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Navuluri N, Lanford T, Shapiro A, Krishnan G, Johnson AB, Riley IL, Zullig LL, Cox CE, Shofer S. Barriers and Facilitators Impacting Lung Cancer Screening Uptake Among Black Veterans: A Qualitative Study. J Natl Compr Canc Netw 2024:1-6. [PMID: 38640946 DOI: 10.6004/jnccn.2023.7098] [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: 08/10/2023] [Accepted: 10/20/2023] [Indexed: 04/21/2024]
Abstract
BACKGROUND Racial disparities in lung cancer screening (LCS) are well established. Black Veterans are among those at the highest risk for developing lung cancer but are less likely to complete LCS. We sought to identify barriers and facilitators to LCS uptake among Black Veterans. PATIENTS AND METHODS A qualitative study using semistructured interviews was conducted with 32 Black Veterans to assess for barriers, facilitators, and contextual factors for LCS and strategies to improve screening. Veterans were purposively sampled by age, sex, and LCS participation status (ie, patients who received a low-dose CT [LDCT], patients who contacted the screening program but did not receive an LDCT, and patients who did not connect with the screening program nor receive an LDCT). Interview guides were developed using the Theoretical Domains Framework and Health Belief Model. Data were analyzed using rapid qualitative analysis. RESULTS Barriers of LCS uptake among Black Veterans include self-reported low LCS knowledge and poor memory, attention, and decision processes associated with the centralized LCS process. Facilitators of LCS uptake among Black Veterans include social/professional role; identity and social influences; perceived susceptibility, threat, and consequences due to smoking status and military or occupational exposures; emotion, behavioral regulation, and intentions; and high trust in providers. Environmental context and resources (eg, transportation) and race and racism serve as contextual factors that did not emerge as having a major impact on LCS uptake. Strategies to improve LCS uptake included increased social messaging surrounding LCS, various forms of information dissemination, LCS reminders, balanced and repeated shared decision-making discussions, and streamlined referrals. CONCLUSIONS We identified addressable barriers and facilitators for LCS uptake among Black Veterans that can help focus efforts to improve disparities in screening. Future studies should explore provider perspectives and test interventions to improve equity in LCS.
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Affiliation(s)
- Neelima Navuluri
- 1Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke University School of Medicine, Durham, NC
- 2Department of Medicine, Durham Veterans Affairs Medical Center, Durham, NC
- 3Duke Global Health Institute, Duke University, Durham, NC
| | - Tiera Lanford
- 4Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veteran Affairs Health Care System, Durham, NC
| | - Abigail Shapiro
- 4Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veteran Affairs Health Care System, Durham, NC
| | - Govind Krishnan
- 1Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke University School of Medicine, Durham, NC
| | | | - Isaretta L Riley
- 1Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke University School of Medicine, Durham, NC
- 2Department of Medicine, Durham Veterans Affairs Medical Center, Durham, NC
| | - Leah L Zullig
- 4Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veteran Affairs Health Care System, Durham, NC
- 6Department of Population Health Sciences, Duke University, Durham, NC
| | - Christopher E Cox
- 1Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Scott Shofer
- 1Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke University School of Medicine, Durham, NC
- 2Department of Medicine, Durham Veterans Affairs Medical Center, Durham, NC
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Zullig LL, Drake C, Check DK, Brunkert T, Deschodt M, Olson MS, De Geest S. Embedding implementation science in the research pipeline. Transl Behav Med 2024; 14:73-79. [PMID: 37688798 DOI: 10.1093/tbm/ibad050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2023] Open
Abstract
Clinical and health services researchers seek to discover effective programs, practices, and interventions to improve people's health. The current paradigm for evidence generation is incremental and misaligned to translate evidence-based discoveries into real-world settings. This persistent challenge are "valleys of death" that represent missed opportunities and preventable missteps to actually use scientific advancements in real-world clinical settings where they can improve health and well-being (De Geest S, Zúñiga F, Brunkert T et al. Powering Swiss health care for the future: implementation science to bridge "the valley of death". 2020;150:w20323). Only one in seven of evidence-based interventions is ever implemented. It is after an average of 17 years. We propose embedding the principles of implementation science throughout the research pipeline, from discovery to adoption, to efficiently translate discoveries into real-world contexts (Balas EA, Boren SA. Managing clinical knowledge for health care improvement. 2000;9:65-70). We outline implications for capacity building, including composition of the research team, study design, and competencies that could bolster the value proposition of implementation science. We describe a research paradigm that recognizes scientists' responsibility to ensure their discoveries be translated into real-world settings.
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Affiliation(s)
- Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Connor Drake
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Thekla Brunkert
- Institute of Nursing Science, Department Public Health, University of Basel, Basel, Switzerland
- University Department of Geriatric Medicine, Basel, Switzerland
| | - Mieke Deschodt
- Gerontology and Geriatrics, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Competence Center of Nursing, University Hospitals Leuven, Leuven, Belgium
| | - Melvin Skip Olson
- Evidence Generation, Medical Affairs, Novartis Pharma AG, Basel, Switzerland
| | - Sabina De Geest
- Institute of Nursing Science, Department Public Health, University of Basel, Basel, Switzerland
- Academic Centre for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
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Meernik C, Dorfman CS, Zullig LL, Lazard AJ, Fish L, Farnan L, Nichols HB, Oeffinger KC, Akinyemiju T. Health Care Access Barriers and Self-Reported Health Among Adolescent and Young Adult Cancer Survivors. J Adolesc Young Adult Oncol 2024; 13:112-122. [PMID: 37307018 DOI: 10.1089/jayao.2023.0024] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023] Open
Abstract
Purpose: Adolescents and young adult (AYA) cancer survivors (15-39 years at diagnosis) are at risk for treatment-related late effects but face barriers in accessing survivorship care. We examined the prevalence of five health care access (HCA) barriers: affordability, accessibility, availability, accommodation, and acceptability. Methods: We identified AYA survivors from the University of North Carolina (UNC) Cancer Survivorship Cohort who completed a baseline questionnaire in 2010-2016. Participants had a history of cancer, were ≥18 years of age, and receiving care at a UNC oncology clinic. The sample was restricted to AYA survivors who were interviewed ≥1 year postdiagnosis. We used modified Poisson regression to estimate prevalence ratios (PRs) for the association between HCA barriers and self-reported fair or poor health, adjusted for sociodemographic and cancer characteristics. Results: The sample included 146 AYA survivors who were a median age of 39 at the time of the survey. The majority (71%)-and 92% of non-Hispanic Black survivors-reported at least one HCA barrier, including acceptability (40%), accommodation (38%), or affordability (31%). More than one-quarter of survivors (28%) reported fair or poor health. Affordability barriers (PR: 1.89, 95% confidence interval [CI]: 1.13-3.18) and acceptability barriers (PR: 1.60, 95% CI: 0.96-2.66) were associated with a higher prevalence of fair/poor health, as were the cumulative effects of multiple HCA dimensions reported as barriers. Conclusions: Barriers across multiple HCA dimensions were prevalent and associated with worse health in AYA survivors. Findings highlight the need to better understand and target specific barriers to care for diverse AYA survivors to improve their long-term health.
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Affiliation(s)
- Clare Meernik
- Department of Population Health Sciences and Duke University School of Medicine, Durham, North Carolina, USA
| | - Caroline S Dorfman
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Leah L Zullig
- Department of Population Health Sciences and Duke University School of Medicine, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Allison J Lazard
- Hussman School of Journalism and Media, and University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Laura Fish
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - Laura Farnan
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Hazel B Nichols
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kevin C Oeffinger
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Tomi Akinyemiju
- Department of Population Health Sciences and Duke University School of Medicine, Durham, North Carolina, USA
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Connolly SL, Sherman SE, Dardashti N, Duran E, Bosworth HB, Charness ME, Newton TJ, Reddy A, Wong ES, Zullig LL, Gutierrez J. Defining and Improving Outcomes Measurement for Virtual Care: Report from the VHA State-of-the-Art Conference on Virtual Care. J Gen Intern Med 2024; 39:29-35. [PMID: 38252238 PMCID: PMC10937867 DOI: 10.1007/s11606-023-08464-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 10/06/2023] [Indexed: 01/23/2024]
Abstract
Virtual care, including synchronous and asynchronous telehealth, remote patient monitoring, and the collection and interpretation of patient-generated health data (PGHD), has the potential to transform healthcare delivery and increase access to care. The Veterans Health Administration (VHA) Office of Health Services Research and Development (HSR&D) convened a State-of-the-Art (SOTA) Conference on Virtual Care to identify future virtual care research priorities. Participants were divided into three workgroups focused on virtual care access, engagement, and outcomes. In this article, we report the findings of the Outcomes Workgroup. The group identified virtual care outcome areas with sufficient evidence, areas in need of additional research, and areas that are particularly well-suited to be studied within VHA. Following a rigorous process of literature review and consensus, the group focused on four questions: (1) What outcomes of virtual care should we be measuring and how should we measure them?; (2) how do we choose the "right" care modality for the "right" patient?; (3) what are potential consequences of virtual care on patient safety?; and (4) how can PGHD be used to benefit provider decision-making and patient self-management?. The current article outlines key conclusions that emerged following discussion of these questions, including recommendations for future research.
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Affiliation(s)
- Samantha L Connolly
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA.
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
| | - Scott E Sherman
- Virtual Care Consortium of Research (VC CORE), VA New York Harbor Healthcare System, New York, NY, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Navid Dardashti
- Virtual Care Consortium of Research (VC CORE), VA New York Harbor Healthcare System, New York, NY, USA
| | - Elizabeth Duran
- Virtual Care Consortium of Research (VC CORE), VA New York Harbor Healthcare System, New York, NY, USA
| | - Hayden B Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) Durham Veterans Affairs Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - Michael E Charness
- Chief of Staff of the VA Boston Healthcare System, Boston, MA, USA
- Department of Neurology, Harvard Medical School, Boston, MA, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Terry J Newton
- Director of Clinical Analytics, VA Office of Connected Care, Washington, DC, USA
| | - Ashok Reddy
- General Medicine Service, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Edwin S Wong
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, USA
| | - Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) Durham Veterans Affairs Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - Jeydith Gutierrez
- Center for Access and Delivery Research, Iowa City VA Healthcare System, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
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Kappler CB, Coffman CJ, Stechuchak KM, Choate A, Meyer C, Zullig LL, Hughes JM, Drake C, Sperber NR, Kaufman BG, Van Houtven CH, Allen KD, Hastings SN. Evaluation of strategies to support implementation of a hospital walking program: protocol for a type III effectiveness-implementation hybrid trial. Implement Sci Commun 2024; 5:8. [PMID: 38216967 PMCID: PMC10790254 DOI: 10.1186/s43058-024-00544-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/29/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND STRIDE is a supervised walking program designed to address the negative consequences of immobility during hospitalization for older adults. In an 8-hospital stepped wedge randomized controlled trial, STRIDE was associated with reduced odds of hospital discharge to skilled nursing facility. STRIDE has the potential to become a system-wide approach to address hospital-associated disability in Veteran's Affairs; however, critical questions remain about how best to scale and sustain the program. The overall study goal is to compare the impact of two strategies on STRIDE program penetration (primary), fidelity, and adoption implementation outcomes. METHODS Replicating Effective Programs will be used as a framework underlying all implementation support activities. In a parallel, cluster randomized trial, we will use stratified blocked randomization to assign hospitals (n = 32) to either foundational support, comprised of standard, low-touch activities, or enhanced support, which includes the addition of tailored, high-touch activities if hospitals do not meet STRIDE program benchmarks at 6 and 8 months following start date. All hospitals begin with foundational support for 6 months until randomization occurs. The primary outcome is implementation penetration defined as the proportion of eligible hospitalizations with ≥ 1 STRIDE walks at 10 months. Secondary outcomes are fidelity and adoption with all implementation outcomes additionally examined at 13 and 16 months. Fidelity will be assessed for STRIDE hospitalizations as the percentage of eligible hospital days with "full dose" of the program, defined as two or more documented walks or one walk for more than 5 min. Program adoption is a binary outcome defined as ≥ 5 patients with a STRIDE walk or not. Analyses will also include patient-level effectiveness outcomes (e.g., discharge to nursing home, length of stay) and staffing and labor costs. We will employ a convergent mixed-methods approach to explore and understand pre-implementation contextual factors related to differences in hospital-level adoption. DISCUSSION Our study results will dually inform best practices for promoting successful implementation of an evidence-based hospital-based walking program. This information may support other programs by advancing our understanding of how to apply and scale-up national implementation strategies. TRIAL REGISTRATION This study was registered on June 1, 2021, at ClinicalTrials.gov (identifier NCT04868656 ).
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Affiliation(s)
- Caitlin B Kappler
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA.
| | - Cynthia J Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Karen M Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
| | - Ashley Choate
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
| | - Cassie Meyer
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
| | - Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Jaime M Hughes
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Section On Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Connor Drake
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Nina R Sperber
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Brystana G Kaufman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Kelli D Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Medicine & Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Susan N Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
- Geriatrics Research, Education, and Clinical Center, Durham VA Health Care System, Durham, NC, USA
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, Durham, NC, USA
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Drake C, Alfaro JM, Blalock DV, Ito K, Batch BC, Bosworth HB, Berkowitz SA, Zullig LL. Association of Unmet Social Needs With Metformin Use Among Patients With Type 2 Diabetes. Diabetes Care 2023; 46:2044-2049. [PMID: 37756533 PMCID: PMC10620532 DOI: 10.2337/dc23-0448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/23/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVE To evaluate the relationship between social needs and metformin use among adults with type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS In a prospective cohort study of adults with T2D (n = 722), we linked electronic health record (EHR) and Surescripts (Surescripts, LLC) prescription network data to abstract data on patient-reported social needs and to calculate metformin adherence based on expected refill frequency using a proportion of days covered methodology. RESULTS After adjusting for demographics and clinical complexity, two or more social needs (-0.046; 95% CI -0.089, 0.003), being uninsured (-0.052; 95% CI -0.095, -0.009) and while adjusting for other needs, being without housing (-0.069; 95% CI -0.121, -0.018) and lack of access to medicine/health care (-0.058; 95% CI -0.115, -0.000) were associated with lower use. CONCLUSIONS We found that overall social need burden and specific needs, particularly housing and health care access, were associated with clinically significant reductions in metformin adherence among patients with T2D.
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Affiliation(s)
- Connor Drake
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC
| | - Jorge Morales Alfaro
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Dan V. Blalock
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC
| | | | - Bryan C. Batch
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Hayden B. Bosworth
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC
- Department of Medicine, Duke University School of Medicine, Durham, NC
- Duke University School of Nursing, Durham, NC
| | - Seth A. Berkowitz
- Division of General Internal Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Leah L. Zullig
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC
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Kheterpal MK, Borre ED, Cheema U, Nicholas MW, Cooner EW, Phinney D, Gagnon K, Zullig LL, King HA, Malcolm EJ, Chen SC. Implementation evaluation of a teledermatology virtual clinic at an academic medical center. Implement Sci Commun 2023; 4:130. [PMID: 37891695 PMCID: PMC10612341 DOI: 10.1186/s43058-023-00508-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 10/04/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Teledermatology (TD) is an evidence-based practice that may increase access to dermatologic care. We sought to use the Exploration, Preparation, Implementation, and Sustainment (EPIS) and the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) frameworks to evaluate implementation of TD at Duke. METHODS The EPIS and RE-AIM frameworks were deployed to design and implement a TD program that leveraged the strengths of the Duke University Health System and addressed previously reported barriers to implementation of store-and-forward and synchronous TD models. In the resultant hybrid TD model, trained primary care providers (PCPs) sent e-comm referrals with clinical and dermatoscopic images to dermatology. These e-consults were reviewed asynchronously and patients were scheduled for a synchronous video visit with dermatology within days. Dermatologists managed the patient plan. This hybrid TD model was piloted at four primary care clinics. Pertinent outcomes from a TD-adapted RE-AIM framework were tracked using electronic health record data. Patient satisfaction was assessed using a post-video visit survey (n = 18). Implementation barriers and facilitators were also collected through provider surveys (n = 24 PCPs, n = 10 dermatologists, n = 10 dermatology residents). RESULTS At four PCP clinics throughout 9/1/2021-4/30/2022, there were 218 TD referrals. Video visits occurred on average 7.5 ± 0.5 days after referral and 18/18 patients completing the post-visit survey were satisfied. Adoption varied between clinics, with one placing 22% of all dermatology referrals as TD and another placing 2%. The primary PCP barriers to TD were time burdens, lack of fit in clinic flow, and discomfort with image taking. Top-endorsed potential facilitating interventions included allowing for rash referrals without dermoscopy and assurance for clinical evaluation within 3 days. CONCLUSIONS The use of implementation science frameworks allowed for identification of system and contextual strengths which informed the hybrid TD pilot. Barriers and facilitating interventions will provide guidance for expansion and ongoing maintenance of TD.
