV) vaccination rates are low in young adults. Clinical decision support (CDS) in primary care may increase HPV vaccination. We tested the treatment effect of algorithm-driven, web-based, and electronic health record-linked CDS with or without shared decision-making tools (SDMT) on HPV vaccination rates compared to usual care (UC). METHODS In a clinic cluster-randomized control trial conducted in a healthcare system serving a largely rural population, we randomized 34 primary care clinic clusters (with three clinics sharing clinicians randomized together) to: CDS; CDS+SDMT; UC. The sample included young adults aged 18-26 due for HPV vaccination with a study index visit from 08/01/2018-03/15/2019 in a study clinic. Generalized linear mixed models tested differences in HPV vaccination status 12 months after index visits by study arm. RESULTS Among 10,253 patients, 6,876 (65.2%) were due for HPV vaccination, and 5,054 met study eligibility criteria. In adjusted analyses, the HPV vaccination series was completed by 12 months in 2.3% (95% CI: 1.6%-3.2%) of CDS, 1.6% (95% CI: 1.1%-2.3%) of CDS+SDMT, and 2.2% (95% CI: 1.6%-3.0%) of UC patients, and at least one HPV vaccine was received by 12 months in 13.1% (95% CI: 10.6%-16.1%) of CDS, 9.2% (95% CI: 7.3%-11.6%) of CDS+SDMT, and 11.2% (95% CI: 9.1%-13.7%) of UC patients. Differences were not significant between arms. Females, those with prior HPV vaccinations, and those seen at urban clinics had significantly higher odds of HPV vaccination in adjusted models. DISCUSSION CDS may require optimization for young adults to significantly impact HPV vaccination. TRIAL REGISTRATION clinicaltrials.gov NCT02986230, 12/6/2016.
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Saman DM, Allen CI, Freitag LA, Harry ML, Sperl-Hillen JM, Ziegenfuss JY, Haapala JL, Crain AL, Desai JR, Ohnsorg KA, O’Connor PJ. Clinician perceptions of a clinical decision support system to reduce cardiovascular risk among prediabetes patients in a predominantly rural healthcare system. BMC Med Inform Decis Mak 2022; 22:301. [PMID: 36402988 PMCID: PMC9675125 DOI: 10.1186/s12911-022-02032-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: 01/04/2022] [Accepted: 10/27/2022] [Indexed: 11/20/2022] Open
Abstract
Background The early detection and management of uncontrolled cardiovascular risk factors among prediabetes patients can prevent cardiovascular disease (CVD). Prediabetes increases the risk of CVD, which is a leading cause of death in the United States. CVD clinical decision support (CDS) in primary care settings has the potential to reduce cardiovascular risk in patients with prediabetes while potentially saving clinicians time. The objective of this study is to understand primary care clinician (PCC) perceptions of a CDS system designed to reduce CVD risk in adults with prediabetes. Methods We administered pre-CDS implementation (6/30/2016 to 8/25/2016) (n = 183, 61% response rate) and post-CDS implementation (6/12/2019 to 8/7/2019) (n = 131, 44.5% response rate) independent cross-sectional electronic surveys to PCCs at 36 randomized primary care clinics participating in a federally funded study of a CVD risk reduction CDS tool. Surveys assessed PCC demographics, experiences in delivering prediabetes care, perceptions of CDS impact on shared decision making, perception of CDS impact on control of major CVD risk factors, and overall perceptions of the CDS tool when managing cardiovascular risk. Results We found few significant differences when comparing pre- and post-implementation responses across CDS intervention and usual care (UC) clinics. A majority of PCCs felt well-prepared to discuss CVD risk factor control with patients both pre- and post-implementation. About 73% of PCCs at CDS intervention clinics agreed that the CDS helped improve risk control, 68% reported the CDS added value to patient clinic visits, and 72% reported they would recommend use of this CDS system to colleagues. However, most PCCs disagreed that the CDS saves time talking about preventing diabetes or CVD, and most PCCs also did not find the clinical domains useful, nor did PCCs believe that the clinical domains were useful in getting patients to take action. Finally, only about 38% reported they were satisfied with the CDS. Conclusions These results improve our understanding of CDS user experience and can be used to guide iterative improvement of the CDS. While most PCCs agreed the CDS improves CVD and diabetes risk factor control, they were generally not satisfied with the CDS. Moreover, only 40–50% agreed that specific suggestions on clinical domains helped patients to take action. In spite of this, an overwhelming majority reported they would recommend the CDS to colleagues, pointing for the need to improve upon the current CDS. Trial registration: NCT02759055 03/05/2016.
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Sperl-Hillen JM, Anderson JP, Margolis KL, Rossom RC, Kopski KM, Averbeck BM, Rosner JA, Ekstrom HL, Dehmer SP, O'Connor PJ. Bolstering the Business Case for Adoption of Shared Decision-Making Systems in Primary Care: Randomized Controlled Trial. JMIR Form Res 2022; 6:e32666. [PMID: 36201392 PMCID: PMC9585448 DOI: 10.2196/32666] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 07/27/2022] [Accepted: 08/23/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Limited budgets may often constrain the ability of health care delivery systems to adopt shared decision-making (SDM) systems designed to improve clinical encounters with patients and quality of care. OBJECTIVE This study aimed to assess the impact of an SDM system shown to improve diabetes and cardiovascular patient outcomes on factors affecting revenue generation in primary care clinics. METHODS As part of a large multisite clinic randomized controlled trial (RCT), we explored the differences in 1 care system between clinics randomized to use an SDM intervention (n=8) versus control clinics (n=9) regarding the (1) likelihood of diagnostic coding for cardiometabolic conditions using the 10th Revision of the International Classification of Diseases (ICD-10) and (2) current procedural terminology (CPT) billing codes. RESULTS At all 24,138 encounters with care gaps targeted by the SDM system, the proportion assigned high-complexity CPT codes for level of service 5 was significantly higher at the intervention clinics (6.1%) compared to that in the control clinics (2.9%), with P<.001 and adjusted odds ratio (OR) 1.64 (95% CI 1.02-2.61). This was consistently observed across the following specific care gaps: diabetes with glycated hemoglobin A1c (HbA1c)>8% (n=8463), 7.2% vs 3.4%, P<.001, and adjusted OR 1.93 (95% CI 1.01-3.67); blood pressure above goal (n=8515), 6.5% vs 3.7%, P<.001, and adjusted OR 1.42 (95% CI 0.72-2.79); suboptimal statin management (n=17,765), 5.8% vs 3%, P<.001, and adjusted OR 1.41 (95% CI 0.76-2.61); tobacco dependency (n=7449), 7.5% vs. 3.4%, P<.001, and adjusted OR 2.14 (95% CI 1.31-3.51); BMI >30 kg/m2 (n=19,838), 6.2% vs 2.9%, P<.001, and adjusted OR 1.45 (95% CI 0.75-2.8). Compared to control clinics, intervention clinics assigned ICD-10 diagnosis codes more often for observed cardiometabolic conditions with care gaps, although the difference did not reach statistical significance. CONCLUSIONS In this randomized study, use of a clinically effective SDM system at encounters with care gaps significantly increased the proportion of encounters assigned high-complexity (level 5) CPT codes, and it was associated with a nonsignificant increase in assigning ICD-10 codes for observed cardiometabolic conditions. TRIAL REGISTRATION ClinicalTrials.gov NCT02451670; https://clinicaltrials.gov/ct2/show/NCT02451670.
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Affiliation(s)
- JoAnn M Sperl-Hillen
- HealthPartners Institute, Bloomington, MN, United States
- Research Department, HealthPartners Center for Chronic Care Innovation, Bloomington, MN, United States
| | | | | | | | | | | | | | - Heidi L Ekstrom
- HealthPartners Institute, Bloomington, MN, United States
- Research Department, HealthPartners Center for Chronic Care Innovation, Bloomington, MN, United States
| | | | - Patrick J O'Connor
- HealthPartners Institute, Bloomington, MN, United States
- Research Department, HealthPartners Center for Chronic Care Innovation, Bloomington, MN, United States
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Margolis KL, Crain AL, Green BB, O'Connor PJ, Solberg LI, Beran M, Bergdall AR, Pawloski PA, Ziegenfuss JY, JaKa MM, Appana D, Sharma R, Kodet AJ, Trower NK, Rehrauer DJ, McKinney Z, Norton CK, Haugen P, Anderson JP, Crabtree BF, Norman SK, Sperl-Hillen JM. Comparison of explanatory and pragmatic design choices in a cluster-randomized hypertension trial: effects on enrollment, participant characteristics, and adherence. Trials 2022; 23:673. [PMID: 35978336 PMCID: PMC9387034 DOI: 10.1186/s13063-022-06611-3] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 08/01/2022] [Indexed: 11/17/2022] Open
Abstract
Background Explanatory trials are designed to assess intervention efficacy under ideal conditions, while pragmatic trials are designed to assess whether research-proven interventions are effective in “real-world” settings without substantial research support. Methods We compared two trials (Hyperlink 1 and 3) that tested a pharmacist-led telehealth intervention in adults with uncontrolled hypertension. We applied PRagmatic Explanatory Continuum Indicator Summary-2 (PRECIS-2) scores to describe differences in the way these studies were designed and enrolled study-eligible participants, and the effect of these differences on participant characteristics and adherence to study interventions. Results PRECIS-2 scores demonstrated that Hyperlink 1 was more explanatory and Hyperlink 3 more pragmatic. Recruitment for Hyperlink 1 was conducted by study staff, and 2.9% of potentially eligible patients enrolled. Enrollees were older, and more likely to be male and White than non-enrollees. Study staff scheduled the initial pharmacist visit and adherence to attending this visit was 98%. Conversely for Hyperlink 3, recruitment was conducted by clinic staff at routine encounters and 81% of eligible patients enrolled. Enrollees were younger, and less likely to be male and White than non-enrollees. Study staff did not assist with scheduling the initial pharmacist visit and adherence to attending this visit was only 27%. Compared to Hyperlink 1, patients in Hyperlink 3 were more likely to be female, and Asian or Black, had lower socioeconomic indicators, and were more likely to have comorbidities. Owing to a lower BP for eligibility in Hyperlink 1 (>140/90 mm Hg) than in Hyperlink 3 (>150/95 mm Hg), mean baseline BP was 148/85 mm Hg in Hyperlink 1 and 158/92 mm Hg in Hyperlink 3. Conclusion The pragmatic design features of Hyperlink 3 substantially increased enrollment of study-eligible patients and of those traditionally under-represented in clinical trials (women, minorities, and patients with less education and lower income), and demonstrated that identification and enrollment of a high proportion of study-eligible subjects could be done by usual primary care clinic staff. However, the trade-off was much lower adherence to the telehealth intervention than in Hyperlink 1, which is likely to reflect uptake under real-word conditions and substantially dilute intervention effect on BP. Trial registration The Hyperlink 1 study (NCT00781365) and the Hyperlink 3 study (NCT02996565) are registered at ClinicalTrials.gov.
