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Okado I, Liu M, Elhajj C, Wilkens L, Holcombe RF. Patient reports of cancer care coordination in rural Hawaii. J Rural Health 2024. [PMID: 38225683 DOI: 10.1111/jrh.12821] [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: 07/11/2023] [Revised: 12/16/2023] [Accepted: 01/02/2024] [Indexed: 01/17/2024]
Abstract
PURPOSE Rural residents experience disproportionate burdens of cancer, and poorer cancer health outcomes in rural populations are partly attributed to care delivery challenges. Cancer patients in rural areas often experience unique challenges with care coordination. In this study, we explored patient reports of care coordination among rural Hawaii patients with cancer and compared rural and urban patients' perceptions of cancer care coordination. METHODS 80 patients receiving active treatment for cancer from rural Hawaii participated in a care coordination study in 2020-2021. Participants completed the Care Coordination Instrument, a validated oncology patient questionnaire. FINDINGS Mean age of rural cancer patients was 63.0 (SD = 12.1), and 57.7% were female. The most common cancer types were breast and GI. Overall, rural and urban patients' perceptions of care coordination were comparable (p > 0.05). There were statistically significant differences between rural and urban patients' perceptions in communication and navigation aspects of care coordination (p = 0.02 and 0.04, respectively). Specific differences included a second opinion consultation, clinical trial considerations, and after-hours care. 43% of rural patients reported traveling by air for part or all of their cancer treatment. CONCLUSIONS Findings suggest that while overall perceptions of care coordination were similar between rural and urban patients, differential perceptions of specific care coordination areas between rural and urban patients may reflect limited access to care for rural patients. Improving access to cancer care may be a potential strategy to enhance care coordination for rural patients and ultimately address rural-urban cancer health disparities.
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Affiliation(s)
- Izumi Okado
- Population Sciences in the Pacific Program, University of Hawaii Cancer Center, Honolulu, Hawaii, USA
| | - Michelle Liu
- Population Sciences in the Pacific Program, University of Hawaii Cancer Center, Honolulu, Hawaii, USA
| | - Carry Elhajj
- Population Sciences in the Pacific Program, University of Hawaii Cancer Center, Honolulu, Hawaii, USA
| | - Lynne Wilkens
- Population Sciences in the Pacific Program, University of Hawaii Cancer Center, Honolulu, Hawaii, USA
| | - Randall F Holcombe
- Population Sciences in the Pacific Program, University of Hawaii Cancer Center, Honolulu, Hawaii, USA
- University of Vermont Cancer Center, Department of Medicine, Division of Hematology/Oncology, University of Vermont, Burlington, Vermont, USA
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Bongiovanni T, Pletcher MJ, Robinson A, Lancaster E, Zhang L, Behrends M, Wick E, Auerbach A. Electronic health record intervention to increase use of NSAIDs as analgesia for hospitalised patients: a cluster randomised controlled study. BMJ Health Care Inform 2023; 30:e100842. [PMID: 38159932 PMCID: PMC10759061 DOI: 10.1136/bmjhci-2023-100842] [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: 06/30/2023] [Accepted: 12/13/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Prescribing non-opioid pain medications, such as non-steroidal anti-inflammatory (NSAIDs) medications, has been shown to reduce pain and decrease opioid use, but it is unclear how to effectively encourage multimodal pain medication prescribing for hospitalised patients. Therefore, the aim of this study is to evaluate the effect of prechecking non-opioid pain medication orders on clinician prescribing of NSAIDs among hospitalised adults. METHODS This was a cluster randomised controlled trial of adult (≥18 years) hospitalised patients admitted to three hospital sites under one quaternary hospital system in the USA from 2 March 2022 to 3 March 2023. A multimodal pain order panel was embedded in the admission order set, with NSAIDs prechecked in the intervention group. The intervention group could uncheck the NSAID order. The control group had access to the same NSAID order. The primary outcome was an increase in NSAID ordering. Secondary outcomes include NSAID administration, inpatient pain scores and opioid use and prescribing and relevant clinical harms including acute kidney injury, new gastrointestinal bleed and in-hospital death. RESULTS Overall, 1049 clinicians were randomised. The study included 6239 patients for a total of 9595 encounters. Both NSAID ordering (36 vs 43%, p<0.001) and administering (30 vs 34%, p=0.001) by the end of the first full hospital day were higher in the intervention (prechecked) group. There was no statistically significant difference in opioid outcomes during the hospitalisation and at discharge. There was a statistically but perhaps not clinically significant difference in pain scores during both the first and last full hospital day. CONCLUSIONS This cluster randomised controlled trial showed that prechecking an order for NSAIDs to promote multimodal pain management in the admission order set increased NSAID ordering and administration, although there were no changes to pain scores or opioid use. While prechecking orders is an important way to increase adoption, safety checks should be in place.