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Affiliation(s)
- Meenal K Kheterpal
- Department of Dermatology, Duke University Medical Center, DUMC Box 3135, Durham, NC, 27710, USA.
| | - Ethan D Borre
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | | | - Matilda W Nicholas
- Department of Dermatology, Duke University Medical Center, DUMC Box 3135, Durham, NC, 27710, USA
| | - Edward W Cooner
- Duke Primary Care, Duke University School of Medicine, Durham, NC, USA
| | - Donna Phinney
- Duke Telehealth Office, Duke University Health System, Durham, NC, USA
| | - Kelly Gagnon
- Performance Services, Duke University Health System, Durham, NC, USA
| | - Leah L Zullig
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
| | - Heather A King
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Elizabeth J Malcolm
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Suephy C Chen
- Department of Dermatology, Duke University Medical Center, DUMC Box 3135, Durham, NC, 27710, USA
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Webb S, Drake C, Coffman CJ, Sullivan C, Sperber N, Tucker M, Zullig LL, Hughes JM, Kaufman BG, Pura JA, Anderson L, Hastings SN, Van Houtven CH, Abbate LM, Hoenig H, Ballengee LA, Wang V, Allen KD. Group physical therapy for knee osteoarthritis: protocol for a hybrid type III effectiveness-implementation trial. Implement Sci Commun 2023; 4:125. [PMID: 37828564 PMCID: PMC10571277 DOI: 10.1186/s43058-023-00502-7] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/09/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Knee osteoarthritis (OA) is a leading cause of chronic pain and disability and one of the most common conditions treated in outpatient physical therapy (PT). Because of the high and growing prevalence of knee OA, there is a need for efficient approaches for delivering exercise-based PT to patients with knee OA. A prior randomized controlled trial (RCT) showed that a 6-session Group Physical Therapy Program for Knee OA (Group PT) yields equivalent or greater improvements in pain and functional outcomes compared with traditional individual PT, while requiring fewer clinician hours per patient to deliver. This manuscript describes the protocol for a hybrid type III effectiveness-implementation trial comparing two implementation packages to support delivery of Group PT. METHODS In this 12-month embedded trial, a minimum of 16 Veterans Affairs Medical Centers (VAMCs) will be randomized to receive one of two implementation support packages for their Group PT programs: a standard, low-touch support based on Replicating Effective Programs (REP) versus enhanced REP (enREP), which adds tailored, high-touch support if sites do not meet Group PT adoption and sustainment benchmarks at 6 and 9 months following launch. Implementation outcomes, including penetration (primary), adoption, and fidelity, will be assessed at 6 and 12 months (primary assessment time point). Additional analyses will include patient-level effectiveness outcomes (pain, function, satisfaction) and staffing and labor costs. A robust qualitative evaluation of site implementation context and experience, as well as site-led adaptations to the Group PT program, will be conducted. DISCUSSION To our knowledge, this study is the first to evaluate the impact of tailored, high-touch implementation support on implementation outcomes when compared to standardized, low-touch support for delivering a PT-based intervention. The Group PT program has strong potential to become a standard offering for PT, improving function and pain-related outcomes for patients with knee OA. Results will provide information regarding the effectiveness and value of this implementation approach and a deeper understanding of how healthcare systems can support wide-scale adoption of Group PT. TRIAL REGISTRATION This study was registered on March 7, 2022 at ClinicalTrials.gov (identifier NCT05282927 ).
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Affiliation(s)
- Sara Webb
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
| | - Connor Drake
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Cynthia J Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Caitlin Sullivan
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
| | - Nina Sperber
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Matthew Tucker
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
| | - Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Jaime M Hughes
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Section On Gerontology and Geriatric Medicine, Division of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Brystana G Kaufman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - John A Pura
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- AstraZeneca, Durham, NC, USA
| | - Livia Anderson
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
| | - Susan N Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Lauren M Abbate
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- VA Eastern Colorado Geriatric Research Education and Clinical Center and University of Colorado School of Medicine, Aurora, CO, USA
| | - Helen Hoenig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Physical Medicine and Rehabilitation Services, Durham VA Health Care System, Durham, NC, USA
| | - Lindsay A Ballengee
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Virginia Wang
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Margolis Center for Health Policy, Duke University, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Kelli D Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA.
- Department of Medicine & Thurston Arthritis Research Center, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA.
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9
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Wycoff KL, Coleman JG, Santoro CM, Zullig LL, Darden N, Holland PM, Cruice JF, Mitchell S, Smith M, McNeil SJ, Herring SJ. Multilevel Community Engagement to Inform a Randomized Clinical Trial. Obstet Gynecol 2023; 142:929-939. [PMID: 37734093 PMCID: PMC10510772 DOI: 10.1097/aog.0000000000005344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/01/2023] [Accepted: 05/11/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE To explore how patients, community-based perinatal support professionals, and health system clinicians and staff perceived facilitators and barriers to implementation of a randomized clinical trial (RCT) designed to optimize Black maternal heart health. METHODS This article describes the formative work that we believed needed to occur before the start of the Change of H.E.A.R.T (Here for Equity, Advocacy, Reflection and Transformation) RCT. We used a qualitative, descriptive design and community-based, participatory approach, the latter of which allowed our team to intentionally focus on avoiding harm and equalizing power dynamics throughout the research process. Data were collected between November 2021 and January 2022 through six semistructured focus groups that included attending physicians and midwives (n=7), residents (n=4), nurses (n=6), support staff (n=7), community-based perinatal support professionals (n=6), and patients (n=8). RESULTS Four primary themes emerged. The first three themes were present across all groups and included: 1) Trauma in the Community and Health System, 2) Lack of Trust, and 3) Desire to Be Heard and Valued. The fourth theme, Hope and Enthusiasm, was expressed predominantly by patients, community-based perinatal support professionals, residents, and support staff, and less so by the attending physician group. CONCLUSION Participants articulated a number of key sentiments regarding facilitators and barriers to implementing Change of H.E.A.R.T. We noted variability in perceptions from different groups. This has important implications for health equity efforts in similarly underresourced health systems where Black birthing people experience the greatest morbidity and mortality. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT05499507.
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Affiliation(s)
- Kirby L Wycoff
- Department of Counseling and Behavioral Health, College of Health Professions, Thomas Jefferson University, the Maternal Wellness Village, the Program for Maternal Health Equity, Center for Urban Bioethics, the Department of Urban Health and Population Science, and the Department of Internal Medicine, Lewis Katz School of Medicine at Temple University, and the Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and the Department of Urban Health and Population Science, Duke University, Durham, North Carolina
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10
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Goldstein KM, Patel DB, Van Loon KA, Shapiro A, Rushton S, Lewinski AA, Lanford TJ, Cantrell S, Zullig LL, Wilson SM, Shepherd-Banigan M, Alton Dailey S, Sims C, Robinson C, Chawla N, Bosworth HB, Hamilton A, Naylor J, Gierisch JM. Optimizing the Equitable Deployment of Virtual Care for Women: Protocol for a Qualitative Evidence Synthesis Examining Patient and Provider Perspectives Supplemented with Primary Qualitative Data. Health Equity 2023; 7:570-580. [PMID: 37731781 PMCID: PMC10507937 DOI: 10.1089/heq.2023.0089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 09/22/2023] Open
Abstract
Introduction Women experience numerous barriers to patient-centered health care (e.g., lack of continuity). Such barriers are amplified for women from marginalized communities. Virtual care may improve equitable access. We are conducting a partner-engaged, qualitative evidence synthesis (QES) of patients' and providers' experiences with virtual health care delivery for women. Methods We use a best-fit framework approach informed by the Non-adoption, Abandonment, Scale-up, Spread, and Sustainability framework and Public Health Critical Race Praxis. We will supplement published literature with qualitative interviews with women from underrepresented communities and their health care providers. We will engage patients and other contributors through multiple participatory methods. Results Our search identified 5525 articles published from 2010 to 2022. Sixty were eligible, of which 42 focused on women and 24 on provider experiences. Data abstraction and analysis are ongoing. Discussion This work offers four key innovations to advance health equity: (1) conceptual foundation rooted in an antiracist action-oriented praxis; (2) worked example of centering QES on marginalized communities; (3) supplementing QES with primary qualitative information with populations historically marginalized in the health care system; and (4) participatory approaches that foster longitudinal partnered engagement. Health Equity Implications Our approach to exploring virtual health care for women demonstrates an antiracist praxis to inform knowledge generation. In doing so, we aim to generate findings that can guide health care systems in the equitable deployment of comprehensive virtual care for women.
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Affiliation(s)
- Karen M. Goldstein
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Dhara B. Patel
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
| | - Katherine A. Van Loon
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
| | - Abigail Shapiro
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
| | - Sharron Rushton
- School of Nursing, Duke University, Durham, North Carolina, USA
| | - Allison A. Lewinski
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
- School of Nursing, Duke University, Durham, North Carolina, USA
| | - Tiera J. Lanford
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
| | - Sarah Cantrell
- School of Medicine, Duke University Medical Center Library, Durham, North Carolina, USA
| | - Leah L. Zullig
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Sarah M. Wilson
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Megan Shepherd-Banigan
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
- Duke Margolis Center for Health Policy, Durham, North Carolina, USA
- VA VISN-6 Mid-Atlantic Mental Illness Research and Education Clinical Center, Durham, North Carolina, USA
| | - Susan Alton Dailey
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
| | - Catherine Sims
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
- Department of Medicine, Division of Rheumatology, Duke University, Durham, North Carolina, USA
| | - Cheryl Robinson
- Clinical Translational Sciences Institute, School of Medicine, Duke University, Durham, North Carolina, USA
- Veteran Research Engagement Panel, VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
| | - Neetu Chawla
- VA Center for the Study of Healthcare Innovation Implementation and Policy, Los Angeles, California, USA
| | - Hayden B. Bosworth
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Alison Hamilton
- VA Center for the Study of Healthcare Innovation Implementation and Policy, Los Angeles, California, USA
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Jennifer Naylor
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
- VA VISN-6 Mid-Atlantic Mental Illness Research and Education Clinical Center, Durham, North Carolina, USA
| | - Jennifer M. Gierisch
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
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11
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Decosimo K, Drake C, Coffman CJ, Sperber NR, Tucker M, Hughes JM, Zullig LL, Chadduck T, Christensen L, Kaufman B, Allen KD, Hastings SN, Van Houtven CH. Implementation intensification to disseminate a skills-based caregiver training program: protocol for a type III effectiveness-implementation hybrid trial. Implement Sci Commun 2023; 4:97. [PMID: 37587517 PMCID: PMC10428549 DOI: 10.1186/s43058-023-00475-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 07/24/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Family caregiver training decreases caregiver psychological burden and improves caregiver depressive symptoms and health-related quality of life. Caregivers FIRST is an evidence-based group skills training curriculum for family caregivers and was announced for national dissemination in partnership with the Veterans Health Administration (VHA) National Caregiver Support Program (CSP). Previous evaluations of Caregivers FIRST implementation highlighted that varying support was needed to successfully implement the program, ranging from minimal technical assistance to intensive assistance and support. However, we do not know the optimal level of support needed to inform cost-effective national scaling of the program. We describe a protocol for randomizing 24 non-adopting VA medical centers 1:1 to a tailored, high-touch implementation support or a standard, low-touch implementation support to test the primary hypothesis that high-touch support increases Caregivers FIRST penetration, fidelity, and adoption. Additionally, we describe the methods for evaluating the effect of Caregivers FIRST participation on Veteran outcomes using a quasi-experimental design and the methods for a business case analysis to examine cost of delivery differences among sites assigned to a low or high-touch implementation support. METHODS We use a type III hybrid implementation-effectiveness study design enrolling VA medical centers that do not meet Caregivers FIRST adoption benchmarks following the announcement of the program as mandated within the CSP. Eligible medical centers will be randomized to receive a standard low-touch implementation support based on Replicating Effective Programs (REP) only or to an enhanced REP (high-touch) implementation support consisting of facilitation and tailored technical assistance. Implementation outcomes include penetration (primary), fidelity, and adoption at 12 months. Mixed methods will explore sites' perceptions and experiences of the high-touch intensification strategy. Additional analyses will include a patient-level effectiveness outcome (Veteran days at home and not in an institution) and a business case analysis using staffing and labor cost data. DISCUSSION This pragmatic trial will lead to the development and refinement of implementation tools to support VA in spreading and sustaining Caregivers FIRST in the most efficient means possible. TRIAL REGISTRATION This study was registered on April 8, 2022, at ClinicalTrials.gov (identifier NCT05319535).
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Affiliation(s)
- Kasey Decosimo
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, 27705, USA.
| | - Connor Drake
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Cynthia J Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, 27705, USA
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Nina R Sperber
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Matthew Tucker
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, 27705, USA
| | - Jaime M Hughes
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, 27705, USA
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Section On Gerontology and Geriatric Medicine, Division of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Trisha Chadduck
- Veteran's Health Administration Central Office, Washington, DC, USA
| | - Leah Christensen
- Veteran's Health Administration Central Office, Washington, DC, USA
| | - Brystana Kaufman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Kelli D Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, 27705, USA
- Department of Medicine & Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - S Nicole Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, NC, USA
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
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Noyd DH, Liu Q, Yasui Y, Chow EJ, Bhatia S, Nathan PC, Landstrom AP, Tonorezos E, Casillas J, Berkman A, Ness KK, Mulrooney DA, Leisenring WM, Howell CR, Shoag J, Kirchhoff A, Howell RM, Gibson TM, Zullig LL, Armstrong GT, Oeffinger KC. Cardiovascular Risk Factor Disparities in Adult Survivors of Childhood Cancer Compared With the General Population. JACC CardioOncol 2023; 5:489-500. [PMID: 37614575 PMCID: PMC10443116 DOI: 10.1016/j.jaccao.2023.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 01/18/2023] [Accepted: 01/26/2023] [Indexed: 08/25/2023] Open
Abstract
Background It is unknown whether a history of childhood cancer modifies the established disparities in cardiovascular risk factors (CVRFs) observed in the general population. Objectives We sought to determine if disparities in CVRFs by race/ethnicity are similar among childhood cancer survivors compared with the general population. Methods The Childhood Cancer Survivor Study (CCSS) is a retrospective cohort with a longitudinal follow-up of 24,084 5-year survivors diagnosed between 1970 and 1999. Multivariable piecewise exponential regression estimated incidence rate ratios (IRRs) for hypertension, hyperlipidemia, diabetes, obesity, and ≥2 CVRFs by race/ethnicity. The CCSS sibling cohort and the National Health and Nutrition Examination Survey cohort were used to compare the sociodemographic-adjusted IRRs for same-race/same-ethnicity disparities. Results Non-Hispanic Black (NHB) (n = 1,092) and Hispanic (n = 1,405) survivors compared with non-Hispanic White (NHW) (n = 13,960) survivors reported a higher cumulative incidence of diabetes (8.4%, 9.7%, and 5.1%, respectively); obesity (47.2%, 48.9%, and 30.2%, respectively); multiple CVRFs (17.7%, 16.6%, and 12.3%, respectively); and, for NHB survivors, hypertension (19.5%, 13.6%, and 14.3%, respectively) by 40 years of age (P < 0.001). Controlling for sociodemographic and treatment factors compared with NHW survivors, IRRs for NHB were increased for hypertension (IRR: 1.4; 95% CI: 1.1-1.8), obesity (IRR: 1.7; 95% CI: 1.4-2.1), and multiple CVRFs (IRR: 1.6; 95% CI: 1.2-2.1). IRRs for Hispanic survivors were increased for diabetes (IRR: 1.8; 95% CI: 1.2-2.6) and obesity (IRR: 1.4; 95% CI: 1.2-1.7). The pattern of IRRs for CVRF differences was similar among CCSS sibling and National Health and Nutrition Examination Survey cohorts. Conclusions The higher burden of CVRFs among NHB and Hispanic survivors compared with NHW survivors was similar to the general population. The promotion of cardiovascular health equity is critical in this high-risk population.