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Affiliation(s)
- Karen L Margolis
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA.
| | - A Lauren Crain
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Av, Seattle, WA, 98101, USA
| | - Patrick J O'Connor
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Leif I Solberg
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - MarySue Beran
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Anna R Bergdall
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Pamala A Pawloski
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Jeanette Y Ziegenfuss
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Meghan M JaKa
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Deepika Appana
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Rashmi Sharma
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Amy J Kodet
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Nicole K Trower
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Daniel J Rehrauer
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Zeke McKinney
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Christine K Norton
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Patricia Haugen
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Jeffrey P Anderson
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Benjamin F Crabtree
- Rutgers Robert Wood Johnson Medical School, Department of Family Medicine and Community Health, New Brunswick, NJ, 08901, USA
| | - Sarah K Norman
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - JoAnn M Sperl-Hillen
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
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Kottke TE, Anderson JP, Zillhardt JD, Sperl-Hillen JM, O’Connor PJ, Green BB, Williams RA, Averbeck BM, Stiffman MN, Beran M, Rakotz M, Margolis KL. Association of an Automated Blood Pressure Measurement Quality Improvement Program With Terminal Digit Preference and Recorded Mean Blood Pressure in 11 Clinics. JAMA Netw Open 2022; 5:e2229098. [PMID: 36044216 PMCID: PMC9434355 DOI: 10.1001/jamanetworkopen.2022.29098] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Terminal digit preference has been shown to be associated with inaccurate blood pressure (BP) recording. OBJECTIVE To evaluate whether converting from manual BP measurement with aneroid sphygmomanometers to automated BP measurement was associated with terminal digit preference, mean levels of recorded BP, and the rate at which hypertension was diagnosed. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study was conducted from May 9, 2021, to March 24, 2022, using interrupted time series analysis of medical record data from 11 primary care clinics in a single health care system from April 2008 to April 2015. The study population was patients aged 18 to 75 years who had their BP measured and recorded at least once during the study period. EXPOSURES Manual BP measurement before April 2012 vs automated BP measurement with the Omron HEM-907XL monitor from May 2012 to April 2015. MAIN OUTCOMES AND MEASURES The main outcome was the distribution of terminal digits and mean systolic BP (SBP) values obtained during 4 years of manual measurement vs 3 years of automated measurement, assessed using a generalized linear mixed regression model with a random intercept for clinic and adjusted for seasonal fluctuations and patient demographic and clinical characteristics. RESULTS The study included 1 541 227 BP measurements from 225 504 unique patients during the entire study period, with 849 978 BP measurements from 165 137 patients (mean [SD] age, 47.1 [15.2] years; 58.2% female) during the manual measurement period and 691 249 measurements from 149 080 patients (mean [SD] age, 48.4 [15.3] years; 56.3% female) during the automated measurement period. With manual measurement, 32.8% of SBP terminal digits were 0 (20% was the expected value because nursing staff was instructed to record BP to the nearest even digit). This proportion decreased to 12.4% during the automated measurement period (expected value, 10%) when both even and odd digits were to be recorded. After automated measurement was implemented, the mean SBP estimated with statistical modeling increased by 5.09 mm Hg (95% CI, 4.98-5.19 mm Hg). Fewer BP values recorded during the automated than the manual measurement period were below 140/90 mm Hg (69.9% vs 84.3%; difference, -14.5%; 95% CI, -14.6% to -14.3%) and below 130/80 mm Hg (42.1% vs 60.0%; difference, -17.9%; 95% CI, -18.0% to -17.7%). The proportion of patients with a diagnosis of hypertension was 4.3 percentage points higher (23.4% vs 19.1%) during the automated measurement period. CONCLUSIONS AND RELEVANCE In this quality improvement study, automated BP measurement was associated with decreased terminal digit preference and significantly higher mean BP levels. The method of BP measurement was also associated with the rate at which hypertension was diagnosed. These findings may have implications for pay-for-performance programs, which may create an incentive to record BP levels that meet a particular goal and a disincentive to adopt automated measurement of BP.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - MarySue Beran
- Park Nicollet Health Services, Saint Louis Park, Minnesota
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11
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Hooker SA, O’Connor PJ, Sperl-Hillen JM, Crain AL, Ohnsorg K, Kane S, Rossom R. Depression and cardiovascular risk in primary care patients. J Psychosom Res 2022; 158:110920. [PMID: 35461074 PMCID: PMC9237849 DOI: 10.1016/j.jpsychores.2022.110920] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 04/12/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE This study assessed the relationship of both depression diagnosis and clinically significant depressive symptoms with individual cardiovascular risk factors and estimated total cardiovascular risk in primary care patients. METHODS This study used a cross-sectional and retrospective design. Patients who had a primary care encounter between January 2016 and September 2018 and completed depression screening (PHQ-9) during the year prior to their appointment (N = 70,980) were included in this study. Data examining estimated total cardiovascular risk, specific cardiovascular risk factors, and relevant clinical diagnoses (including depression diagnosis) were extracted from the electronic health record. Patients were categorized into three groups: no depression (PHQ-9 < 10 and no depression diagnosis), controlled depression (PHQ-9 < 10 with previous depression diagnosis), and current depression (PHQ-9 ≥ 10). Groups were compared on estimated total risk and specific cardiovascular risk factors (e.g., body mass index [BMI], smoking status, lipids, blood pressure, and glucose). RESULTS In adjusted analyses, patients with current depression (n = 18,267) demonstrated significantly higher 10-year and 30-year cardiovascular risk compared to patients with controlled depression (n = 33,383; 10-year: b = 0.59 [95% CI = 0.44,0.74]; 30-year: OR = 1.32 [95% CI = 1.26,1.39]) and patients without depression (n = 19,330; 10-year: b = 0.55 [95% CI = 0.37,0.73]; 30-year: OR = 1.56 [95% CI = 1.48,1.65]). Except for low-density lipoprotein (LDL), patients with current depression had the greatest cardiovascular risk across specific risk factors. CONCLUSIONS Individuals who had a depression diagnosis and clinically significant depressive symptoms had the greatest cardiovascular risk. Pathways to prevent cardiovascular disease in those with depression might focus on treating depressive symptoms as well as specific uncontrolled cardiovascular risk factors.
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Affiliation(s)
- Stephanie A. Hooker
- Corresponding author at: HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN 55425, United States of America. (S.A. Hooker)
| | | | | | | | - Kris Ohnsorg
- HealthPartners Institute, Research and Evaluation Division, Minneapolis, MN, United States of America.
| | - Sheryl Kane
- HealthPartners Institute, Research and Evaluation Division, Minneapolis, MN, United States of America.
| | - Rebecca Rossom
- HealthPartners Institute, Research and Evaluation Division, Minneapolis, MN, United States of America.
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12
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Rossom RC, Crain AL, O’Connor PJ, Waring SC, Hooker SA, Ohnsorg K, Taran A, Kopski KM, Sperl-Hillen JM. Effect of Clinical Decision Support on Cardiovascular Risk Among Adults With Bipolar Disorder, Schizoaffective Disorder, or Schizophrenia: A Cluster Randomized Clinical Trial. JAMA Netw Open 2022; 5:e220202. [PMID: 35254433 PMCID: PMC8902652 DOI: 10.1001/jamanetworkopen.2022.0202] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE Adults with schizophrenia, schizoaffective disorder, or bipolar disorder, collectively termed serious mental illness (SMI), have shortened life spans compared with people without SMI. The leading cause of death is cardiovascular (CV) disease. OBJECTIVE To assess whether a clinical decision support (CDS) system aimed at primary care clinicians improves CV health for adult primary care patients with SMI. DESIGN, SETTING, AND PARTICIPANTS In this cluster randomized clinical trial conducted from March 2, 2016, to September 19, 2018, restricted randomization assigned 76 primary care clinics in 3 Midwestern health care systems to receive or not receive a CDS system aimed at improving CV health among patients with SMI. Eligible clinics had at least 20 patients with SMI; clinicians and their adult patients with SMI with at least 1 modifiable CV risk factor not at the goal set by the American College of Cardiology/American Heart Association guidelines were included. Statistical analysis was conducted on an intention-to-treat basis from January 10, 2019, to December 29, 2021. INTERVENTION The CDS system assessed modifiable CV risk factors and provided personalized treatment recommendations to clinicians and patients. MAIN OUTCOMES AND MEASURES Patient-level change in total modifiable CV risk over 12 months, summed from individual modifiable risk factors (smoking, body mass index, low-density lipoprotein cholesterol level, systolic blood pressure, and hemoglobin A1c level). RESULTS A total of 80 clinics were randomized; 4 clinics were excluded for having fewer than 20 eligible patients, leaving 42 intervention clinics and 34 control clinics. A total of 8937 patients with SMI (4922 women [55.1%]; mean [SD] age, 48.4 [13.5] years) were enrolled. There was a 4% lower rate of increase in total modifiable CV risk among intervention patients relative to control patients (relative rate ratio [RR], 0.96; 95% CI, 0.94-0.98). The intervention favored patients who were 18 to 29 years of age (RR, 0.89; 95% CI, 0.81-0.98) or 50 to 59 years of age (RR, 0.93; 95% CI, 0.90-0.96), Black (RR, 0.93; 95% CI, 0.88-0.98), or White (RR, 0.96; 95% CI, 0.94-0.98). Men (RR, 0.96; 95% CI, 0.94-0.99) and women (RR, 0.95; 95% CI, 0.92-0.97), as well as patients with any SMI subtype (bipolar disorder: RR, 0.96; 95% CI, 0.94-0.99; schizoaffective disorder: RR, 0.94; 95% CI, 0.90-0.98; schizophrenia: RR, 0.92; 95% CI, 0.85-0.99) also benefited from the intervention. Despite treatment effects favoring the intervention, there were no significant differences in individual modifiable risk factors. CONCLUSIONS AND RELEVANCE This CDS intervention resulted in a rate of change in total modifiable CV risk that was 4% lower among intervention patients compared with control patients. Results were driven by the cumulative effects of incremental and mostly nonsignificant changes in individual modifiable risk factors. These findings emphasize the value of using CDS to prompt early primary care intervention for adults with SMI. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02451670.
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Affiliation(s)
- Rebecca C. Rossom
- Department of Research, HealthPartners Institute, Minneapolis, Minnesota
| | - A. Lauren Crain
- Department of Research, HealthPartners Institute, Minneapolis, Minnesota
| | | | - Stephen C. Waring
- Essentia Health and Essentia Institute of Rural Health, Duluth, Minnesota
| | | | - Kris Ohnsorg
- Department of Research, HealthPartners Institute, Minneapolis, Minnesota
| | - Allise Taran
- Essentia Health and Essentia Institute of Rural Health, Duluth, Minnesota
| | - Kristen M. Kopski
- Park Nicollet Health Services, Minneapolis, Minnesota
- Now with Medica Health Plan, Minnetonka, Minnesota
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13
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Elliott TE, Asche SE, O'Connor PJ, Dehmer SP, Ekstrom HL, Truitt AR, Chrenka EA, Harry ML, Saman DM, Allen CI, Bianco JA, Freitag LA, Sperl-Hillen JM. Clinical Decision Support with or without Shared Decision Making to Improve Preventive Cancer Care: A Cluster-Randomized Trial. Med Decis Making 2022; 42:808-821. [PMID: 35209775 DOI: 10.1177/0272989x221082083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Innovative interventions are needed to address gaps in preventive cancer care, especially in rural areas. This study evaluated the impact of clinical decision support (CDS) with and without shared decision making (SDM) on cancer-screening completion. METHODS In this 3-arm, parallel-group, cluster-randomized trial conducted at a predominantly rural medical group, 34 primary care clinics were randomized to clinical decision support (CDS), CDS plus shared decision making (CDS+SDM), or usual care (UC). The CDS applied web-based clinical algorithms identifying patients overdue for United States Preventive Services Task Force-recommended preventive cancer care and presented evidence-based recommendations to patients and providers on printouts and on the electronic health record interface. Patients in the CDS+SDM clinic also received shared decision-making tools (SDMTs). The primary outcome was a composite indicator of the proportion of patients overdue for breast, cervical, or colorectal cancer screening at index who were up to date on these 1 y later. RESULTS From August 1, 2018, to March 15, 2019, 69,405 patients aged 21 to 74 y had visits at study clinics and 25,198 were overdue for 1 or more cancer screening tests at an index visit. At 12-mo follow-up, 9,543 of these (37.9%) were up to date on the composite endpoint. The adjusted, model-derived percentage of patients up to date was 36.5% (95% confidence interval [CI]: 34.0-39.1) in the UC group, 38.1% (95% CI: 35.5-40.9) in the CDS group, and 34.4% (95% CI: 31.8-37.2) in the CDS+SDM group. For all comparisons, the screening rates were higher than UC in the CDS group and lower than UC in the CDS+SDM group, although these differences did not reach statistical significance. CONCLUSION The CDS did not significantly increase cancer-screening rates. Exploratory analyses suggest a deeper understanding of how SDM and CDS interact to affect cancer prevention decisions is needed. Trial registration: ClinicalTrials.gov ID: NCT02986230, December 6, 2016.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Daniel M Saman
- Essentia Institute of Rural Health, Duluth, MN, USA.,Nicklaus Children's Health System, Doral, FL, USA
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14
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Gold R, Larson AE, Sperl-Hillen JM, Boston D, Sheppler CR, Heintzman J, McMullen C, Middendorf M, Appana D, Thirumalai V, Romer A, Bava J, Davis JV, Yosuf N, Hauschildt J, Scott K, Moore S, O’Connor PJ. Effect of Clinical Decision Support at Community Health Centers on the Risk of Cardiovascular Disease: A Cluster Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2146519. [PMID: 35119463 PMCID: PMC8817199 DOI: 10.1001/jamanetworkopen.2021.46519] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
IMPORTANCE Management of cardiovascular disease (CVD) risk in socioeconomically vulnerable patients is suboptimal; better risk factor control could improve CVD outcomes. OBJECTIVE To evaluate the impact of a clinical decision support system (CDSS) targeting CVD risk in community health centers (CHCs). DESIGN, SETTING, AND PARTICIPANTS This cluster randomized clinical trial included 70 CHC clinics randomized to an intervention group (42 clinics; 8 organizations) or a control group that received no intervention (28 clinics; 7 organizations) from September 20, 2018, to March 15, 2020. Randomization was by CHC organization accounting for organization size. Patients aged 40 to 75 years with (1) diabetes or atherosclerotic CVD and at least 1 uncontrolled major risk factor for CVD or (2) total reversible CVD risk of at least 10% were the population targeted by the CDSS intervention. INTERVENTIONS A point-of-care CDSS displaying real-time CVD risk factor control data and personalized, prioritized evidence-based care recommendations. MAIN OUTCOMES AND MEASURES One-year change in total CVD risk and reversible CVD risk (ie, the reduction in 10-year CVD risk that was considered achievable if 6 key risk factors reached evidence-based levels of control). RESULTS Among the 18 578 eligible patients (9490 [51.1%] women; mean [SD] age, 58.7 [8.8] years), patients seen in control clinics (n = 7419) had higher mean (SD) baseline CVD risk (16.6% [12.8%]) than patients seen in intervention clinics (n = 11 159) (15.6% [12.3%]; P < .001); baseline reversible CVD risk was similarly higher among patients seen in control clinics. The CDSS was used at 19.8% of 91 988 eligible intervention clinic encounters. No population-level reduction in CVD risk was seen in patients in control or intervention clinics; mean reversible risk improved significantly more among patients in control (-0.1% [95% CI, -0.3% to -0.02%]) than intervention clinics (0.4% [95% CI, 0.3% to 0.5%]; P < .001). However, when the CDSS was used, both risk measures decreased more among patients with high baseline risk in intervention than control clinics; notably, mean reversible risk decreased by an absolute 4.4% (95% CI, -5.2% to -3.7%) among patients in intervention clinics compared with 2.7% (95% CI, -3.4% to -1.9%) among patients in control clinics (P = .001). CONCLUSIONS AND RELEVANCE The CDSS had low use rates and failed to improve CVD risk in the overall population but appeared to have a benefit on CVD risk when it was consistently used for patients with high baseline risk treated in CHCs. Despite some limitations, these results provide preliminary evidence that this technology has the potential to improve clinical care in socioeconomically vulnerable patients with high CVD risk. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03001713.