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Affiliation(s)
- Tasce Bongiovanni
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Mark J Pletcher
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Andrew Robinson
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Elizabeth Lancaster
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Li Zhang
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Matthias Behrends
- Department of Anesthesia, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Andrew Auerbach
- Division of Hospital Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
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Majumder MS, Cusick M, Rose S. Measuring concordance of data sources used for infectious disease research in the USA: a retrospective data analysis. BMJ Open 2023; 13:e065751. [PMID: 36854597 PMCID: PMC9980358 DOI: 10.1136/bmjopen-2022-065751] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 02/07/2023] [Indexed: 03/02/2023] Open
Abstract
OBJECTIVES As highlighted by the COVID-19 pandemic, researchers are eager to make use of a wide variety of data sources, both government-sponsored and alternative, to characterise the epidemiology of infectious diseases. The objective of this study is to investigate the strengths and limitations of sources currently being used for research. DESIGN Retrospective descriptive analysis. PRIMARY AND SECONDARY OUTCOME MEASURES Yearly number of national-level and state-level disease-specific case counts and disease clusters for three diseases (measles, mumps and varicella) during a 5-year study period (2013-2017) across four different data sources: Optum (health insurance billing claims data), HealthMap (online news surveillance data), Morbidity and Mortality Weekly Reports (official government reports) and National Notifiable Disease Surveillance System (government case surveillance data). RESULTS Our study demonstrated drastic differences in reported infectious disease incidence across data sources. When compared with the other three sources of interest, Optum data showed substantially higher, implausible standardised case counts for all three diseases. Although there was some concordance in identified state-level case counts and disease clusters, all four sources identified variations in state-level reporting. CONCLUSIONS Researchers should consider data source limitations when attempting to characterise the epidemiology of infectious diseases. Some data sources, such as billing claims data, may be unsuitable for epidemiological research within the infectious disease context.
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Affiliation(s)
- Maimuna S Majumder
- Computational Health Informatics, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Marika Cusick
- Department of Health Policy, Stanford University, Stanford, California, USA
| | - Sherri Rose
- Department of Health Policy, Stanford University, Stanford, California, USA
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Boltri JM, Tracer H, Strogatz D, Idzik S, Schumacher P, Fukagawa N, Leake E, Powell C, Shell D, Wu S, Herman WH. The National Clinical Care Commission Report to Congress: Leveraging Federal Policies and Programs to Prevent Diabetes in People With Prediabetes. Diabetes Care 2023; 46:e39-e50. [PMID: 36701590 PMCID: PMC9887613 DOI: 10.2337/dc22-0620] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 11/03/2022] [Indexed: 01/27/2023]
Abstract
Individuals with an elevated fasting glucose level, elevated glucose level after glucose challenge, or elevated hemoglobin A1c level below the diagnostic threshold for diabetes (collectively termed prediabetes) are at increased risk for type 2 diabetes. More than one-third of U.S. adults have prediabetes but fewer than one in five are aware of the diagnosis. Rigorous scientific research has demonstrated the efficacy of both intensive lifestyle interventions and metformin in delaying or preventing progression from prediabetes to type 2 diabetes. The National Clinical Care Commission (NCCC) was a federal advisory committee charged with evaluating and making recommendations to improve federal programs related to the prevention of diabetes and its complications. In this article, we describe the recommendations of an NCCC subcommittee that focused primarily on prevention of type 2 diabetes in people with prediabetes. These recommendations aim to improve current federal diabetes prevention activities by 1) increasing awareness of and diagnosis of prediabetes on a population basis; 2) increasing the availability of, referral to, and insurance coverage for the National Diabetes Prevention Program and the Medicare Diabetes Prevention Program; 3) facilitating Food and Drug Administration review and approval of metformin for diabetes prevention; and 4) supporting research to enhance the effectiveness of diabetes prevention. Cognizant of the burden of type 1 diabetes, the recommendations also highlight the importance of research to advance our understanding of the etiology of and opportunities for prevention of type 1 diabetes.