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Affiliation(s)
- David H. Noyd
- Duke University Medical Center, Durham, North Carolina, USA
- The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Qi Liu
- University of Alberta, Edmonton, Canada
| | - Yutaka Yasui
- University of Alberta, Edmonton, Canada
- St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Eric J. Chow
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Smita Bhatia
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Paul C. Nathan
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | - Jacqueline Casillas
- University of California Los Angeles Medical Center, Los Angeles, California, USA
| | - Amy Berkman
- Duke University Medical Center, Durham, North Carolina, USA
| | - Kirsten K. Ness
- St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | | | | | | | | | | | - Rebecca M. Howell
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Leah L. Zullig
- Duke University Medical Center, Durham, North Carolina, USA
- Durham Veterans Administration Health Care System, Durham, North Carolina, USA
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13
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Muluneh B, Muir MA, Collins JB, Proco D, Mackler E, Leak Bryant A, Wood WA, Tilkens M, Reichard JS, Foster M, Gatwood J, Wheeler SB, Zullig LL, Elston Lafata J. Barriers and facilitators associated with implementing interventions to support oral anticancer agent adherence in academic and community cancer center settings. PLoS One 2023; 18:e0286630. [PMID: 37478078 PMCID: PMC10361464 DOI: 10.1371/journal.pone.0286630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 05/19/2023] [Indexed: 07/23/2023] Open
Abstract
PURPOSE The goal of this study is to determine barriers and facilitators to the implementation of medication adherence interventions to support cancer patients taking novel, targeted oral anticancer agents (OAAs). METHODS We conducted qualitative interviews using a semi-structured guide from the Consolidated Framework for Implementation Research (CFIR). We used purposive sampling to identify clinicians (physicians, pharmacists, nurse practitioners, nurses) and administrators (leadership from medicine, pharmacy, and nursing) who delivered care and/or oversee care delivery for patients with chronic leukemia prescribed an OAA. RESULTS A total of 19 individuals participated in an interview (12 clinicians and 7 administrators), with 10 primarily employed by an academic cancer center; 5 employed by the community cancer center; and 4 employed by the integrated health-system specialty pharmacy. Barriers identified included low awareness of adherence interventions, difficulty in adherence measurement, complexity of designing and implementing a structured adherence intervention, and competing priorities. Facilitators identified included support of hospital administrators, value for pharmacists, and willingness to embrace change. Participants also made recommendations moving forward including standardizing workflow, designating champions, iterating implementation strategies, and improving communication between clinicians and with patients. CONCLUSION Individual and system level factors were identified as determinants of implementation effectiveness of medication adherence interventions. A multidisciplinary advisory panel will be assembled to design comprehensive and actionable strategies to refine and implement a structured intervention to improve medication adherence in cancer patients.
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Affiliation(s)
- Benyam Muluneh
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Michele A. Muir
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - James Bernard Collins
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Darrian Proco
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Emily Mackler
- Michigan Oncology Quality Consortium, Ann Arbor, MI, United States of America
| | - Ashley Leak Bryant
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - William A. Wood
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Michael Tilkens
- Department of Pharmacy, University of North Carolina Medical Centerat Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Jeffrey S. Reichard
- Department of Pharmacy, University of North Carolina Medical Centerat Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Matthew Foster
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Justin Gatwood
- College of Pharmacy, University of Tennessee Health Science Center at Memphis, Memphis, Tennessee, United States of America
| | - Stephanie B. Wheeler
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Leah L. Zullig
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States of America
| | - Jennifer Elston Lafata
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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14
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Van Houtven CH, Drake C, Malo TL, Decosimo K, Tucker M, Sullivan C, D'Adolf J, Hughes JM, Christensen L, Grubber JM, Coffman CJ, Sperber NR, Wang V, Allen KD, Hastings SN, Shea CM, Zullig LL. Ready, set, go! The role of organizational readiness to predict adoption of a family caregiver training program using the Rogers' diffusion of innovation theory. Implement Sci Commun 2023; 4:69. [PMID: 37337208 DOI: 10.1186/s43058-023-00447-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 05/30/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Caregivers FIRST is an evidence-based program addressing gaps in caregivers' skills. In 2020, the Veterans Health Administration Caregiver Support Program (CSP) nationally endorsed Caregivers FIRST, offering credit in leadership performance plans to encourage all VA medical centers (VAMCs) to implement locally. This study examines the association of organizational readiness with VAMC adoption of Caregivers FIRST. METHODS In a cohort observational study, we surveyed CSP managers about their facilities' readiness to implement using the Organizational Readiness for Implementing Change (ORIC) instrument and compared change commitment and change efficacy domains among VAMCs "adopters" defined as delivering Caregivers FIRST within 1 year of the national announcement to those that did not ("non-adopters"). Within "adopters," we categorized time to adoption based on Rogers' diffusion of innovation theory including "innovators," "early adopters," "early majority," "late adopters," and "laggards." Organizational readiness and site characteristics (facility complexity, staffing levels, volume of applications for caregiver assistance services) were compared between "adopters," "non-adopters," and between time to adoption subcategories. Separate logistic regression models were used to assess whether ORIC and site characteristics were associated with early adoption among "adopters." RESULTS Fifty-one of 63 (81%) VAMCs with CSP manager survey respondents adopted Caregivers FIRST during the first year. ORIC change commitment and efficacy were similar for "adopters" and "non-adopters." However, sites that adopted earlier (innovators and early adopters) had higher ORIC change commitment and efficacy scores than the rest of the "adopters." Logistic regression results indicated that higher ORIC change commitment (odds ratio [OR] = 2.57; 95% confidence interval [CI], 1.11-5.95) and ORIC change efficacy (OR = 2.60; 95% CI, 1.12-6.03) scores were associated with increased odds that a VAMC was an early adopter (categorized as an "innovator," "early adopter", or "early majority"). Site-level characteristics were not associated with Caregivers FIRST early adoption. CONCLUSIONS To our knowledge, this study is the first to prospectively assess organizational readiness and the timing of subsequent program adoption. Early adoption was associated with higher ORIC change commitment and change efficacy and not site-level characteristics. These findings yield insights into the role of organizational readiness to accelerate program adoption. TRIAL REGISTRATION ClinicalTrials.gov, NCT03474380. Registered on March 22, 2018.
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Affiliation(s)
- Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Connor Drake
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Teri L Malo
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
| | - Kasey Decosimo
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA.
| | - Matthew Tucker
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
| | - Caitlin Sullivan
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
| | - Josh D'Adolf
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
| | - Jaime M Hughes
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Section on Gerontology and Geriatric Medicine, Division of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Leah Christensen
- Veteran's Health Administration Central Office, Washington, DC, USA
| | - Janet M Grubber
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Cooperative Studies Program Coordinating Center, Veterans Affairs Boston Healthcare System, Boston, MA, USA
| | - Cynthia J Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Nina R Sperber
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Virginia Wang
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Kelli D Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Medicine & Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - S Nicole Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, NC, USA
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Christopher M Shea
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System (152), 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
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15
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Zullig LL, Lewinski AA, Woolson SL, White-Clark C, Miller C, Bosworth HB, Burleson SC, Garrett MP, Darling KL, Crowley MJ. Research-practice partnerships: Adapting a care coordination intervention for rural Veterans over 3 years at multiple sites. J Rural Health 2023; 39:575-581. [PMID: 36661336 DOI: 10.1111/jrh.12740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE Rural Veterans are more likely than urban Veterans to qualify for community care (Veterans Health Administration [VHA]-paid care delivered outside of VHA) due to wait times ≥30 days and longer travel times for VHA care. For rural Veterans receiving both VHA and community care, suboptimal care coordination between VHA and community providers can result in poor follow-up and care fragmentation. We developed Telehealth-based Coordination of Non-VHA Care (TECNO Care) to address this problem. METHODS We iteratively developed and adapted TECNO Care with partners from the VHA Office of Rural Health and site-based Home Telehealth Care in the Community programs. Using templated electronic health record notes, Home Telehealth nurses contacted Veterans monthly to facilitate communication with VHA/community providers, coordinate referrals, reconcile medications, and follow up on acute episodes. We evaluated TECNO Care using a patient-level, pre-post effectiveness assessment and rapid qualitative analysis with individual interviews of Veterans and VHA collaborators. Our primary effectiveness outcome was a validated care coordination quality measure. We calculated mean change scores for each care continuity domain. FINDINGS Between March 2019 and October 2021, 83 Veterans received TECNO Care. Veterans were predominately White (86.4%) and male (88.6%) with mean age 71.4 years (SD 10.4). Quantitative data demonstrated improvements in perceived care coordination following TECNO Care in 7 categories. Qualitative interviews indicated that Veterans and Home Telehealth nurses perceived TECNO Care as beneficial and addressing an area of high need. CONCLUSIONS TECNO Care appeared to improve the coordination of VHA and community care and was valued by Veterans.
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Affiliation(s)
- Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Allison A Lewinski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- School of Nursing, Duke University, Durham, North Carolina, USA
| | - Sandra L Woolson
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Courtney White-Clark
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Christopher Miller
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Hayden B Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- School of Nursing, Duke University, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, School of Nursing, Duke University, Durham, North Carolina, USA
| | | | - Mary P Garrett
- Durham VA Health Care System, Durham, North Carolina, USA
| | - Kristen L Darling
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Matthew J Crowley
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Division of Endocrinology, Diabetes, and Metabolism, Duke University School of Medicine, Durham, North Carolina, USA
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16
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Navuluri N, Morrison S, Green CL, Woolson SL, Riley IL, Cox CE, Zullig LL, Shofer S. Racial Disparities in Lung Cancer Screening Among Veterans, 2013 to 2021. JAMA Netw Open 2023; 6:e2318795. [PMID: 37326987 PMCID: PMC10276308 DOI: 10.1001/jamanetworkopen.2023.18795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/02/2023] [Indexed: 06/17/2023] Open
Abstract
Importance Racial disparities in lung cancer screening (LCS) are often ascribed to barriers such as cost, insurance status, access to care, and transportation. Because these barriers are minimized within the Veterans Affairs system, there is a question of whether similar racial disparities exist within a Veterans Affairs health care system in North Carolina. Objectives To examine whether racial disparities in completing LCS after referral exist at the Durham Veterans Affairs Health Care System (DVAHCS) and, if so, what factors are associated with screening completion. Design, Setting, and Participants This cross-sectional study assessed veterans referred to LCS between July 1, 2013, and August 31, 2021, at the DVAHCS. All included veterans self-identified as White or Black and met the US Preventive Services Task Force eligibility criteria as of January 1, 2021. Participants who died within 15 months of consultation or who were screened before consultation were excluded. Exposures Self-reported race. Main Outcomes and Measures Screening completion was defined as completing computed tomography for LCS. The associations among screening completion, race, and demographic and socioeconomic risk factors were assessed using logistic regression models. Results A total of 4562 veterans (mean [SD] age, 65.4 [5.7] years; 4296 [94.2%] male; 1766 [38.7%] Black and 2796 [61.3%] White) were referred for LCS. Of all veterans referred, 1692 (37.1%) ultimately completed screening; 2707 (59.3%) never connected with the LCS program after referral and an informational mailer or telephone call, indicating a critical point in the LCS process. Screening rates were substantially lower among Black compared with White veterans (538 [30.5%] vs 1154 [41.3%]), with Black veterans having 0.66 times lower odds (95% CI, 0.54-0.80) of screening completion after adjusting for demographic and socioeconomic factors. Conclusions and Relevance This cross-sectional study found that after referral for initial LCS via a centralized program, Black veterans had 34% lower odds of LCS screening completion compared with White veterans, a disparity that persisted even after accounting for numerous demographic and socioeconomic factors. A critical point in the screening process was when veterans must connect with the screening program after referral. These findings may be used to design, implement, and evaluate interventions to improve LCS rates among Black veterans.
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Affiliation(s)
- Neelima Navuluri
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Durham Veterans Affairs Medical Center, Durham, North Carolina
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Samantha Morrison
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Cynthia L. Green
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | | | - Isaretta L. Riley
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Christopher E. Cox
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Leah L. Zullig
- Durham Veterans Affairs Medical Center, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Scott Shofer
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Durham Veterans Affairs Medical Center, Durham, North Carolina
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17
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Jazowski SA, Samuel-Ryals CA, Wood WA, Zullig LL, Trogdon JG, Dusetzina SB. Association between low-income subsidies and inequities in orally administered antimyeloma therapy use. Am J Manag Care 2023; 29:246-254. [PMID: 37229783 PMCID: PMC10268034 DOI: 10.37765/ajmc.2023.89357] [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] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES The Medicare Part D low-income subsidy program drastically reduces patient cost sharing and may improve access to and equitable use of high-cost antimyeloma therapy. We compared initiation of and adherence to orally administered antimyeloma therapy between full-subsidy and nonsubsidy enrollees and assessed the association between full subsidies and racial/ethnic inequities in orally administered antimyeloma treatment use. STUDY DESIGN Retrospective cohort study. METHODS We used Surveillance, Epidemiology, and End Results-Medicare data to identify beneficiaries diagnosed with multiple myeloma between 2007 and 2015. Separate Cox proportional hazards models assessed time from diagnosis to treatment initiation and time from therapy initiation to discontinuation. Modified Poisson regression examined therapy initiation in the 30, 60, and 90 days following diagnosis and adherence to and discontinuation of treatment in the 180 days following initiation. RESULTS Receipt of full subsidies was not associated with earlier initiation of or improved adherence to orally administered antimyeloma therapy. Full-subsidy enrollees were 22% (adjusted HR [aHR], 1.22; 95% CI, 1.08-1.38) more likely to experience earlier treatment discontinuation than nonsubsidy enrollees. Receipt of full subsidies did not appear to reduce racial/ethnic inequities in orally administered antimyeloma therapy use. Black full-subsidy and nonsubsidy enrollees were 14% less likely than their White counterparts to ever initiate treatment (full subsidy: aHR, 0.86; 95% CI, 0.73-1.02; nonsubsidy: aHR, 0.86; 95% CI, 0.74-0.99). CONCLUSIONS Full subsidies alone are insufficient to increase uptake or equitable use of orally administered antimyeloma therapy. Addressing known barriers to care (eg, social determinants of health, implicit bias) could improve access to and use of high-cost antimyeloma therapy.
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Affiliation(s)
- Shelley A Jazowski
- Department of Health Policy, Vanderbilt University School of Medicine, 2525 West End Ave, Ste 1200, Nashville, TN 37203.
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18
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Zullig LL, Raska W, McWhirter G, Sherman SE, Makarov D, Becker D, King HA, Pura J, Jeffreys AS, Danus S, Passero V, Goldstein KM, Kelley MJ. Veterans Health Administration National TeleOncology Service. JCO Oncol Pract 2023; 19:e504-e510. [PMID: 36649579 PMCID: PMC10113113 DOI: 10.1200/op.22.00455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 10/19/2022] [Accepted: 11/28/2022] [Indexed: 01/18/2023] Open
Abstract
PURPOSE As the largest integrated health care system in the United States, the Veterans Health Administration (VA) is a leader in telehealth-delivered care. All 10 million Veterans cared for within the VA are eligible for telehealth. The VA cares for approximately 46,000 Veteran patients with newly diagnosed cancer and an estimated 400,000 prevalent cases annually. With nearly 38% of VA health care system users residing in rural areas and only 44% of rural counties having an oncologist, many Veterans lack local access to specialized cancer services. METHODS We describe the VA's National TeleOncology (NTO) Service. NTO was established to provide Veterans with the opportunity for specialized treatment regardless of geographical location. Designed as a hub-and-spoke model, VA oncologists from across the country can provide care to patients at spoke sites. Spoke sites are smaller and rural VA medical centers that are less able to independently provide the full range of services available at larger facilities. In addition to smaller rural spoke sites, NTO also provides subspecialized oncology care to Veterans located in larger VA medical facilities that do not have subspecialties available or that have limited capacity. RESULTS As of fiscal year 2021, 23 clinics are served by or engaged in planning for delivery of NTO and there are 24 physicians providing care through the NTO virtual hub. Most NTO physicians continue to provide patient care in separate traditional in-person clinics. Approximately 4,300 unique Veterans have used NTO services. Approximately half (52%) of Veterans using NTO lived in rural areas. Most of these Veterans had more than one remote visit through NTO. CONCLUSION NTO is a state-of-the-art model that has the potential to revolutionize the way cancer care is delivered, which should improve the experience of Veterans receiving cancer care.