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Affiliation(s)
- Rachel Gold
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
- OCHIN Inc, Portland, Oregon
| | | | | | | | | | | | - Carmit McMullen
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | | | | | | | | | | | - James V. Davis
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Nadia Yosuf
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
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Pratt R, Saman DM, Allen C, Crabtree B, Ohnsorg K, Sperl-Hillen JM, Harry M, Henzler-Buckingham H, O'Connor PJ, Desai J. Assessing the implementation of a clinical decision support tool in primary care for diabetes prevention: a qualitative interview study using the Consolidated Framework for Implementation Science. BMC Med Inform Decis Mak 2022; 22:15. [PMID: 35033029 PMCID: PMC8760770 DOI: 10.1186/s12911-021-01745-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 12/30/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND In this paper we describe the use of the Consolidated Framework for Implementation Research (CFIR) to study implementation of a web-based, point-of-care, EHR-linked clinical decision support (CDS) tool designed to identify and provide care recommendations for adults with prediabetes (Pre-D CDS). METHODS As part of a large NIH-funded clinic-randomized trial, we identified a convenience sample of interview participants from 22 primary care clinics in Minnesota, North Dakota, and Wisconsin that were randomly allocated to receive or not receive a web-based EHR-integrated prediabetes CDS intervention. Participants included 11 clinicians, 6 rooming staff, and 7 nurse or clinic managers recruited by study staff to participate in telephone interviews conducted by an expert in qualitative methods. Interviews were recorded and transcribed, and data analysis was conducted using a constructivist version of grounded theory. RESULTS Implementing a prediabetes CDS tool into primary care clinics was useful and well received. The intervention was integrated with clinic workflows, supported primary care clinicians in clearly communicating prediabetes risk and management options with patients, and in identifying actionable care opportunities. The main barriers to CDS use were time and competing priorities. Finally, while the implementation process worked well, opportunities remain in engaging the care team more broadly in CDS use. CONCLUSIONS The use of CDS tools for engaging patients and providers in care improvement opportunities for prediabetes is a promising and potentially effective strategy in primary care settings. A workflow that incorporates the whole care team in the use of such tools may optimize the implementation of CDS tools like these in primary care settings. Trial registration Name of the registry: Clinicaltrial.gov. TRIAL REGISTRATION NUMBER NCT02759055. Date of registration: 05/03/2016. URL of trial registry record: https://clinicaltrials.gov/ct2/show/NCT02759055 Prospectively registered.
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Affiliation(s)
- Rebekah Pratt
- Department of Family Medicine and Community Health, University of Minnesota, 717 Delaware Street, Minneapolis, MN, 55414, USA.
| | - Daniel M Saman
- Essentia Institute of Rural Health Research, 502 E 2nd St, Duluth, MN, 55805, USA
- Carle Foundation Hospital Clinical Business and Intelligence, 611 W Park Street, Urbana, IL, 61801, USA
| | - Clayton Allen
- Essentia Institute of Rural Health Research, 502 E 2nd St, Duluth, MN, 55805, USA
| | - Benjamin Crabtree
- Department of Family Medicine and Community Health, Rutgers University, 112 Paterson Street, New Brunswick, NJ, 08901, USA
| | - Kris Ohnsorg
- HealthPartners Institute, 8170 33rd Avenue South, Bloomington, MN, 55425, USA
| | | | - Melissa Harry
- Essentia Institute of Rural Health Research, 502 E 2nd St, Duluth, MN, 55805, USA
| | | | - Patrick J O'Connor
- HealthPartners Institute, 8170 33rd Avenue South, Bloomington, MN, 55425, USA
| | - Jay Desai
- HealthPartners Institute, 8170 33rd Avenue South, Bloomington, MN, 55425, USA
- Minnesota Department of Health, 85 East 7th Place, PO Box 64882, St. Paul, MN, 55164-0882, USA
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Desai J, Saman D, Sperl-Hillen JM, Pratt R, Dehmer SP, Allen C, Ohnsorg K, Wuorio A, Appana D, Hitz P, Land A, Sharma R, Wilkerson L, Crain AL, Crabtree BF, Bianco J, O'Connor PJ. Implementing a prediabetes clinical decision support system in a large primary care system: Design, methods, and pre-implementation results. Contemp Clin Trials 2022; 114:106686. [DOI: 10.1016/j.cct.2022.106686] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 01/14/2022] [Accepted: 01/18/2022] [Indexed: 11/30/2022]
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Abstract
The coronavirus disease 2019 (COVID-19) pandemic instigated major changes in care delivery, but our understanding of how the rapid transition from in-person to telehealth encounters affected the care of patients with chronic conditions such as type 2 diabetes remains incomplete. This study examined changes in primary care encounters, A1C testing rates, and the likelihood of meeting A1C guidelines before and during the first 9 months of the COVID-19 pandemic in a large health care system. It found significant decreases in utilization and testing rates and the likelihood of meeting A1C guidelines, primarily driven by missing A1C tests. Patients who had all telehealth encounters or no encounters, who identified as racial or ethnic minorities, or had Medicaid or no insurance were significantly more likely to miss A1C tests.
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18
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Saman DM, Harry ML, Freitag LA, Allen CI, O’Connor PJ, Sperl-Hillen JM, Bianco JA, Truitt AR, Ekstrom HL, Elliott TE. Patient Perceptions of Using Clinical Decision Support for Cancer Screening and Prevention: "I wouldn't have thought about getting screened without it.". J Patient Cent Res Rev 2021; 8:297-306. [PMID: 34722797 PMCID: PMC8530236 DOI: 10.17294/2330-0698.1863] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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] [Indexed: 12/30/2022] Open
Abstract
PURPOSE We sought to gain an understanding of cancer prevention and screening perspectives among patients exposed to a clinical decision support (CDS) tool because they were due or overdue for certain cancer screenings or prevention. METHODS Semi-structured qualitative interviews were conducted with 37 adult patients due or overdue for cancer prevention services in 10 primary care clinics within the same health system. Data were thematically segmented and coded using qualitative content analysis. RESULTS We identified three themes: 1) The CDS tool had more strengths than weaknesses, with areas for improvement; 2) Many facilitators and barriers to cancer prevention and screening exist; and 3) Discussions and decision-making varied by type of cancer prevention and screening. Almost all participants made positive comments regarding the CDS. Some participants learned new information, reporting the CDS helped them make a decision they otherwise would not have made. Participants who used the tool with their provider had higher self-reported rates of deciding to be screened than those who did not. CONCLUSIONS Learning about patients' perceptions of a CDS tool may increase understanding of how patient-tailored CDS impacts cancer screening and prevention rates. Participants found a personalized CDS tool for cancer screening and prevention in primary care useful and a welcome addition to their visit. However, many providers were not using the tool with eligible patients.
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Sperl-Hillen JM, Crain AL, Chumba L, Ekstrom HL, Appana D, Kopski KM, Wetmore JB, Wheeler J, Ishani A, O'Connor PJ. Pragmatic clinic randomized trial to improve chronic kidney disease care: Design and adaptation due to COVID disruptions. Contemp Clin Trials 2021; 109:106501. [PMID: 34271175 PMCID: PMC8276567 DOI: 10.1016/j.cct.2021.106501] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/24/2021] [Accepted: 06/30/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND We describe a clinic-randomized trial to improve chronic kidney disease (CKD) care through a CKD-clinical decision support (CKD-CDS) intervention in primary care clinics and the challenges we encountered due to COVID-19 care disruption. METHODS/DESIGN Primary care clinics (N = 32) were randomized to usual care (UC) or to CKD-CDS. Between April 17, 2019 and March 14, 2020, more than 7000 patients had accrued for analysis by meeting study-eligibility criteria at an index office visit: age 18-75, laboratory criteria for stage 3 or 4 CKD (eGFR 15-59 mL/min/1.73 m2), and one or more opportunities algorithmically identified to improve CKD care such as blood pressure (BP) or glucose control, angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) use, discontinuance of a nonsteroidal anti-inflammatory drug (NSAID), or nephrology referral. At CKD-CDS clinics, CDS provided individualized treatment suggestions that were printed for patients and clinicians at the start of office encounters and were viewable within the electronic health record. By initial design, the impact of the CKD-CDS intervention on care gaps was to be assessed 12 months after the index date, but COVID-19 caused major disruptions to care delivery during the intervention period. In response to disruptions, the intervention was temporarily suspended while we expanded CDS use for telehealth encounters and programmed new criteria for displaying the CKD-CDS to intervention patients due to clinic closures and scheduling changes. DISCUSSION We describe a NIH-funded pragmatic trial of web-based EHR-integrated CKD-CDS and modifications necessary mid-study to complete the study as intended in the face of COVID-19 pandemic challenges.