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Affiliation(s)
| | - Howard Tracer
- Agency for Healthcare Research and Quality, Department of Health and Human Services, Rockville, MD
| | | | - Shannon Idzik
- School of Nursing, University of Maryland, Baltimore, MD
| | - Pat Schumacher
- Centers for Disease Control and Prevention, Department of Health and Human Services, Atlanta, GA
| | | | - Ellen Leake
- Juvenile Diabetes Research Foundation, Jackson, MS
| | - Clydette Powell
- School of Medicine and Health Services, George Washington University, Washington, DC
| | | | - Samuel Wu
- U.S. Office of Minority Health, Rockville, MD
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Conlin PR, Boltri JM, Bullock A, Greenlee MC, Lopata AM, Powell C, Schillinger D, Tracer H, Herman WH. The National Clinical Care Commission Report to Congress: Summary and Next Steps. Diabetes Care 2023; 46:e60-e63. [PMID: 36701591 PMCID: PMC9887605 DOI: 10.2337/dc22-0622] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 11/02/2022] [Indexed: 01/27/2023]
Abstract
The U.S. is experiencing an epidemic of type 2 diabetes. Socioeconomically disadvantaged and certain racial and ethnic groups experience a disproportionate burden from diabetes and are subject to disparities in treatment and outcomes. The National Clinical Care Commission (NCCC) was charged with making recommendations to leverage federal policies and programs to more effectively prevent and control diabetes and its complications. The NCCC determined that diabetes cannot be addressed simply as a medical problem but must also be addressed as a societal problem requiring social, clinical, and public health policy solutions. As a result, the NCCC's recommendations address policies and programs of both non-health-related and health-related federal agencies. The NCCC report, submitted to the U.S. Congress on 6 January 2022, makes 39 specific recommendations, including three foundational recommendations that non-health-related and health-related federal agencies coordinate their activities to better address diabetes, that all federal agencies and departments ensure that health equity is a guiding principle for their policies and programs that impact diabetes, and that all Americans have access to comprehensive and affordable health care. Specific recommendations are also made to improve general population-wide policies and programs that impact diabetes risk and control, to increase awareness and prevention efforts among those at high risk for type 2 diabetes, and to remove barriers to access to effective treatments for diabetes and its complications. Finally, the NCCC recommends that an Office of National Diabetes Policy be established to coordinate the activities of health-related and non-health-related federal agencies to address diabetes prevention and treatment. The NCCC urges Congress and the Secretary of Health and Human Services to implement these recommendations to protect the health and well-being of the more than 130 million Americans at risk for and living with diabetes.