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Affiliation(s)
- Leah L. Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
| | - Whitney Raska
- Department of Veterans Affairs, National Oncology Program, Washington, DC
| | - Gina McWhirter
- Department of Veterans Affairs, National Oncology Program, Washington, DC
| | - Scott E. Sherman
- VA New York Harbor Healthcare System, New York, NY
- Department of Population Health, New York University Grossman School of Medicine, New York, NY
| | - Danil Makarov
- VA New York Harbor Healthcare System, New York, NY
- Department of Population Health, New York University Grossman School of Medicine, New York, NY
- Department of Urology, New York University Grossman School of Medicine, New York, NY
| | - Daniel Becker
- VA New York Harbor Healthcare System, New York, NY
- Perlmutter Cancer Center, New York University Grossman School of Medicine, New York, NY
| | - Heather A. King
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
- Division of General Internal Medicine, Duke University, Durham, NC
| | - John Pura
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
| | - Amy S. Jeffreys
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
| | - Susanne Danus
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
| | - Vida Passero
- Division of Hematology/Oncology, University of Pittsburgh, Pittsburgh, PA
- Department of Hematology/Oncology, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Karen M. Goldstein
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- Division of General Internal Medicine, Duke University, Durham, NC
| | - Michael J. Kelley
- Department of Veterans Affairs, National Oncology Program, Washington, DC
- Division of Medical Oncology, Duke University Medical Center, Durham, NC
- Hematology-Oncology, Durham Veterans Affairs Health Care System, Durham, NC
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19
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Katz AJ, Chen RC, Usinger DS, Danus SM, Zullig LL. Cardiovascular disease prevention and management of pre-existent cardiovascular disease in a cohort of prostate cancer survivors. J Cancer Surviv 2023; 17:351-359. [PMID: 35790675 PMCID: PMC9813269 DOI: 10.1007/s11764-022-01229-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/17/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Cardiovascular disease (CVD) is a common cause of mortality among men with prostate cancer. However, receipt of preventive care and management of pre-existent CVD has not been well studied in prostate cancer survivors. METHODS This study examined a prospective cohort of men newly diagnosed with localized prostate cancer between 2011 and 2013 throughout North Carolina linked to Medicare and private insurance claims and clinical data from the Veterans Affairs (VA). In patients without pre-existent CVD, the primary outcome was a composite measure of annual preventive care (blood glucose screening, cholesterol level testing, and ≥ 1 primary care provider visit). In patients with pre-existent CVD, the primary outcome was annual cardiologist visit; blood glucose, cholesterol level testing, and primary care visits were also assessed. RESULTS Our sample comprised 492 patients successfully linked to insurance claims and/or VA data, among whom 103 (20.9%) had pre-existent CVD. Receipt of preventive care declined from 52.7% (95% confidence interval [CI], 47.7 to 57.6%) during the first year after prostate cancer diagnosis to 40.8% (95% CI: 33.7 to 48.4%) during the third year. Among patients with pre-existent CVD, only 23.4% (95% CI: 13.6 to 37.2%) visited a cardiologist in all 3 years. Black men were more likely than White men to visit a cardiologist the first year (risk ratio [RR] = 1.72, 95% CI: 1.10 to 2.71). CONCLUSION In a population-based cohort of prostate cancer survivors, receipt of CVD preventive care declined over time, and frequency of cardiologist-led management of pre-existent CVD was low. IMPLICATIONS FOR CANCER SURVIVORS There is a need to improve clinical strategies for reducing cardiovascular risk and managing pre-existent CVD in prostate cancer survivors.
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Affiliation(s)
- Aaron J Katz
- Department of Population Health, University of Kansas Medical Center, Kansas City, KS, 66160, USA.
| | - Ronald C Chen
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Deborah S Usinger
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Susanne M Danus
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
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20
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Navuluri N, Morrison S, Green CL, Zullig LL, Woolson SL, Cox C, Riley I, Shofer S. YIA23-091: Disparities in Lung Cancer Screening Among Black Veterans. J Natl Compr Canc Netw 2023. [DOI: 10.6004/jnccn.2022.7120] [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: 04/03/2023]
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21
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Hughes JM, Zullig LL, Choate AL, Decosimo KP, Wang V, Van Houtven CH, Allen KD, Nicole Hastings S. Intensification of Implementation Strategies: Developing a Model of Foundational and Enhanced Implementation Approaches to Support National Adoption and Scale-up. Gerontologist 2023; 63:604-613. [PMID: 36029028 PMCID: PMC10461172 DOI: 10.1093/geront/gnac130] [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: 04/05/2022] [Indexed: 11/13/2022] Open
Abstract
Implementation strategies are activities to support integration of evidence-based programs (EBPs) into routine care. Comprised of 170+ facilities, the Veterans Affairs Healthcare System is conducive to evaluating feasibility and scalability of implementation strategies on a national level. In previous work evaluating implementation of three EBPs for older Veterans (hospital-based walking, caregiver skills training, group physical therapy), we found facilities varied in their need for implementation support, with some needing minimal guidance and others requiring intensive support. Committed to national scalability, our team developed an implementation intensification model consisting of foundational (low-touch) and enhanced (high-touch) implementation support. This Forum article describes our multilevel and multistep process to develop and evaluate implementation intensification. Steps included (a) review completed trial data; (b) conduct listening sessions; (c) review literature; (d) draft foundational and enhanced implementation support packages; (e) iteratively refine packages; and (7) devise an evaluation plan. Our model of implementation intensification may be relevant to other health care systems seeking strategies that can adapt to diverse delivery settings, optimize resources, help build capacity, and ultimately enhance implementation outcomes. As more health care systems focus on spread of EBPs into routine care, identifying scalable and effective implementation strategies will be critical.
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Affiliation(s)
- Jaime M Hughes
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ashley L Choate
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Kasey P Decosimo
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Virginia Wang
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kelli D Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Medicine, University of North Carolina at Chapel Hill School of Medicine , Chapel Hill, North Carolina, USA
| | - S Nicole Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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22
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Sperber NR, Boucher N, Hughes JM, Bruening R, Zullig LL, Decosimo K, Tucker M, Christensen LA, Allen KD, Hastings SN, Van Houtven CH. Mandated Caregiver Training in the Veterans Health Administration: Caregiver Inquiry Informs National Dissemination. Gerontologist 2023; 63:534-544. [PMID: 36327120 PMCID: PMC10461180 DOI: 10.1093/geront/gnac162] [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: 03/15/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND AND OBJECTIVES A minority of family caregivers receive training, with implications for their own and their recipient's outcomes. Federal policy has supported the implementation and expansion of caregiver training and support. The Department of Veterans Affairs (VA) has developed a national Caregiver Support Program and collaborated with VA health services researchers to explore caregivers' acceptance of an evidence-based training program in preparation for system-wide dissemination. RESEARCH DESIGN AND METHODS This approach entailed a convergent mixed-methods design, which involved separate analyses of quantitative and qualitative data. Survey questions based on the Kirkpatrick model for training evaluation measured caregivers' reaction and learning, and interview questions elicited caregivers' reports about the value of the program for them. RESULTS Most caregivers reported satisfaction with the training when responding to survey questions, although qualitative interviews revealed caveats suggesting need to hone the best timing and specific group of caregivers for maximal benefit. DISCUSSION AND IMPLICATIONS Our findings indicate that understanding program-user fit may be particularly critical when implementing training for caregivers as they come to the program at different points along their caregiving journey, needing differing types and intensities of support. While a general program may appeal to policymakers aiming to scale caregiver training within a large, heterogeneous system, there may be shortcomings in terms of end-user acceptance and subsequent downstream outcomes such as reach and ultimately program effectiveness. Good, iterative communication flow between program developers and policymakers facilitates this understanding and, in turn, decisions about scaling.
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Affiliation(s)
- Nina R Sperber
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Nathan Boucher
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Sanford School of Public Policy, Duke University, Durham, North Carolina, USA
| | - Jaime M Hughes
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Rebecca Bruening
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Kasey Decosimo
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Matthew Tucker
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Leah A Christensen
- Veteran's Health Administration Central Office, Washington, District of Columbia, USA
| | - Kelli D Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susan N Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
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23
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Kheterpal M, Borre ED, Nicholas MW, Cooner EW, Phinney D, Gagnon K, Zullig LL, King HA, Malcolm EJ, Chen SC. Implementation Evaluation of a Teledermatology Virtual Clinic at an Academic Medical Center. Res Sq 2023:rs.3.rs-2558425. [PMID: 36909611 PMCID: PMC10002841 DOI: 10.21203/rs.3.rs-2558425/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Background Teledermatology (TD) is an evidence-based practice that may increase access to dermatologic care. We sought to evaluate implementation of TD at four Duke primary care practices. Methods We implemented a hybrid TD program where trained primary care providers (PCPs) sent referrals with clinical and dermatoscopic images to dermatology. Patients were seen by dermatologists over video visit within days, and dermatologists managed the patient plan. We evaluated implementation using the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework using electronic health record data. Implementation barriers and facilitators were collected through surveys (n = 24 PCPs, n = 10 dermatologists, n = 10 dermatology residents). Results At four PCP clinics throughout 9/1/2021-4/30/2022 there were 218 TD referrals. Video visits occurred on average 7.5 days after referral and 18/18 patients completing the post-visit survey were satisfied. Adoption varied between clinics, with one placing 22% of all dermatology referrals as TD and another placing 2%. The primary PCP barriers to TD were time burdens, lack of fit in clinic flow, and discomfort with image taking. Top-endorsed potential facilitating interventions included allowing for rash referrals without dermoscopy and assurance for clinical evaluation within 3 days. Conclusions Addressing TD process fit into PCP clinic flow and reducing time burdens may increase PCP uptake of TD.
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24
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Wong WB, Seetasith A, Hung A, Zullig LL. Impact of list price changes on out-of-pocket costs and adherence in four high-rebate specialty drugs. PLoS One 2023; 18:e0280570. [PMID: 36656871 PMCID: PMC9851557 DOI: 10.1371/journal.pone.0280570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 01/03/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Insurers manage the cost of specialty medicines via rebates, however it is unclear if the savings are passed on to patients, and whether reducing rebates may lead to changes in patient out-of-pocket (OOP) costs and medication adherence. This study examined two drug classes to understand the impact of reducing list prices to net prices, via lower-priced national drug codes (NDCs) or authorized generics, on patient OOP costs and adherence. METHODS This retrospective analysis assessed IQVIA PharMetrics ® Plus adjudicated medical and pharmacy claims for commercially insured patients. Patient OOP costs per prescription and payer drug costs were assessed for evolocumab or alirocumab (proprotein convertase subtilisin/kexin type 9 inhibitors [PCSK9is]) or velpatasvir/sofosbuvir or ledipasvir/sofosbuvir (hepatitis C virus [HCV] medications). For PCSK9is and HCV medications, the original and lower-priced versions were compared. Adherence was estimated based on proportion of days covered (PDC) (PCSK9is) and receipt of full treatment regimen (HCV medications). RESULTS In total, 10,640 patients were included (evolocumab, 5,042; alirocumab, 1,438; velpatasvir/sofosbuvir, 2,952; ledipasvir/sofosbuvir,1,208). After list price reductions, mean payer drug costs decreased by over 60%, while patient OOP cost reductions ranged from 14% to 55% (evolocumab: 55%, p < 0.01; alirocumab: 51%, p < 0.01; velpatasvir/sofosbuvir: 30%, p < 0.01; ledipasvir/sofosbuvir: 14%, p = 0.03). Patients with coinsurance as the largest contributor to their OOP costs had the largest reductions in OOP costs, ranging from adjusted, mean values of US$135 to US$379 (>60% reductions). Six-month PDC for PCSK9is and proportion receiving full HCV treatment regimen were high with the original versions and did not substantially differ with the new, lower-priced versions. CONCLUSIONS Reducing list prices to approximate net prices (as a proxy for reducing rebates) resulted in lower patient OOP costs, particularly for those with coinsurance. Our findings suggest that future reduction of rebates may assist in patient affordability, although additional transparency is needed.
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Affiliation(s)
| | | | - Anna Hung
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States of America
- Duke-Margolis Center for Health Policy, Durham, NC, United States of America
| | - Leah L. Zullig
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States of America
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25
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Rushton S, Lewinski AA, Hwang S, Zullig LL, Ball Ricks KA, Ramos K, Gordon A, Ear B, Ballengee LA, Brahmajothi MV, Moore T, Blalock DV, Williams JW, Cantrell SE, Gierisch JM, Goldstein KM. Barriers and facilitators to the implementation and adoption of improvement coaching: A qualitative evidence synthesis. J Clin Nurs 2023; 32:3-30. [PMID: 35403322 DOI: 10.1111/jocn.16247] [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: 07/26/2021] [Revised: 10/15/2021] [Accepted: 01/12/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Healthcare organisations and teams perform improvement activities to facilitate high-quality healthcare. The use of an improvement coach who provides support and guidance to the healthcare team may facilitate improvement activities; however, no systematic review exists on the facilitators and barriers to implementing an improvement coach. AIMS We conducted a qualitative evidence synthesis to examine the facilitators and barriers to the implementation of improvement coaching. METHODS We searched MEDLINE® , Embase and CINAHL. The final search was in March 2021. The screening eligibility criteria included the following: interdisciplinary team receiving the coaching, improvement coaching, designs with a qualitative component and primary purpose of evaluating practice facilitation in OECD countries. An ecologically-informed consolidated framework for implementation research (CFIR) served as the framework for coding. Patterns of barriers and facilitators across domains were identified through matrix analysis. Risk of bias was assessed using Critical Appraisal Skills Program. PRISMA reporting guidelines served as a guide for reporting this review. RESULTS Nineteen studies with a qualitative component met the inclusion criteria. Four themes of barriers and facilitators crossed multiple CFIR domains: adaptability (e.g. making adjustments to the project; process, or approach); knowledge and skills (e.g. understanding of content and process for the project); engagement (e.g. willingness to be involved in the process) and resources (e.g. assets required to complete the improvement process). CONCLUSION Improvement coaching is a complex intervention that influences the context, healthcare team being coached and improvement activities. Improvement coaches should understand how to minimise barriers and promote facilitators that are unique to each improvement project across the domains. Limitations of the study are related to the nature of the intervention including potential publication bias given quality improvement focus; the variety of terms similar to improvement coaching or selection of framework.
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Affiliation(s)
- Sharron Rushton
- School of Nursing, Duke University, Durham, North Carolina, USA
| | - Allison A Lewinski
- School of Nursing, Duke University, Durham, North Carolina, USA.,Durham Veterans Affairs Health Care System, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
| | - Soohyun Hwang
- Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Leah L Zullig
- Durham Veterans Affairs Health Care System, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA.,Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Katharine A Ball Ricks
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Katherine Ramos
- Durham Veterans Affairs Health Care System, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA.,Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Adelaide Gordon
- Durham Veterans Affairs Health Care System, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
| | - Belinda Ear
- Durham Veterans Affairs Health Care System, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
| | - Lindsay A Ballengee
- Durham Veterans Affairs Health Care System, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA.,Department of Orthopedic Surgery, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Mulugu V Brahmajothi
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Thomasena Moore
- Durham Veterans Affairs Health Care System, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
| | - Dan V Blalock
- Durham Veterans Affairs Health Care System, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
| | - John W Williams
- Durham Veterans Affairs Health Care System, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University, Durham, North Carolina, USA.,Division of General Internal Medicine, Department of Medicine, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Sarah E Cantrell
- School of Medicine, Duke University Medical Center Library & Archives, Duke University, Durham, North Carolina, USA
| | - Jennifer M Gierisch
- Durham Veterans Affairs Health Care System, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA.,Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA.,Division of General Internal Medicine, Department of Medicine, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Karen M Goldstein
- Durham Veterans Affairs Health Care System, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA.,Division of General Internal Medicine, Department of Medicine, School of Medicine, Duke University, Durham, North Carolina, USA
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26
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Yip O, Mendieta MJ, Zullig LL, Zeller A, De Geest S, Deschodt M, Siqeca F, Zúñiga F, Briel M, Schwenkglenks M, Quinto C, Dhaini S. Protocol for a mixed methods feasibility and implementation study of a community-based integrated care model for home-dwelling older adults: The INSPIRE project. PLoS One 2022; 17:e0278767. [PMID: 36542596 PMCID: PMC9770388 DOI: 10.1371/journal.pone.0278767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Evaluations of integrated care models for home-dwelling frail older adults have shown inconclusive results on health and service outcomes. However, limited research has focused on the implementation of integrated care models. Applying implementation science methods may facilitate uptake of integrated care models, thus generating positive outcomes e.g., reduced hospital admissions. This paper describes the protocol to assess the feasibility of an integrated care model (featuring a four-step comprehensive geriatric assessment: screening, a multi-dimensional assessment, a coordinated individualized care plan and follow-up) designed for a new community-based center for home-dwelling older adults in Switzerland. The study includes the following objectives: 1) to assess implementation by a) monitoring respondents to the outreach strategies and describing the Center's visitors; b) assessing implementation outcomes related to the care model (i.e., adoption, acceptability, feasibility, fidelity) and implementation processes related to collaboration; and 2) assessing implementation costs. METHODS For objective 1a, we will use a descriptive design to assess respondents to the outreach strategies and describe the Center's visitors. We will use a parallel convergent mixed methods design for objective 1b. Implementation outcomes data will be collected from meetings with the Center's staff, interviews with older adults and their informal caregivers, and reviewing older adults' health records at the Center. Implementation processes related to collaboration will be assessed through a questionnaire to external collaborators (e.g., GPs) towards the end of the study. For objective 2, implementation costs will be calculated using time-driven activity-based costing methods. Data collection is anticipated to occur over approximately six months. DISCUSSION This study of a contextually adapted integrated care model will inform adaptations to the outreach strategies, care model and implementation strategies in one community center, prior to evaluating the care model effectiveness and potentially scaling out the intervention. TRIAL REGISTRATION Feasibility study registration ID with clinicaltrials.gov: NCT05302310; registration ID with BMC: ISRCTN12324618.