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Affiliation(s)
| | - A Lauren Crain
- HealthPartners Institute, Minneapolis, MN, United States of America
| | - Lilian Chumba
- HealthPartners Institute, Minneapolis, MN, United States of America
| | - Heidi L Ekstrom
- HealthPartners Institute, Minneapolis, MN, United States of America
| | - Deepika Appana
- HealthPartners Institute, Minneapolis, MN, United States of America
| | - Kristen M Kopski
- Park Nicollet Medical Group, Minneapolis, MN, United States of America
| | - James B Wetmore
- Division of Nephrology, Hennepin County Medical Center, Minneapolis, MN, United States of America
| | - James Wheeler
- Park Nicollet Medical Group, Minneapolis, MN, United States of America
| | - Areef Ishani
- Minneapolis Veterans Affairs Health Care System and the University of Minnesota, Minneapolis, MN, United States of America
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20
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Saman DM, Chrenka EA, Harry ML, Allen CI, Freitag LA, Asche SE, Truitt AR, Ekstrom HL, O'Connor PJ, Sperl-Hillen JM, Ziegenfuss JY, Elliott TE. The impact of personalized clinical decision support on primary care patients' views of cancer prevention and screening: a cross-sectional survey. BMC Health Serv Res 2021; 21:592. [PMID: 34154588 PMCID: PMC8215810 DOI: 10.1186/s12913-021-06551-9] [Citation(s) in RCA: 3] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/18/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Few studies have assessed the impact of clinical decision support (CDS), with or without shared decision-making tools (SDMTs), on patients' perceptions of cancer screening or prevention in primary care settings. This cross-sectional survey was conducted to understand primary care patient's perceptions on cancer screening or prevention. METHODS We mailed surveys (10/2018-1/2019) to 749 patients aged 18 to 75 years within 15 days after an index clinical encounter at 36 primary care clinics participating in a clinic-randomized control trial of a CDS system for cancer prevention. All patients were overdue for cancer screening or human papillomavirus vaccination. The survey compared respondents' answers by study arm: usual care; CDS; or CDS + SDMT. RESULTS Of 387 respondents (52% response rate), 73% reported having enough time to discuss cancer prevention options with their primary care provider (PCP), 64% reported their PCP explained the benefits of the cancer screening choice very well, and 32% of obese patients reported discussing weight management, with two-thirds reporting selecting a weight management intervention. Usual care respondents were significantly more likely to decide on colorectal cancer screening than CDS respondents (p < 0.01), and on tobacco cessation than CDS + SDMT respondents (p = 0.02) and both CDS and CDS + SDMT respondents (p < 0.001). CONCLUSIONS Most patients reported discussing cancer prevention needs with PCPs, with few significant differences between the three study arms in patient-reported cancer prevention care. Upcoming research will assess differences in screening and vaccination rates between study arms during the post-intervention follow-up period. TRIAL REGISTRATION clinicaltrials.gov , NCT02986230 , December 6, 2016.
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Affiliation(s)
- Daniel M Saman
- Nicklaus Children's Health System, 3601 NW 107th Ave, Doral, FL, 33178, USA
- Essentia Institute of Rural Health, 502 E. Second Street, Duluth, MN, 55805, USA
| | - Ella A Chrenka
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - Melissa L Harry
- Essentia Institute of Rural Health, 502 E. Second Street, Duluth, MN, 55805, USA.
| | - Clayton I Allen
- Essentia Institute of Rural Health, 502 E. Second Street, Duluth, MN, 55805, USA
| | - Laura A Freitag
- Essentia Institute of Rural Health, 502 E. Second Street, Duluth, MN, 55805, USA
| | - Stephen E Asche
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - Anjali R Truitt
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - Heidi L Ekstrom
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - Patrick J O'Connor
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - JoAnn M Sperl-Hillen
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | | | - Thomas E Elliott
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
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21
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Rossom RC, Sperl-Hillen JM, O'Connor PJ, Crain AL, Nightingale L, Pylkas A, Huntley KV, Bart G. A pilot study of the functionality and clinician acceptance of a clinical decision support tool to improve primary care of opioid use disorder. Addict Sci Clin Pract 2021; 16:37. [PMID: 34130758 PMCID: PMC8207778 DOI: 10.1186/s13722-021-00245-7] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 06/03/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Most Americans with opioid use disorder (OUD) do not receive indicated medical care. A clinical decision support (CDS) tool for primary care providers (PCPs) could address this treatment gap. Our primary objective was to build OUD-CDS tool and demonstrate its functionality and accuracy. Secondary objectives were to achieve high use and approval rates and improve PCP confidence in diagnosing and treating OUD. METHODS A convenience sample of 55 PCPs participated. Buprenorphine-waivered PCPs (n = 8) were assigned to the intervention. Non-waivered PCPs (n = 47) were randomized to intervention (n = 24) or control (n = 23). Intervention PCPs received access to the OUD-CDS, which alerted them to patients at potentially increased risk for OUD or overdose and guided diagnosis and treatment. Control PCPs provided care as usual. RESULTS The OUD-CDS was functional and accurate following extensive multi-phased testing. PCPs used the OUD-CDS in 5% of encounters with at-risk patients, far less than the goal of 60%. OUD screening confidence increased for all intervention PCPs and OUD diagnosis increased for non-waivered intervention PCPs. Most PCPs (65%) would recommend the OUD-CDS and found it helpful with screening for OUD and discussing and prescribing OUD medications. DISCUSSION PCPs generally liked the OUD-CDS, but use rates were low, suggesting the need to modify CDS design, implementation strategies and integration with existing primary care workflows. CONCLUSION The OUD-CDS tool was functional and accurate, but PCP use rates were low. Despite low use, the OUD-CDS improved confidence in OUD screening, diagnosis and use of buprenorphine. NIH Trial registration NCT03559179. Date of registration: 06/18/2018. URL: https://clinicaltrials.gov/ct2/show/NCT03559179.
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Affiliation(s)
- Rebecca C Rossom
- HealthPartners Institute, Minneapolis, MN, USA. .,University of Minnesota School of Medicine, Minneapolis, MN, USA.
| | | | | | | | | | - Anne Pylkas
- HealthPartners Medical Group, Minneapolis, MN, USA.,Sage Prairie Clinic, Eagan, MN, USA
| | - Kristen V Huntley
- Center for the Clinical Trials Network, National Institute on Drug Abuse, Bethesda, MA, USA
| | - Gavin Bart
- University of Minnesota School of Medicine, Minneapolis, MN, USA.,Hennepin Healthcare, Minneapolis, MN, USA
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22
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Beran M, Bergdall AR, Kodet AJ, JaKa MM, Sperl-Hillen JM, Margolis KL. Primary care physician perspectives on using team care in clinical practice. J Am Pharm Assoc (2003) 2021; 61:745-752.e1. [PMID: 34303614 DOI: 10.1016/j.japh.2021.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 06/03/2021] [Accepted: 06/03/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Primary care physicians were prompted to refer eligible patients with uncontrolled hypertension (HTN) to a program that offered home blood pressure telemonitoring and pharmacist care management. Understanding attitudes, barriers and facilitators, and use of team care in this program provides insight into how physicians incorporate team care into their practice. OBJECTIVE To understand physician attitudes and use of team care in the context of a study intervention that included telehealth care with pharmacist care management. METHODS Clinicians who were part of the telehealth intervention arm of the Hyperlink 3 study and had at least 20 opportunities to refer an eligible patient with HTN to a clinical pharmacist were invited to be interviewed. Nine physician interviews were conducted, recorded, and transcribed. Each interview lasted approximately 30 minutes and followed an interview guide, allowing for some variation and deeper dives into content on the basis of the clinician response. Three research staff coded each interview and sorted coded text to identify patterns at the physician level and then identified themes across interviews using a comparative process. RESULTS Physicians had an overall positive attitude about team care. Communication, access, trust, and perceived role competency of team members influenced physician engagement in team care. Individualized practice styles influenced how physicians used team care and which care team members they involved most often. All physicians felt that their individual style best achieved high-quality care. CONCLUSION For health care teams to be most effective, an understanding of how a physician's practice style influences their use of team care is likely to be more successful than a one-size-fits-all approach. Incorporating practice style into the key factors necessary for high-functioning teams, such as communication, access, and trust, is necessary for health care teams to thrive.
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23
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Elliott TE, O'Connor PJ, Asche SE, Saman DM, Dehmer SP, Ekstrom HL, Allen CI, Bianco JA, Chrenka EA, Freitag LA, Harry ML, Truitt AR, Sperl-Hillen JM. Design and rationale of an intervention to improve cancer prevention using clinical decision support and shared decision making: A clinic-randomized trial. Contemp Clin Trials 2021; 102:106271. [PMID: 33503497 DOI: 10.1016/j.cct.2021.106271] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 05/04/2020] [Revised: 12/21/2020] [Accepted: 12/28/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Despite decades of research the gap in primary and secondary cancer prevention services in the U. S. remains unacceptably wide. Innovative interventions are needed to address this persistent challenge. Electronic health records linked with Web-based clinical decision support may close this gap, especially if delivered to both patients and their providers. OBJECTIVES The Cancer Prevention Wizard (CPW) study is an implementation, clinic-randomized trial designed to achieve these aims: 1) assess impact of the Cancer Prevention Wizard-Clinical Decision Support (CPW-CDS) alone and CPW-CDS plus Shared Decision Making Tools (CPW + SDMTs) compared to usual care (UC) on tobacco cessation counseling and drugs, HPV vaccinations, and screening tests for breast, cervical, colorectal, or lung cancer; 2) assess cost of the CPW-CDS intervention; and 3) describe critical facilitators and barriers for CPW-CDS implementation, use, and clinical impact using a mixed-methods approach supported by the CFIR and RE-AIM frameworks. METHODS 34 predominantly rural, primary care clinics were randomized to CPW-CDS, CPW + SMDTs, or UC. Between August 2018 and October 2020, primary care providers and their patients who met inclusion criteria in intervention clinics were exposed to the CPW-CDS with or without SDMTs. Study outcomes at 12 months post index visit include patients up to date on screening tests and HPV vaccinations, overall healthcare costs, and diagnostic codes and billing levels for cancer prevention services. CONCLUSIONS We will test in rural primary care settings whether CPW-CDS with or without SDMTs can improve delivery of primary and secondary cancer prevention services. The trial and analyses are ongoing with results expected in 2021.
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Affiliation(s)
- Thomas E Elliott
- HealthPartners Institute, 8170 33rd Ave. South, Minneapolis, MN 55425, USA.
| | - Patrick J O'Connor
- HealthPartners Institute, 8170 33rd Ave. South, Minneapolis, MN 55425, USA.
| | - Stephen E Asche
- HealthPartners Institute, 8170 33rd Ave. South, Minneapolis, MN 55425, USA.
| | - Daniel M Saman
- Essentia Institute of Rural Health, 502 E. 2nd St., Duluth, MN 55805, USA.
| | - Steven P Dehmer
- HealthPartners Institute, 8170 33rd Ave. South, Minneapolis, MN 55425, USA.
| | - Heidi L Ekstrom
- HealthPartners Institute, 8170 33rd Ave. South, Minneapolis, MN 55425, USA.
| | - Clayton I Allen
- Essentia Institute of Rural Health, 502 E. 2nd St., Duluth, MN 55805, USA.
| | | | - Ella A Chrenka
- HealthPartners Institute, 8170 33rd Ave. South, Minneapolis, MN 55425, USA.
| | - Laura A Freitag
- Essentia Institute of Rural Health, 502 E. 2nd St., Duluth, MN 55805, USA.
| | - Melissa L Harry
- Essentia Institute of Rural Health, 502 E. 2nd St., Duluth, MN 55805, USA.
| | - Anjali R Truitt
- HealthPartners Institute, 8170 33rd Ave. South, Minneapolis, MN 55425, USA.
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24
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Margolis KL, Sperl-Hillen JM, Crain LA, Ziegenfuss JY, Solberg LI, Bergdall AR, Beran M, Anderson JP, Pawloski PA, Rehrauer DJ, Norton C, Haugen PK, Green BB, McKinney ZJ, Kodet AJ, Appana D, Sharma R, Trower NK, Crabtree B, Haapala JL, Kottke TE, O'Connor PJ. Abstract P165: Improvement In Self-monitoring Frequency, Electronic Data Sharing, And Medication Changes In A Pragmatic Cluster-randomized Trial Of Home Blood Pressure Telemonitoring And Pharmacist Care (Hyperlink 3). Hypertension 2020. [DOI: 10.1161/hyp.76.suppl_1.p165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Telehealth and remote monitoring have become critical to patient access to care during the COVID-19 pandemic. We measured the effect of a telehealth care intervention on frequency, sharing methods, and clinical usage of home blood pressure (BP) measurements.
Methods:
Hyperlink 3 is an ongoing pragmatic cluster-randomized trial in 3072 patients with uncontrolled hypertension in 21 primary care clinics in an integrated health system. Clinics were randomized to Clinic-based Care (CC, 9 clinics, 1648 patients) or Telehealth Care (TC, 12 clinics, 1424 patients). TC patients were offered home BP telemonitoring with pharmacist care management. Patients were surveyed at baseline (Nov 2017 - Apr 2019) and after 6 mo of study enrollment.
Results:
In the TC group, about 37% of patients attended an intake pharmacist visit and 434 (30%) participated in home BP telemonitoring. Baseline surveys were completed by 1719 (56%) of patients at baseline (goal 50%) and 1301 (76%) of those completing the baseline survey completed the 6 mo survey (goal 75%). Baseline survey respondents' mean age was 62, 46% were men, 19% were black, and mean BP was 164/93 mm Hg. Nearly all patients (>90%) took antihypertensive medications (median 2). The odds ratio (OR) for change in measuring BP
>
2 times/week vs. less often was 0.97 (95% CI 0.87 - 1.42) in CC, and 2.01 (95% CI 1.56 - 2.59) in TC. The OR for change in frequent measurement in TC vs CC was 2.08 (95% CI 1.45 - 2.97).