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Affiliation(s)
- Paul R. Conlin
- Department of Veterans Affairs Boston Healthcare System, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Ann Bullock
- Division of Diabetes Treatment and Prevention, Indian Health Service, Rockville, MD
| | | | - Aaron M. Lopata
- Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, MD
| | - Clydette Powell
- School of Medicine and Health Services, George Washington University, Washington, DC
| | - Dean Schillinger
- University of California San Francisco and San Francisco General Hospital, San Francisco, CA
| | - Howard Tracer
- Agency for Healthcare Research and Quality, Department of Health and Human Services, Rockville, MD
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Greenlee MC, Bolen S, Chong W, Dokun A, Gonzalvo J, Hawkins M, Herman WH, Leake E, Linder B, Conlin PR. The National Clinical Care Commission Report to Congress: Leveraging Federal Policies and Programs to Improve Diabetes Treatment and Reduce Complications. Diabetes Care 2023; 46:e51-e59. [PMID: 36701593 PMCID: PMC9887628 DOI: 10.2337/dc22-0621] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 09/08/2022] [Indexed: 01/27/2023]
Abstract
The Treatment and Complications subcommittee of the National Clinical Care Commission focused on factors likely to improve the delivery of high-quality care to all people with diabetes. The gap between available resources and the needs of people living with diabetes adversely impacts both treatment and outcomes. The Commission's recommendations are designed to bridge this gap. At the patient level, the Commission recommends reducing barriers and streamlining administrative processes to improve access to diabetes self-management training, diabetes devices, virtual care, and insulin. At the practice level, we recommend enhancing programs that support team-based care and developing capacity to support technology-enabled mentoring interventions. At the health system level, we recommend that the Department of Health and Human Services routinely assess the needs of the health care workforce and ensure funding of training programs directed to meet those needs. At the health policy level, we recommend establishing a process to identify and ensure pre-deductible insurance coverage for high-value diabetes treatments and services and developing a quality measure that reduces risk of hypoglycemia and enhances patient safety. We also identified several areas that need additional research, such as studying the barriers to uptake of diabetes self-management education and support, exploring methods to implement team-based care, and evaluating the importance of digital connectivity as a social determinant of health. The Commission strongly encourages Congress, the Department of Health and Human Services, and other federal departments and agencies to take swift action to implement these recommendations to improve health outcomes and quality of life among people living with diabetes.
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Affiliation(s)
| | - Shari Bolen
- Population Health Research Institute and Center for Health Care Research and Policy, Case Western Reserve at The MetroHealth System, Cleveland, OH
| | - William Chong
- Office of Generic Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Rockville, MD
| | - Ayotunde Dokun
- Division of Endocrinology and Metabolism, Carver School of Medicine, University of Iowa, Iowa City, IA
| | - Jasmine Gonzalvo
- Center for Health Equity and Innovation, Purdue University, Indianapolis, IN
| | - Meredith Hawkins
- Global Diabetes Institute, Albert Einstein College of Medicine, Bronx, NY
| | | | - Ellen Leake
- Juvenile Diabetes Research Foundation, Jackson, MS
| | - Barbara Linder
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Paul R. Conlin
- Department of Veterans Affairs Boston Healthcare System, Boston, MA
- Harvard Medical School, Boston, MA
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Herman WH, Schillinger D, Bolen S, Boltri JM, Bullock A, Chong W, Conlin PR, Cook JW, Dokun A, Fukagawa N, Gonzalvo J, Greenlee MC, Hawkins M, Idzik S, Leake E, Linder B, Lopata AM, Schumacher P, Shell D, Strogatz D, Towne J, Tracer H, Wu S. The National Clinical Care Commission Report to Congress: Recommendations to Better Leverage Federal Policies and Programs to Prevent and Control Diabetes. Diabetes Care 2023; 46:255-261. [PMID: 36701592 PMCID: PMC9887614 DOI: 10.2337/dc22-1587] [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] [Received: 08/15/2022] [Accepted: 11/01/2022] [Indexed: 01/27/2023]
Abstract
The National Clinical Care Commission (NCCC) was established by Congress to make recommendations to leverage federal policies and programs to more effectively prevent and treat diabetes and its complications. The NCCC developed a guiding framework that incorporated elements of the Socioecological and Chronic Care Models. It surveyed federal agencies and conducted follow-up meetings with representatives from 10 health-related and 11 non-health-related federal agencies. It held 12 public meetings, solicited public comments, met with numerous interested parties and key informants, and performed comprehensive literature reviews. The final report, transmitted to Congress in January 2022, contained 39 specific recommendations, including 3 foundational recommendations that addressed the necessity of an all-of-government approach to diabetes, health equity, and access to health care. At the general population level, the NCCC recommended that the federal government adopt a health-in-all-policies approach so that the activities of non-health-related federal agencies that address agriculture, food, housing, transportation, commerce, and the environment be coordinated with those of health-related federal agencies to affirmatively address the social and environmental conditions that contribute to diabetes and its complications. For individuals at risk for type 2 diabetes, including those with prediabetes, the NCCC recommended that federal policies and programs be strengthened to increase awareness of prediabetes and the availability of, referral to, and insurance coverage for intensive lifestyle interventions for diabetes prevention and that data be assembled to seek approval of metformin for diabetes prevention. For people with diabetes and its complications, the NCCC recommended that barriers to proven effective treatments for diabetes and its complications be removed, the size and competence of the workforce to treat diabetes and its complications be increased, and new payment models be implemented to support access to lifesaving medications and proven effective treatments for diabetes and its complications. The NCCC also outlined an ambitious research agenda. The NCCC strongly encourages the public to support these recommendations and Congress to take swift action.