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Affiliation(s)
- Olivia Yip
- Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland
| | - Maria Jose Mendieta
- Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland
- Academic Center for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Leah L. Zullig
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, United States of America
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, United States of America
| | - Andreas Zeller
- Centre for Primary Health Care, University of Basel, Basel, Switzerland
| | - Sabina De Geest
- Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland
- Academic Center for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- * E-mail:
| | - Mieke Deschodt
- Gerontology and Geriatrics, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Competence Center of Nursing, University Hospitals Leuven, Leuven, Belgium
| | - Flaka Siqeca
- Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland
| | - Franziska Zúñiga
- Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland
| | - Matthias Briel
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Matthias Schwenkglenks
- Department of Public Health, Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
| | | | - Suzanne Dhaini
- Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland
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27
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Mielke J, Brunkert T, Zúñiga F, Simon M, Zullig LL, De Geest S. Methodological approaches to study context in intervention implementation studies: an evidence gap map. BMC Med Res Methodol 2022; 22:320. [PMID: 36517765 PMCID: PMC9749183 DOI: 10.1186/s12874-022-01772-w] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/25/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Within implementation science studies, contextual analysis is increasingly recognized as foundational to interventions' successful and sustainable implementation. However, inconsistencies between methodological approaches currently limit progress in studying context and guidance to standardize the use of those approaches is scant. Therefore, this study's objective was to systematically review and map current methodological approaches to contextual analysis in intervention implementation studies. The results would help us both to systematize the process of contextual analysis and identify gaps in the current evidence. METHODS We conducted an evidence gap map (EGM) based on literature data via a stepwise approach. First, using an empirically developed search string, we randomly sampled 20% of all intervention implementation studies available from PubMed per year (2015-2020). Second, we assessed included studies that conducted a contextual analysis. Data extraction and evaluation followed the Basel Approach for CoNtextual ANAlysis (BANANA), using a color-coded rating scheme. Also based on BANANA and on the Context and Implementation of Complex Interventions (CICI) framework-an implementation framework that pays ample attention to context- we created visual maps of various approaches to contextual analysis. RESULTS Of 15, 286 identified intervention implementation studies and study protocols, 3017 were screened for inclusion. Of those, 110 warranted close examination, revealing 22% that reported on contextual analysis. Only one study explicitly applied a framework for contextual analysis. Data were most commonly collected via surveys (n = 15) and individual interviews (n = 13). Ten studies reported mixed-methods analyses. Twenty-two assessed meso-level contextual and setting factors, with socio-cultural aspects most commonly studied. Eighteen described the use of contextual information for subsequent project phases (e.g., intervention development/adaption, selecting implementation strategies). Nine reported contextual factors' influences on implementation and/or effectiveness outcomes. CONCLUSIONS This study describes current approaches to contextual analysis in implementation science and provides a novel framework for evaluating and mapping it. By synthesizing our findings graphically in figures, we provide an initial evidence base framework that can incorporate new findings as necessary. We strongly recommend further development of methodological approaches both to conduct contextual analysis and to systematize the reporting of it. These actions will increase the quality and consistency of implementation science research.
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Affiliation(s)
- Juliane Mielke
- Institute of Nursing Science, Department Public Health, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland
| | - Thekla Brunkert
- Institute of Nursing Science, Department Public Health, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland
- University Department of Geriatric Medicine FELIX PLATTER, Basel, Switzerland
| | - Franziska Zúñiga
- Institute of Nursing Science, Department Public Health, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland
| | - Michael Simon
- Institute of Nursing Science, Department Public Health, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland
| | - Leah L. Zullig
- Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System and Department of Population Health Sciences, Duke University Medical Center, Durham, NC USA
| | - Sabina De Geest
- Institute of Nursing Science, Department Public Health, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland
- Department of Public Health and Primary Care, KU Leuven, Academic Center for Nursing and Midwifery, Louvain, Belgium
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28
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Bruening RA, Sperber N, Wang V, Mahanna E, Choate A, Tucker M, Zullig LL, Van Houtven CH, Allen KD, Hastings SN. Self-Organization of Interprofessional Staff to Improve Mobility of Hospitalized Patients with STRIDE: a Complexity Science-Informed Qualitative Study. J Gen Intern Med 2022; 37:4216-4222. [PMID: 35319083 PMCID: PMC9708971 DOI: 10.1007/s11606-022-07482-9] [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: 11/09/2021] [Accepted: 03/03/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Inpatient mobility programs can help older adults maintain function during hospitalization. Changing hospital practice can be complex and require engagement of various staff levels and disciplines; however, we know little about how interprofessional teams organize around implementing such interventions. Complexity science can inform approaches to understanding and improving multidisciplinary collaboration to implement clinical programs. OBJECTIVE To examine, through a complexity science lens, how clinical staff's understanding about roles in promoting inpatient mobility evolved during implementation of the STRIDE (assiSTed eaRly mobIlity for hospitalizeD older vEterans) hospital mobility program. DESIGN Qualitative study using semi-structured interviews. PARTICIPANTS Ninety-two clinical staff at eight Veterans Affairs hospitals. INTERVENTIONS STRIDE is a supervised walking program for hospitalized older adults designed to maintain patients' mobility and function. APPROACH We interviewed key staff involved in inpatient mobility efforts at each STRIDE site in pre- and post-implementation periods. Interviews elicited staff's perception of complexity-science aspects of inpatient mobility teams (e.g., roles over time, team composition). We analyzed data using complexity science-informed qualitative content analysis. KEY RESULTS We identified three key themes related to patterns of self-organization: (1) individuals outside of the "core" STRIDE team voluntarily assumed roles as STRIDE advocates, (2) leader-champions adapted their engagement level to match local implementation team needs during implementation, and (3) continued leadership support and physical therapy involvement were key factors for sustainment. CONCLUSIONS Staff self-organized around implementation of a new clinical program in ways that were responsive to changing program and contextual needs. These findings demonstrate the importance of effective self-organization for clinical program implementation. Researchers and practitioners implementing clinical programs should allow for, and encourage, flexibility in staff roles in planning for implementation of a new clinical program, encourage the development of advocates, and engage leaders in program planning and sustainment efforts.
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Affiliation(s)
- Rebecca A Bruening
- ADAPT Center of Innovation, Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
| | - Nina Sperber
- ADAPT Center of Innovation, Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA.
- Department of Population Health Sciences, Duke University School of Medicine, Durham, USA.
| | - Virginia Wang
- ADAPT Center of Innovation, Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, USA
- Department of Medicine, Duke University School of Medicine, Durham, USA
| | - Elizabeth Mahanna
- ADAPT Center of Innovation, Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
| | - Ashley Choate
- ADAPT Center of Innovation, Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
| | - Matthew Tucker
- ADAPT Center of Innovation, Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
| | - Leah L Zullig
- ADAPT Center of Innovation, Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, USA
| | - Courtney Harold Van Houtven
- ADAPT Center of Innovation, Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, USA
| | - Kelli D Allen
- ADAPT Center of Innovation, Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Medicine and Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Susan N Hastings
- ADAPT Center of Innovation, Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, USA
- Department of Medicine, Duke University School of Medicine, Durham, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, USA
- Geriatrics Research, Education, and Clinical Center, Durham VA Health Care System, Durham, USA
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29
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De Geest S, Thys A, Zullig LL. Implementation science: accelerating the pharma pipeline to its full potential. J Comp Eff Res 2022; 11:1309-1311. [PMID: 36426902 DOI: 10.2217/cer-2022-0152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Sabina De Geest
- Department of Public Health, Institute of Nursing Science, University of Basel, Basel, CH 4051S, Switzerland.,Department of Public Health & Primary Care, Academic Center for Nursing & Midwifery, KU Leuven, Leuven, B-3000, Belgium
| | | | - Leah L Zullig
- Center for Innovation to Accelerate Discovery & Practice Transformation (ADAPT), Durham Veterans Affairs Health Care & System, NC 27701, USA.,Department of Population Health Sciences, School of Medicine, Duke University, NC 27701, USA
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30
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Lewinski AA, Jazowski SA, Goldstein KM, Whitney C, Bosworth HB, Zullig LL. Intensifying approaches to address clinical inertia among cardiovascular disease risk factors: A narrative review. Patient Educ Couns 2022; 105:3381-3388. [PMID: 36002348 PMCID: PMC9675717 DOI: 10.1016/j.pec.2022.08.005] [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] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/01/2022] [Accepted: 08/09/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Clinical inertia, the absence of treatment initiation or intensification for patients not achieving evidence-based therapeutic goals, is a primary contributor to poor clinical outcomes. Effectively combating clinical inertia requires coordinated action on the part of multiple representatives including patients, clinicians, health systems, and the pharmaceutical industry. Despite intervention attempts by these representatives, barriers to overcoming clinical inertia in cardiovascular disease (CVD) risk factor control remain. METHODS We conducted a narrative literature review to identify individual-level and multifactorial interventions that have been successful in addressing clinical inertia. RESULTS Effective interventions included dynamic forms of patient and clinician education, monitoring of real-time patient data to facilitate shared decision-making, or a combination of these approaches. Based on findings, we describe three possible multi-level approaches to counter clinical inertia - a collaborative approach to clinician training, use of a population health manager, and use of electronic monitoring and reminder devices. CONCLUSION To reduce clinical inertia and achieve optimal CVD risk factor control, interventions should consider the role of multiple representatives, be feasible for implementation in healthcare systems, and be flexible for an individual patient's adherence needs. PRACTICE IMPLICATIONS Representatives (e.g., patients, clinicians, health systems, and the pharmaceutical industry) could consider approaches to identify and monitor non-adherence to address clinical inertia.
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Affiliation(s)
- Allison A Lewinski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Attn: HSR&D COIN (558/152), 508 Fulton Street, Durham, NC 27705, USA; Duke University School of Nursing, Box 3322 DUMC, Durham, NC 27710, USA.
| | - Shelley A Jazowski
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, 170 Rosenau Hall, CB #7400, 135 Dauer Drive, Chapel Hill, NC 27599‑7400, USA; Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701, USA; Department of Health Policy, Vanderbilt University School of Medicine, 2525 West End Ave, Suite 1200, Nashville, TN 37203, USA.
| | - Karen M Goldstein
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Attn: HSR&D COIN (558/152), 508 Fulton Street, Durham, NC 27705, USA; Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 200 Morris Street, Durham, NC 27701, USA.
| | - Colette Whitney
- Cascades East Family Medicine Residency, Oregon Health & Sciences University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239-3098, USA.
| | - Hayden B Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Attn: HSR&D COIN (558/152), 508 Fulton Street, Durham, NC 27705, USA; Duke University School of Nursing, Box 3322 DUMC, Durham, NC 27710, USA; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, 170 Rosenau Hall, CB #7400, 135 Dauer Drive, Chapel Hill, NC 27599‑7400, USA; Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701, USA; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, P.O. Box 102508, Durham, NC 27710, USA.
| | - Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Attn: HSR&D COIN (558/152), 508 Fulton Street, Durham, NC 27705, USA; Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701, USA.
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Yip O, Dhaini S, Esser J, Siqeca F, Mendieta MJ, Huber E, Zeller A, De Geest S, Deschodt M, Zúñiga F, Zullig LL, King HA, Urfer P, Vounatsou P, Obas K, Briel M, Schwenkglenks M, Quinto C, Blozik E. Health and social care of home-dwelling frail older adults in Switzerland: a mixed methods study. BMC Geriatr 2022; 22:857. [PMID: 36376806 PMCID: PMC9663289 DOI: 10.1186/s12877-022-03552-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/14/2022] [Indexed: 11/16/2022] Open
Abstract
Background Home-dwelling frail older adults are often faced with multimorbidity and complex care needs, requiring health and social care systems that support frail older adults to age in place. The objective of this paper was to investigate the types of formal health and social care as well as informal care and social support used by home-dwelling frail older adults; whether they perceive their support as sufficient; and their experience with and preferences for care and support. Methods Using an explanatory sequential mixed methods design, we first conducted a secondary analysis of a subset of cross-sectional data from the ImplemeNtation of a community-baSed care Program for home dwelling senIoR citizEns (INSPIRE) population survey using descriptive analysis. Subsequently, we analyzed existing data from interviews in the parent study to help explain the survey results using applied thematic analysis. Results were organized according to adapted domains and concepts of the SELFIE framework and integrated via a joint display table. Results Of the parent population survey respondents, 2314 older adults indicating frailty were included in the quantitative arm of this study. Interview data was included from 7 older adults who indicated frailty. Support from health and social, formal and informal caregivers is diverse and anticipated to increase (e.g., for ‘care and assistance at home’ and ‘meal services’). Informal caregivers fulfilled various roles and while some older adults strongly relied on them for support, others feared burdening them. Most participants (93.5%) perceived their overall support to meet their needs; however, findings suggest areas (e.g., assessment of overall needs) which merit attention to optimize future care. Conclusions Given the anticipated demand for future care and support, we recommend efforts to prevent fragmentation between health and social as well as formal and informal care. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03552-z.
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Mielke J, Leppla L, Valenta S, Zullig LL, Zúñiga F, Staudacher S, Teynor A, De Geest S. Unraveling implementation context: the Basel Approach for coNtextual ANAlysis (BANANA) in implementation science and its application in the SMILe project. Implement Sci Commun 2022; 3:102. [PMID: 36183141 PMCID: PMC9526967 DOI: 10.1186/s43058-022-00354-7] [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: 04/07/2022] [Accepted: 09/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Designing intervention and implementation strategies with careful consideration of context is essential for successful implementation science projects. Although the importance of context has been emphasized and methodology for its analysis is emerging, researchers have little guidance on how to plan, perform, and report contextual analysis. Therefore, our aim was to describe the Basel Approach for coNtextual ANAlysis (BANANA) and to demonstrate its application on an ongoing multi-site, multiphase implementation science project to develop/adapt, implement, and evaluate an integrated care model in allogeneic SteM cell transplantatIon facILitated by eHealth (the SMILe project). METHODS BANANA builds on guidance for assessing context by Stange and Glasgow (Contextual factors: the importance of considering and reporting on context in research on the patient-centered medical home, 2013). Based on a literature review, BANANA was developed in ten discussion sessions with implementation science experts and a medical anthropologist to guide the SMILe project's contextual analysis. BANANA's theoretical basis is the Context and Implementation of Complex Interventions (CICI) framework. Working from an ecological perspective, CICI acknowledges contextual dynamics and distinguishes between context and setting (the implementation's physical location). RESULTS BANANA entails six components: (1) choose a theory, model, or framework (TMF) to guide the contextual analysis; (2) use empirical evidence derived from primary and/or secondary data to identify relevant contextual factors; (3) involve stakeholders throughout contextual analysis; (4) choose a study design to assess context; (5) determine contextual factors' relevance to implementation strategies/outcomes and intervention co-design; and (6) report findings of contextual analysis following appropriate reporting guidelines. Partly run simultaneously, the first three components form a basis both for the identification of relevant contextual factors and for the next components of the BANANA approach. DISCUSSION Understanding of context is indispensable for a successful implementation science project. BANANA provides much-needed methodological guidance for contextual analysis. In subsequent phases, it helps researchers apply the results to intervention development/adaption and choices of contextually tailored implementation strategies. For future implementation science projects, BANANA's principles will guide researchers first to gather relevant information on their target context, then to inform all subsequent phases of their implementation science project to strengthen every part of their work and fulfill their implementation goals.