Conclusions:
A telehealth care intervention markedly increased the frequency of home BP self- monitoring, electronic data sharing, and data-driven BP medication changes, even though only a minority of TC patients received the intervention.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Beverly B Green
- Kaiser Permanente Washington Health Rsch Institute, Seattle, WA
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25
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Harry ML, Saman DM, Truitt AR, Allen CI, Walton KM, O'Connor PJ, Ekstrom HL, Sperl-Hillen JM, Bianco JA, Elliott TE. Pre-implementation adaptation of primary care cancer prevention clinical decision support in a predominantly rural healthcare system. BMC Med Inform Decis Mak 2020; 20:117. [PMID: 32576202 PMCID: PMC7310565 DOI: 10.1186/s12911-020-01136-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 05/24/2020] [Indexed: 01/12/2023] Open
Abstract
Background Cancer is a leading cause of death in the United States. Primary care providers (PCPs) juggle patient cancer prevention and screening along with managing acute and chronic health problems. However, clinical decision support (CDS) may assist PCPs in addressing patients’ cancer prevention and screening needs during short clinic visits. In this paper, we describe pre-implementation study design and cancer screening and prevention CDS changes made to maximize utilization and better fit a healthcare system’s goals and culture. We employed the Consolidated Framework for Implementation Research (CFIR), useful for evaluating the implementation of CDS interventions in primary care settings, in understanding barriers and facilitators that led to those changes. Methods In a three-arm, pragmatic, 36 clinic cluster-randomized control trial, we integrated cancer screening and prevention CDS and shared decision-making tools (SDMT) into an existing electronic medical record-linked cardiovascular risk management CDS system. The integrated CDS is currently being tested within a predominately rural upper Midwestern healthcare system. Prior to CDS implementation, we catalogued pre-implementation changes made from 2016 to 2018 based on: pre-implementation site engagement; key informant interviews with healthcare system rooming staff, providers, and leadership; and pilot testing. We identified influential barriers, facilitators, and changes made in response through qualitative content analysis of meeting minutes and supportive documents. We then coded pre-implementation changes made and associated barriers and facilitators using the CFIR. Results Based on our findings from system-wide pre-implementation engagement, pilot testing, and key informant interviews, we made changes to accommodate the needs of the healthcare system based on barriers and facilitators that fell within the Intervention Characteristics, Inner Setting, and Outer Setting CFIR domains. Changes included replacing the expansion of medical assistant roles in one intervention arm with targeted SDMT, as well as altering cancer prevention CDS and study design elements. Conclusions Pre-implementation changes to CDS may help meet healthcare systems’ evolving needs and optimize the intervention by being responsive to real-world implementation barriers and facilitators. Frameworks like the CFIR are useful tools for identifying areas where pre-implementation barriers and facilitators may result in design changes, both to research studies and CDS systems. Trial registration NCT02986230.
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Affiliation(s)
- Melissa L Harry
- Essentia Health, Essentia Institute of Rural Health, 6AV-2, 502 East Second Street, Duluth, MN, 55805, USA
| | - Daniel M Saman
- Essentia Health, Essentia Institute of Rural Health, 6AV-2, 502 East Second Street, Duluth, MN, 55805, USA.
| | - Anjali R Truitt
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - Clayton I Allen
- Essentia Health, Essentia Institute of Rural Health, 6AV-2, 502 East Second Street, Duluth, MN, 55805, USA
| | - Kayla M Walton
- Essentia Health, Essentia Institute of Rural Health, 6AV-2, 502 East Second Street, Duluth, MN, 55805, USA
| | - Patrick J O'Connor
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - Heidi L Ekstrom
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - JoAnn M Sperl-Hillen
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - Joseph A Bianco
- Essentia Health - Ely Clinic, 300 W Conan Street, Ely, MN, 55731, USA
| | - Thomas E Elliott
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
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26
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Margolis KL, Crain AL, Bergdall AR, Beran M, Anderson JP, Solberg LI, O'Connor PJ, Sperl-Hillen JM, Pawloski PA, Ziegenfuss JY, Rehrauer D, Norton C, Haugen P, Green BB, McKinney Z, Kodet A, Appana D, Sharma R, Trower NK, Williams R, Crabtree BF. Design of a pragmatic cluster-randomized trial comparing telehealth care and best practice clinic-based care for uncontrolled high blood pressure. Contemp Clin Trials 2020; 92:105939. [PMID: 31981712 DOI: 10.1016/j.cct.2020.105939] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 10/03/2019] [Revised: 01/16/2020] [Accepted: 01/20/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Uncontrolled hypertension is the largest single contributor to all-cause and cardiovascular mortality in the U.S. POPULATION Nurse- and pharmacist-led team-based care and telehealth care interventions have been shown to result in large and lasting improvements in blood pressure (BP); however, it is unclear how successfully these can be implemented at scale in real-world settings. It is also uncertain how telehealth interventions impact patient experience compared to traditional clinic-based care. AIMS/OBJECTIVES To compare the effects of two evidence-based blood pressure care strategies in the primary care setting: (1) best-practice clinic-based care and (2) telehealth care with home BP telemonitoring and management by a clinical pharmacist. To evaluate implementation using mixed-methods supported by the RE-AIM framework and Consolidated Framework for Implementation Research. METHODS The design is a cluster-randomized comparative effectiveness pragmatic trial in 21 primary care clinics (9 clinic-based care, 12 telehealth care). Adult patients (age 18-85) with hypertension are enrolled via automated electronic health record (EHR) tools during primary care encounters if BP is elevated to ≥150/95 mmHg at two consecutive visits. The primary outcome is change in systolic BP over 12 months as extracted from the EHR. Secondary outcomes are change in key patient-reported outcomes over 6 months as measured by surveys. Qualitative data are collected at various time points to investigate implementation barriers and help explain intervention effects. CONCLUSION This pragmatic trial aims to inform health systems about the benefits, strengths, and limitations of implementing home BP telemonitoring with pharmacist management for uncontrolled hypertension in real-world primary care settings.
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Affiliation(s)
- Karen L Margolis
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America.
| | - A Lauren Crain
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Anna R Bergdall
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - MarySue Beran
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Jeffrey P Anderson
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Leif I Solberg
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Patrick J O'Connor
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - JoAnn M Sperl-Hillen
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Pamala A Pawloski
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Jeanette Y Ziegenfuss
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Dan Rehrauer
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Christine Norton
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Patricia Haugen
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Av, Seattle, WA 98101, United States of America
| | - Zeke McKinney
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Amy Kodet
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Deepika Appana
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Rashmi Sharma
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Nicole K Trower
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - RaeAnn Williams
- HealthPartners, Mailstop 31100A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Benjamin F Crabtree
- Rutgers Robert Wood Johnson Medical School, Department of Family Medicine and Community Health, New Brunswick, NJ 08901, United States of America
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Rossom RC, O'Connor PJ, Crain AL, Waring S, Ohnsorg K, Taran A, Kopski K, Sperl-Hillen JM. Pragmatic trial design of an intervention to reduce cardiovascular risk in people with serious mental illness. Contemp Clin Trials 2020; 91:105964. [PMID: 32087336 PMCID: PMC7263956 DOI: 10.1016/j.cct.2020.105964] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 01/29/2020] [Accepted: 02/17/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cardiovascular (CV) disease is the leading cause of death for people with serious mental illness (SMI), but clinicians are often slow to address this risk. METHODS/DESIGN 78 Midwestern primary care clinics were randomized to receive or not receive access to a clinical decision support (CDS) tool. Between March 2016 and September 2018, primary care clinicians (PCPs) received CDS alerts during visits with adult patients with SMI who met minimal inclusion criteria and had at least one CV risk factor not at goal. The PCP CDS included a summary of six modifiable CV risk factors and patient-specific treatment recommendations. Psychiatrists received CDS alerts during their next visit with an eligible patient with SMI that alerted them to an elevated body mass index or recent weight gain and the presence of an obesogenic SMI medication. Study outcomes include total modifiable CV risk, six modifiable CV risk factors, and use of obesogenic SMI medications. DISCUSSION This cluster-randomized pragmatic trial allowed PCPs and psychiatrists the opportunity to improve CV risk in a timely manner for patients with SMI. Effectiveness will be assessed using an intent-to-treat analysis, and outcomes will be assessed largely through electronic health record data harvested by the CDS tool itself. In total, 10,347 patients with SMI had an index primary care visit in a randomized clinic, and 8937 patients had at least one follow-up visit. Analyses are ongoing, and trial results are expected in mid-2020. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02451670.
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Affiliation(s)
- Rebecca C Rossom
- HealthPartners Institute, Minneapolis, MN, United States of America.
| | | | - A Lauren Crain
- HealthPartners Institute, Minneapolis, MN, United States of America
| | | | - Kris Ohnsorg
- HealthPartners Institute, Minneapolis, MN, United States of America
| | - Allise Taran
- Essentia Health, Duluth, MN, United States of America
| | - Kris Kopski
- HealthPartners Medical Group, Minneapolis, MN, United States of America
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Saman DM, Walton KM, Harry ML, Asche SE, Truitt AR, Henzler-Buckingham HA, Allen CI, Ekstrom HL, O'Connor PJ, Sperl-Hillen JM, Ziegenfuss JY, Bianco JA, Elliott TE. Understanding primary care providers' perceptions of cancer prevention and screening in a predominantly rural healthcare system in the upper Midwest. BMC Health Serv Res 2019; 19:1019. [PMID: 31888630 PMCID: PMC6937782 DOI: 10.1186/s12913-019-4872-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 12/24/2019] [Indexed: 11/10/2022] Open
Abstract
Background Cancer is the leading cause of death in the United States, with the burden expected to rise in the coming decades, increasing the need for effective cancer prevention and screening options. The United States Preventive Services Task Force has suggested that a shared decision-making process be used when clinicians and patients discuss cancer screening. The electronic medical record (EMR) often provides only reminders or alerts to primary care providers (PCPs) when screenings are due, a strategy with limited efficacy. Methods We administered a cross-sectional electronic survey to PCPs (n = 165, 53% response rate) at 36 Essentia Health primary care clinics participating in a large, National Cancer Institute-funded study on a cancer prevention clinical decision support (CDS) tool. The survey assessed PCP demographics, perceptions of the EMR’s ability to help assess and manage patients’ cancer risk, and experience and comfort level discussing cancer screening and prevention with patients. Results In these predominantly rural clinics, only 49% of PCPs thought the EMR was well integrated to help assess and manage cancer risk. Both advanced care practitioners and physicians agreed that cancer screening and informed discussion of cancer risks are important; however, only 53% reported their patients gave cancer screening a high priority relative to other health issues. Conclusions The impact of EMR-linked CDS delivered to both patients and PCPs may improve cancer screening, but only if it is easy to use and saves PCPs time.
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Affiliation(s)
- Daniel M Saman
- Essentia Institute of Rural Health, 502 E. Second Street, Duluth, MN, 55805, USA.
| | - Kayla M Walton
- Essentia Institute of Rural Health, 502 E. Second Street, Duluth, MN, 55805, USA
| | - Melissa L Harry
- Essentia Institute of Rural Health, 502 E. Second Street, Duluth, MN, 55805, USA
| | - Stephen E Asche
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - Anjali R Truitt
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | | | - Clayton I Allen
- Essentia Institute of Rural Health, 502 E. Second Street, Duluth, MN, 55805, USA
| | - Heidi L Ekstrom
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - Patrick J O'Connor
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - JoAnn M Sperl-Hillen
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | | | - Joseph A Bianco
- Essentia Health - Ely Clinic, 300 W. Conan Street, Ely, MN, 55731, USA
| | - Thomas E Elliott
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
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Sperl-Hillen JM, Crain AL, Margolis KL, Ekstrom HL, Appana D, Amundson G, Sharma R, Desai JR, O'Connor PJ. Clinical decision support directed to primary care patients and providers reduces cardiovascular risk: a randomized trial. J Am Med Inform Assoc 2019; 25:1137-1146. [PMID: 29982627 DOI: 10.1093/jamia/ocy085] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 06/04/2018] [Indexed: 12/18/2022] Open
Abstract
Objective To test the hypothesis that use of a clinical decision support (CDS) system in a primary care setting can reduce cardiovascular (CV) risk in patients. Materials and Methods Twenty primary care clinics were randomly assigned to usual care (UC) or CDS. For CDS clinic patients identified algorithmically with high CV risk, rooming staff were prompted by the electronic health record (EHR) to print CDS that identified evidence-based treatment options for lipid, blood pressure, weight, tobacco, or aspirin management and prioritized them based on potential benefit to the patient. The intention-to-treat analysis included 7914 adults who met high CV risk criteria at an index clinic visit and had at least one post-index visit, accounted for clustering, and assessed impact on predicted annual rate of change in 10-year CV risk over a 14-month period. Results The CDS was printed at 75% of targeted visits, and providers reported 85% to 98% satisfaction with various aspects of the intervention. Predicted annual rate of change in absolute 10-year CV risk was significantly better in CDS clinics than in UC clinics (-0.59% vs. +1.66%, -2.24%; P < .001), with difference in 10-year CV risk at 12 months post-index favoring the CDS group (UC 24.4%, CDS 22.5%, P < .03). Discussion Deploying to both patients and providers within primary care visit workflow and limiting CDS display and print burden to two mouse clicks by rooming staff contributed to high CDS use rates and high provider satisfaction. Conclusion This EHR-integrated, web-based outpatient CDS system significantly improved 10-year CV risk trajectory in targeted adults.