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Affiliation(s)
| | - Dean Schillinger
- University of California San Francisco and San Francisco General Hospital, San Francisco, CA
| | - Shari Bolen
- Case Western Reserve at The MetroHealth System, Cleveland, OH
| | - John M. Boltri
- Northeast Ohio Medical University College of Medicine, Rootstown, OH
| | - Ann Bullock
- Division of Diabetes Treatment and Prevention, Indian Health Service, Rockville, MD
| | | | - Paul R. Conlin
- Department of Veterans Affairs Boston Healthcare System, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Ayotunde Dokun
- Carver School of Medicine, University of Iowa, Iowa City, IA
| | - Naomi Fukagawa
- Beltsville Human Nutrition Research Center, U.S. Department of Agriculture Agricultural Research Service, Beltsville, MD
| | | | | | | | - Shannon Idzik
- School of Nursing, University of Maryland Baltimore, Baltimore, MD
| | - Ellen Leake
- International Board of Directors, Juvenile Diabetes Research Foundation, Jackson, MS
| | - Barbara Linder
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Aaron M. Lopata
- Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, MD
| | - Pat Schumacher
- Centers for Disease Control and Prevention, Department of Health and Human Services, Atlanta, GA
| | | | | | - Jana Towne
- Division of Diabetes Treatment and Prevention, Indian Health Service, Rockville, MD
| | - Howard Tracer
- Agency for Healthcare Research and Quality, Department of Health and Human Services, Rockville, MD
| | - Samuel Wu
- Office of Minority Health, Department of Health and Human Service, Rockville, MD
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Schillinger D, Bullock A, Powell C, Fukagawa NK, Greenlee MC, Towne J, Gonzalvo JD, Lopata AM, Cook JW, Herman WH. The National Clinical Care Commission Report to Congress: Leveraging Federal Policies and Programs for Population-Level Diabetes Prevention and Control: Recommendations From the National Clinical Care Commission. Diabetes Care 2023; 46:e24-e38. [PMID: 36701595 PMCID: PMC9887620 DOI: 10.2337/dc22-0619] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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] [Received: 03/29/2022] [Accepted: 10/04/2022] [Indexed: 01/27/2023]
Abstract
The etiology of type 2 diabetes is rooted in a myriad of factors and exposures at individual, community, and societal levels, many of which also affect the control of type 1 and type 2 diabetes. Not only do such factors impact risk and treatment at the time of diagnosis but they also can accumulate biologically from preconception, in utero, and across the life course. These factors include inadequate nutritional quality, poor access to physical activity resources, chronic stress (e.g., adverse childhood experiences, racism, and poverty), and exposures to environmental toxins. The National Clinical Care Commission (NCCC) concluded that the diabetes epidemic cannot be treated solely as a biomedical problem but must also be treated as a societal problem that requires an all-of-government approach. The NCCC determined that it is critical to design, leverage, and coordinate federal policies and programs to foster social and environmental conditions that facilitate the prevention and treatment of diabetes. This article reviews the rationale, scientific evidence base, and content of the NCCC's population-wide recommendations that address food systems; consumption of water over sugar-sweetened beverages; food and beverage labeling; marketing and advertising; workplace, ambient, and built environments; and research. Recommendations relate to specific federal policies, programs, agencies, and departments, including the U.S. Department of Agriculture, the Food and Drug Administration, the Federal Trade Commission, the Department of Housing and Urban Development, the Environmental Protection Agency, and others. These population-level recommendations are transformative. By recommending health-in-all-policies and an equity-based approach to governance, the NCCC Report to Congress has the potential to contribute to meaningful change across the diabetes continuum and beyond. Adopting these recommendations could significantly reduce diabetes incidence, complications, costs, and inequities. Substantial political resolve will be needed to translate recommendations into policy. Engagement by diverse members of the diabetes stakeholder community will be critical to such efforts.