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Affiliation(s)
- Juliane Mielke
- grid.6612.30000 0004 1937 0642Institute of Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland
| | - Lynn Leppla
- grid.6612.30000 0004 1937 0642Institute of Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland ,grid.7708.80000 0000 9428 7911Department of Medicine I, Faculty of Medicine, Medical Center University of Freiburg, Freiburg im Breisgau, Germany
| | - Sabine Valenta
- grid.6612.30000 0004 1937 0642Institute of Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland ,grid.410567.1Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Leah L. Zullig
- grid.26009.3d0000 0004 1936 7961Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care & System, and Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC USA
| | - Franziska Zúñiga
- grid.6612.30000 0004 1937 0642Institute of Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland
| | - Sandra Staudacher
- grid.6612.30000 0004 1937 0642Institute of Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland ,grid.5012.60000 0001 0481 6099Department of Health Services Research, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Alexandra Teynor
- grid.440970.e0000 0000 9922 6093University of Applied Sciences Augsburg, Faculty of Computer Science, Augsburg, Germany
| | - Sabina De Geest
- grid.6612.30000 0004 1937 0642Institute of Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland ,grid.5596.f0000 0001 0668 7884Academic Center for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
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Zullig LL, Peterson ED, Shah BR, Grambow SC, Oddone EZ, McCant F, Lindquist JH, Bosworth HB. Secondary Prevention Risk Interventions via Telemedicine and Tailored Patient Education (SPRITE): A randomized trial to improve post myocardial infarction management. Patient Educ Couns 2022; 105:2962-2968. [PMID: 35618550 DOI: 10.1016/j.pec.2022.05.011] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 05/10/2022] [Accepted: 05/15/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE We evaluated the impact of a low intensity web-based and intensive nurse-administered intervention to reduce systolic blood pressure (SBP) among patients with prior MI. METHODS Secondary Prevention Risk Interventions via Telemedicine and Tailored Patient Education (SPRITE) was a three-arm trial. Patients were randomized to 1) post-MI education-only; 2) nurse-administered telephone program; or 3) web-based interactive tool. The study was conducted 2009-2013. RESULTS Participants (n = 415) had a mean age of 61 years (standard deviation [SD], 11). Relative to the education-only group, the 12-month differential improvement in SBP was - 3.97 and - 3.27 mmHg for nurse-administered telephone and web-based groups, respectively. Neither were statistically significant. Post hoc exploratory subgroup analyses found participants who received a higher dose (>12 encounters) in the nurse-administered telephone intervention (n = 60; 46%) had an 8.8 mmHg (95% CI, 0.69, 16.89; p = 0.03) differential SBP improvement versus low dose (<11 encounters; n = 71; 54%). For the web-based intervention, those who had higher dose (n = 73; 53%; >1 web encounter) experienced a 2.3 mmHg (95% CI, -10.74, 6.14; p = 0.59) differential SBP improvement versus low dose (n = 65; 47%). CONCLUSIONS The main effects were not statistically significant. PRACTICAL IMPLICATIONS Completing the full dose of the intervention may be essential to experience the intervention effect. CLINICAL TRIAL REGISTRATION The unique identifier is NCT00901277 (http://www. CLINICALTRIALS gov/ct2/show/NCT00901277?term=NCT00901277&rank=1).
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Affiliation(s)
- Leah L Zullig
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States; Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
| | | | | | - Steven C Grambow
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, United States
| | - Eugene Z Oddone
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
| | - Felicia McCant
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
| | - Jennifer Hoff Lindquist
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
| | - Hayden B Bosworth
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States; Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States.
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Goldstein KM, Perry KR, Lewinski A, Walsh C, Shepherd-Banigan ME, Bosworth HB, Weidenbacher H, Blalock DV, Zullig LL. How can equitable video visit access be delivered in primary care? A qualitative study among rural primary care teams and patients. BMJ Open 2022; 12:e062261. [PMID: 37919249 PMCID: PMC9361743 DOI: 10.1136/bmjopen-2022-062261] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 07/20/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The COVID-19 pandemic sparked exponential growth in video visit use in primary care. The rapid shift to virtual from in-person care exacerbated digital access disparities across racial groups and rural populations. Moving forward, it is critical to understand when and how to incorporate video visits equitably into primary care. We sought to develop a novel clinical algorithm to guide primary care clinics on how and when to employ video visits as part of care delivery. DESIGN Qualitative data collection: one team member conducted all patient semistructured interviews and led all focus groups with four other team members taking notes during groups. SETTING 3 rural primary care clinics in the USA. PARTICIPANTS 24 black veterans living in rural areas and three primary care teams caring for black veterans living in rural areas. PRIMARY AND SECONDARY OUTCOME MEASURES Findings from semistructured interviews with patients and focus groups with primary care teams. RESULTS Key issues around appropriate use of video visits for clinical teams included having adequate technical support, encouraging engagement during video visits and using video visits for appropriate clinical situations. Patients reported challenges with broadband access, inadequate equipment, concerns about the quality of video care, the importance of visit modality choice, and preferences for in-person care experience over virtual care. We developed an algorithm that requires input from both patients and their care team to assess fit for each clinical encounter. CONCLUSIONS Informed matching of patients and clinical situations to the right visit modality, along with individual patient technology support could reduce virtual access disparities.
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Affiliation(s)
- Karen M Goldstein
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kathleen R Perry
- Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Allison Lewinski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- School of Nursing, Duke University, Durham, NC, USA
| | - Conor Walsh
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Megan E Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Hayden B Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- School of Nursing, Duke University, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Hollis Weidenbacher
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Dan V Blalock
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
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Maradiaga Panayotti GM, Martinez-Bianchi V, Corsino L, Silberberg M, Zullig LL, Felsman IC, Gonzalez-Guarda R, Nagy GA, Rocha P, Vergara E, Smith L, Peña A, Granados I, Kennedy D, Pollak KI. LATIN-19: A Grassroots Coalition to Mitigate the Effect of COVID-19 on the Latinx Community in North Carolina. Prog Community Health Partnersh 2022; 16:33-38. [PMID: 35912655 DOI: 10.1353/cpr.2022.0036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Social inequity is a primary driver of health disparities, creating multiple barriers to good health. These inequities were exacerbated during the coronavirus disease 2019 (COVID-19) pandemic, with Latinx communities suffering more than others. Grassroots collaborations have long existed to address disparities. OBJECTIVE We describe the creation and work of the Latinx Advocacy Team and Interdisciplinary Network for COVID-19 (LATIN-19; http://latin19.org/), a multisector coalition in North Carolina created to address the unique challenges of COVID-19 in the Latinx community. METHODS We discuss challenges and solutions that LATIN-19 addressed and the impact of LATIN-19 on community partners and members. RESULTS LATIN-19 learned of challenges including, lack of awareness, need for data systems to track disparities, the need to increase access to resources, the need for policy changes, and the need to coordinate services by community organizations. CONCLUSIONS LATIN-19 represents a grassroots organization that has had an impact on community and community organizations that spans beyond COVID-19.
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Ballengee LA, Bosworth HB, Zullig LL. The role of accountability in adherence programs. Patient Educ Couns 2022; 105:2635-2636. [PMID: 35667936 DOI: 10.1016/j.pec.2022.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- L A Ballengee
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
| | - H B Bosworth
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA; Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - L L Zullig
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA; Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
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Mielke J, De Geest S, Zúñiga F, Brunkert T, Zullig LL, Pfadenhauer LM, Staudacher S. Understanding dynamic complexity in context-Enriching contextual analysis in implementation science from a constructivist perspective. Front Health Serv 2022; 2:953731. [PMID: 36925847 PMCID: PMC10012673 DOI: 10.3389/frhs.2022.953731] [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] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/01/2022] [Indexed: 01/24/2023]
Abstract
Context in implementation science includes not only characteristics of a setting in which an intervention will be delivered, but also social systems (e.g., interrelationships). Context is dynamic and interacts with both, the intervention and its implementation. Therefore, contextual analysis is recognized as an indispensable part of implementation science methodology: it provides the foundation for successful and sustainable implementation projects. Yet, driven by the prevailing post-positivist understanding of context, contextual analysis typically focuses on individual characteristics of context i.e., contextual dynamics and interactions go unnoticed. Conducting contextual analysis from a constructivist perspective promotes a multilayered approach, building a more comprehensive understanding of context, and thus facilitating successful implementation. In this article, we highlight the limitations of prevailing perspectives on context and approaches to contextual analysis. We then describe how contextual analysis can be enriched by working from a constructivist perspective. We finish with a discussion of the methodological and practical implications the proposed changes would entail. Emerging literature attempts to address both the concept of context and methods for contextual analysis. Various theories, models and frameworks consider context, however, many of these are reductionistic and do not acknowledge the dynamic nature of context or interactions within it. To complement recent conceptualizations of context, we suggest consider the following five constructivist concepts: 1) social space; 2) social place; 3) agency; 4) sensation; and 5) embodiment. We demonstrate the value of these concepts using COVID-19 vaccination uptake as an example and integrate the concepts in the Context and Implementation of Complex Interventions (CICI) framework-an implementation science framework that pays ample attention to context. To study context from a constructivist perspective, we also suggest additional considerations in view of methodologies for data collection and analysis, e.g., rapid ethnographic methods. A constructivist perspective contributes to a stronger conceptualization of contextual analysis. Considering the five constructivist concepts helps to overcome contextual analysis' current shortcomings, while revealing complex dynamics that usually go unnoticed. Thus, more comprehensive understanding of context can be developed to inform subsequent phases of an implementation project, thereby maximizing an intervention's uptake and sustainability.
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Affiliation(s)
- Juliane Mielke
- Institute of Nursing Science, Department Public Health, University of Basel, Basel, Switzerland
| | - Sabina De Geest
- Institute of Nursing Science, Department Public Health, University of Basel, Basel, Switzerland
- Academic Center for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Franziska Zúñiga
- Institute of Nursing Science, Department Public Health, University of Basel, Basel, Switzerland
| | - Thekla Brunkert
- Institute of Nursing Science, Department Public Health, University of Basel, Basel, Switzerland
- University Department of Geriatric Medicine FELIX PLATTER, Basel, Switzerland
| | - Leah L. Zullig
- Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care, Durham, NC, United States
- System and Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, United States
| | - Lisa M. Pfadenhauer
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig Maximilian University of Munich, Munich, Germany
- Pettenkofer School of Public Health, Ludwig Maximilian University of Munich, Munich, Germany
| | - Sandra Staudacher
- Institute of Nursing Science, Department Public Health, University of Basel, Basel, Switzerland
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
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Jazowski SA, Wilson L, Dusetzina SB, Zafar SY, Zullig LL. Association of High-Deductible Health Plan Enrollment With Spending on and Use of Lenalidomide Therapy Among Commercially Insured Patients With Multiple Myeloma. JAMA Netw Open 2022; 5:e2215720. [PMID: 35671056 PMCID: PMC9175078 DOI: 10.1001/jamanetworkopen.2022.15720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE High-deductible health plans (HDHPs) require high upfront cost-sharing, which has been associated with suboptimal anticancer medication uptake and adherence. Whether HDHP enrollment has limited the affordability and use of lenalidomide therapy among commercially insured patients with multiple myeloma is unknown. OBJECTIVE To assess the association of HDHP enrollment with out-of-pocket spending on and adherence to lenalidomide therapy. DESIGN, SETTING, AND PARTICIPANTS In this cohort study, data were obtained from the IBM MarketScan Commercial Claims and Encounters Database for adults aged 18 to 64 years with multiple myeloma who newly initiated lenalidomide therapy between April 1, 2013, and June 30, 2017. Quantile regression and modified Poisson regression evaluated out-of-pocket spending, and group-based trajectory models and multinomial logistic regression examined patterns of and factors associated with adherence. Analyses were conducted from April to August 2020. EXPOSURES High-deductible health plan enrollment in the 3 months before and 6 months after initiation of lenalidomide therapy. MAIN OUTCOMES AND MEASURES Distribution of out-of-pocket spending, the probability of paying more than $100 for the first and any lenalidomide prescription fill, and monthly lenalidomide therapy adherence using the proportion of days covered (≥80%). RESULTS Of the 3163 commercially insured patients who initiated lenalidomide therapy (median age, 57 years [IQR, 53-60 years for HDHP enrollees and 52-61 years for non-HDHP enrollees]), 328 (10.4%) were enrolled in HDHPs and 1769 (55.9%) were women. Among the highest spenders (95th percentile), HDHP enrollees paid $376 (95% CI, -$28 to $780) and $217 (95% CI, $106-$323) more for their first and any lenalidomide prescription fill, respectively, compared with non-HDHP enrollees in the 6 months after initiation. High-deductible health plan enrollment was also associated with an increased risk of paying more than $100 for the initial (adjusted risk ratio [aRR], 1.30 [95% CI, 1.13-1.50]) and any (aRR, 1.26 [95% CI, 1.12-1.42]) lenalidomide prescription fill. Three adherence trajectory groups were identified: those with high adherence (n = 1273), late nonadherence (n = 1084), and early nonadherence (n = 805). High-deductible health plan enrollment was not associated with adherence group assignment. CONCLUSIONS AND RELEVANCE In this cohort study, HDHP enrollment was associated with higher out-of-pocket spending per lenalidomide prescription fill; however, no statistically significant differences in adherence patterns between HDHP and non-HDHP enrollees were observed. Patient (eg, perceptions of treatment benefits), payer (eg, out-of-pocket maximums), and clinician (eg, counseling patients on disease severity) factors may have limited the potential for nonadherence among commercially insured patients who initiated lenalidomide therapy.
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Affiliation(s)
- Shelley A. Jazowski
- Department of Health Policy and Management, UNC (University of North Carolina at Chapel Hill) Gillings School of Global Public Health
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Lauren Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Stacie B. Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - S. Yousuf Zafar
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Division of Medical Oncology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Sanford School of Public Policy, Duke University, Durham, North Carolina
| | - Leah L. Zullig
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
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Zullig LL, Sung AD, Khouri MG, Jazowski S, Shah NP, Sitlinger A, Blalock DV, Whitney C, Kikuchi R, Bosworth HB, Crowley MJ, Goldstein KM, Klem I, Oeffinger KC, Dent S. Cardiometabolic Comorbidities in Cancer Survivors. JACC CardioOncol 2022; 4:149-165. [PMID: 35818559 PMCID: PMC9270612 DOI: 10.1016/j.jaccao.2022.03.005] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 03/16/2022] [Accepted: 03/18/2022] [Indexed: 12/28/2022] Open
Abstract
There are nearly 17 million cancer survivors in the United States, including those who are currently receiving cancer therapy with curative intent and expected to be long-term survivors, as well as those with chronic cancers such as metastatic disease or chronic lymphocytic leukemia, who will receive cancer therapy for many years. Current clinical practice guidelines focus on lifestyle interventions, such as exercise and healthy eating habits, but generally do not address management strategies for clinicians or strategies to increase adherence to medications. We discuss 3 cardiometabolic comorbidities among cancer survivors and present the prevalence of comorbidities prior to a cancer diagnosis, treatment of comorbidities during cancer therapy, and management considerations of comorbidities in long-term cancer survivors or those on chronic cancer therapy. Approaches to support medication adherence and potential methods to enhance a team approach to optimize care of the individual with cancer across the continuum of disease are discussed. Cancer survivors are at increased risk for several chronic conditions, including hypertension, dyslipidemia, and diabetes. Determining optimal management of comorbidities for patients with cancer is critical. A multidisciplinary care approach is recommended throughout the continuum of active cancer treatment and survivorship. Survivorship research should focus on medication adherence and coordination of care.