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Affiliation(s)
- JoAnn M Sperl-Hillen
- HealthPartners Center for Chronic Care Innovation, Minneapolis, Minnesota, USA.,HealthPartners Institute, Minneapolis, Minnesota, USA
| | | | - Karen L Margolis
- HealthPartners Center for Chronic Care Innovation, Minneapolis, Minnesota, USA.,HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Heidi L Ekstrom
- HealthPartners Center for Chronic Care Innovation, Minneapolis, Minnesota, USA.,HealthPartners Institute, Minneapolis, Minnesota, USA
| | | | | | - Rashmi Sharma
- HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Jay R Desai
- HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Patrick J O'Connor
- HealthPartners Center for Chronic Care Innovation, Minneapolis, Minnesota, USA.,HealthPartners Institute, Minneapolis, Minnesota, USA
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Harry ML, Truitt AR, Saman DM, Henzler-Buckingham HA, Allen CI, Walton KM, Ekstrom HL, O'Connor PJ, Sperl-Hillen JM, Bianco JA, Elliott TE. Barriers and facilitators to implementing cancer prevention clinical decision support in primary care: a qualitative study. BMC Health Serv Res 2019; 19:534. [PMID: 31366355 PMCID: PMC6668099 DOI: 10.1186/s12913-019-4326-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [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: 02/14/2019] [Accepted: 07/05/2019] [Indexed: 01/22/2023] Open
Abstract
Background In the United States, primary care providers (PCPs) routinely balance acute, chronic, and preventive patient care delivery, including cancer prevention and screening, in time-limited visits. Clinical decision support (CDS) may help PCPs prioritize cancer prevention and screening with other patient needs. In a three-arm, pragmatic, clinic-randomized control trial, we are studying cancer prevention CDS in a large, upper Midwestern healthcare system. The web-based, electronic health record (EHR)-linked CDS integrates evidence-based primary and secondary cancer prevention and screening recommendations into an existing cardiovascular risk management CDS system. Our objective with this study was to identify adoption barriers and facilitators before implementation in primary care. Methods We conducted semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR) with 28 key informants employed by the healthcare organization in either leadership roles or the direct provision of clinical care. Transcribed interviews were analyzed using qualitative content analysis. Results EHR, CDS workflow, CDS users (providers and patients), training, and organizational barriers and facilitators were identified related to Intervention Characteristics, Outer Setting, Inner Setting, and Characteristics of Individuals CFIR domains. Conclusion Identifying and addressing key informant-identified barriers and facilitators before implementing cancer prevention CDS in primary care may support a successful implementation and sustained use. The CFIR is a useful framework for understanding pre-implementation barriers and facilitators. Based on our findings, the research team developed and instituted specialized training, pilot testing, implementation plans, and post-implementation efforts to maximize identified facilitators and address barriers. Trial registration clinicaltrials.gov, NCT02986230, December 6, 2016. Electronic supplementary material The online version of this article (10.1186/s12913-019-4326-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Melissa L Harry
- Essentia Institute of Rural Health, 502 East Second Street, Duluth, MN, 55805, USA
| | - Anjali R Truitt
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - Daniel M Saman
- Essentia Institute of Rural Health, 502 East Second Street, Duluth, MN, 55805, USA.
| | | | - Clayton I Allen
- Essentia Institute of Rural Health, 502 East Second Street, Duluth, MN, 55805, USA
| | - Kayla M Walton
- Essentia Institute of Rural Health, 502 East Second Street, Duluth, MN, 55805, USA
| | - Heidi L Ekstrom
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - Patrick J O'Connor
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - JoAnn M Sperl-Hillen
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
| | - Joseph A Bianco
- Essentia Health - Ely Clinic, 300 W Conan Street, Ely, MN, 55731, USA
| | - Thomas E Elliott
- HealthPartners Institute, 3311 E. Old Shakopee Road, Bloomington, MN, 55425, USA
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O'Connor PJ, Sperl-Hillen JM. Current Status and Future Directions for Electronic Point-of-Care Clinical Decision Support to Improve Diabetes Management in Primary Care. Diabetes Technol Ther 2019; 21:S226-S234. [PMID: 31169426 DOI: 10.1089/dia.2019.0070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 11/12/2022]
Abstract
In the past decade there have been major improvements in the design, use, and effectiveness of point-of-care clinical decision support (CDS) systems to improve quality of care for patients with diabetes and related conditions. Advances in data exchange, data security, and human factors research have driven these improvements. Current diabetes CDS systems have high use rates, high clinician/user satisfaction rates, and have measurably improved glucose control, blood pressure control, and cardiovascular risk trajectories in adults with diabetes. As diabetes care increasingly relies on complex biomarker-driven risk prediction methods to optimize care goals and prioritize treatment options based on potential benefit to an individual patient, CDS systems will become indispensable tools to guide clinician and patient decision-making. In this study we describe specific challenges that must be addressed further to improve the design, implementation, and effectiveness of primary care diabetes CDS systems in coming years.
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Affiliation(s)
- Patrick J O'Connor
- 1 HealthPartners Institute, Minneapolis, Minnesota
- 2 HealthPartners Center for Chronic Care Innovation, Minneapolis, Minnesota
| | - JoAnn M Sperl-Hillen
- 1 HealthPartners Institute, Minneapolis, Minnesota
- 2 HealthPartners Center for Chronic Care Innovation, Minneapolis, Minnesota
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Sperl-Hillen JM, Rossom RC, Kharbanda EO, Gold R, Geissal ED, Elliott TE, Desai JR, Rindal DB, Saman DM, Waring SC, Margolis KL, O’Connor PJ. Priorities Wizard: Multisite Web-Based Primary Care Clinical Decision Support Improved Chronic Care Outcomes with High Use Rates and High Clinician Satisfaction Rates. EGEMS (Wash DC) 2019; 7:9. [PMID: 30972358 PMCID: PMC6450247 DOI: 10.5334/egems.284] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 01/29/2019] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Priorities Wizard is an electronic health record-linked, web-based clinical decision support (CDS) system designed and implemented at multiple Health Care Systems Research Network (HCSRN) sites to support high quality outpatient chronic disease and preventive care. The CDS system (a) identifies patients who could substantially benefit from evidence-based actions; (b) presents prioritized evidence-based treatment options to both patient and clinician at the point of care; and (c) facilitates efficient ordering of recommended medications, referrals or procedures. METHODS The CDS system extracts relevant data from electronic health records (EHRs), processes the data using Web-based clinical decision support algorithms, and displays the CDS output seamlessly on the EHR screen for use by the clinician and patient. Through a series of National Institutes of Health-funded projects led by HealthPartners Institute and the HealthPartners Center for Chronic Care Innovation and HCSRN partners, Priorities Wizard has been evaluated in cluster-randomized trials and expanded to include over 20 clinical domains. RESULTS Cluster-randomized trials show that this CDS system significantly improved glucose and blood pressure control in diabetes patients, reduced 10-year cardiovascular (CV) risk in high-CV risk adults without diabetes, improved management of smoking in dental patients, and improved high blood pressure identification and management in adolescents. CDS output was used at 71-77 percent of targeted visits, 85-98 percent of clinicians were satisfied with the CDS system, and 94 percent reported they would recommend it to colleagues. CONCLUSIONS Recently developed EHR-linked, Web-based CDS systems have significantly improved chronic disease care outcomes and have high use rates and primary care clinician satisfaction.
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Harry ML, Saman DM, Allen CI, Ohnsorg KA, Sperl-Hillen JM, O’Connor PJ, Ziegenfuss JY, Dehmer SP, Bianco JA, Desai JR. Understanding Primary Care Provider Attitudes and Behaviors Regarding Cardiovascular Disease Risk and Diabetes Prevention in the Northern Midwest. Clin Diabetes 2018; 36:283-294. [PMID: 30363898 PMCID: PMC6187954 DOI: 10.2337/cd17-0116] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
IN BRIEF We sought to fill critical gaps in understanding primary care providers' (PCPs') beliefs regarding diabetes prevention and cardiovascular disease risk in the prediabetes population, including through comparison of attitudes between rural and non-rural PCPs. We used data from a 2016 cross-sectional survey sent to 299 PCPs practicing in 36 primary clinics that are part of a randomized control trial in a predominately rural northern Midwestern integrated health care system. Results showed a few significant, but clinically marginal, differences between rural and non-rural PCPs. Generally, PCPs agreed with the importance of screening for prediabetes and thoroughly and clearly discussing CV risk with high-risk patients.
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Affiliation(s)
| | - Daniel M. Saman
- Essentia Health, Essentia Institute of Rural Health, Duluth, MN
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Margolis KL, Asche SE, Dehmer SP, Bergdall AR, Green BB, Sperl-Hillen JM, Nyboer RA, Pawloski PA, Maciosek MV, Trower NK, O’Connor PJ. Long-term Outcomes of the Effects of Home Blood Pressure Telemonitoring and Pharmacist Management on Blood Pressure Among Adults With Uncontrolled Hypertension: Follow-up of a Cluster Randomized Clinical Trial. JAMA Netw Open 2018; 1:e181617. [PMID: 30646139 PMCID: PMC6324502 DOI: 10.1001/jamanetworkopen.2018.1617] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Hypertension is a leading cause of cardiovascular disease. The results were previously reported of a trial of home blood pressure (BP) telemonitoring and pharmacist management intervention in which the interventions stopped after 12 months. There were significantly greater reductions in systolic BP (SBP) in the intervention group than in the usual care group at 6, 12, and 18 months (-10.7, -9.7, and -6.6 mm Hg, respectively). OBJECTIVES To examine the durability of the intervention effect on BP through 54 months of follow-up and to compare BP measurements performed in the research clinic and in routine clinical care. DESIGN, SETTING, AND PARTICIPANTS Follow-up of a cluster randomized clinical trial among 16 primary care clinics and 450 patients with uncontrolled hypertension in a large health system from March 2009 to November 2015. INTERVENTIONS A home BP telemonitoring intervention with pharmacist management or usual care. MAIN OUTCOMES AND MEASURES Change from baseline to 54 months in SBP and diastolic BP (DBP) measured as the mean of 3 measurements obtained at each research clinic visit. RESULTS Among 450 patients, 228 (mean [SD] age, 62.0 [11.7] years; 54.8% male) were randomized to the telemonitoring intervention and 222 (mean [SD] age, 60.2 [12.2] years; 55.9% male) to usual care. Research clinic BP measurements were obtained from 326 of 450 (72.4%) study patients at the 54-month follow-up visit, including 162 (mean [SD] age, 62.0 [11.1] years; 54.9% male) randomized to the telemonitoring intervention and 164 (mean [SD] age, 60.0 [11.2] years; 57.3% male) to usual care. Routine clinical care BP measurements were obtained from 439 of 450 (97.6%) study patients at 6248 visits during the follow-up period. Based on research clinic measurements, baseline mean SBP was 148 mm Hg in both groups. In the intervention group, mean SBP at 6-, 12-, 18-, and 54-month follow-up was 126.7, 125.7, 126.9, and 130.6 mm Hg, respectively. In the usual care group, mean SBP at 6-, 12-, 18-, and 54-month follow-up was 136.9, 134.8, 133.0, and 132.6 mm Hg, respectively. The differential reduction by study group in SBP from baseline to 54 months was -2.5 mm Hg (95% CI, -6.3 to 1.2 mm Hg; P = .18). The DBP followed a similar pattern, with a differential reduction by study group from baseline to 54 months of -1.0 mm Hg (95% CI, -3.2 to 1.2 mm Hg; P = .37). The SBP and DBP results from routine clinical measurements suggested significantly lower BP in the intervention group for up to 24 months. CONCLUSIONS AND RELEVANCE This intensive intervention had sustained effects for up to 24 months (12 months after the intervention ended). Long-term maintenance of BP control is likely to require continued monitoring and resumption of the intervention if BP increases. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00781365.