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Affiliation(s)
- Dean Schillinger
- Division of General Internal Medicine, Center for Vulnerable Populations, San Francisco General Hospital, University of California San Francisco School of Medicine, San Francisco, CA
| | - Ann Bullock
- Division of Diabetes Treatment and Prevention, Indian Health Service, Rockville, MD
| | - Clydette Powell
- Division of Neurology, Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Naomi K. Fukagawa
- Beltsville Human Nutrition Research Center, U.S. Department of Agriculture Agricultural Research Service, Beltsville, MD
| | | | - Jana Towne
- Division of Diabetes Treatment and Prevention, Indian Health Service, Rockville, MD
| | - Jasmine D. Gonzalvo
- Center for Health Equity and Innovation, Purdue University/Eskenazi Health, Indianapolis, IN
| | - Aaron M. Lopata
- Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, MD
| | | | - William H. Herman
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Epidemiology, University of Michigan, Ann Arbor, MI
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Hobensack M, Ojo M, Barrón Y, Bowles KH, Cato K, Chae S, Kennedy E, McDonald MV, Rossetti SC, Song J, Sridharan S, Topaz M. Documentation of hospitalization risk factors in electronic health records (EHRs): a qualitative study with home healthcare clinicians. J Am Med Inform Assoc 2022; 29:805-812. [PMID: 35196369 PMCID: PMC9006696 DOI: 10.1093/jamia/ocac023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 02/08/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To identify the risk factors home healthcare (HHC) clinicians associate with patient deterioration and understand how clinicians respond to and document these risk factors. METHODS We interviewed multidisciplinary HHC clinicians from January to March of 2021. Risk factors were mapped to standardized terminologies (eg, Omaha System). We used directed content analysis to identify risk factors for deterioration. We used inductive thematic analysis to understand HHC clinicians' response to risk factors and documentation of risk factors. RESULTS Fifteen HHC clinicians identified a total of 79 risk factors that were mapped to standardized terminologies. HHC clinicians most frequently responded to risk factors by communicating with the prescribing provider (86.7% of clinicians) or following up with patients and caregivers (86.7%). HHC clinicians stated that a majority of risk factors can be found in clinical notes (ie, care coordination (53.3%) or visit (46.7%)). DISCUSSION Clinicians acknowledged that social factors play a role in deterioration risk; but these factors are infrequently studied in HHC. While a majority of risk factors were represented in the Omaha System, additional terminologies are needed to comprehensively capture risk. Since most risk factors are documented in clinical notes, methods such as natural language processing are needed to extract them. CONCLUSION This study engaged clinicians to understand risk for deterioration during HHC. The results of our study support the development of an early warning system by providing a comprehensive list of risk factors grounded in clinician expertize and mapped to standardized terminologies.