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Affiliation(s)
- Leah L. Zullig
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Address for correspondence: Dr Leah Zullig, Duke University, 411 West Chapel Hill Street, Suite 600, Durham, North Carolina 27701, USA. @LeahZullig
| | - Anthony D. Sung
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michel G. Khouri
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Shelley Jazowski
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nishant P. Shah
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andrea Sitlinger
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Dan V. Blalock
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina, USA
| | - Colette Whitney
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina, USA
- Cascades East–Oregon Health and Science University, Klamath Falls, Oregon, USA
| | - Robin Kikuchi
- Keck School of Medicine, University of California-Los Angeles, Los Angeles, California, USA
| | - Hayden B. Bosworth
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina, USA
| | - Matthew J. Crowley
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Karen M. Goldstein
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Igor Klem
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kevin C. Oeffinger
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Susan Dent
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Hogervorst S, Vervloet M, Adriaanse MC, Zamboni K, Zullig LL, Schoonmade L, Hugtenburg JG, van Dijk L. Scalability of effective adherence interventions for patients using cardiovascular disease medication - a realist synthesis inspired systematic review. Br J Clin Pharmacol 2022. [PMID: 35617955 DOI: 10.1111/bcp.15418] [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] [Received: 12/30/2021] [Revised: 04/15/2022] [Accepted: 05/12/2022] [Indexed: 11/28/2022] Open
Abstract
Upscaling of medication adherence interventions to routine care is still challenging. This realist theory inspired review aimed to assess which intervention aspects are potentially important for the scalability of effective cardiovascular disease (CVD) medication adherence interventions and how they are reported in effectiveness studies. A total of 4097 articles from four databases were screened of which ultimately 31 studies were included. Relevant information on scalability was extracted using a theoretic framework based on the scalability assessment tool used in the QUALIDEC study for the following domains; (i) innovation, (ii) implementers and patients, (iii) adopting organizations and health system and (iv) socio-political context. Extracted articles were analysed for themes and chains of inference, which were grouped based on commonality and source of evidence to form new hypotheses. Six different domains relevant for scalability of adherence interventions were identified: 1) Complexity of the intervention 2) training; 3) customization of the intervention; 4) drivers of the intervention; 5) technical interventions 6) stakeholder involvement. These six domains might be useful for the development of more scalable interventions by bridging the gap between research and practice. Data relevant for scalability is not well reported on in effectiveness trials for CVD medication adherence interventions and only limited data on scalability has been published in additional papers. We believe the adoption and reach of effective CVD medication adherence interventions will improve with increased awareness for the necessity of scalability in all phases of intervention development.
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Affiliation(s)
- Stijn Hogervorst
- Department of Health Sciences, Faculty of Science, Vrije Universiteit, Amsterdam, The Netherlands.,Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Marcia Vervloet
- Nivel, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Marcel C Adriaanse
- Department of Health Sciences, Faculty of Science, Vrije Universiteit, Amsterdam, The Netherlands.,Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Karen Zamboni
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Leah L Zullig
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Linda Schoonmade
- University Library, Vrije Universiteit, Amsterdam, The Netherlands
| | - Jacqueline G Hugtenburg
- Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands.,Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC, Amsterdam, The Netherlands
| | - Liset van Dijk
- Nivel, Netherlands Institute for Health Services Research, Utrecht, The Netherlands.,Department of PharmacoTherapy, Epidemiology & Economics (PTEE), Faculty of Mathematics and Natural Sciences, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands
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Abstract
OBJECTIVES Patient assistance programs (eg, co-pay assistance) may reduce patients' out-of-pocket costs for prescription medicines, providing financial assistance to access medicines for reduced or no cost. A literature review to identify peer-reviewed articles on studies evaluating the impact of co-pay assistance on clinical, patient, and economic outcomes was conducted. STUDY DESIGN A literature review was conducted by searching Embase and MEDLINE. METHODS The population of interest was patients who had received co-pay assistance; the intervention was co-pay assistance; comparator was no co-pay assistance; and outcomes were treatment adherence, compliance, discontinuation, interruption, barriers to adherence, and specific therapeutic outcomes. Articles from the United States published between January 2015 and June 2021 were included. RESULTS A total of 1249 initial articles were identified, of which 19 published articles representing 12 studies were included. Most studies were retrospective claims analyses (n = 10); there was also 1 randomized controlled trial and 1 prospective and observational study. One article assessed the association between co-pay assistance and patient-reported outcomes, 7 explored the relationship between co-pay assistance and clinical outcomes, and 6 assessed the impact of policy/program changes on co-pay assistance. Co-pay assistance was associated with improved treatment persistence/adherence across various diseases, with limited indirect evidence of this translating into clinical outcomes improvements. Lack of long-term outcomes and uncertainty around program sustainment from co-pay assistance programs are limitations. CONCLUSIONS Limited evidence suggests a potential link between co-pay assistance and clinical outcomes; future research addressing study design challenges in measuring the effects of co-pay assistance is needed.
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Semvua SK, Kim CY, Muiruri C, Peter TA, Mmbaga BT, Bartlett JA, Zullig LL, Jazowski SA, Knettel BA, Karia FP, Ramadhani HO. Predictors of Self-repackaging of Antiretroviral Therapy in Northern Tanzania. Am J Health Behav 2022; 46:124-133. [PMID: 35501963 DOI: 10.5993/ajhb.46.2.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objectives: In this study, we explored determinants of "researcher-observed" patient-initiated antiretroviral therapy (ART) repackaging practices among people living with HIV (PLHIV) in Northern Tanzania. Methods: We used a quasi-experimental design to describe the prevalence of ART self- repackaging; we conducted face-to-face surveys to determine factors associated with ART self- repackaging practices. Data collection sites included the Kilimanjaro Christian Medical Centre and the Mawenzi Referral Hospital. We used study-specific numerical identifiers assigned to ARTs packaging to determine self-repackaging behavior. Self-repackaging was defined as a binary variable where participants who discarded antiretroviral drugs packaging in at least 2 clinic visits were classified as self- repackagers. We used multivariable logistic regression to assess the determinants of patient-initiated repackaging practices. Results: Among 590 study participants, 57.6% self-repackaged based on researcher observation and 55.6% self-repackaged based on patient report. Researcher-observed self- repackaging was associated with gender (AOR = 1.590; 95% CI: 1.011, 2.502), employment status (AOR = 0.475: 95% CI; 0.239, 0.942), and study site (AOR = 0.218; 95% CI: 0.134, 0.355). Conclusions: A substantial proportion of patients self-repackage their ARTs for various reasons. Health system interventions should focus on addressing the attributes of repackaging among men and unemployed patients.
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Affiliation(s)
- Seleman Khamis Semvua
- Seleman K. Semvua, Kilimanjaro Christian Medical University College, Moshi, Tanzania;,
| | - Christine Yaeree Kim
- Christine Yaeree Kim, Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States, and Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC,
United States
| | - Charles Muiruri
- Charles Muiruri, Kilimanjaro Christian Medical University College, Moshi, Tanzania, and Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States, and Duke Global Health Institute, Duke University,
Durham, NC, United States
| | - Timothy Antipas Peter
- Timothy Antipas Peter, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Blandina T. Mmbaga
- Blandina T. Mmbaga, Kilimanjaro Christian Medical University College, Moshi, Tanzania, and Duke Global Health Institute, Duke University, Durham, NC, United States
| | - John A. Bartlett
- John A. Bartlett, Kilimanjaro Christian Medical University College, Moshi, Tanzania, and Duke Global Health Institute, Duke University, Durham, NC, United States
| | - Leah L. Zullig
- Leah L. Zullig, Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States, and Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Shelley A. Jazowski
- Shelley A. Jazowski, Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States, and Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel
Hill, NC, United States
| | - Brandon A. Knettel
- Brandon A. Knettel, Duke Global Health Institute, Duke University, Durham, NC, United States, and School of Nursing, Duke University, Durham, NC, United States
| | - Francis P. Karia
- Francis P. Karia, Kilimanjaro Christian Medical University College, Moshi, Tanzania, and Duke Office of Clinical Research. Duke University School of Medicine, Durham, NC, United States
| | - Habib O. Ramadhani
- Habib O. Ramadhani, Kilimanjaro Christian Medical University College, Moshi, Tanzania, and Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, United States
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Dusetzina SB, Huskamp HA, Rothman RL, Pinheiro LC, Roberts AW, Shah ND, Walunas TL, Wood WA, Zuckerman AD, Zullig LL, Keating NL. Many Medicare Beneficiaries Do Not Fill High-Price Specialty Drug Prescriptions. Health Aff (Millwood) 2022; 41:487-496. [PMID: 35377748 DOI: 10.1377/hlthaff.2021.01742] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
For high-price drugs, Medicare Part D beneficiaries who do not receive a low-income subsidy must pay a percentage of the drug's price for each medication fill. Without that subsidy, which lowers out-of-pocket spending, beneficiaries typically pay hundreds or thousands of dollars for a single fill. We estimated the proportion of Part D beneficiaries in fee-for-service Medicare, with and without a subsidy, who do not initiate treatment (that is, do not fill a new prescription) with high-price Part D drugs newly prescribed for four conditions. Examining 17,076 new prescriptions issued between 2012 and 2018 for Part D beneficiaries from eleven geographically diverse health systems, we found that beneficiaries receiving subsidies were nearly twice as likely to obtain the prescribed drug within ninety days as those without subsidies. Among beneficiaries without subsidies, we observed noninitiation for 30 percent of prescriptions written for anticancer drugs, 22 percent for hepatitis C treatments, and more than 50 percent for disease-modifying therapies for either immune system disorders or hypercholesterolemia. Our findings support current legislative efforts to increase the accessibility of high-price medications by reducing out-of-pocket expenses under Medicare Part D, particularly for beneficiaries without low-income subsidies.
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Affiliation(s)
- Stacie B Dusetzina
- Stacie B. Dusetzina , Vanderbilt University Medical Center and Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | | | | | | | | | - Nilay D Shah
- Nilay D. Shah, Delta Air Lines, Atlanta, Georgia
| | | | - William A Wood
- William A. Wood, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Leah L Zullig
- Leah L. Zullig, Duke University, Durham, North Carolina
| | - Nancy L Keating
- Nancy L. Keating, Harvard University and Brigham and Women's Hospital, Boston, Massachusetts
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Lian T, Reid H, Rader A, Dewitt-Feldman S, Hezarkhani E, Gu E, Scott M, Kutzer K, Sandhu S, Crowder C, Ito K, Eisenson H, Bettger JP, Shaw RJ, Lewinski AA, Ming DY, Bosworth HB, Zullig LL, Batch BC, Drake C. A Tailored SMS Text Message Based Intervention to Facilitate Patient Access to Referred Community-Based Social Needs Resources: Protocol for a Feasibility and Acceptability Pilot (Preprint). JMIR Res Protoc 2022; 11:e37316. [PMID: 36222790 PMCID: PMC9597426 DOI: 10.2196/37316] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 08/18/2022] [Accepted: 08/30/2022] [Indexed: 11/15/2022] Open
Abstract
Background Health care providers are increasingly screening patients for unmet social needs (eg, food, housing, transportation, and social isolation) and referring patients to relevant community-based resources and social services. Patients’ connection to referred services is often low, however, suggesting the need for additional support to facilitate engagement with resources. SMS text messaging presents an opportunity to address barriers related to contacting resources in an accessible, scalable, and low-cost manner. Objective In this multi-methods pilot study, we aim to develop an automated SMS text message–based intervention to promote patient connection to referred social needs resources within 2 weeks of the initial referral and to evaluate its feasibility and patient acceptability. This protocol describes the intervention, conceptual underpinnings, study design, and evaluation plan to provide a detailed illustration of how SMS technology can complement current social needs screening and referral practice patterns without disrupting care. Methods For this pilot prospective cohort study, this SMS text message–based intervention augments an existing social needs screening, referral, and navigation program at a federally qualified health center. Patients who received at least one referral for any identified unmet social need are sent 2 rounds of SMS messages over 2 weeks. The first round consists of 5-10 messages that deliver descriptions of and contact information for the referred resources. The second round consists of 2 messages that offer a brief reminder to contact the resources. Participants will evaluate the intervention via a survey and a semistructured interview, informed by an adapted technology acceptance model. Rapid qualitative and thematic analysis will be used to extract themes from the responses. Primary outcomes are implementation feasibility and patient acceptability. Secondary outcomes relate to intervention effectiveness: self-reported attempt to connect and successful connection to referred resources 2 weeks after the initial referral encounter. Results The study received regulatory approval in May 2021, and we anticipate enrolling 15-20 participants for this initial pilot. Conclusions This protocol presents detailed implementation methods about a novel automated SMS intervention for social care integration within primary care. By sharing the study protocol early, we intend to facilitate the development and adoption of similar tools across different clinical settings, as more health care providers seek to address the unmet social needs of patients. Study findings will provide practical insights into the design and implementation of SMS text message–based interventions to improve social and medical care coordination. International Registered Report Identifier (IRRID) DERR1-10.2196/37316
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Affiliation(s)
- Tyler Lian
- Department of Population Health Science, Duke University School of Medicine, Durham, NC, United States
| | - Hadley Reid
- School of Medicine, Duke University, Durham, NC, United States
| | - Abigail Rader
- Department of Population Health Science, Duke University School of Medicine, Durham, NC, United States
| | | | - Elmira Hezarkhani
- Trinity College of Arts & Science, Duke University, Durham, NC, United States
| | - Elizabeth Gu
- Trinity College of Arts & Science, Duke University, Durham, NC, United States
| | - Malik Scott
- Trinity College of Arts & Science, Duke University, Durham, NC, United States
| | - Kate Kutzer
- Trinity College of Arts & Science, Duke University, Durham, NC, United States
| | - Sahil Sandhu
- Trinity College of Arts & Science, Duke University, Durham, NC, United States
| | | | - Kristin Ito
- Lincoln Community Health Center, Durham, NC, United States
| | - Howard Eisenson
- Lincoln Community Health Center, Durham, NC, United States
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC, United States
| | - Janet Prvu Bettger
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, United States
| | - Ryan J Shaw
- Duke University School of Nursing, Durham, NC, United States
| | - Allison A Lewinski
- Duke University School of Nursing, Durham, NC, United States
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Medical Center, Durham, NC, United States
| | - David Y Ming
- Department of Population Health Science, Duke University School of Medicine, Durham, NC, United States
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Hayden B Bosworth
- Department of Population Health Science, Duke University School of Medicine, Durham, NC, United States
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Medical Center, Durham, NC, United States
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Leah L Zullig
- Department of Population Health Science, Duke University School of Medicine, Durham, NC, United States
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Medical Center, Durham, NC, United States
| | - Bryan C Batch
- Department of Medicine, Division of Endocrinology, Duke University School of Medicine, Durham, NC, United States
| | - Connor Drake
- Department of Population Health Science, Duke University School of Medicine, Durham, NC, United States
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Medical Center, Durham, NC, United States
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Ballengee LA, Rushton S, Lewinski AA, Hwang S, Zullig LL, Ricks KAB, Ramos K, Brahmajothi MV, Moore TS, Blalock DV, Cantrell S, Kosinski AS, Gordon A, Ear B, Williams JW, Gierisch JM, Goldstein KM. Effectiveness of Quality Improvement Coaching on Process Outcomes in Health Care Settings: A Systematic Review. J Gen Intern Med 2022; 37:885-899. [PMID: 34981354 PMCID: PMC8904663 DOI: 10.1007/s11606-021-07217-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 10/08/2020] [Accepted: 10/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND A culture of improvement is an important feature of high-quality health care systems. However, health care teams often need support to translate quality improvement (QI) activities into practice. One method of support is consultation from a QI coach. The literature suggests that coaching interventions have a positive impact on clinical outcomes. However, the impact of coaching on specific process outcomes, like adoption of clinical care activities, is unknown. Identifying the process outcomes for which QI coaching is most effective could provide specific guidance on when to employ this strategy. METHODS We searched multiple databases from inception through July 2021. Studies that addressed the effects of QI coaching on process of care outcomes were included. Two reviewers independently extracted study characteristics and assessed risk of bias. Certainty of evidence was assessed using GRADE. RESULTS We identified 1983 articles, of which 23 cluster-randomized trials met eligibility criteria. All but two took place in a primary care setting. Overall, interventions typically targeted multiple simultaneous processes of care activities. We found that coaching probably has a beneficial effect on composite process of care outcomes (n = 9) and ordering of labs and vital signs (n = 6), and possibly has a beneficial effect on changes in organizational process of care (n = 5), appropriate documentation (n = 5), and delivery of appropriate counseling (n = 3). We did not perform meta-analyses because of conceptual heterogeneity around intervention design and outcomes; rather, we synthesized the data narratively. Due to imprecision, inconsistency, and high risk of bias of the included studies, we judged the certainty of these results as low or very low. CONCLUSION QI coaching interventions may affect certain processes of care activities such as ordering of labs and vital signs. Future research that advances the identification of when QI coaching is most beneficial for health care teams seeking to implement improvement processes in pursuit of high-quality care will support efficient use of QI resources. PROTOCOL REGISTRATION This study was registered and followed a published protocol (PROSPERO: CRD42020165069).
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Affiliation(s)
- Lindsay A Ballengee
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA.