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Affiliation(s)
- Karen L. Margolis
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
| | - Stephen E. Asche
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
| | - Steven P. Dehmer
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
| | - Anna R. Bergdall
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
| | | | | | - Rachel A. Nyboer
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
| | - Pamala A. Pawloski
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
| | | | - Nicole K. Trower
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
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Margolis KL, Bergdall AR, Crain AL, O'Connor PJ, Solberg LI, Beran M, Ziegenfuss JY, Green BB, Pawloski PA, Rehrauer DJ, Appana D, Sharma R, Norton CK, Haugen P, Sperl-Hillen JM. Abstract P373: Design for a Pragmatic Trial Comparing Telehealth Care and Clinic-Based Care for Uncontrolled High Blood Pressure. Hypertension 2018. [DOI: 10.1161/hyp.72.suppl_1.p373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The 2017 ACC/AHA hypertension guideline strongly recommends systematic follow-up and monitoring of treatment using team-based care and telehealth, based on Level A evidence. However, different models for organizing team-based care and telehealth have not been compared. We describe the design of a PCORI-funded pragmatic trial with the following objectives: Aim 1) compare the effects on BP and patient-reported outcomes of two models of team-based care for uncontrolled hypertension, and Aim 2) study how the two models are carried out in the real-world setting of a large health system. The study is a 5-year cluster-randomized trial in 2000 patients age 18-85 with uncontrolled hypertension cared for in 21 primary care clinics at HealthPartners, a large integrated healthcare system in the Twin Cities area of Minnesota and western Wisconsin. Clinic-based care uses recommended best practices and face-to-face visits primarily with physicians, nurses and medical assistants. The telehealth care approach adapts a research-tested model with systematic use of home BP telemonitoring and home-based telehealth care coordinated by a clinical pharmacist or nurse practitioner. Patients in both groups are recruited directly from primary care clinics using electronic health record (EHR) prompts. Exclusions are few: pregnancy, advanced kidney disease, hospice care, and nursing home residence. The primary outcomes for Aim 1 are:1) change in BP over 12 months, and 2) change in patient-reported outcomes over six months, including treatment side effects, experiences with hypertension care, self-monitoring rates, and confidence in self-care. Secondary outcomes include other heart- and stroke-related risk factors and safety. Patients contributed extensively to the selection of the outcomes. Outcomes are collected over 24 months without reliance on research visits: patient-reported outcomes are measured by surveys and BP and other clinical outcomes are measured using routinely collected data documented in the EHR. We also use EHR data supplemented by qualitative data to assess how the two care models are carried out in practice. The results of this comparative effectiveness trial will assess pragmatic methods for implementing hypertension guideline recommendations.
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Affiliation(s)
| | | | - A L Crain
- Healthpartners Institute, Minneapolis, MN
| | | | | | | | | | - Beverly B Green
- Kaiser Permanente Washington Health Rsch Institute, Seattle, WA
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Beran M, Asche SE, Bergdall AR, Crabtree B, Green BB, Groen SE, Klotzle KJ, Michels RD, Nyboer RA, O'Connor PJ, Pawloski PA, Rehrauer DJ, Sperl-Hillen JM, Trower NK, Margolis KL. Key components of success in a randomized trial of blood pressure telemonitoring with medication therapy management pharmacists. J Am Pharm Assoc (2003) 2018; 58:614-621. [PMID: 30077564 DOI: 10.1016/j.japh.2018.07.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 05/03/2018] [Accepted: 07/02/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The Hyperlink trial tested a 12-month intervention of home blood pressure (BP) telemonitoring with pharmacist case management in adults with uncontrolled hypertension. The intervention resulted in improved BP control compared with usual care at both 6 (72% vs. 45%; P < 0.001) and 12 months (71% vs. 53%; P = 0.005). We sought to investigate factors contributing to intervention success. DESIGN Mixed-methods analysis of process of care data, patient focus groups, and pharmacist interviews. PARTICIPANTS Data from 228 intervention patients were examined from the original 450 patients randomly assigned from 16 primary care clinics. Five patient focus groups and 4 pharmacist interviews were conducted to ascertain the patient and pharmacist perspective. Focus group and interview data were coded, and themes relevant to pharmacists were identified. OUTCOME MEASURES Home BP readings of less than 135/85 mm Hg and patient focus group and pharmacist interview themes. RESULTS Mean BP at the intake visit was 148/85 mm Hg. Antihypertensive medications were adjusted in 10% of patients at the initial in-person visit, 33% at phone visit 1, 36% at phone visit 2, and 19% at phone visit 3. Thereafter, medication changes declined. The mean home BP for patients at the first phone visit was 136/80 mm Hg, 126/74 mm Hg at 3 months, and 123/73 mm Hg at 5 months, with little change thereafter. Key components of success from patient and pharmacist interviews included a strong patient-pharmacist relationship, individualized treatment plans, and frequent phone contact with the pharmacist. CONCLUSION Frequent adjustments to the antihypertensive treatment regimen based on home BP telemonitoring resulted in rapid lowering of BP. Our results suggest that an intensive telephone-based intervention with the key components of medication adjustments, a strong patient and pharmacist relationship, and individualized treatment plans can achieve BP control in only 3 months in many patients with uncontrolled hypertension.
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Dehmer SP, Maciosek MV, Trower NK, Asche SE, Bergdall AR, Nyboer RA, O'Connor PJ, Pawloski PA, Sperl-Hillen JM, Green BB, Margolis KL. Economic Evaluation of the Home Blood Pressure Telemonitoring and Pharmacist Case Management to Control Hypertension (Hyperlink) Trial. J Am Coll Clin Pharm 2018; 1:21-30. [PMID: 30320302 DOI: 10.1002/jac5.1001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Background Pharmacist-managed (team-based) care for hypertension with home blood pressure monitoring support interventions have been widely studied and shown to be effective in improving rates of hypertension control and lowering blood pressure; however, few studies have evaluated the economic considerations related to bringing these programs into usual practice. Objective To analyze the economic outcomes of the Blood Pressure Telemonitoring and Pharmacist Management on Blood Pressure (Hyperlink) study, a cluster randomized controlled trial which used home blood pressure telemonitoring and pharmacist case management to achieve better blood pressure control in patients with uncontrolled hypertension. Methods A prospective analysis compared differences in medical costs and encounters in the Hyperlink telemonitoring intervention and usual care groups in the 12 months pre- and post-enrollment using medical and pharmacy insurance claims from a health care sector perspective. Generalized estimating equation models were used to estimate differences between groups over time. These results, combined with previously published prospective study results on intervention costs and blood pressure outcomes, were used to estimate cost-effectiveness measures for blood pressure control and reduction. Findings Total medical costs in the intervention group were lower compared with the usual care group by an average of $281 per person, but this difference was not statistically significant. Clinic-based office visit, radiology, pharmacy, and hospital costs were also non-significantly lower in the intervention group. Statistically significant differences were found in lipid-related laboratory costs (higher) and in hypertension- (higher) and lipid-related (lower) pharmacy costs. Patterns in medical costs were similar for medical encounters. On average, the intervention cost $7337 per person achieving hypertension control and $139 or $265 per mm Hg reduction in systolic or diastolic blood pressure, respectively. Conclusions Home blood pressure monitoring and pharmacist case management to improve hypertension care can be implemented without increasing, and potentially reducing, overall medical care costs.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
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Margolis KL, Asche SE, Bergdall AR, Dehmer SP, Green BB, Sperl-Hillen JM, O’Connor PJ, Nyboer RA, Pawloski PA, Maciosek MV, Trower NK. Abstract P494: Long-term Outcomes of a Cluster-randomized Trial Testing the Effects Blood Pressure Telemonitoring and Pharmacist Management. Hypertension 2017. [DOI: 10.1161/hyp.70.suppl_1.p494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background/Aims:
Hypertension is a common condition and leading cause of cardiovascular disease. We previously reported results of a cluster-randomized trial evaluating a home blood pressure (BP) telemonitoring and pharmacist management intervention, with significant reductions in BP favoring the intervention arm over 18 months. This analysis examined the durability of the intervention effect on BP through 54 months of follow-up and compared BP measurements performed in the research clinic and in routine clinical care.
Methods:
The Hyperlink trial randomized 16 primary care clinics having 450 study-enrolled patients with uncontrolled hypertension to either Telemonitoring Intervention (TI) or usual care (UC) study arms. BP was measured as the mean of 3 measurements obtained at each research clinic visit. General linear mixed models utilizing a direct likelihood-based ignorable approach for missing data were used to examine change from baseline to 54 months in systolic and diastolic BP (SBP and DBP).
Results:
Research clinic BP measurements were obtained from 326 (72%) study patients at the 54 month follow-up visit. Routine clinical care BP measurements were obtained from 444 (99%) of study patients from 7025 visits during the follow-up period. For TI patients, based on research clinic measurements baseline SBP was 148.2 mm Hg and 54 month follow-up was 131.2 mm Hg (-17.0 mm Hg, p<.001). For UC patients, baseline SBP was 147.7 mm Hg and 54 month follow-up was 131.7 mm Hg ( -16.0 mm Hg, p<.001). The differential reduction by study arm in SBP from baseline to 54 months was -1.0 mm Hg (95% CI: -5.4 to 3.4, p=0.63). For TI patients, baseline DBP was 84.4 mm Hg and 54 month follow-up was 77.8 (-6.6 mm Hg, p<.001). For UC patients, baseline DBP was 85.1 mm Hg and 54 month follow-up was 79.1 mm Hg (-6.0 mm Hg, p<.001). The differential reduction by study arm in DBP from baseline to 54 months was -0.6 mm Hg (95% CI: -3.5 to 2.4, p=0.67). SBP and DBP results from routine clinical measurements closely approximated the pattern of results from research clinic measurements.
Conclusion:
Significant BP reductions in the TI arm relative to UC were no longer seen at 54 month follow-up. To maintain intervention benefits over a longer period of time additional intervention is needed.
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Affiliation(s)
| | | | | | | | - Beverly B Green
- Kaiser Permanente Washington Health Rsch Institute, Seattle, WA
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O'Connor PJ, Sperl-Hillen JM, Margolis KL, Kottke TE. Strategies to Prioritize Clinical Options in Primary Care. Ann Fam Med 2017; 15:10-13. [PMID: 28376456 PMCID: PMC5217839 DOI: 10.1370/afm.2027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 11/18/2016] [Accepted: 11/29/2016] [Indexed: 12/18/2022] Open
Affiliation(s)
- Patrick J O'Connor
- HealthPartners Institute, Minneapolis, Minnesota. HealthPartners Center for Chronic Care Innovation, Minneapolis, Minnesota
| | - JoAnn M Sperl-Hillen
- HealthPartners Institute, Minneapolis, Minnesota. HealthPartners Center for Chronic Care Innovation, Minneapolis, Minnesota
| | - Karen L Margolis
- HealthPartners Institute, Minneapolis, Minnesota. HealthPartners Center for Chronic Care Innovation, Minneapolis, Minnesota
| | - Thomas E Kottke
- HealthPartners Institute, Minneapolis, Minnesota. HealthPartners Center for Chronic Care Innovation, Minneapolis, Minnesota
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Asche SE, O'Connor PJ, Dehmer SP, Green BB, Bergdall AR, Maciosek MV, Nyboer RA, Pawloski PA, Sperl-Hillen JM, Trower NK, Margolis KL. Patient characteristics associated with greater blood pressure control in a randomized trial of home blood pressure telemonitoring and pharmacist management. ACTA ACUST UNITED AC 2016; 10:873-880. [PMID: 27720142 DOI: 10.1016/j.jash.2016.09.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [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: 06/03/2016] [Revised: 09/19/2016] [Accepted: 09/20/2016] [Indexed: 12/16/2022]
Abstract
This paper reports subgroup analysis of a successful cluster-randomized trial to identify attributes of hypertensive patients who benefited more or less from an intervention combining blood pressure (BP) telemonitoring and pharmacist management. The end point was BP < 140/90 mm Hg at 6-month follow-up. Fourteen baseline patient characteristics were selected a priori as subgroup variables. Among the 351 trial participants, 44% were female, 84% non-Hispanic white, mean age was 60.9 years, and mean BP was 149/86 mm Hg. The overall adjusted odds ratio for BP control in the intervention versus usual care group was 3.64 (P < .001). The effect of the intervention was significantly larger in patients who were younger (interaction P = .02), did not have diabetes (P = .005), had high baseline diastolic BP (P = .02), added salt less than daily in food preparation (P = .007), and took 0-2 (rather than 3-6) antihypertensive medication classes at baseline (P = .02). These findings may help prioritize patients for whom the intervention is most effective.