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Affiliation(s)
- Mollie Hobensack
- Columbia University School of Nursing, New York City, New York, USA
| | - Marietta Ojo
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York City, New York, USA
| | - Yolanda Barrón
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York City, New York, USA
| | - Kathryn H Bowles
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York City, New York, USA
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Kenrick Cato
- Columbia University School of Nursing, New York City, New York, USA
- Emergency Medicine, Columbia University Irving Medical Center, New York City, New York, USA
| | - Sena Chae
- College of Nursing, University of Iowa, Iowa City, Iowa, USA
| | - Erin Kennedy
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Margaret V McDonald
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York City, New York, USA
| | - Sarah Collins Rossetti
- Columbia University School of Nursing, New York City, New York, USA
- Department of Biomedical Informatics, Columbia University, New York City, New York, USA
| | - Jiyoun Song
- Columbia University School of Nursing, New York City, New York, USA
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York City, New York, USA
| | - Sridevi Sridharan
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York City, New York, USA
| | - Maxim Topaz
- Columbia University School of Nursing, New York City, New York, USA
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York City, New York, USA
- Data Science Institute, Columbia University, New York City, New York, USA
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Pestka DL, White KM, DeRoche KK, Benson BJ, Beebe TJ. 'Trying to fly the plane while we were building it'. Applying a learning health systems approach to evaluate early-stage barriers and facilitators to implementing primary care transformation: a qualitative study. BMJ Open 2022; 12:e053209. [PMID: 34980618 PMCID: PMC8724704 DOI: 10.1136/bmjopen-2021-053209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE A learning health system (LHS) uses data to generate evidence and answer questions required to continually improve system performance and patient care. Given the complexities of practice transformation, an area where LHS is particularly important is the study of primary care transformation (PCT) as PCT generates several practice-level questions that require study where the findings can be readily implemented. In May 2019, a large integrated health delivery system in Minnesota began implementation of a population management PCT in two of its 40 primary care clinics. In this model of care, patients are grouped into one of five service bundles based on their complexity of care; patient appointment lengths and services provided are then tailored to each service bundle. The objective of this study was to examine the use of a LHS in PCT by utilising the Consolidated Framework for Implementation Research (CFIR) to categorise implementation lessons from the initial two PCT clinics to inform further implementation of the PCT within the health system. DESIGN This was a formative evaluation in which semistructured qualitative interviews were carried out. Observational field notes were also taken. Inductive coding of the data was performed and resultant codes were mapped to the CFIR. SETTING Two suburban primary care clinics in the Twin Cities, Minnesota. PARTICIPANTS Twenty-two care team members from the first two clinics to adopt the PCT. RESULTS Seventeen codes emerged to describe care team members' perceived implementation influences. Codes occurred in each of the five CFIR domains (intervention characteristics, outer setting, inner setting, characteristics of individuals and process), with most codes occurring in the 'inner setting' domain. CONCLUSIONS Using an LHS approach to determine early-stage implementation influences is key to guiding further PCT implementation, understanding modifications that need to be made and additional research that needs to occur.
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Affiliation(s)
- Deborah L Pestka
- College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Katie M White
- School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Bradley J Benson
- School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Timothy J Beebe
- School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
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Snyder C, Choi Y, Smith KC, Wilson RF, Yuan CT, Nathan PC, Zhang A, Robinson KA. OUP accepted manuscript. JNCI Cancer Spectr 2022; 6:6525236. [PMID: 35603840 PMCID: PMC8946685 DOI: 10.1093/jncics/pkac012] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 12/10/2021] [Accepted: 12/21/2021] [Indexed: 11/12/2022] Open
Abstract
Appropriate models of survivorship care for the growing number of adult survivors of childhood cancer are unclear. We conducted a realist review to describe how models of care that include primary care and relevant resources (eg, tools, training) could be effective for adult survivors of childhood cancer. We first developed an initial program theory based on qualitative literature (studies, commentaries, opinion pieces) and stakeholder consultations. We then reviewed quantitative evidence and consulted stakeholders to refine the program theory and develop and refine context-mechanism-outcome hypotheses regarding how models of care that include primary care could be effective for adult survivors of childhood cancer. Effectiveness for both resources and models is defined by survivors living longer and feeling better through high-value care. Intermediate measures of effectiveness evaluate the extent to which survivors and providers understand the survivor’s history, risks, symptoms and problems, health-care needs, and available resources. Thus, the models of care and resources are intended to provide information to survivors and/or primary care providers to enable them to obtain/deliver appropriate care. The variables from our program theory found most consistently in the literature include oncology vs primary care specialty, survivor and provider knowledge, provider comfort treating childhood cancer survivors, communication and coordination between and among providers and survivors, and delivery/receipt of prevention and surveillance of late effects. In turn, these variables were prominent in our context-mechanism-outcome hypotheses. The findings from this realist review can inform future research to improve childhood cancer survivorship care and outcomes.