- Department of Orthopaedic Surgery, Duke University School of Medicine, Division of Physical Therapy, Duke University, Durham, NC, USA.
| | | | - Allison A Lewinski
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- School of Nursing, Duke University, Durham, NC, USA
| | - Soohyun Hwang
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Leah L Zullig
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
| | - Katharine A Ball Ricks
- Cecil G. Sheps Center for Health Service Research, University of North Carolina, Chapel Hill, NC, USA
| | - Katherine Ramos
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- Department of Medicine Geriatrics, Duke University, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, NC, USA
| | - Mulugu V Brahmajothi
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC, USA
| | - Thomasena S Moore
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
| | - Dan V Blalock
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Sarah Cantrell
- Duke University Medical Center Library, Duke University School of Medicine, Durham, NC, USA
| | - Andrzej S Kosinski
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Adelaide Gordon
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
| | - Belinda Ear
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
| | - John W Williams
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer M Gierisch
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
| | - Karen M Goldstein
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
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Tsai J, Szymkowiak D, Zullig LL. Epidemiology and psychiatric correlates of cancer among homeless and unstably housed veterans in the VA healthcare system. Cancer Epidemiol Biomarkers Prev 2022; 32:617-624. [PMID: 36791363 DOI: 10.1158/1055-9965.epi-22-1154] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/07/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND This study examined the incidence and correlates of cancer among homeless and unstably housed (HUH) veterans as compared to stably housed (SH) veterans. METHODS Using VA administrative data from 564,563 HUH and 5,213,820 SH veterans in 2013 and 2014, we examined the types and stages of 69 different types of cancer diagnosed among HUH and SH veterans. Sociodemographic and psychiatric characteristics associated with cancer were also examined. RESULTS The one-year incidence rate of cancer was 21.5% lower among HUH veterans than SH veterans (0.68% and 0.86% respectively). There was no difference in the most common stages and types of cancer among HUH and SH veterans. The most common primary sites of cancer were in the prostate, lung, and bronchus. HUH veterans were more likely than SH veterans to have cancer of the liver and intrahepatic bile ducts (∆4.79%). Among HUH veterans, older age and alcohol use disorder were associated with greater risk for any incident cancer while suicidal ideation/behaviors were associated with lower risk. Psychiatric conditions were often diagnosed before cancer diagnosis for SH and HUH veterans; rates of substance use disorders and suicidal ideation/behaviors decreased in HUH veterans after cancer diagnosis. CONCLUSIONS The VA healthcare system serves many HUH veterans with cancer. Mental health and substance use disorders are important to treat in veterans at risk of cancer and as potential sequalae of cancer. IMPACT The high prevalence of psychiatric disorders in HUH populations is important to consider in the diagnosis and treatment of cancer in these populations.
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Affiliation(s)
- Jack Tsai
- National Center on Homelessness among Veterans, Homeless Programs Office, U.S. Department of Veterans Affairs Central Office, Washington, District of Columbia
- School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas
| | - Dorota Szymkowiak
- National Center on Homelessness among Veterans, Homeless Programs Office, U.S. Department of Veterans Affairs Central Office, Washington, District of Columbia
| | - Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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Ballengee LA, Zullig LL, George SZ. Implementation of Psychologically Informed Physical Therapy for Low Back Pain: Where Do We Stand, Where Do We Go? J Pain Res 2021; 14:3747-3757. [PMID: 34908873 PMCID: PMC8665872 DOI: 10.2147/jpr.s311973] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 08/07/2021] [Accepted: 11/15/2021] [Indexed: 12/28/2022] Open
Abstract
Low back pain continues to be a leading cause of disability and cost throughout the world. Evidence-based guidelines recommend use of non-pharmacological interventions to address decreases in physical function due to low back pain. Psychologically informed physical therapy (PIPT) is one way to effectively and efficiently address the need for non-pharmacological approaches. However, adoption of psychologically informed practice (PiP) by physical therapists has shown mixed results due to implementation challenges. In this perspective, we discuss the current state of PIPT training and implementation. We also propose a conceptual roadmap for future implementation needs related to increasing delivery of PIPT-informed approaches.
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Affiliation(s)
- Lindsay A Ballengee
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- Division of Physical Therapy, Duke University, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Leah L Zullig
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Steven Z George
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
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Colón-Emeric CS, Lee R, Pieper CF, Lyles KW, Zullig LL, Nelson RE, Robinson K, Igwe I, Jadhav J, Adler RA. Protocol for the models of primary osteoporosis screening in men (MOPS) cluster randomized trial. Contemp Clin Trials 2021; 112:106634. [PMID: 34844000 DOI: 10.1016/j.cct.2021.106634] [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: 08/04/2021] [Revised: 11/15/2021] [Accepted: 11/22/2021] [Indexed: 11/25/2022]
Abstract
Current guidelines recommend primary osteoporosis screening for at-risk men to reduce the morbidity, mortality, and cost associated with osteoporotic fractures. However, analyses in a national Veterans Health Administration cohort of over 4,000,000 men demonstrated that primary osteoporosis screening as it is currently operationalized does not benefit most older Veterans due to inefficient targeting and low subsequent treatment and adherence rates. The overall objective of this study is to determine whether a new model of primary osteoporosis screening reduces fracture risk compared to usual care. We are conducting a pragmatic group randomized trial of 38 primary care teams assigned to usual care or a Bone Health Service (BHS) screening model in which screening and adherence activities are managed by a centralized expert team. The study will: 1) compare the impact of the BHS model on patient-level outcomes strongly associated with fracture rates (eligible proportion screened, proportion meeting treatment criteria who receive osteoporosis medications, medication adherence, and femoral neck bone mineral density); 2) quantify the impact on provider and facility-level outcomes including change in DXA volume, change in metabolic bone disease clinic volume, and PACT provider time and satisfaction; and 3) estimate the impact on health system and policy outcomes using Markov models of screening program cost per quality adjusted life year based from health system and societal perspectives.
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Affiliation(s)
- Cathleen S Colón-Emeric
- Durham VA Geriatric Research Education and Clinical Center and Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), 508 Fulton St. Durham, NC 27705, USA; Duke University School of Medicine, Box 3003 DUMC, Durham, NC 27710, USA.
| | - Richard Lee
- Durham VA Geriatric Research Education and Clinical Center and Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), 508 Fulton St. Durham, NC 27705, USA; Duke University School of Medicine, Box 3003 DUMC, Durham, NC 27710, USA
| | - Carl F Pieper
- Duke University School of Medicine, Box 3003 DUMC, Durham, NC 27710, USA
| | - Kenneth W Lyles
- Durham VA Geriatric Research Education and Clinical Center and Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), 508 Fulton St. Durham, NC 27705, USA; Duke University School of Medicine, Box 3003 DUMC, Durham, NC 27710, USA
| | - Leah L Zullig
- Durham VA Geriatric Research Education and Clinical Center and Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), 508 Fulton St. Durham, NC 27705, USA; Duke University School of Medicine, Box 3003 DUMC, Durham, NC 27710, USA
| | - Richard E Nelson
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City VA Health Care System, 500 Foothills Drive, Salt Lake City, UT 84148, USA; University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132, USA
| | - Katina Robinson
- Durham VA Geriatric Research Education and Clinical Center and Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), 508 Fulton St. Durham, NC 27705, USA
| | - Ivuoma Igwe
- Durham VA Geriatric Research Education and Clinical Center and Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), 508 Fulton St. Durham, NC 27705, USA
| | - Jyotsna Jadhav
- Durham VA Geriatric Research Education and Clinical Center and Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), 508 Fulton St. Durham, NC 27705, USA
| | - Robert A Adler
- Hunter Holmes McGuire VA Medical Center, 1201 Broad Rock Blvd, Richmond, VA 23249, USA
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Zullig LL, Shahsahebi M, Neely B, Hyslop T, Avecilla RAV, Griffin BM, Clayton-Stiglbauer K, Coles T, Owen L, Reeve BB, Shah K, Shelby RA, Sutton L, Dinan MA, Zafar SY, Shah NP, Dent S, Oeffinger KC. Low-touch, team-based care for co-morbidity management in cancer patients: the ONE TEAM randomized controlled trial. BMC Fam Pract 2021; 22:234. [PMID: 34794388 PMCID: PMC8600877 DOI: 10.1186/s12875-021-01569-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 10/19/2021] [Indexed: 01/22/2023]
Abstract
Background As treatments for cancer have improved, more people are surviving cancer. However, compared to people without a history of cancer, cancer survivors are more likely to die of cardiovascular disease (CVD). Increased risk for CVD-related mortality among cancer survivors is partially due to lack of medication adherence and problems that exist in care coordination between cancer specialists, primary care physicians, and cardiologists. Methods/Design The Onco-primary care networking to support TEAM-based care (ONE TEAM) study is an 18-month cluster-randomized controlled trial with clustering at the primary care clinic level. ONE TEAM compares the provision of the iGuide intervention to patients and primary care providers versus an education-only control. For phase 1, at the patient level, the intervention includes video vignettes and a live webinar; provider-level interventions include electronic health records-based communication and case-based webinars. Participants will be enrolled from across North Carolina one of their first visits with a cancer specialist (e.g., surgeon, radiation or medical oncologist). We use a sequential multiple assignment randomized trial (SMART) design. Outcomes (measured at the patient level) will include Healthcare Effectiveness Data and Information Set (HEDIS) quality measures of management of three CVD comorbidities using laboratory testing (glycated hemoglobin [A1c], lipid profile) and blood pressure measurements; (2) medication adherence assessed pharmacy refill data using Proportion of Days Covered (PDC); and (3) patient-provider communication (Patient-Centered Communication in Cancer Care, PCC-Ca-36). Primary care clinics in the intervention arm will be considered non-responders if 90% or more of their participating patients do not meet the modified HEDIS quality metrics at the 6-month measurement, assessed once the first enrollee from each practice reaches the 12-month mark. Non-responders will be re-randomized to either continue to receive the iGuide 1 intervention, or to receive the iGuide 2 intervention, which includes tailored videos for participants and specialist consults with primary care providers. Discussion As the population of cancer survivors grows, ONE TEAM will contribute to closing the CVD outcomes gap among cancer survivors by optimizing and integrating cancer care and primary care teams. ONE TEAM is designed so that it will be possible for others to emulate and implement at scale. Trial registration This study (NCT04258813) was registered in clinicaltrals.gov on February 6, 2020.
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Affiliation(s)
- Leah L Zullig
- Department of Population Health Sciences, Duke University School Of Medicine, 215 Morris St, Durham, NC, 27701, USA. .,Department of Population Health Sciences, Duke University School of Medicine, 411 West Chapel Hill Street, Suite 600, Durham, NC, 27701, USA.
| | - Mohammad Shahsahebi
- Duke University Family Medicine and Community Health, 2424 Erwin Rd, Ste 601, DUMC, Box 2714, Durham, NC, 27705, USA.,Center for Onco-Primary Care, Duke Cancer Institute, 2424 Erwin Road, Hock Plaza, Ste 601, Durham, NC, 27705, USA
| | - Benjamin Neely
- Duke Cancer Institute, Duke University, 2424 Erwin Rd, Durham, NC, 27701, USA
| | - Terry Hyslop
- Department of Biostatistics, Duke University, 2424 Erwin Road, 9064 Hock Plaza, Durham, NC, 27705, USA
| | - Renee A V Avecilla
- Center for Onco-Primary Care, Duke Cancer Institute, 2424 Erwin Road, Hock Plaza, Ste 601, Durham, NC, 27705, USA
| | - Brittany M Griffin
- Center for Onco-Primary Care, Duke Cancer Institute, 2424 Erwin Road, Hock Plaza, Ste 601, Durham, NC, 27705, USA
| | - Kacey Clayton-Stiglbauer
- Center for Onco-Primary Care, Duke Cancer Institute, 2424 Erwin Road, Hock Plaza, Ste 601, Durham, NC, 27705, USA
| | - Theresa Coles
- Department of Population Health Sciences, Duke University School Of Medicine, 215 Morris St, Durham, NC, 27701, USA
| | - Lynda Owen
- Duke Cancer Network, 20 Duke Medicine Circle, Durham, NC, 27710, USA
| | - Bryce B Reeve
- Department of Population Health Sciences, Duke University School Of Medicine, 215 Morris St, Durham, NC, 27701, USA
| | - Kevin Shah
- Duke Institute for Health Innovation, Duke University Health System, 200 Morris St, Durham, NC, 27701, USA
| | - Rebecca A Shelby
- Duke Psychiatry and Behavioral Sciences, Duke University School of Medicine, 2200 W. Main St, Ste 340, Durham, NC, 27705, USA
| | - Linda Sutton
- Duke Cancer Network, 20 Duke Medicine Circle, Durham, NC, 27710, USA
| | - Michaela A Dinan
- Department of Chronic Disease Epidemiology, Yale School of Public Health, 60 College Street, New Haven, CT, 06510, USA
| | - S Yousuf Zafar
- Duke University School of Medicine, 2200 W. Main St, Ste 340, Durham, NC, 27705, USA
| | - Nishant P Shah
- Duke Heart Center, Duke University School of Medicine, 2200 W. Main St, Ste 340, Durham, NC, 27705, USA
| | - Susan Dent
- Duke Cancer Institute, Duke University, 2200 W. Main St, Ste 340, Durham, NC, 27705, USA
| | - Kevin C Oeffinger
- Duke Cancer Institute, Duke University School of Medicine, 2200 W. Main St, Ste 340, Durham, NC, 27705, USA
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50
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Kostalova B, Ribaut J, Dobbels F, Gerull S, Mala-Ladova K, Zullig LL, De Geest S. Medication adherence interventions in transplantation lack information on how to implement findings from randomized controlled trials in real-world settings: A systematic review. Transplant Rev (Orlando) 2021; 36:100671. [PMID: 34773910 DOI: 10.1016/j.trre.2021.100671] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/19/2021] [Accepted: 09/19/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Growing numbers of randomized controlled trials (RCTs) are showing the effectiveness of interventions to improve medication adherence in transplantation recipients. However, real-world implementation is still a major challenge. This systematic review assesses the range of information available in RCTs supporting these interventions' clinical adoption in adult transplant populations. METHODS We included RCTs of interventions that a) targeted any phase of medication adherence in solid organ or allogeneic stem cell transplantation recipients and b) were published between January 2015 and November 2020. We excluded study protocols, conference abstracts and studies focusing only on pediatric populations. We identified relevant database and trial registries as well as traced references backward and citations forward. Implementation-relevant information was evaluated using adapted versions of Peters' ten criteria: 1. healthcare/organizational context; 2. social/economic/policy context; 3. patient involvement; 4. other stakeholder involvement; 5. sample representativeness; 6. trial conducted in a real-world-setting; 7. presence of feasibility study; 8. implementation strategy; 9. process evaluation; 10. implementation outcomes, using a stoplight color-rating system. RESULTS Screening 17'004 titles/abstracts resulted in 23 eligible RCTs, including 2'339 patients (n = 19-209/study). All included studies focused on the implementation phase of medication adherence. The best-reported criteria were feasibility study (43%), representative sample (17%) and conducted in a real-world-setting (17%). Least reported were context (9%), implementation strategies (4%), process evaluation (4%). CONCLUSIONS RCTs testing medication adherence interventions tend to report limited implementation-relevant information. This hinders their translation to real-world transplant settings. Integrating implementation science principles early in the conceptualization of RCTs would fuel real-world-translation, reducing research waste.
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Affiliation(s)
- Barbora Kostalova
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Akademika Heyrovskeho 1203, 500 05 Hradec Kralove, Czech Republic.
| | - Janette Ribaut
- Institute of Nursing Science, Department of Public Health, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland; Department of Theragnostic, Hematology, University Hospital of Basel, Petersgraben 4, 4031 Basel, Switzerland.
| | - Fabienne Dobbels
- Institute of Nursing Science, Department of Public Health, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland; Academic Center for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 35 blok d, box 7001, 3000 Leuven, Belgium.
| | - Sabine Gerull
- Department of Theragnostic, Hematology, University Hospital of Basel, Petersgraben 4, 4031 Basel, Switzerland; Department of Hematology, Cantonal Hospital of Aarau, Tellstrasse 25, 5001 Aarau, Switzerland.
| | - Katerina Mala-Ladova
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Akademika Heyrovskeho 1203, 500 05 Hradec Kralove, Czech Republic.
| | - Leah L Zullig
- Department of Population Health Science, Duke University, 215 Morris St, Durham, NC 27701, USA; Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton St, Durham, NC 27705, USA.
| | - Sabina De Geest
- Institute of Nursing Science, Department of Public Health, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland; Academic Center for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 35 blok d, box 7001, 3000 Leuven, Belgium.
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