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Affiliation(s)
- Stephen E Asche
- HealthPartners Institute for Education and Research, Minneapolis, MN, USA
| | - Patrick J O'Connor
- HealthPartners Institute for Education and Research, Minneapolis, MN, USA
| | - Steven P Dehmer
- HealthPartners Institute for Education and Research, Minneapolis, MN, USA
| | | | - Anna R Bergdall
- HealthPartners Institute for Education and Research, Minneapolis, MN, USA
| | - Michael V Maciosek
- HealthPartners Institute for Education and Research, Minneapolis, MN, USA
| | - Rachel A Nyboer
- HealthPartners Institute for Education and Research, Minneapolis, MN, USA
| | - Pamala A Pawloski
- HealthPartners Institute for Education and Research, Minneapolis, MN, USA
| | | | - Nicole K Trower
- HealthPartners Institute for Education and Research, Minneapolis, MN, USA
| | - Karen L Margolis
- HealthPartners Institute for Education and Research, Minneapolis, MN, USA.
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Solberg LI, Engebretson KI, Sperl-Hillen JM, O'Connor PJ, Hroscikoski MC, Crain AL. Ambulatory Care Quality Measures for the 6 Aims From Administrative Data. Am J Med Qual 2016; 21:310-6. [PMID: 16973947 DOI: 10.1177/1062860606289071] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pressure is building for performance measures that can be collected inexpensively and repeatedly for internal and external accountability and quality improvement. The objective of this study was to develop and test measures obtainable from administrative data covering each of the Institute of Medicine's (IOM) 6 aims. Measure definitions were developed for 3 common chronic conditions and were revised after testing the feasibility of collecting them from claims data. The setting was a large, multispecialty medical group in the Midwest and included all adult patients with diabetes, coronary heart disease, or depression. Problems identified in the original 99 measures led to refinements or elimination. The resulting 46 measures ready for use include 11 measures for 5 aims applicable to most common chronic conditions, plus 10 to 14 effectiveness measures for each condition. They have been successfully used to describe care quality changes for these patients over time. This starter set for the 6 IOM aims should be tested and expanded by others.
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Affiliation(s)
- Leif I Solberg
- Care Improvement Research, HealthPartners Research Foundation, Minneapolis, MN 55440, USA.
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Bergdall AR, Sperl-Hillen JM, O'Connor PJ, Asche SE, Crabtree BF, Smith EA, Nyober RA, Dehmer SP, Maciosek MV, Pawlowski PA, Trower NK, Margolis KL. Qualitative Data from a Trial of Home Blood Pressure Telemonitoring and Pharmacist Management (Hyperlink). J Patient Cent Res Rev 2016. [DOI: 10.17294/2330-0698.1308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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O'Connor PJ, Sperl-Hillen JM, Asche SE, Crain AL, Ekstrom HL, Margolis KL. Design Features of Successful Outpatient Chronic Disease Care Clinical Decision Support Systems. J Patient Cent Res Rev 2016. [DOI: 10.17294/2330-0698.1324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Sperl-Hillen JM, Crain A, Ekstrom HL, Margolis KL, O'Connor PJ. A Clinical Decision Support System Promotes Shared Decision-Making and Cardiovascular Risk Factor Management. J Patient Cent Res Rev 2016. [DOI: 10.17294/2330-0698.1383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Sperl-Hillen JM, O'Connor PJ, Margolis KL, Crain AL, Ekstrom HL. Overuse and Underuse of Aspirin for Primary Prevention of Cardiovascular Events in Primary Care. J Patient Cent Res Rev 2016. [DOI: 10.17294/2330-0698.1311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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46
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Pawloski PA, Asche SE, Trower NK, Bergdall AR, Dehmer SP, Maciosek MV, Nyboer RA, O'Connor PJ, Sperl-Hillen JM, Green BB, Margolis KL. A substudy evaluating treatment intensification on medication adherence among hypertensive patients receiving home blood pressure telemonitoring and pharmacist management. J Clin Pharm Ther 2016; 41:493-8. [PMID: 27363822 DOI: 10.1111/jcpt.12414] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 06/02/2016] [Indexed: 01/07/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Hypertension is a leading cause of death and major contributor to heart attacks, strokes, heart and kidney failure. Antihypertensive (HTN medication) non-adherence contributes to uncontrolled hypertension. Effective initiatives to improve uncontrolled hypertension include a team-based approach with home blood pressure (BP) monitoring. Our study objective was to evaluate whether objectively measured medication adherence was influenced by home BP telemonitoring and pharmacist management. METHODS We analysed HTN medication adherence in 240 patients who received home BP telemonitoring and pharmacist intervention (TI). Adherence was measured based on prescription fills and the proportion of days covered (PDC). HTN medications continued pre- to post-baseline were similar for telemonitoring intervention (TI) and usual care (UC) patients (rate ratio = 1·00, P = 0·90). RESULTS AND DISCUSSION More HTN medications were discontinued pre- to post-baseline in TI patients (rate ratio = 1·38, P = 0·04). Similarly, more HTN medications were added in TI patients (rate ratio = 2·46, P < 0·001). The proportion with a mean PDC ≥ 0·8 for HTN medications added after baseline and overall adherence did not differ between groups. WHAT IS NEW AND CONCLUSION Medication adherence was high in both groups; however, medication adherence was not significantly altered by the intervention. There were more medication modifications and greater medication intensification among TI patients.
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Affiliation(s)
| | - S E Asche
- HealthPartners Institute, Minneapolis, MN, USA
| | - N K Trower
- HealthPartners Institute, Minneapolis, MN, USA
| | | | - S P Dehmer
- HealthPartners Institute, Minneapolis, MN, USA
| | | | - R A Nyboer
- HealthPartners Institute, Minneapolis, MN, USA
| | | | | | - B B Green
- Group Health Research Institute, Seattle, WA, USA
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O'Connor PJ, Sperl-Hillen JM, Fazio CJ, Averbeck BM, Rank BH, Margolis KL. Outpatient diabetes clinical decision support: current status and future directions. Diabet Med 2016; 33:734-41. [PMID: 27194173 PMCID: PMC5642968 DOI: 10.1111/dme.13090] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2016] [Indexed: 12/13/2022]
Abstract
Outpatient clinical decision support systems have had an inconsistent impact on key aspects of diabetes care. A principal barrier to success has been low use rates in many settings. Here, we identify key aspects of clinical decision support system design, content and implementation that are related to sustained high use rates and positive impacts on glucose, blood pressure and lipid management. Current diabetes clinical decision support systems may be improved by prioritizing care recommendations, improving communication of treatment-relevant information to patients, using such systems for care coordination and case management and integrating patient-reported information and data from remote devices into clinical decision algorithms and interfaces.
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Affiliation(s)
- P J O'Connor
- Center for Chronic Care Innovation, Minneapolis, MN, USA
- HealthPartners Institute, Minneapolis, MN, USA
| | - J M Sperl-Hillen
- Center for Chronic Care Innovation, Minneapolis, MN, USA
- HealthPartners Institute, Minneapolis, MN, USA
| | - C J Fazio
- HealthPartners, Minneapolis, MN, USA
| | | | - B H Rank
- HealthPartners, Minneapolis, MN, USA
| | - K L Margolis
- Center for Chronic Care Innovation, Minneapolis, MN, USA
- HealthPartners Institute, Minneapolis, MN, USA
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Margolis KL, Asche SE, Bergdall AR, Dehmer SP, Maciosek MV, Nyboer RA, O'Connor PJ, Pawloski PA, Sperl-Hillen JM, Trower NK, Tucker AD, Green BB. A Successful Multifaceted Trial to Improve Hypertension Control in Primary Care: Why Did it Work? J Gen Intern Med 2015; 30:1665-72. [PMID: 25952653 PMCID: PMC4617923 DOI: 10.1007/s11606-015-3355-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [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: 11/29/2022]
Abstract
BACKGROUND It is important to understand which components of successful multifaceted interventions are responsible for study outcomes, since some components may be more important contributors to the intervention effect than others. OBJECTIVE We conducted a mediation analysis to determine which of seven factors had the greatest effect on change in systolic blood pressure (BP) after 6 months in a trial to improve hypertension control. DESIGN The study was a preplanned secondary analysis of a cluster-randomized clinical trial. Eight clinics in an integrated health system were randomized to provide usual care to their patients (n = 222), and eight were randomized to provide a telemonitoring intervention (n = 228). PARTICIPANTS Four hundred three of 450 trial participants completing the 6-month follow-up visit were included. INTERVENTIONS Intervention group participants received home BP telemonitors and transmitted measurements to pharmacists, who adjusted medications and provided advice to improve adherence to medications and lifestyle modification via telephone visits. MAIN MEASURES Path analytic models estimated indirect effects of the seven potential mediators of intervention effect (defined as the difference between the intervention and usual care groups in change in systolic BP from baseline to 6 months). The potential mediators were change in home BP monitor use, number of BP medication classes, adherence to BP medications, physical activity, salt intake, alcohol use, and weight. KEY RESULTS The difference in change in systolic BP was 11.3 mmHg. The multivariable mediation model explained 47 % (5.3 mmHg) of the intervention effect. Nearly all of this was mediated by two factors: an increase in medication treatment intensity (24 %) and increased home BP monitor use (19 %). The other five factors were not significant mediators, although medication adherence and salt intake improved more in the intervention group than in the usual care group. CONCLUSIONS Most of the explained intervention effect was attributable to the combination of self-monitoring and medication intensification. High adherence at baseline and the relatively low intensity of resources directed toward lifestyle change may explain why these factors did not contribute to the improvement in BP.
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Affiliation(s)
- Karen L Margolis
- HealthPartners Institute for Education and Research, Mailstop 23301A, PO Box 1524, Minneapolis, MN, 55440-1524, USA.
| | - Stephen E Asche
- HealthPartners Institute for Education and Research, Mailstop 23301A, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Anna R Bergdall
- HealthPartners Institute for Education and Research, Mailstop 23301A, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Steven P Dehmer
- HealthPartners Institute for Education and Research, Mailstop 23301A, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Michael V Maciosek
- HealthPartners Institute for Education and Research, Mailstop 23301A, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Rachel A Nyboer
- HealthPartners Institute for Education and Research, Mailstop 23301A, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Patrick J O'Connor
- HealthPartners Institute for Education and Research, Mailstop 23301A, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Pamala A Pawloski
- HealthPartners Institute for Education and Research, Mailstop 23301A, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - JoAnn M Sperl-Hillen
- HealthPartners Institute for Education and Research, Mailstop 23301A, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Nicole K Trower
- HealthPartners Institute for Education and Research, Mailstop 23301A, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Ann D Tucker
- HealthPartners Institute for Education and Research, Mailstop 23301A, PO Box 1524, Minneapolis, MN, 55440-1524, USA
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Sperl-Hillen JM, O'Connor PJ. In Reply to Wayne et al. Acad Med 2015; 90:1181-1182. [PMID: 26307923 DOI: 10.1097/acm.0000000000000847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- JoAnn M Sperl-Hillen
- Senior investigator and codirector, Center for Chronic Care Innovation, HealthPartners Institute for Education and Research, Minneapolis, Minnesota; . Senior investigator and codirector, Center for Chronic Care Innovation, HealthPartners Institute for Education and Research, Minneapolis, Minnesota
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Crain AL, Sperl-Hillen JM, Ekstrom HL, O'Connor PJ, Margolis KL, Rush WA, Amundson GH, Appana D. Sustaining Use of a Clinical Decision Support Tool for Primary Care Providers. J Patient Cent Res Rev 2015. [DOI: 10.17294/2330-0698.1141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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