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Affiliation(s)
- Claire Snyder
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
- Correspondence to: Claire Snyder, PhD, Professor of Medicine, Oncology, and Health Policy and Management, Johns Hopkins Schools of Medicine and Public Health, 624 N. Broadway, 6th Floor, Baltimore, MD 21205, USA (e-mail: )
| | - Youngjee Choi
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Katherine C Smith
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Renee F Wilson
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christina T Yuan
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Paul C Nathan
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
- Departments of Pediatrics and Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada
| | - Allen Zhang
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Karen A Robinson
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Figueroa CA, Aguilera A, Chakraborty B, Modiri A, Aggarwal J, Deliu N, Sarkar U, Jay Williams J, Lyles CR. Adaptive learning algorithms to optimize mobile applications for behavioral health: guidelines for design decisions. J Am Med Inform Assoc 2021; 28:1225-1234. [PMID: 33657217 PMCID: PMC8200266 DOI: 10.1093/jamia/ocab001] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/07/2021] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE Providing behavioral health interventions via smartphones allows these interventions to be adapted to the changing behavior, preferences, and needs of individuals. This can be achieved through reinforcement learning (RL), a sub-area of machine learning. However, many challenges could affect the effectiveness of these algorithms in the real world. We provide guidelines for decision-making. MATERIALS AND METHODS Using thematic analysis, we describe challenges, considerations, and solutions for algorithm design decisions in a collaboration between health services researchers, clinicians, and data scientists. We use the design process of an RL algorithm for a mobile health study "DIAMANTE" for increasing physical activity in underserved patients with diabetes and depression. Over the 1.5-year project, we kept track of the research process using collaborative cloud Google Documents, Whatsapp messenger, and video teleconferencing. We discussed, categorized, and coded critical challenges. We grouped challenges to create thematic topic process domains. RESULTS Nine challenges emerged, which we divided into 3 major themes: 1. Choosing the model for decision-making, including appropriate contextual and reward variables; 2. Data handling/collection, such as how to deal with missing or incorrect data in real-time; 3. Weighing the algorithm performance vs effectiveness/implementation in real-world settings. CONCLUSION The creation of effective behavioral health interventions does not depend only on final algorithm performance. Many decisions in the real world are necessary to formulate the design of problem parameters to which an algorithm is applied. Researchers must document and evaulate these considerations and decisions before and during the intervention period, to increase transparency, accountability, and reproducibility. TRIAL REGISTRATION clinicaltrials.gov, NCT03490253.
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Affiliation(s)
- Caroline A Figueroa
- School of Social Welfare, University of California Berkeley, Berkeley, California, USA
| | - Adrian Aguilera
- School of Social Welfare, University of California Berkeley, Berkeley, California, USA
- UCSF Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Bibhas Chakraborty
- Centre for Quantitative Medicine, Duke-National University of Singapore Medical School, Singapore, Singapore
- Department of Statistics and Applied Probability, National University of Singapore, Singapore, Singapore
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Arghavan Modiri
- Department of Computer Science, University of Toronto, Toronto, Canada
| | - Jai Aggarwal
- Department of Computer Science, University of Toronto, Toronto, Canada
| | - Nina Deliu
- Department of Computer Science, University of Toronto, Toronto, Canada
- Department of Statistical Sciences, Sapienza University of Rome, Rome, Italy
| | - Urmimala Sarkar
- UCSF Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | | | - Courtney R Lyles
- UCSF Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
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